Tuesday, December 8, 2009
Starting Treatment & Patient-centred care
The question about when to start treatment has been a hotly-debated one, and over time, the target has been moving back-and-forth between lower and higher numbers of CD4s as a base for recommending the beginning of antiretroviral use. However, the decision remains a personal one that each individual must make in connection, and after discussion, with his or her healthcare provider. Gone are the days where one simply presents to a doctor with an illness and whatever is handed for treatment is taken without question. Patient-centred care is not only a valid buzzword but also a most necessary part of decision-making: When medications no longer have side effects, when food no longer needs to be taken, when housing and other necessities of life are fully assured, then there might be every reason to follow the doctor's advice without question, but still: You have a choice. Things must be carefully weighed and balanced, both medical considerations as well as personal ones, and the decision remains an individual one. If you need help making such a lifelong committment to treatment, you're not alone; there is support, and there are professonals to speak with who may be able to help with the reasoning process, and other important actions, as well. The take-home message is that one doesn't simply take a strong medical recommendation and follow it blindly without thinking about what it means. It has to be a balanced and thoughtful approach toward treatment. What do folks think about this?
Tuesday, December 1, 2009
World AIDS Day
Today is World AIDS Day. You may be hearing about funding cuts to HIV community based organizations in the Vancouver area today. How does this affect your health? Programs and services are needed for HIV-positive individuals as each year sees approximately 200-300 new HIV-positive results. What do you think of this? Share your thoughts on this.
Monday, November 23, 2009
HIV and Belly Fat
Belly fat is an issue for HIV-positive individuals (also known as lipodystrophy) and is a side effect of some HIV medications. As individuals age, they may also develop body fat especially with poor diet. Diet and exercise are increasingly important to reduce body fat. Some individuals have used alternative treatments to reduce fat levels. Tesamorelin is a new drug used for belly fat that has shown promising results so far. What have you been doing? Are you concerned about belly fat and what do you wish to know?
Thursday, November 12, 2009
Naturopathy and HIV
BCPWA Treatment Information Program has started up an HIV Complementary Care Clinic which runs every Wednesday evening. This is a partnership with the Boucher Institute of Naturopathic Medicine in which naturopath students provide treatments under the supervision of a naturopath. Some of the naturopathic treatments available include: acupuncture, vitamin & mineral supplementation, nutritional counseling, homeopathy and botanical medicine. Have you used such treatments and what has been your experience? Share with us.
Tuesday, November 3, 2009
Cancer and HIV - News
There was a recent journal article from Lancet reporting that both non AIDS related and AIDS related cancer can occur earlier for HIV-positive individuals with low CD4 counts - by as much as 20 years earlier! This is another argument for starting treatment earlier to get your CD4 counts high and viral load to undetectable. What do you think of this?
Tuesday, October 27, 2009
H1N1
We've been away for a while and now back. The big news of this fall season is H1N1 (or also called swine flu). Flu risk is highest from November to March and this year, we expect both regular flu and H1N1. People with chronic conditions, like HIV, are at greater risk & the H1N1 vaccine is now available. Ask your doctor if you should be vaccinated. Do you have any questions for us? What do you wish to know about H1N1 & we'll try our best to answer. Also, if you have experienced H1N1, let us know on here how you managed.
Thursday, July 23, 2009
2009 INT'L AIDS SOCIETY CONFERENCE - SOUTH AFRICA - FINAL DAY
Here is the final summary of some main events occurring in Capetown, South Africa, at the International AIDS Society’s 2009 5th Conference on HIV Pathogenesis, Treatment and Prevention. The Conference concludes on Wednesday, July 22nd.
Again, please remember that it is always difficult, and is a necessarily subjective process, to cull from various sources and limit the detail while offering such coverage.
Once more, the official sources for this information (as suggested by the Conference organizers) are:
- The Live Conference Blog
- News Releases
- Facebook
- twitter
- Clinical Care Options
- Rapporteur summaries
For more in-depth information on these and other subjects arising from this Conference, please visit: http://www.ias2009.org/
I HOPE THE MATERIAL, THIS WEEK, HAS BEEN OF INTEREST.
