PRN has long supported efforts to prevent the devastating outcomes of anal cancer in people living with HIV (PLWH). Much progress has been made through the success of the ANCHOR Study which was ended ahead of schedule due to the indisputably favorable outcomes for people receiving treatment for pre-cancerous anal lesions. This confirmation of proactive efforts to destroy high-grade squamous intraepithelial lesions in and around the anus using high-resolution anoscopy emphasizes the role that we in HIV primary care must routinely incorporate into our care for all PLWH. In this program, Dr. Joel Palefsky, the principal investigator of the ANCHOR Study, will update us on the most recent guidelines for anal cancer prevention.
Cardiovascular disease is an ongoing problem in HIV management. We are pleased that Mabel Toribio is able to provide an update for cisgender and transgender men and women with or at risk for CVD.
Thanks to the benefits of antiretroviral therapy, we rarely see AIDS-defining cancers in people living with HIV. Yet as our patients age, they are at higher risk for other cancers and Dr. Keith Sigel will bring us up to date on screening, diagnosis, and treatment of non-AIDS-defining cancers in PLWH.
Is the experience of diagnosis and treatment of prostate cancer different in gay and bisexual men than it is in straight men? Dr. Channa Amarasekera, the director of the first Gay and Bisexual Men’s Urology Program in the country, thinks so. In this important presentation, you will learn about his efforts to improve the urologic care experience, outcomes and quality of life for cisgender men who identify as gay or bisexual. You will also appreciate how HIV infection influences prostate cancer screening and treatment.
We have known for a long time that the incidence of anal cancer associated with HPV infection is higher amongst people living with HIV. But now, with the results of the ANCHOR study, we know that identification of anal high-grade squamous intraepithelial lesions (HSIL) through high resolution anoscopy (HRA) followed by destruction of these pre-cancerous lesions has been proven to prevent progression to anal cancer. In this presentation, Joel Palefsky returns to PRN to share the exciting results of the ANCHOR study and its implications for a new standard of care in people living with HIV.
In addition to genetic testing that we can order for clinical purposes, our patients are increasingly turning to direct-to-consumer (DTC) genetic testing on their own, to explore their ancestry. But if one of these DTC tests also shows increased risk for cardiovascular disease (CVD), then your patient’s next likely stop will be with you to discuss the relative importance of this discovery. Are you ready for this? Dr. Wendy Post, an expert on CVD and HIV/AIDS, is also immersed in the study of the genetics of CVD. In this presentation, Dr. Post will review what is currently known about the genetic risks for CVD, and how lifestyle modification can influence the genetic risk for CVD. She will also review the strengths and limitations of polygenic risk scores for CVD and commercially available genetic testing.
We all know that some of our patients living with HIV may one day need a heart, liver or kidney transplant—but do all of our HIV positive patients know that they can be organ donors? In her comprehensive and up-to-date presentation, Sapna Mehta reviews the current studies evaluating outcomes of HIV positive organ use for HIV positive recipients. It’s time to spread the word.
Addressing Behavioral Health Needs During the COVID-19 Pandemic: Patients with HIV and the Health Care Team
The Covid-19 pandemic has caused much distress – not just for our patients, but for our fellow healthcare providers as well. But how can we differentiate mental distress from mental disorder? In this presentation, Dr. Francine Cournos will share findings from peer-reviewed literature pertaining to the behavioral health needs of patients with HIV and their health care providers alike. She will also share simple behavioral health strategies, including the World Health Organization Pyramid of Mental Health Services to the COVID-19 pandemic.
We all know that our patients living with HIV are at higher risk for atherosclerotic cardiovascular disease. But data on women has been lacking. In this presentation by Mabel Toribio, you will learn to describe mechanisms of heightened atherosclerotic cardiovascular disease among people living with HIV, along with prevention and treatment strategies. Dr. Toribio will be presenting her most current research, which includes under-represented populations – in particular, transgender and cisgender women.
The COVID 19 pandemic has complicated every aspect of medical care including the screening and prevention of anal cancer. Are there barriers to screening that are new? Do we need to be taking special precautions in the screening and care of our patients living with HIV and HPV in the face of the COVID pandemic? In this presentation, Joel Palefsky provides an update on the epidemiology of anal HPV infection, detection, and treatment of pre-cancerous lesions among people living with HIV, as well as an update on the ANCHOR study – all in the face of the COVID 19 pandemic.
As the incidence of HPV-associated cervical cancer is declining, the incidence of anal cancer is rising in women. But the dangers of HPV-associated dysplasia do not stop with the cervix and anus-- we must also be aware of the ways that dysplasia and cancer can present in women with vulvar and perianal complaints, and what we can do to stop it. Don’t miss this important review by Elizabeth Stier on screening, diagnosis and treatment of HPV-related disease in the entire female anogenital tract.
The incidence of HPV-associated anal cancer has increased every year for the past decade, and so has mortality, especially in our patients living with HIV. But questions remain about how to best screen people at risk, and how to prevent progression from high-grade precancerous lesions to anal cancer. This comprehensive lecture by Stephen Goldstone discusses the known risk factors, existing preventive and diagnostic strategies, the associated medical controversies, and the ongoing research needed to safeguard our patients’ health and quality of life
Are drug interactions still an HIV treatment issue in 2019? You bet they are, but how can we differentiate ARVs in terms of their mechanisms of action and interaction potential? And what commonly co-administered drugs, such as statins, psychotropics, proton pump inhibitors, steroids, and gender affirming hormones do we need to be on high-alert for? All this, plus interactions with recreational drugs, especially those used in chem-sex, are discussed. Don’t miss this important presentation by David Back, internationally recognized for his groundbreaking work in online interactive drug-drug interaction awareness. Your patients will thank you.
