New research was presented at CROI 2015, the annual Conference on Retroviruses and Opportunistic Infections, from February 23 to 26 in Seattle. The features below highlight some of the studies that emerged from the conference.
Deferring HCV Treatment in Patients With HIV
The Particulars: Studies have shown that successful treatment of hepatitis C virus (HCV) reduces the risk of liver-related complications. However, treatment is often deferred in patients with limited liver fibrosis due to cost considerations and the promise of better treatment options in the future. Little is known about the impact of deferring HCV treatment on liver progression among patients with HIV.
Data Breakdown: For a study, researchers compared liver-related events and duration of infectiousness between patients with HIV who were treated for HCV 1 month after an HCV diagnosis, 1 year after a diagnosis, or as they reached fibrosis grades F2, F3, or F4. When compared with treating patients 1 month after diagnosis, delaying treatment until 1 year after diagnosis or until F2, F3, or F4 led to 14, 43, 142, and 418 additional cases of liver-related death per 1,000 HCV infections, respectively. The average length of time that patients were infectious increased from 5 years with treatment started 1 month after diagnosis to 21 years with treatment started at grade F4 fibrosis.
Take Home Pearl: Timely treatment of HCV infection among patients with HIV appears to help prevent liver-related death and decrease the length of time that patients are infectious.
Incentivizing Linkage to Care & Viral Suppression
The Particulars: Data are lacking on the effect of financial incentives for linkage to care and viral suppression (VS) among HIV-infected patients.
Data Breakdown: For a study, patients infected with HIV were randomized to receive standard care or financial incentives if a care visit occurred within 3 months and for every 3 months that patients had VS. Financial incentives did not significantly increase overall linkage to care when compared with standard care. However, financial incentives did result in substantial increases in VS at hospital clinics, smaller sites, and sites with lower VS. Financial incentives also increased continuity of care by 8% overall.
Take Home Pearl: Financial incentives do not appear to increase linkage to care among HIV-infected patients but do appear to increase VS for sites with fewer patients, lower VS, and hospital-based clinics.
Trends in Linkage to Care & Viral Suppression
The Particulars: Guidelines for HIV management advocate timely linkage to care and earlier initiation of antiretroviral therapy after diagnosis. In 2010, a New York State Law was passed requiring linkage to care for consenting newly diagnosed patients. Trends in linkage to care and viral suppression (VS) in New York City can provide indications of guideline adherence by providers and changes in outcomes.
Data Breakdown: For a study, timely linkage to care and VS were calculated among adults in New York City who were newly diagnosed with HIV in 2006 to 2013. During the study period, timely linkage to care increased from 68% to 76% overall. Linkage to care and VS both increased overall and in most CD4 cell count and age groups. The researchers also observed larger year-over-year increases by CD4 cell count following the release of updated recommendations.
Take Home Pearls: Timely linkage to care and VS appear to have increased among adults with HIV living in New York City between 2006 and 2013. The improvements suggest improved outcomes with better adherence to recent guidelines but indicate areas of need for further improvement.
Can Statins Benefit HIV Patients?
The Particulars: Statin therapy has been shown to reduce cardiovascular events and deter atherosclerosis progression. Studies have suggested that patients with HIV have higher risks for myocardial infarction, but the ability of statin treatment to achieve regression of coronary atherosclerosis in this patient population has not been well described.
Data Breakdown: Patients with HIV and subclinical coronary atherosclerosis who participated in a study were randomized to placebo or statin therapy for 12 months. When compared with placebo, statin therapy reduced non-calcified coronary plaque volume by nearly 20%. The statin therapy group also had fewer high-risk plaques and lower LDL-cholesterol levels when compared with the placebo group.
Take Home Pearl: Among HIV-infected patients with subclinical coronary atherosclerosis, statin therapy appears to reduce non-calcified plaque volume and high-risk plaque features.
Cost Savings From Preventing HIV
The Particulars: Strategies for preventing HIV infection, such as pre-exposure prophylaxis for high-risk individuals, have been shown to be costly. However, few studies have assessed the costs saved by averting HIV infection in the United States.
Data Breakdown: Study investigators estimated lifetime medical costs in people with and without HIV to determine the costs saved by preventing one HIV infection. They estimated the lifetime cost for patients infected with HIV at age 35 to be $326,500. The estimated medical costs saved by avoiding one HIV infection were $229,800.
Take Home Pearl: The economic value of HIV prevention in the U.S. appears to be substantial given the high costs associated with treating HIV.
Detecting Acute HIV
The Particulars: Laboratory-based HIV testing guidelines were recently revised by the Clinical and Laboratory Standards Institute (CLSI). These revisions include an updated algorithm that facilitates the detection of acute HIV. Few analyses have explored the impact of the revised guidelines.