CANADA’S OWN STEPHEN LEWIS
(earlier this week)
Darunavir/ritonavir monotherapy does well
Two separate studies have shown that treatment with ritonavir-boosted darunavir (Prezista) monotherapy may be a viable option after a person has first suppressed their viral load to undetectable levels using conventional triple-drug HIV therapy.
The first of the studies (MONET) involved 256 patients in Europe. All had suppressed their viral load to below 50 copies/ml for at least six months using a combination of three drugs that included darunavir/ritonavir.
Half the patients were randomised to continue taking triple therapy, whereas treatment for the others consisted of darunavir/ritonavir only.
After a year equal proportions of patients (approximately 85%) maintained an undetectable viral load.
The second study (MONOI) was conducted in France and involved 225 patients. This also demonstrated the non-inferiority of darunavir/ritonavir monotherapy to standard three-drug treatment.
[I think this was reported on Wednesday – but this shows more detail, today.]
Boosted and unboosted atazanavir both effective
A two-year study has shown that atazanavir (Reyataz), regardless of whether it is boosted by ritonavir, is effective at suppressing viral load to undetectable levels when used as part of triple-drug antiretroviral therapy.
After 84 weeks of follow-up, 86% of those taking unboosted atazanavir had a viral load below 50 copies/ml, compared to 81% of those treated with the boosted version of the drug.
Gains in CD4 cell counts were comparable, but the research showed that individuals taking unboosted atazanavir were less likely to develop the side-effect hyperbilirubinaemia than those taking atazanavir/ritonavir (4% vs 10%). Furthermore, cholesterol fell in those taking the unboosted drug, but it increased in those treated with the ritonavir booster.
Aciclovir reduces risk of HIV disease progression and death
Twice-daily treatment with the anti-herpes drug aciclovir significantly reduced rates of HIV disease progression and death, a study has shown.
The study involved 3408 HIV-positive patients. They were randomised to take either twice-daily doses of aciclovir (400mg) or a placebo.
Patients taking the anti-herpes drug were 19% less likely to need to start HIV treatment, a finding that was of borderline significance. Moreover, they were significantly less likely to experience a fall in their CD4 cell count to below 200 cells/mm3.
Although treatment with the drug reduced the risk of HIV transmission to a negative partner by 17%, this finding was not significant.
Successful treatment for hepatitis C improves liver damage in co-infected patients
Individuals co-infected with HIV and hepatitis C who have a successful response to hepatitis C treatment with pegylated interferon and ribavirin experience an improvement in their liver fibrosis and, in some cases, cirrhosis, according to new research.
The study involved 294 patients. All had a liver biopsy and were assessed after 44 months after completion of hepatitis C therapy using FibroScan.
An improvement in fibrosis was observed in 36% of individuals who had a sustained response to this treatment. There were even cases of cirrhosis improving.
Statistical analysis showed that successful hepatitis C treatment was the only factor significantly associated with an improvement in fibrosis.
Anal cancer
US research has shown that new diagnoses of anal cancer in HIV-positive men are increasing.
The rate of anal cancer increased from 11 per 100,000 before HIV treatment became available in 1996, to 55 per 100,000 between 1996 and 2008.
An AIDS diagnosis and a low nadir CD4 cell count were significantly associated with the risk of developing the malignancy.
A second study showed that 53% of HIV-positive men with anal human papilloma virus were not infected with the strains of the virus most associated with a high risk of anal cancer.
This finding suggests than many HIV-positive individuals could benefit from receiving the new vaccines that offer a very high level of protection against the strain of human papilloma virus most associated with genital cancers.
Three ART Combinations Lower MTCT Rate During Breastfeeding to 1%
Author: Mark Mascolini
--------------------------------------------------------------------------------
22 July 2009
Three antiretroviral therapy (ART) combinations taken before and after delivery by women in Botswana all controlled viral replication in the women and kept mother-to-child transmission rates at 1% throughout breastfeeding—the lowest rate yet recorded during breastfeeding by HIV-infected women.
The study involved 730 HIV-positive women, 560 of them with a CD4 count above 199 cells/µL randomized to coformulated abacavir plus zidovudine plus lamivudine or to lopinavir/ritonavir plus coformulated zidovudine/lamivudine. The 170 women with a CD4 count below 200 cells/µL took nevirapine plus coformulated zidovudine/lamivudine.