With the success of antiretroviral therapy, our patients are approaching near-normal life-expectancy. But we are also seeing a higher risk for end-organ disease in our aging HIV patients, and greater need for organ transplants. Even with the addition of HIV-positive organ donors, what is the wait time for recipients most in need? If the organ donor also has hepatitis C, can transplantation to an HCV-negative donor still be safe? And the outcomes-- how are HIV-positive recipients of liver, kidney, heart and lung transplants doing, as compared to the general population? For answers to these questions and much more about HIV-positive transplant recipients and donors, do not miss this exciting and informative program by Sapna Mehta.
Whether we are initiating antiretroviral therapy for HIV infection or pre-exposure prophylaxis to prevent it, we must not forget to screen for underlying kidney disease, and to establish baselines from which nephrotoxicity secondary to treatment can be detected and managed. This presentation by Christina Wyatt is packed with clinical pearls that will help you screen and evaluate kidney disease in your patients, including changes secondary to ARV toxicities and comorbid conditions such as diabetes and/or hypertension, strategies to maintain kidney health, as well as management of patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD).
You may not be seeing facial lipoatrophy or buffalo humps like we did in the early years of HAART, but body fat changes persist now, even with newer regimens. In this program, Todd Brown discusses the past and present body fat changes in the long-term management of HIV disease, the critical importance of lifestyle changes for the management of liopohypertrophy and obesity in HIV, the risk and benefits of pharmacologic approaches to treatment, and research strategies to guide treatment in the future.
Even with early initiation of combination antiretroviral therapy, there is still a gap in life expectancy between our HIV-positive and HIV-negative patients, and age-associated morbidities and multimorbidities are more common in people aging with HIV. Don’t miss this fascinating and clinically important presentation by Peter Hunt on the effects of immune activation in our patients aging with HIV, what life-style changes and anti-inflammatory drugs may be helpful, and research strategies targeting root causes of chronic inflammation that may help our patients age more normally with fewer complications in the future.
In the days before combination antiretroviral therapy, one of the most stigmatizing AIDS-defining complications of HIV disease was Kaposi Sarcoma (KS), caused by coinfection with Kaposi Sarcoma-associated Herpes Virus (KSHV), also known as Human Herpesvirus-8 (HHV-8). Thankfully, we see KS infrequently now, but still need to keep it in the back of our minds. KSHV infection is life-long, similar to other herpesviruses, and even though overall KSHV seroprevalence in the USA is less than 10%, it is much higher in HIV-negative MSM (20-30%) and even higher in HIV-positive MSM (30-60%). So what are the implications for these patient populations as they age? Don’t miss this important review by Susan Krown, a leader in KS diagnosis and treatment from the earliest days of the AIDS epidemic in NYC, who is still involved in the fight against KS internationally.
When anal cancer prevention efforts fail, or when initial physical exam and screening lead to the diagnosis of malignancy, what next? This presentation by Stephen Goldstone, a surgeon, and Peter Kozuck, an oncologist, will walk you through the typical and atypical presentations of anal cancer, standard approaches to therapy, post-treatment follow-up, and consequent morbidities that that your patients may face.
As a medical provider, you can have a powerful impact on the behavioral health of your patients living with HIV, but you need to know how to sort out what is required and what is optional, and utilize practical behavioral strategies to evaluate and manage depression, anxiety and stress. This presentation by Dr. Francine Cournos is packed with clinical pearls that will help you serve your patients mental health needs more effectively, while preserving your own sanity.
If we do not address mental health issues at the primary care level, we are very unlikely to be able to bring an end to the HIV epidemic. Mental health problems contribute not only to HIV acquisition, but also to poorer outcomes at every step in the HIV treatment cascade. Since people living with HIV disease have significantly higher rates of mental health disorders than that of the general population, in this program, Dr. Robert Remien focuses on strategies we can use to integrate mental health assessment and treatment into routine HIV care. Only then will we be able to achieve our “90-90-90” and “EtE” goals.
We all know that natural disasters disrupt healthcare services, and when they cause catastrophic levels of destruction to infrastructure, as in the case of hurricane Maria in Puerto Rico, the consequences can be overwhelming. But some services, like labor and delivery, simply cannot be interrupted or postponed. This presentation by Carmen Zorrilla underscores the urgency of keeping her high-risk obstetrical unit operational throughout this devastating event, and the consequent struggle to restore broader healthcare services in San Juan and throughout Puerto Rico in the aftermath of a hurricane.
There are many treatment options for chronic pain. But dealing with this common problem in clinical practice can be stressful due to patient expectations and the complex issues surrounding prescription opioid use and opioid use disorder. Hardly a day goes by that we don’t read something new in the papers about drug overdose and the opioid epidemic that is sweeping the country. So don’t miss this practical and helpful program on strategies for successful pain management, how to use tools such as urine testing to identify and treat opioid use disorder, and how to counsel patients on the risks of illicit drugs and the use of naloxone to prevent death from opioid overdose.
Resistance to antiretroviral therapy and virologic failure have been a challenge to optimal treatment of HIV throughout this epidemic. With the more potent and adherence-friendly regimens we have today, the treatment failures we used to see so often, are less frequent now, but no less important when they occur. We still need to be alert to the current risks for drug resistance, not just for our patients on chronic therapy for HIV, but also for our patients who seroconvert while failing PrEP. And that is why are pleased to present this important update on HIV drug resistance by one of the foremost experts in the field—Dan Kuritzkes.
