New research was presented at CROI 2019, the annual Conference on Retroviruses and Opportunistic Infections, from March 4-7 in Seattle. The features below highlight some of the studies that emerged from the conference.
COPD & MI in PLWH
Prior research indicates that people living with HIV (PLWH) are at increased risk of chronic obstructive pulmonary disease (COPD) when compared with those without the infection, among whom COPD has been shown to be a risk factor for cardiovascular disease, including myocardial infarction (MI). However, few studies have assessed the relationship between COPD and MI in PLWH. To test the hypothesis that COPD is associated with increased risk of MI in PLWH, researchers analyzed data from more than 25,000 patients. The study team found that COPD was associated with significantly increased risk of MI, even after adjusting for smoking status. COPD was significantly associated with both type 1 (atherothrombotic coronary plaque rupture) and type 2 (supply-demand mismatch, as with sepsis) MI In unadjusted analysis but only type 2 MI in adjusted analyses, and this was only minimally attenuated by smoking status. This association was particularly notable for type 2 MI due to sepsis/bacteremia.
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Rates & Predictors of Syphylis in Women With HIV
Although women with HIV are considered to be high risk for sexually transmitted infection screening, rates and predictors of syphilis in this population are not well defined. To determine unique predictors of incident syphilis among a cohort of women living with HIV, study investigators examined data from the records of women with at least one HIV clinic visit between 2005 and 2016. Each year in care was analyzed separately, and more than one incident syphilis infection was allowed. Among the 4,219 women (88%) tested for syphilis, there were 7.6 cases per 1,000 person-years. In an unadjusted model, active drug abuse, prior intravenous drug abuse (IVDA), hepatitis C, HIV viral load >1,000 copies/mL, African-American race and later year of entry to care predicted incident syphilis. In an adjusted model, independent predictors were prior IVDA, HCV, later year of entry to care, and African-American race. Age and HIV viral load were not predictors.
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Improving Viral Suppression & Retention in Care
With the goal of comparing point-of-care (POC) viral load (VL) testing with standard laboratory VL testing for achieving VL suppression and retention in care for people living with HIV, researchers conducted an open-label, randomized controlled trial among adults (≥18 years) enrolled 6 months after ART initiation at an urban public clinic. Participants were randomized to POC VL testing and same-day counseling or standard-of-care (SOC) laboratory VL testing. All participants were followed for 12 months and received care that included clinic visits every 2 months, VL testing at month 6 and 12 after ART initiation, and consideration for decentralized ART delivery at community pharmacies 1 year after ART initiation. At 12 months, 89.7% of the POC group and 75.9% of the SOC group were retained with VL suppression, an increase of 13.9% among those who received POC VL testing compared with those who received laboratory VL testing. When disaggregated, POC VL testing increased VL suppression by from 83.1% to 93.3% and retention from 84.6% to 92.3%. During the study period, 99.5% of the POC group received same-day VL results, whereas 74.7% of the SOC group received results a median of 41 days after blood draw. The POC group had a 3.4-fold higher rate of entry into decentralized ART delivery.
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Access to Care, Depression &Viral Suppression
Data indicate that depression is among the most common, yet unaddressed, comorbidities among people living with HIV, with under-diagnosis and –treatment in this patient population contributing to negative health outcomes. While the collaborative care model (CCM) has been shown to help improve depression outcomes and comorbid medical outcomes in primary care, data are limited on its use in HIV care settings. For a study, the CCM— routine depression screening with the PHQ-9, measurement-based care, and care management for all patients scoring ≥10—was rolled out in an HIV clinic from June 2015 to June 2016. Among more than 1,400 patients screened for depression, nearly 600 reported moderate-to-severe symptoms at least once. When compared with those with a viral load documented in the year prior to the initial PHQ-9 score, those without reported more severe depressive symptoms. When compared with patients with Medicaid, uninsured patients had more severe depressive symptoms, whereas those with Medicare reported less severe symptoms. Patients in the CCM group who did not follow-up for re-measurement within 1 year were 65% less likely to achieve viral suppression at first PHQ-9 measurement when compared with those who never reported depressive symptoms.
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The Aging Ryan White HIV/AIDS Program Population
Data indicate that the population of people living with HIV (PLWH) who are aged 50 or older grew nearly 40% between 2011 and 2015, highlighting the need to identify and implement aging-appropriate HIV care and support services. With the Ryan White HIV/AIDS Program (RWHAP) supporting the care of more than 50% of PLWH in the US, researchers examined the sociodemographic characteristics, service utilization, and viral suppression (VS) of current RWHAP clients and projected the growth of the aging RWHAP population by 2030. Using client-level data from the RWHAP Services Report, they found that 44% of RWHAP patients in 2016 were aged 50 or older, up from 32% in 2010. When compared with younger patients, a higher proportion of older patients were Caucasian, lived above the poverty level, had stable housing, and accessed food-related services. In 2016, viral suppression rates were 90% in older patients and 81% in younger patients, with rates increasing across all subpopulations of older patients during the study period. The study authors project that 66% of RWHAP patients will be aged 50 or older by 2030.
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HIV & Overdose Among PWID
Prior research indicates that drug overdose-related mortality has been increasing in the US for the past decade, with people who inject drugs (PWID) with HIV at heightened overdose risk due to a higher burden of age-related comorbidities. With the context of drug use changing across the US in recent years, study investigators sought to characterize trends from 2014-2018 in fatal and non-fatal overdose and associations with HIV infection among a community-based cohort of PWID in a city with a long-standing opioid epidemic. During the first half of the study, the drug-related mortality rate was 6.2 per 1,000 person-years. When compared with HIV-negative PWID, PWID with HIV had a significantly higher risk of drug-related mortality (adjusted hazard ratio, 2.4), after adjusting for age, gender, and race. During the second half of the study, the rate of non-fatal overdoses for PWID was 28.5 per 100 person-years, with rates increasing significantly throughout the study.
