HIV and Comorbid Conditions: Guidelines Going Unheeded

With the advent of effective antiretroviral therapies (ART), the prognosis for patients infected with the virus has expanded exponentially, and many individuals can now expect to live a normal lifespan. However, this longer lifespan and, in some instances, the virus itself, increases the risk of developing non-AIDS conditions such as heart disease, liver disease, cancer, and neurocognitive impairments.¹

Coupled with the effects of the infection on the immune system, aging HIV-infected individuals could have a higher disease burden than their non-infected peers. Other concomitant conditions often related to lifestyle, such as alcoholism or co-infection with viral hepatitis, can also affect ART outcomes and increase the risk of adverse effects.

Although there are no specific guidelines on managing non-AIDS related conditions in HIV-infected patients, international guidelines from the Department of Health and Human Services do recommend assessing comorbidities as part of numerous other factors prior to beginning ART treatment.¹

The authors note that this is particularly important in older patients, who are more likely to have comorbidities that can complicate treatment, while HIV treatment or the virus may negatively impact those comorbid conditions. For instance, one criterion for selecting an ART regimen is the presence of comorbid conditions such as cardiovascular disease (CVD), chemical dependency, liver disease, psychiatric disease, renal disease, or tuberculosis (TB).

However, the guidelines also note that the benefits of ART generally outweigh the risks. Some comorbid conditions such as CVD, anemia, and renal impairment may be more likely in untreated individuals.

The guidelines also recommend monitoring for patients before and after beginning ART, including tests for hepatitis, basic chemistry and liver panels, a complete blood count with differential, a fasting lipid profile, a fasting glucose, and urinalysis. The reasons for this are many, including contraindications for certain drugs in patients with certain conditions or who taking medications for comorbid conditions such as dyslipidemia.

A study recently published in the Journal of Acquired Immune Deficiency Syndromes, however, found low adherence rates for such testing prior to ART initiation.

Poor Follow-Through in Primary Care

The researchers audited medical records of 500 patients with a median CD4 count of 270 cells/mm³ at 4 sites in Australia. Participants were a mean 3.1 years from diagnosis to ART initiation. Fifty-four physicians provided treatment. The researchers found a high adherence to guideline recommendations for when to start ART (87.6% patients) and forstarting preferred or alternative drugs (88.7%). However, ART was initiated in most patients while hospitalized or via a clinical trial, with hospitals more likely to use preferred regimens than primary care sites (76.8% vs 62%, P=0.0002).

One of the few studies to evaluate adherence to guidelines for ART initiation in a clinical setting found an adherence rate of just of 53%, while another evaluating the correlation between physician specialty and  guideline adherence found poorer adherence among generalists and physicians with less HIV/AIDS experience (57%) than among infectious disease (ID) specialists (88%).^2,3

The Australian study found significant disparities in adherence to comorbid disease assessment. No primary care physicians tested patients for TB. Just 22% did a urinalysis; 48.8% assessed fasting cholesterol, and 52.4% obtained a fasting glucose. Fewer than 45% screened for cytomegalovirus, toxoplasmic IgG, or hepatitis A. Only half of primary care physicians had even recorded a blood pressure.

Overall, mean adherence to comorbid disease parameters was 58.6%, with a miniscule 1.6% of patients receiving all 11 recommended assessments. As might be expected, adherence was greatest for patients enrolled in clinical trials or after an AIDS diagnosis.

Since 2008, when the audit was conducted, the authors note that we have become more aware of HIV-related comorbidities. Nonetheless, the article provides a reminder to primary care clinicians regarding the importance of assessing for these conditions prior to beginning ART, and continuing to monitor them as treatment progresses.

New Guidelines for Hepatitis C Virus Testing

Primary care physicians received a wake-up call last month when the Centers for Disease Control and Prevention recommended testing for the hepatitis C virus (HCV) in all baby boomers (those born between 1946 and 1964), of whom the HIV infected are only a fraction. The recommendation is at least partly due to the approval of new therapies that can eradicate the virus in up to 75% of those infected, avoiding the liver disease and cancer that may occur with long-term infection.

Currently, an estimated 2 million Baby Boomers are infected. The CDC estimates that widespread testing could identify more than 800,000 other infected individuals, saving more than 120,000 lives.

Besides HIV-infected individuals, those at highest risk include:

•  Current or former injection drug users, even those who injected only once many years ago
•  Recipients of clotting factor concentrates made before 1987, when more advanced methods for manufacturing those products were developed
•  Recipients of blood transfusions or solid organ transplants before July 1992, when better testing of blood donors became available
•  Chronic hemodialysis patients
•  Persons with known exposures to HCV, such as health care workers after needlesticks involving HCV-positive blood
•  Recipients of blood or organs from a donor who tested HCV-positive
•  Children born to HCV-positive mothers