Our patients living with HIV are at higher risk for HPV-related anal cancer, but when and how should we be screening them? At what age do we start? Is anal cytology enough, or are there other tests that could improve screening? Are inspection of perianal skin and digital rectal exams really necessary? What do we do with abnormal screening results? Does ablation of precancerous lesions really help, or do they just keep coming back in the same places? For answers to these and many other questions, don’t miss this important program.
The prevention and treatment of endocrine and metabolic diseases, such as diabetes, dyslipidemia, osteoporosis, and hypogonadism, will improve the health and quality of life of our patients living with HIV disease, and also attenuate aging-related declines in physical and cognitive function. Laboratory screening for metabolic problems and early treatment with medication and lifestyle modification can significantly decrease the risk of complications from cardiovascular disease and bone fracture in HIV-positive patients, resulting in a healthier aging process.
Yes we are all getting older, and older. And thanks to combination antiretroviral therapy, our patients living with HIV are getting older too. But what additional risks in aging do they face? And how do the risks of older people who have been on ART for years differ from people who become newly infected with HIV at an older age? This program helps us better understand and assess age-related syndromes, the risks for frailty, and ways to improve the care of our patients living with and growing older with HIV disease.
As clinicians traditionally involved in the treatment of HIV become increasingly involved in efforts to treat and cure hepatitis C, it is important that we all know about and are able to advocate for advances in harm reduction. Harm reduction, such as needle exchange, has already demonstrated the power of this approach in lowering the risk HIV transmission in people who inject drugs. Another successful harm reduction approach, taken in a number of other countries but yet to openly be practiced in the USA, is the establishment of medically supervised injection facilities in communities where public injection of illicit drugs, particularly opioids, is a problem. Supervised injection facilities have been shown to reduce overdose fatalities, improve linkage to care, and may also help reduce transmission of infectious diseases such as hepatitis C and HIV. Don’t miss this cutting-edge presentation from Dr. Sharon Stancliff, Director of the Harm Reduction Coalition.
Patients in all primary care practices have anorectal complaints, but when they do, are we asking the right questions, and are we doing an adequate physical exam? Too often, both patients and providers may prefer to skip the exam, which slows or prevents the diagnosis and treatment of common problems, some of which may be sexually transmissible or lead to cancer. Don’t miss this important update by Steve Goldstone on anorectal problems in HIV medicine, and what you can do to help.
Integrating Immunotherapy with the Standard-of-Care for HPV-related Head and Neck Cancer in HIV Patients
The major cause of throat cancer used to be environmental carcinogens, such as smoking, but now it is human papillomavirus (HPV) that is transmitted through orogenital sex. In fact, HPV-related cancer is the fastest growing cause of head and neck cancer in the general population. This risk is even greater in HIV-coinfected people, and antiretroviral therapy does not reduce the risk. Unlike anogenital cancer, we do not have screening cytology tests for early detection of throat cancer. The good news is that, even when diagnosed late, HPV-related cancers of the head and neck have a much more favorable prognosis than tobacco-related cancers have had in the past. This program will help acquaint you with the various types of immunotherapy that are increasingly being used in combination with standard-of-care chemoradiotherapy for HPV-related oropharyngeal cancer in HIV–positives.
Are you evaluating your patients for osteoporosis aggressively enough? Bone loss begins in early adulthood in both men and women, so it is important for clinicians to evaluate risk factors for bone loss in both genders. But HIV infection increases this risk, resulting in the significantly higher prevalence of fracture in HIV-positive men and women as they age. Fortunately, there are antiretroviral treatment strategies you can recoomend to reduce the impact on bone, and there are other treatments you can offer to improve bone health in your patients. Don’t miss this important update on evaluating bone health in your HIV-positive patients and steps you can take to help them avoid disabling fractures.
You are probably aware that iiver disease is the leading cause of non-AIDS-related death in our HIV-infected patients, but did you know that non-alcoholic fatty liver disease (NAFLD) is the most common liver abnormality in the absence of viral hepatitis? And that NAFLD is more common in HIV-positives than in HIV-negatives? This important program will help you recognize and stage NAFLD as part routine metabolic monitoring, and you will also learn about novel treatment strategies that in clinical trials, and treatments that may soon be available for your highest risk patients.
HIV is associated with persistent inflammation that can impact cardiovascular disease (CVD) risk directly or indirectly through multiple pathways, especially in our aging patients. And this risk may be further exacerbated in our postmenopausal patients. The SMART Study showed that viral suppression with uninterrupted antiretroviral therapy can reduce non-AIDS associated illness including CVD. But what else can be done? A lot; so don’t miss this important program on the multifaceted approach to reducing CVD risk, including information about the REPRIEVE Trial-- the first large-scale randomized clinical trial to test a strategy utilizing statin therapy for preventing heart disease in people living with HIV, and the Follow YOUR Heart Campaign that will assess the relationship between reproductive aging, immune activation, cardiovascular disease risk and risk reduction among HIV-infected women with reduced ovarian reserve.
There is a growing need for liver and kidney transplants in our HIV-positive patients, and wait-lists can be frustrating. But after passage of the HIV Organ Policy Equity (HOPE) Act, it is now possible to use HIV-positive organ donors for HIV-positive candidates in need of solid organ transplant. Christine Durand, from the HOPE in Action study team, and principal investigator of the first pilot study of HIV-to-HIV kidney and liver transplant at Johns Hopkins, is also leading a national consortium of more than 30 transplant centers in organizing efforts to study HIV-to-HIV transplant at sites across the country. Learn more about the management challenges for both recipients and donors in this important program.
