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Date of Report: 08/2006
Source: New England AETC
New England AETC (NEAETC) is a major supporter of the National Association of HIV Over Fifty (NAHOF). NEAETC consistently participates in NAHOF's educational events and curriculum planning, and has made care of the older HIV patients an additional focus of our agency. This selection is condensed from an article published in the journal.
The 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI) held in, February 2006 in Denver, Colorado attracted almost four thousand delegates representing more than 50 countries. While there were no specific presentations at CROI aimed at the Over 50 population, there were new data presented that have implications for aging with HIV disease.
Recent trials in antiretroviral-naïve patients were reviewed. One study compared boosted vs. unboosted atazanavir (Reyetaz). Atazanavir is being used as a first-line protease inhibitor that theoretically has less adverse effects on lipid metabolism.
However, ritonavir (Norvir), the coadministrated "booster," can have many deleterious metabolic effects. While there was no significant difference in the lowering of viral load between either group in this 48 week study, there was a trend toward the development of more viral resistance in the unboosted group. Moreover, when atazanavir is combined with tenofovir (Viread), it must be boosted. They concluded that unboosted atazanavir must be used cautiously.
Another panel reviewed planned treatment interruption, or intermittent treatment studies. Theoretically, this decreases both cost and side effects. In the Boston area, a study evaluating weekends off treatment (FOTO or five on two off) in selected patients has continued to show success. However, many other trials (week on, week off; 8 weeks on, 8 weeks off) have failed. The SMART (Strategies for Management of Antiretroviral Therapy) study, using CD4 cell guided interruption (when CD4 cells are over 350/mm3, resuming treatment when CD4 cells fall below 250/mm3) was stopped early because of continuing treatment failure with developing viral resistance. Treatment interruption is not recommended, unless it is part of a carefully followed protocol.
Further data from the large Data Collection on Adverse Effects of Anti-HIV Drugs (DAD) study, with over 23,000 participants, looks at all cardiovascular (CVD) risks. In this instance, baseline cardiovascular disease risk factors are as follows:
- Dyslipidemia
- Previous history of cardiovascular disease
- Diabetes
- Hypertension
- Previous stroke
- Obesity (Body Mass Index over 30)
- Lipodystrophy
- Family history of cardiovascular disease
- Smoker
With penalties for ex-smokers as well as current smokers, those who still smoke are doing much worse. It seems conclusive that HIV disease in itself is, in part, directly responsible for causing damage to the lining of blood vessels; and that protease inhibitor use is also a factor that increases risks of CVD. The take-home messages for those caring for patients Over 50 are:
- Keep the viral load under control.
- Use NNRTIs instead of PIs, boosted or not when possible.
- If on a PI, make sure to minimize controllable risk factors.
There was little new or optimistic news regarding managing insulin and the metabolic syndrome. Pathways are still unclear, obviously multifactorial, and have few successful treatments. Continuing study using drugs that regulate insulin, carbohydrate, fat metabolism, including metformin, pioglitazone and rosiglitazone are still inconclusive. Further concerns about the possibility of renal failure using tenofovir were voiced, and careful monitoring of renal function is a vital part of patient management. The continued increase in anal dysplasia was also noted, but still no clear guidelines for diagnosis or treatment exist.
NEAETC plans to participate in the next regional NAHOF update, in September, 2006.
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