HIV RNA suppression in women did not differ significantly between the two randomized arms at delivery (96% with abacavir versus 93% with lopinavir, P = 0.18) or throughout breastfeeding (92% versus 93%, P = 0.98). The nonrandomized nevirapine group also had high viral suppression rates at delivery (94%) and throughout breastfeeding (95%).
MTCT rates were low at delivery and during breastfeeding in all three treatment groups and did not differ significantly between the two randomized groups. Among women taking abacavir, 3 had infants infected in utero and 2 infected their infants during breastfeeding (1.8% total). Among women taking lopinavir, only 1 HIV transmission occurred, in utero (P = 0.53 versus the abacavir group). Among women taking nevirapine, 1 transmitted HIV in utero. The overall transmission rate was 1%.
Only 2% of women taking abacavir or lopinavri had treatment-limiting side effects, compared with 11% taking nevirapine. But the higher side-effect rate in the nevirapine group could reflect their more advanced HIV infection when the study began.
Overall, 71% of women breastfed for more than 5 months, but fewer than 1% continued beyond 6 months. Infant mortality was 2% in the abacavir group, 3% in the lopinavir group, and 4% in the nevirapine group.
Abstract WELBB101
IAS HALL
IAS HALL
Track B
Daily summary
22 July (Wednesday)
Today [Wednesday, July 22nd] was the last day of the conference and without doubt the most important one. The CIPRA HT 101 study was presented. This study demonstrated that starting patients on antiretroviral therapy while their CD4 is between 200 and 350 cells/mm3 both decreases mortality and the incidence of tuberculosis. This study ends the discussion on when to start antiretroviral therapy in the developing world, and should have a profound impact on antiretroviral policies around the globe. If you have to take 1 presentation from the whole meeting this should be the one. I have no doubts that you will see this study published in the New England Journal very soon. The main question now is how we implement these changes in recommendations for the initiation of antiretroviral therapy in a world in the middle of a huge economic recession.
VA Cohort: Nonsignificant Association of Abacavir Exposure With Acute MI, Further Reduced by Controlling for Chronic Kidney Disease
Posting Date: July 22, 2009
Retrospective cohort study
Summary of Key Conclusions:
Cumulative abacavir exposure associated with marginal nonstatistically significant increase in risk of acute myocardial infarction (AMI) and cerebrovascular accidents (CVA).
Association further attenuated by adjusting for presence of chronic kidney disease prior to therapy initiation or traditional cardiovascular risk factors
No association found between inclusion of abacavir in last regimen and AMI and CVA events.
Chronic kidney disease associated with significant increase in AMI and CVA
Abacavir use more common in patients with chronic kidney disease
- N = 19,424 patients enrolled
- Mean age at study entry: 46.2 (± 10.2) years
- Total patient follow-up: 76,376 patient-years
- Mean: 3.93 years/patient (range: 0-9)
- Antiretroviral exposure ≥ 30 days: 80%
- Mean antiretroviral therapy duration: 1.93 years (range: 0-8.64)
Substudy Finds No Antiretroviral Class Effect on Long-term Changes in Bone Mineral Density
Posting Date: July 22, 2009
Substudy of randomized SPAR trial
Summary of Key Conclusions:
No significant differences in changes in bone mineral density (BMD) through 144 weeks between patients assigned to a NRTI-sparing regimen or a PI-sparing regimen.
BMD declined during first 24-48 weeks after initiation of HAART, stabilized thereafter.
Investigators suggest that initial BMD decline possibly associated with delayed reversal of bone loss prior to HAART and/or may reflect a transient state between bone resorption and bone formation.
Low baseline CD4+ cell count significant predictor for early BMD loss at spine and hip.
For more detailed info (cut-and-paste):
http://www.clinicaloptions.com/hiv/conference%20coverage/cape%20town%202009.aspx
SUBMISSIONS / QUESTIONS: paulk@bcpwa.org / (604) 646-5309
Again, please remember that it is always difficult, and is a necessarily subjective process, to cull from various sources and limit the detail while offering such coverage.