35 Years of Looking at HIV/AIDS Through the Skin, and How To Diagnose and Treat Dermatological Manifestations of HIV Today
How often does a patient ask “Oh by the way can you take a look at something I noticed on my skin?” In primary care, skin complaints are common, and in HIV medicine, can be a sign of underlying coinfections and complications. With over 30 years of diagnosing and treating skin disorders in people living with HIV, Pat Hennessey has some important clinical tips for providers dealing with skin complaints in HIV medicine today.
Kidneys. We all need them, but both acute and chronic kidney disease and their associated adverse outcomes are more common in HIV-positive patients. How can we help prevent or reduce kidney disease in our patients through diet and better management of antiretroviral therapy and other drugs? When should we be referring our patients for kidney biopsy? And how can we improve options and outcomes for our patients who may need dialysis or transplant? Don’t miss this important update on the prevention and management of kidney disease by Dr. Christina Wyatt.
The risk for HPV-related anal cancer is much higher in our HIV-coinfected patients, despite the many advances in HIV antiretroviral therapy. If given, the HPV vaccines will help prevent anal cancer in our younger patients, but our older patients need help too. Anal cytology and treatment of high-grade squamous intraepithelial lesions (HSIL) may help, and the ANCHOR study, which is now enrolling, is designed to test this hypothesis. Don’t miss this important presentation by Joel Palefsky on ways that you can help your patients prevent this grave complication.
Older clinicians in our audience remember the horror of diagnosing and managing AIDS-defining CMV colitis and retinitis in the pre-HAART era, which have now become rare, thanks to the prevention of severe immune deficiency through early initiation of combination antiretroviral therapy for HIV. But severe complications of cytomegalovirus coinfection still happen in people with undiagnosed and/or untreated HIV/AIDS and we must forever be prepared to suspect, swiftly diagnose, and treat both HIV and the many manifestations of CMV in the setting of immune deficiency.
Since the beginning of the HAART era, and as our patients age with HIV disease, we are seeing more non-AIDS defining cancers (NDACs). In fact, HIV infection is associated with an increased risk for some NDACs. But there are some things we can do right now to prevent some of these cancers, including smoking cessation, hepatitis B vaccination, age-appropriate HPV vaccination, and treatment of hepatitis C. Join us for this important presentation on current challenges in the prevention, screening and treatment of NDACs in HIV-positives, with a special focus on lung cancer, prevention, and research.
From the horrors of AIDS we know so well from the not-so-distant past, aging while on treatment for HIV disease seems like a blessing. But are there surprises awaiting us in this journey? And are there ways that we can prevent complications and improve life expectancy in our patients as they continue to age? For a better understanding of the risks our patients face, and research that is underway to improve the aging process in HIV disease, don’t miss this important lecture by Peter Hunt.
With an estimated prevalence of up to 14% in HIV-infected patients, diabetes is a leading cause of cardiovascular disease, blindness, end-stage renal disease, amputations, and hospitalizations for our patients. Regular screening for diabetes is important, and extra diagnostic caution must be taken in people living with HIV. When diagnosed, changes in lifestyle are critical, and medical management requires individualization. This clinically oriented lecture focuses on therapeutic options including recently approved drugs from new classes of drugs for glycemic control, as well as treatment strategies for optimal management of diabetes and prevention of diabetic morbidities in HIV medicine.
HIV disease is likely associated with a 50% increased risk for cardiovascular disease, but independent HIV-related risk factors suggest that early and continuous antiretroviral therapy may reduce atherosclerotic cardiovascular disease risk in HIV, especially type 1 myocardial infarctions caused by atherosclerotic plaque rupture. In addition to the direct relation of HIV disease to atherosclerotic disease, questions about reported associations of certain antiretroviral drugs with myocardial infarctions, and the potential use of statins to decreased inflammation and promote plaque regression are discussed in this important program.
The recent outbreak of Ebola in West Africa and the fear it caused worldwide are a vivid reminder of reactions to the AIDS epidemic years ago. Both infections are of zoonotic origin, and capable of producing stigma, discrimination, fear and denial. In this program, Dr. El-Sadr discusses how lessons learned in the early years of the HIV epidemic, including community mobilization, human rights measures, workforce innovations, laboratory systems and outreach activities have contributed to a rational and science-based response to contain and control Ebola transmission.
Is testosterone replacement for hypogonadism overprescribed in the United States? Is it safe? The diagnosis of hypogonadism is not uncommon in aging HIV-infected men. So understanding the optimal screening recommendations as well as the potential risks and benefits of testosterone therapy, particularly in older men, is extremely important to their well-being. Join us for this important update by Todd Brown.
Awareness of drug-drug interactions between agents used to treat HIV, coinfections such as hepatitis C, and co-morbidities such cardiovascular, renal, respiratory and metabolic disease, has never been more important. And the risk of adverse interactions of polypharmacy will increase as our patients age and their problem lists get longer. This comprehensive view from David Back, known world-wide for his extensive work in drug interactions at the University of Liverpool, is a must for anybody caring for people living with HIV.
Who, among your HIV-positive patients, may be at higher risk for kidney disease? And what about your HIV-negative patients who have started or are thinking about PrEP? This program will help you recognize the limitations of current screening tests for kidney disease in your patients with and at risk for HIV disease, and understand the diagnosis and management of antiretroviral-associated nephrotoxicity.
Pulmonary complications of HIV are not what they used to be, but they are no less important. The rapidly progressive opportunistic lung infections that were seen so often in the pre-HAART era, are rare now that earlier treatment of HIV is standard. But non-AIDS-defining bacterial pneumonias, malignancy and pulmonary hypertension continue to be serious problems, and accelerated emphysema is a growing concern due to the high prevalence of smoking in HIV-positives. In this program Rob Kaner discusses all of these issues and will help you improve early diagnosis of emphysema and COPD, critical to improved management and quality of life, and when possible, referral to appropriate research studies.