Data Breakdown: For a study, investigators examined patients aged 13 and older who were diagnosed with HIV during 2008 to 2012 and their date of most recent HIV antibody-negative test. Among more than 200,000 patients who were diagnosed with HIV, 25% had a previous negative test date. Of these patients, 3% met the criteria for acute HIV infection. The percentage of acute HIV infection diagnoses was relatively stable from 2008 to 2012, but a significant increase occurred between 2011 and 2012.
Take Home Pearls: Disparities appear to be prevalent in the detection of acute HIV infection among patients with diagnosed HIV. The observed increase of acute HIV infections in 2012 may be the result of a potential shift in testing technology and reporting to public health groups following the revised
CLSI guidelines.
Frontline HIV Prevention
The Particulars: Early initiation of antiretroviral therapy (ART) for HIV-infected patients and pre-exposure prophylaxis (PrEP) for at-risk HIV-negative patients are two strategies that have been shown to decrease the risk of transmitting HIV to others. However, little is known about how clinicians implement these strategies.
Data Breakdown: An online survey of infectious diseases physicians was conducted in September 2014 to assess intentions and practices with early ART, PrEP, and risk reduction counseling. ART initiation was recommended by 87% of providers at HIV diagnosis irrespective of CD4 count. However, 97% of clinicians reported deferring ART in patients who were not ready. Another 47% of physicians reported that patients had untreated depression or psychiatric illness, 68% reported that they had substance abuse disorders, and 50% reported having limited resources. Also, only 32% of survey respondents had prescribed PrEP.
Take Home Pearls: Infectious diseases physicians appear to frequently recommend early ART in HIV-diagnosed patients. However, many defer ART based on patient readiness or psychosocial factors, and only about one-third have prescribed PrEP.
Internalized Stigma in HIV-Infected Adults
The Particulars: Previous research has suggested that internalizing stigma can lead to poor HIV medication adherence, non-disclosure of HIV status to sex partners, and poor health outcomes. However, there are few national estimates of the extent of stigma and factors associated with it among HIV-infected patients.
Data Breakdown: Researchers analyzed data from a nationally representative sample of more than 4,000 HIV-infected adults. They found an average stigma score of 2.6 on a 0.0 to 6.0 scale. Patients with higher stigma scores tended to be:
• Older.
• Female.
• Heterosexual.
• Foreign born.
• Recently diagnosed with HIV.
• African American, Hispanic, or Latino.
Internalized stigma was also associated with depression, binge drinking, and lack of disclosure of HIV status to sex partners.
Take Home Pearl: Interventions to reduce internalized stigma may be most beneficial for HIV-infected adults who are older, heterosexual, foreign born, and recently diagnosed.
HIV Partner Services & Linkage to Care
The Particulars: HIV partner services can allow for more testing of exposed partners for HIV and may lead to timely linkage to care for patients with newly diagnosed HIV infection. Studies to confirm these observations are lacking.
Data Breakdown: Researchers from Seattle examined the impact of receiving partner services on timely linkage to care among more than 1,000 patients aged 15 and older with newly diagnosed HIV from 2010 to 2013. Partner services staff did not close cases until index cases were verified to be linked to care. Within 3 months, 92% of patients were linked to care, and 96% were linked to care within 1 year. Less than 2% did not have at least one CD4 count or HIV viral load reported as of September 2014.
Take Home Pearl: Identifying linkage to care as an explicit outcome for HIV partner services appears to improve the likelihood of timely linkage to care among patients with newly-diagnosed HIV infection.
Reporting of Sexual Risk Behaviors in Newly Diagnosed HIV
The Particulars: Men who have sex with men (MSM) who self-report participating in high-risk behaviors are an important target for HIV prevention interventions. Assessment of such reporting among MSM who are newly diagnosed with HIV may provide insights into the accuracy of self-reporting of high-risk behaviors.
Data Breakdown: For a study, patients at sexually transmitted infection clinics were asked about HIV-related risk behaviors when they were screened for HIV infection. Partner services interviews were provided to those diagnosed with HIV. Risk behaviors reported before testing and during partner services interviews were then compared. Among HIV-infected men who reported a male sex partner during partner services interviews, 23% did not report this behavior at the time of HIV testing. These patients were more likely to have at least one female sex partner when compared with those who did report having a male sex partner at the time of HIV testing. The proportion of patients with at least one HIV-infected partner was similar between groups.
Take Home Pearl: Nearly one-quarter of MSM who are newly diagnosed with HIV do not appear to accurately report risk behavior information at the time of HIV testing.
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