Once more, the official sources for this information (as suggested by the Conference organizers) are:
- The Live Conference Blog
- News Releases
- Clinical Care Options
- Rapporteur summaries
For more in-depth information on these and other subjects arising from this Conference, please visit: http://www.ias2009.org/
I HOPE THE MATERIAL, THIS WEEK, HAS BEEN OF INTEREST.
CANADA’S OWN STEPHEN LEWIS
(earlier this week)
Darunavir/ritonavir monotherapy does well
Two separate studies have shown that treatment with ritonavir-boosted darunavir (Prezista) monotherapy may be a viable option after a person has first suppressed their viral load to undetectable levels using conventional triple-drug HIV therapy.
The first of the studies (MONET) involved 256 patients in Europe. All had suppressed their viral load to below 50 copies/ml for at least six months using a combination of three drugs that included darunavir/ritonavir.
Half the patients were randomised to continue taking triple therapy, whereas treatment for the others consisted of darunavir/ritonavir only.
After a year equal proportions of patients (approximately 85%) maintained an undetectable viral load.
The second study (MONOI) was conducted in France and involved 225 patients. This also demonstrated the non-inferiority of darunavir/ritonavir monotherapy to standard three-drug treatment.
[I think this was reported on Wednesday – but this shows more detail, today.]
Boosted and unboosted atazanavir both effective
A two-year study has shown that atazanavir (Reyataz), regardless of whether it is boosted by ritonavir, is effective at suppressing viral load to undetectable levels when used as part of triple-drug antiretroviral therapy.
After 84 weeks of follow-up, 86% of those taking unboosted atazanavir had a viral load below 50 copies/ml, compared to 81% of those treated with the boosted version of the drug.
Gains in CD4 cell counts were comparable, but the research showed that individuals taking unboosted atazanavir were less likely to develop the side-effect hyperbilirubinaemia than those taking atazanavir/ritonavir (4% vs 10%). Furthermore, cholesterol fell in those taking the unboosted drug, but it increased in those treated with the ritonavir booster.
Aciclovir reduces risk of HIV disease progression and death
Twice-daily treatment with the anti-herpes drug aciclovir significantly reduced rates of HIV disease progression and death, a study has shown.
The study involved 3408 HIV-positive patients. They were randomised to take either twice-daily doses of aciclovir (400mg) or a placebo.
Patients taking the anti-herpes drug were 19% less likely to need to start HIV treatment, a finding that was of borderline significance. Moreover, they were significantly less likely to experience a fall in their CD4 cell count to below 200 cells/mm3.
Although treatment with the drug reduced the risk of HIV transmission to a negative partner by 17%, this finding was not significant.
Successful treatment for hepatitis C improves liver damage in co-infected patients
Individuals co-infected with HIV and hepatitis C who have a successful response to hepatitis C treatment with pegylated interferon and ribavirin experience an improvement in their liver fibrosis and, in some cases, cirrhosis, according to new research.
The study involved 294 patients. All had a liver biopsy and were assessed after 44 months after completion of hepatitis C therapy using FibroScan.
An improvement in fibrosis was observed in 36% of individuals who had a sustained response to this treatment. There were even cases of cirrhosis improving.
Statistical analysis showed that successful hepatitis C treatment was the only factor significantly associated with an improvement in fibrosis.
Anal cancer
US research has shown that new diagnoses of anal cancer in HIV-positive men are increasing.
The rate of anal cancer increased from 11 per 100,000 before HIV treatment became available in 1996, to 55 per 100,000 between 1996 and 2008.
An AIDS diagnosis and a low nadir CD4 cell count were significantly associated with the risk of developing the malignancy.
A second study showed that 53% of HIV-positive men with anal human papilloma virus were not infected with the strains of the virus most associated with a high risk of anal cancer.
This finding suggests than many HIV-positive individuals could benefit from receiving the new vaccines that offer a very high level of protection against the strain of human papilloma virus most associated with genital cancers.
Three ART Combinations Lower MTCT Rate During Breastfeeding to 1%
Author: Mark Mascolini
--------------------------------------------------------------------------------
22 July 2009
Three antiretroviral therapy (ART) combinations taken before and after delivery by women in Botswana all controlled viral replication in the women and kept mother-to-child transmission rates at 1% throughout breastfeeding—the lowest rate yet recorded during breastfeeding by HIV-infected women.