In this lecture Dr Golstone discusses common complaints, workup, diagnosis, treatment and prevention of common anorectal problems in HIV medicine. If your patients ever complain about rectal pain or bleeding, do not forget to do cultures, a digital anorectal exam and if needed, anoscopy, or you may miss something important, something infectious, and something you can treat effectively in your office. To learn more about the skills you will need, as well as practical tips for preventing anorectal problems, please see this important and useful video presentation.
As clinicians caring for people living with HIV, we are already aware of the increased risk of sexual transmission of hepatitis C in HIV-positive MSM, but we may also care for people born between 1945-65, for people with a recent or past history of intravenous drug use, tattoos, piercings, or who had a medical procedure with anesthesia from a multidose vial. With new rapid tests for HCV that are easily performed at the point-of-care, and all-oral interferon-free treatments for hepatitis C that are more effective and better tolerated, the role of the primary care provider in diagnosing HCV has never been more important. In this presentation, Fabienne Laraque discusses the epidemiology of HCV in New York City, and resources that will help all primary-care clinicians improve diagnosis and linkage to care.
Human papillomavirus is, by far, the most common sexually transmitted disease, but in HIV medicine there is a higher risk for HPV-related complications. Why? In addition to high risk of oral and anogenital HPV infection through shared sexual behavioral risk, HIV reduces the immune response to HPV, and direct interactions between HIV and epithelial cells potentiate new HPV infection. So, both primary and secondary prevention efforts, as well as early diagnosis and treatment are critical to the long-term health of our patients with and at-risk for HIV and HPV coinfection. Learn more about the epidemiology, preventive vaccines, physical exam, laboratory assessment, and treatment of HPV-associated complications in this video of Joel Palefsky’s presentation to PRN.
Anal cancer secondary to human papillomavirus (HPV) is an increasing problem, especially in HIV-positive men and women, despite successful treatment of HIV. But just like cervical cancer, anal cancer can be prevented if providers caring for people living with HIV promote and master anal cancer screening and prevention techniques. Following the inaugural meeting of the newly-formed International Anal Neoplasia Society (IANS), Naomy Jay journeyed from San Francisco to New York to share clinical tips and insights with our PRN audience, and has declared 2014 to be “The Year of the Anus.” We are certain that you will find this video of her lecture both engaging and helpful in the care of your patients.
Fractures are likely to be a major source of morbidity in people aging with HIV disease. Although the etiology is multifactorial, initiation of antiretroviral therapy has been associated with clinically significant bone loss. When and how can we best screen our patients for primary and secondary causes of osteoporosis? If found, how can we best treat patients with osteopenia or osteoporosis? In this program, Todd Brown discusses the causes, workup, management, and prevention of complications secondary to osteoporosis in HIV disease.
Immune-mediated Mechanisms of Heightened Cardiovascular Disease Risk in HIV: Clinical Research and Clinical Implications
In aging HIV-positive population, the percentage of deaths due to non-AIDS-defining illness, including cardiovascular disease, is on the rise. And the risk of myocardial infarction is 1.5 to 2 times higher in HIV-positive patients on antiretroviral therapy than in uninfected people, but why? In this presentation Markella Zanni discusses a new paradigm for conceptualizing elevated MI risk in HIV-- the paradoxical state of immune suppression and activation in HIV disease resulting in increased atherogenicity, and potential future immune-modulatory therapeutic strategies to mitigate this risk.
Persistent low-level viremia, when HIV RNA is detectable but less than 1000 copies/mL on repeated measurements, has been associated with new drug-resistance mutations when compared to prior genotyping. Providers should consider repeating genotypic testing especially if the viral load rises to 500 copies/mL or higher, because early detection and appropriate regimen switches may prevent further accumulation of resistance mutations. In this program, Dan Kuritzkes discusses virologic suppresson, incomplete virologic responses, blips, persistent low-level viremia, virologic rebound, virologic failure, and how to use this information to optimize antiretroviral therapy.
Diabetes is common in HIV-infected populations, and prevalence is increasing. Early diagnosis and management of this complication can help prevent cardiovascular disease, blindness, end-stage renal disease, amputations, and hospitalizations. In this presentation Todd Brown discusses regular screening and diagnosis of diabetes HIV-positives, a step-wise approach to individualizing diabetes treatment, and lifestyle changes that can help prevent complications in this aging population.
Human papillomavirus (HPV) is the most common sexually transmitted infection and HPV-associated anal cancer is an increasing concern, especially for HIV-infected patients. Anal HPV infection and associated anal intraepithelial neoplasia (AIN) are highly prevalent in HIV-infected men and women. Due to this increased risk, screening programs for AIN in all HIV-infected individuals, and routine vaccination of HIV-infected patients 9-26 years of age, should be strongly considered. Further research is needed to expand our treatment and prevention options for this life-threatening complication.
With effective antiretroviral therapy, people with HIV are living longer and the burden of cancer in this population continues to increase. Malignancies are more common and occur earlier in HIV-positives than in the general population. The increased risk for both AIDS-defining and non-AIDS-defining cancers in HIV positive populations have clear implications for cancer prevention, screening and evidence-based therapies, yet patients with HIV and cancer have historically been under-represented on cancer clinical trials.
What are the risk factors for immune reconstitution inflammatory syndrome (IRIS) and how can you differentiate IRIS from other conditions that present in similar ways? In this program, David Boulware discusses clinical tips in the diagnosis of this important complication as well as its management and treatment.
Who, among your HIV-positive patients, may be at higher risk for kidney disease? And how can you identify them? This program will help you recognize the limitations of current screening tests for kidney disease and nephrotoxicity in HIV-infected individuals, and understand the diagnosis and management of antiretroviral-associated nephrotoxicity.
Are our patients with HIV disease more likely to develop heart disease than the general population? And if so, is it HIV that increases cardiovascular risk or the medications we use to treat HIV? In this program, Samir Gupta discusses these issues as well as interventions that may reduce the increased risk of cardiovascular disease that many of our patients face.
Skin problems are common in primary care, and in HIV medicine they can be especially challenging. With 30 years of experience caring for people with HIV and AIDS as both an internist and dermatologist, Pat Hennessey shares his library of images and extensive clinical insight regarding everything from Kaposi's sarcoma to itchy red bump disease.
Hypogonadism in HIV-positve men of all ages is a common problem, and the long-term management of hypogonadism is of special concern as men age. Todd Brown returns to PRN to speak on this important endocrine abnormality, and if you have male patients nearing or over the age of 50, you will find this especially interesting and useful.
Before the introduction of HAART, bowel disorders including KS, CMV, and diarrhea with wasting were more common, but understanding these complications can still be helpful, and even life-saving, if you recognize them. Don Kotler's knowledge and experience in the diagnosis and treatment of gastrointestinal disease from the very beginning of the HIV epidemic qualifies him to speak not only about the more common GI problems today, but also the less frequent complications we must consider, and never forget.
Clinicians managing HIV disease have long been aware of drug interactions that affect therapeutic levels or increase risk of toxicity. And now, the introduction of antiretroviral drugs for the treatment of hepatitis C, called directly acting agents (DAA), demands a similar awareness of potential drug interactions, especially when treating HIV and HCV coinfection. Charlie Flexner, well known for his work in HIV drug-drug interactions, returned to PRN to discuss this emerging therapeutic challenge.
A true leader in access to liver and kidney transplants for HIV-infected patients with end-stage liver and kidney disease, Michele Roland returns to PRN to discuss all that has been learned since she first spoke on this subject at PRN in 2000.
Hepatitis B coinfection should either be prevented through vaccination, or diagnosed and treated with HIV disease. Due to an increased risk for severe liver disease, drug resistance and hepatic flair in HIV-HBV coinfection, understanding the laboratory diagnosis and work-up for liver disease in our patients is essential. Marion Peters returns to PRN for an update on the diagnosis and co-management of these viral infections.
With increasing awareness of human papillomavirus (HPV) infection and its link to anal cancer, and the even greater risk for HIV-positive men and women, HPV prevention and treatment is an integral part of HIV medicine. Joel Palefsky returns to PRN to review what is known about anal neoplasia and preventing anal cancer.
The anorectal exam is a routine element of any comprehensive physical exam, but in the examination of MSM with or at risk for HIV disease, it is essential. In this lecture Steve Goldstone shows numerous photos of anorectal pathology and tells us what we can do about it.
The care of HIV-infected patients has become increasingly complex. Endocrine problems, such as osteoporosis and AI, have been frequently reported in the HAART era. Additional considerations may be required regarding the etiologies, diagnosis, and treatment compared with the general population. Further research is required to understand the intricacies of these problems in HIV-infected patients in order to provide optimal care.
Despite the marked benefits of highly active antiretroviral therapy (HAART), up to 70% of patients with HIV develop neurologic complications of the central or peripheral nervous system. Neurologic consequences of HIV can be divided into primary and secondary disorders. The primary neurologic complications include HIV dementia in adults, encephalopathy in children, HIV-associated (vacuolar) myelopathy, and distal peripheral polyneuropathy. Secondary disorders are due to opportunistic infections resulting from HIV immunosuppression. The focus of the presentation and this article is limited to complications in adults.
With the continued widespread use of combination antiretroviral therapy, the incidence of various neurological complications of HIV disease seems to be declining. However, some complications continue to have a serious impact on the lives of HIV-infected patients, and the diagnosis of these neurological complications has become even more complex in recent years. Adverse events, stemming from the long-term use of antiretroviral therapy, can lead to neurological complications. And as HIV-positive people continue to live longer because of antiretroviral therapy, the risk of neurological complications stemming from comorbidities increases. In his presentation to the Physicians' Research Network (PRN), Dr. Justin McArthur discusses some of the most common neurological complications in the setting of HIV, most notably HIV-associated dementia, neurological opportunistic infections, neoplasms and peripheral neuropathy.
For numerous HIV-infected patients, facial lipoatrophy has become a frustrating reality. While not typically life-threatening, it can lead to comorbidities and is one of the most stigmatizing complications of HIV. And because facial lipoatrophy is believed to be an adverse effect of antiretroviral therapy, it can significantly affect a patient’s “relationship” with his or her regimen, potentially resulting in poor adherence or termination of therapy altogether, even if the regimen is achieving a desired effect on viral load and CD4+ cell counts. Although the mechanism(s) by which lipoatrophy occur have not been concluded, progress is at hand. For example, a number of cosmetic modalities are being explored—and used—for the correction of facial lipoatrophy. For Dr. Jeffrey Roth, who has consulted with numerous HIV-infected patients dealing with lipoatrophy, the selection of the right product has been something of a difficult task and requires knowledge of the advantages and drawbacks of each approach.