The study involved 730 HIV-positive women, 560 of them with a CD4 count above 199 cells/µL randomized to coformulated abacavir plus zidovudine plus lamivudine or to lopinavir/ritonavir plus coformulated zidovudine/lamivudine. The 170 women with a CD4 count below 200 cells/µL took nevirapine plus coformulated zidovudine/lamivudine.
HIV RNA suppression in women did not differ significantly between the two randomized arms at delivery (96% with abacavir versus 93% with lopinavir, P = 0.18) or throughout breastfeeding (92% versus 93%, P = 0.98). The nonrandomized nevirapine group also had high viral suppression rates at delivery (94%) and throughout breastfeeding (95%).
MTCT rates were low at delivery and during breastfeeding in all three treatment groups and did not differ significantly between the two randomized groups. Among women taking abacavir, 3 had infants infected in utero and 2 infected their infants during breastfeeding (1.8% total). Among women taking lopinavir, only 1 HIV transmission occurred, in utero (P = 0.53 versus the abacavir group). Among women taking nevirapine, 1 transmitted HIV in utero. The overall transmission rate was 1%.
Only 2% of women taking abacavir or lopinavri had treatment-limiting side effects, compared with 11% taking nevirapine. But the higher side-effect rate in the nevirapine group could reflect their more advanced HIV infection when the study began.
Overall, 71% of women breastfed for more than 5 months, but fewer than 1% continued beyond 6 months. Infant mortality was 2% in the abacavir group, 3% in the lopinavir group, and 4% in the nevirapine group.
Abstract WELBB101
IAS HALL
IAS HALL
Track B
Daily summary
22 July (Wednesday)
Today [Wednesday, July 22nd] was the last day of the conference and without doubt the most important one. The CIPRA HT 101 study was presented. This study demonstrated that starting patients on antiretroviral therapy while their CD4 is between 200 and 350 cells/mm3 both decreases mortality and the incidence of tuberculosis. This study ends the discussion on when to start antiretroviral therapy in the developing world, and should have a profound impact on antiretroviral policies around the globe. If you have to take 1 presentation from the whole meeting this should be the one. I have no doubts that you will see this study published in the New England Journal very soon. The main question now is how we implement these changes in recommendations for the initiation of antiretroviral therapy in a world in the middle of a huge economic recession.
VA Cohort: Nonsignificant Association of Abacavir Exposure With Acute MI, Further Reduced by Controlling for Chronic Kidney Disease
Posting Date: July 22, 2009
Retrospective cohort study
Summary of Key Conclusions:
Cumulative abacavir exposure associated with marginal nonstatistically significant increase in risk of acute myocardial infarction (AMI) and cerebrovascular accidents (CVA).
Association further attenuated by adjusting for presence of chronic kidney disease prior to therapy initiation or traditional cardiovascular risk factors
No association found between inclusion of abacavir in last regimen and AMI and CVA events.
Chronic kidney disease associated with significant increase in AMI and CVA
Abacavir use more common in patients with chronic kidney disease
- N = 19,424 patients enrolled
- Mean age at study entry: 46.2 (± 10.2) years
- Total patient follow-up: 76,376 patient-years
- Mean: 3.93 years/patient (range: 0-9)
- Antiretroviral exposure ≥ 30 days: 80%
- Mean antiretroviral therapy duration: 1.93 years (range: 0-8.64)
Substudy Finds No Antiretroviral Class Effect on Long-term Changes in Bone Mineral Density
Posting Date: July 22, 2009
Substudy of randomized SPAR trial
Summary of Key Conclusions:
No significant differences in changes in bone mineral density (BMD) through 144 weeks between patients assigned to a NRTI-sparing regimen or a PI-sparing regimen.
BMD declined during first 24-48 weeks after initiation of HAART, stabilized thereafter.
Investigators suggest that initial BMD decline possibly associated with delayed reversal of bone loss prior to HAART and/or may reflect a transient state between bone resorption and bone formation.
Low baseline CD4+ cell count significant predictor for early BMD loss at spine and hip.
For more detailed info (cut-and-paste):
http://www.clinicaloptions.com/hiv/conference%20coverage/cape%20town%202009.aspx
SUBMISSIONS / QUESTIONS: paulk@bcpwa.org / (604) 646-5309