Nearly all primary care providers in the United States, especially those with sizeable HIV practices, are aware of the very real dangers of crystal methamphetamine use. When it comes to methamphetamine and HIV, there are potentially multiple levels of interaction. First and foremost is the increased risk of acquiring HIV and other sexually-transmitted infections. Various research teams have documented that, when crystal meth is used in association with sexual activity, condoms are more likely to be abandoned, numerous sex partners are more likely to be had, and trauma to the lining of the anus and/or vagina is more likely to be experienced. In his presentation to the Physicians' Research Network, Dr. Scott Letendre of the University of California, San Diego, discusses significant research involving the effects of methamphetamine on central nervous system function in HIV-positive people.
The impact that HIV has on the pathogenesis of tuberculosis (TB) is clear. It is one of the most important risk factors associated with an increased risk of latent TB infection progressing to active TB disease. HIV-infected people have an annual risk of 5% to 15% of developing active TB once infected. TB is the most common opportunistic infection in people living with HIV worldwide. It is also the most common cause of death in HIV-positive adults living in developing countries, despite being a preventable and treatable disease. This paper describes the global epidemiology of TB and HIV coinfection with an emphasis on its relevance to New York City’s large immigrant population, followed by diagnosis and treatment challenges in these patients.
Rates of depression and other psychiatric disorders are elevated in HIV-positive patients. Various studies have demonstrated high rates of depression in patients chronically infected with the hepatitis C virus. Substance abuse can cause depressive symptoms. Evidence exists for the efficacious treatment of depression. The risk of clinically significant drug interactions is outweighed by the risk of underdiagnosed and undertreated depression in HIV patients.
An integrated approach to healthcare is needed when dealing with injection drug users. Clinicians can help reduce the risk of blood-borne viruses and soft-tissue infections by prescribing clean needles and educating users about safer injection methods. Other treatments include overdose prevention, medication therapies, methadone maintenance and buprenorphine therapy. Patient education and dialogue are important components to treatment
Endocrine abnormalities—specifically testosterone deficiency—are nothing new among HIV-positive patients. Their significance came to light in the earlier days of the AIDS epidemic, particularly as a leading contributor to AIDS-related weight loss and wasting syndrome. While these complications are much less common today, thanks to the restorative benefits of antiretroviral therapy, androgen deficiency is still an issue that many HIV-positive individuals continue to grapple with. Fortunately, there have been a number of studies reported in recent years evaluating the safety and effectiveness of androgen replacement therapy in both men and women. Dr. Steven Grinspoon has played no small role in many of these studies, and thus was considered to be the ideal candidate to address the Physicians’ Research Network in NYC.
The etiology and pathogenesis of antiretroviral therapy-associated morphologic complications—most notably loss of subcutaneous fat and truncal obesity—remain something of a mystery. However, research continues to move forward. To bring PRN members up to date on the various work that is being done to better understand and manage the fat redistribution that is synonymous with HIV-associated with lipoatrophy, Dr. Donald Kotler took the podium at PRN to review some of the newest, most important data that will likely guide clinical research in this arena in the months and years to come.
Restorative Treatment for HIV-Associated Lipoatrophy: A Report from the 6th International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV
Lipodystrophy, which is peripheral lipoatrophy with or without central fat accumulation, is a side effect of HIV and antiretroviral therapy. Several presentations focused on restorative modalities for lipoatrophy at the 6th International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV. This article reviews poly-L-lactic acid (Sculptra), polyalkylimide (Bio-Alcamid), polymethylmethacrylate (PMMA), and autologous fat transfer (ATF).
Resistance of HIV to antiretroviral drugs is one of the most common causes for therapeutic failure in people infected with HIV. Sadly, the emergence of drug-resistant HIV variants is a common occurrence—even under the best of circumstances—given that no antiretroviral drug combination studied as of yet is completely effective in shutting down viral replication. And there is no shortage of data indicating that the emergence of HIV drug resistance is clearly associated with adverse treatment outcomes.
Fortunately, the availability of drug-resistance testing has improved the ability of clinicians to deal knowledgeably with HIV drug resistance head on. On the research front, drug-resistance testing has enabled investigators to more effectively develop and study both novel and older therapeutics for the sake of tailoring treatment for patients with varying resistance profiles. In this respect, therapy can now be individualized, based on our evolving knowledge of drug resistance, drug-resistance testing, and state-of-the-art treatment approaches.
Significant amounts of data presented at scientific conferences have shed additional light on the mechanisms and clinical significance of antiretroviral drug resistance. These include new reports from studies evaluating the incidence and lingering consequences of transmitted drug-resistant HIV, the significance of the K65R mutation in reverse transcriptase, the persistence of minor HIV variants harboring drug-resistance mutations, the selection of TAM pathways, as well as some heartening data indicating that lamivudine retains some activity against HIV carrying the M184V mutation.
For clinicians involved in the management of HIV-infected individuals, human papillomavirus (HPV) coinfection and its sinister sequelae--squamous intraepithelial lesions and invasive cervical or anal carcinoma--are proving to be a significant challenge. This article reviews the epidemiology, pathogenesis, diagnosis, monitoring, and management of cervical and anal dysplasia in the setting of HIV. “Data continue to emerge, supporting the diagnosis and management of cervical and anal dysplasia in HIV-infected patients,” said Dr. Joel Palefsky, who returned to PRN to discuss recent advances in the study and clinical care of HIV/HPV coinfection.
Dr. Marshall Glesby discusses the potential long-term adverse effects of HIV infection and its therapies, including the risk of cardiovascular disease. There have been high rates of metabolic and morphologic abnormalities seen in HIV-infected individuals taking antiretroviral therapy. However, there is confusion about whether or not the high prevalence of cardiovascular disease risk factors has actually resulted in a higher incidence of acute cardiovascular events, particularly myocardial infarctions and strokes. Dr. Glesby reviews the cardiovascular disease risk factors in HIV-infected patients, epidemiology of coronary heart disease and subclinical atherosclerosis, monitoring and management of cardiovascular risk factors, as well as the increased long-term risk of atherosclerosis.
Illicit opioid addiction, which is no stranger to the HIV-infected population, is a complex illness, with relapses possible even after long periods of abstinence. With the passage of the Drug Addiction Treatment Act of 2000 and the recent approval of buprenorphine for the treatment of opioid addiction, primary care clinicians now have the ability to closely follow and treat their opioid-addicted patients.
Smallpox, which is believed to have originated over 3,000 years ago in India or Egypt, is one of the most devastating diseases known to humanity. For centuries, repeated smallpox epidemics swept across continents, decimating populations in their wake. The disease, for which no effective treatment was ever developed, killed as many as 30% of those infected. Between 65% and 80% of survivors were marked with deep-pitted pockmarks, most prominent on the face. Blindness was another complication. In 18th century Europe, a third of all reported cases of blindness were because of smallpox.
Mitochondrial toxicity has been associated with the use of NRTIs. Dr. Hélène Côté and her colleagues at the Vancouver B.C. Centre for Excellence in HIV/AIDS use a validated quantitative mitochondrial DNA assay to study the link between antiretroviral treatment and mitochondrial damage. Researchers use venous lactate measurements to study the relationship between hyperlactatemia and mitochondrial toxicity. Physicians may want to consider using routine venous lactate determinations in the monitoring of patients on NRTI-containing antiretroviral therapy.
Lymphomas have long been some of the most devastating and complex opportunistic diseases of HIV infection. Their epidemiologies, both before and after the widespread use of HAART, have not been fully elucidated, and their various treatments, both in the setting of underlying immune suppression and used concurrently with antiretroviral therapy, have not been officially standardized. As for their etiologies and pathogeneses, there is still much to understand, including the role of Kaposi's sarcoma-associated herpesvirus (KSHV/HHV-8) and the Epstein-Barr virus (EBV) in the transformation of B-cells into lymphomas in the setting of HIV disease. But this much is clear: Lymphomas remain the most lethal complications of HIV disease (Chaisson, 1998). Yet it is also true that the incidence of HIV-related lymphoma has decreased in recent years. What’s more, the immune recovery associated with antiretroviral treatment has enabled many more patients to better tolerate chemotherapy and to live longer, healthier, and cancer-free lives after receiving what is potentially a grim diagnosis.
Sexually transmitted diseases (STDs) are among the most common infectious diseases in the United States today, affecting more than 13 million men and women in this country each year. This article reviews six common STDs—genital herpes, syphilis, gonorrhea, chlamydia, trichomoniasis, and bacterial vaginosis—that can be considered in broad groups according to whether their major initial manifestations are 1) genital sores; 2) urethritis or cervicitis; and 3) vaginal discharge. The diagnostic and treatment recommendations, unless otherwise noted, reflect those specified by the CDC in the 2002 update.
In the United States, it is estimated that 30% of the 800,000 people living with HIV are coinfected with the hepatitis C virus (HCV). Similar rates have been documented in Western Europe, although the actual number of HIV-infected individuals in some countries is not well defined. The magnitude and potential ramifications of HIV/HCV-coinfection is even more alarming in Spain, where Dr. Vincent Soriano suggested that at least half of the 130,000 HIV-positive people in the country are coinfected with HCV (Soriano, 2000). In turn, Spain has become a hotbed for coinfection research and has yielded studies that have helped to address some of the most important questions regarding follow up and treatment facing clinicians today.
Perhaps the greatest advance in the area of AIDS-related malignancies has been the identification of human herpesvirus-8 (HHV-8), also known as Kaposi’s sarcoma-associated herpesvirus (KSHV). Since its discovery by Drs. Yuan Chang and Patrick Moore and their colleagues almost eight years ago, KSHV has been identified in virtually all AIDS- and non-AIDS-related KS lesions. At the same time, several research teams have identified the virus in a subset of other less common pathologic conditions, including primary effusion lymphomas (PEL) and multicentric Castleman’s disease (MCD). But while a definitive link exists between KSHV and these specific malignancies, the precise role that it plays in their development is just now coming into focus.
Tuberculosis (TB) is one of the most dreaded diseases that afflict mankind, yet over 50 years after effective drug treatment was introduced, more people died of TB last year than in recorded history—2 to 3 million deaths, or 1 death every 10 seconds. New recommendations including more aggressive screening and early treatment approaches, particularly among those at the greatest risk for TB: persons living with HIV and AIDS. This discussion of HIV and TB coinfection by Dr Wafaa El-Sadr includes treatment recommendations, drug-drug interactions and paradoxical response to treatment caused by immune restoration inflammatory syndrome.
The success of highly active antiretroviral therapy (HAART) can easily be gauged by the fact that fewer patients are dying of AIDS-related manifestations than ever before. However, there has been a relatively sharp increase in the number of deaths from other complications, including end-stage organ disease. For patients with end-stage liver and kidney disease—not to mention patients with end-stage lung and heart disease—transplantation may be the only option.
The neurological complications of HIV disease most commonly seen are peripheral neuropathy, HIV-associated dementia (HAD), and AIDS-associated myelopathy. This review by Susan Morgello, Alessandro Di Rocco and David Simpson, discusses the clinical diagnosis and management of these debilitating comorbidities of HIV disease.
Skin disorders are more common and more aggressive in HIV disease. Dr. Jeffrey Roth discusses the diagnosis and treatment of warts, molluscum, seborrhea, scabies, herpes, Staphylococcus aureus, Kaposi's Sarcoma and bacillary angiomatosis in the setting of HIV and AIDS.