Abstract
HIV
HIV/AIDS and the Risk for Lung Cancer
To assess whether AIDS-related immunodeficiency and pulmonary infection are independent causes of lung cancer, researchers compared a group of 68 members of the Swiss HIV Cohort Study who had lung cancer with controls. The results confirmed a strong link between smoking and lung cancer: 96.2% of individuals with lung cancer and 72.9% of the control population had ever smoked. But there was no statistically significant link between lung cancer and CD4+ cell count, use of combined antiretroviral therapy, or history of AIDS with or without pulmonary involvement. The authors did not find lung cancer risk to be significantly elevated among HIV-positive former smokers, but the numbers studied were small, and previous studies have suggested a link between HIV infection and the risk of lung cancer.
For example, a study presented at the 17th Conference on Retroviruses & Opportunistic Infections (San Francisco, February 16–19, 2010; Sigel K, et al. HIV infection is an independent risk factor for lung cancer) showed HIV to be an independent risk factor for lung cancer, regardless of smoking history. The data from this study demonstrated an 80% increased risk of lung cancer associated with HIV infection. Furthermore, the incidence rate ratio (IRR) of lung cancer associated with HIV infection remained significant after adjustment for smoking, age, race/ethnicity, and COPD.
Source: Clifford GM, Lise M, Franceschi S, et al. Lung cancer in the Swiss HIV Cohort Study: role of smoking, immunodeficiency and pulmonary infection. Br J Cancer 2012;106:447–452.
Success of Needle Exchange Programs
A comparison of needle disposal practices by intravenous drug users in two U.S. cities—one with (San Francisco, CA) a needle syringe program (NSP), and one without (Miami, FL) a NSP—revealed a more than eightfold greater number of improperly disposed of syringes on the streets of Miami. Walkthroughs of randomly selected drug-affected neighborhoods found 44 syringes in San Francisco and 371 syringes in Miami per 1,000 census blocks. Surveys of intravenous drug users in each city found that 13% of syringes were disposed of improperly during a 30-day period in San Francisco, compared to 95% improper syringe disposal in Miami.
Needle exchange programs are effective and cost saving. Commenting on these latest results, an article in the Miami Herald (Tasker F. Drug users' needles endanger public, study shows. January 13, 2012) cites a 2009 study published in the Journal of Urban Health, which reported that 12% of intravenous drug users in San Francisco were HIV-positive, compared to 23% in Miami-Dade. The article notes that Tom Liberti, chief of the Florida Department of Health HIV/AIDS Bureau, has said that he would support needle exchange programs on the grounds that they reduce disease.
Source: Tookes HE, Kral AH, Wenger LD, et al. A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs. Drug and Alcohol Dependence. 2011;
Perinatal HIV Transmission and Psychiatric Illness
Is there a link between the severity of perinatally acquired HIV and later psychiatric illness and cognitive development? Among 319 youths aged 6–17 years who are part of the International Maternal Pediatrics Adolescent AIDS Clinical Trials Group from the United States and Puerto Rico, there were statistical links between parameters indicative of more severe HIV disease and symptoms of severe conduct disorder, of severe and less severe depression, and of less severe attention-deficit/hyperactivity disorder inattention. In addition, older age at the time of nadir CD4 percentage correlated with lower quality of life, poorer social functioning, and lower scores on a Wechsler Intelligence Scale used to assess cognitive and academic performance. The data did not support an association between specific antiretroviral therapy and the severity of psychiatric symptoms.
Source: Nachman S, Chernoff M, Williams, P, et al. Human immunodeficiency virus disease severity, psychiatric symptoms, and functional outcomes in perinatally infected youth. Arch Pediatr Adolesc Med 2012; doi:10.1001/archpediatrics.2011.1785.
Delayed HIV Treatment Shortens Lives
With access to adequate health care and effective antiretroviral therapy, “the greatest risk of excess mortality [from HIV infection] is due to delays in HIV diagnosis,” concluded the authors of a study in which computer models were used to simulate HIV infection and the effects of ART, and to predict life expectancy. The basis of the computer model was a 30-year-old HIV-infected man who has sex with men (MSM) living in a developed country. If diagnosed early (median CD4 cell count at diagnosis 432 cells/μL), he had a projected life expectancy of 75.0 years, implying 7.0 years of life lost due to HIV. In contrast, in the setting of delayed diagnosis (median CD4 cell count at diagnosis 140 cells/μL), the predicted life expectancy dropped to 71.5 years, with 9.5 years of life lost attributed to HIV infection.
Source: Nakagawa F, Lodwick RK, Smith CJ, et al. Projected life expectancy of people with HIV according to timing of diagnosis. AIDS 2012;26:335–343.
Foregoing HIV Treatment Is All Too Common
In Mississippi, more than two-thirds of people who test positive for HIV do not get medical treatment, according to state Department of Health estimates. The most common reasons for failure to seek treatment for HIV are denial, risk of stigmatization, cost, and other challenges associated with access to care. Compared to the 3.7 national rate of deaths related to HIV per 100,000 population, the rate in Mississippi is 5.9. Women account for nearly a third of all HIV infections in the state. The fastest growing HIV-infected group is 15- to 29-year-olds. Lack of transportation, housing, Medicaid coverage, and coverage for prescription medications and mental health care are all obstacles to accessing care among economically disadvantaged HIV-infected persons.
Source: Mitchell J. Most with HIV skip treatment. Clarion Ledger, January 28, 2012.
Condom Use Increases After HIV Diagnosis
Interview with 129 HIV-infected men and women at an HIV clinic in Santiago, Dominican Republic, found that 72.4% of the participants had been sexually active since learning they were HIV-infected. The majority, 72.8% of the sexually active patients, reported more frequent condom use, and they were more likely to use a condom if they believed that their sexual partner did not have HIV than if they did not know the partner's HIV status. The results indicated that 21.7% of sexually active interviewees used condoms with the same frequency, and 5.4% used condoms less often. The choice not to use a condom after a positive HIV diagnosis was most often due to decreased sexual pleasure according to 70% of the men interviewed, whereas the most common reason among women (71.8%) was refusal to use a condom. Based on these findings, the authors suggested that increased HIV testing might lead to less risky sexual behavior in the Dominican Republic, where more than 1% of adults are HIV-infected and most infections are acquired sexually.
Source: Sears D, Cabrera C, Ortiz F, et al. Sexual risk behavior among HIV-positive patients at an urban clinic in Santiago, Dominican Republic. AIDS Care 2011;23:1637–1643.
Sexual Impulsivity Increased HIV Risk Among MSM
A constellation of psychosocial problems tend to co-occur and increase HIV risk among men who have sex with men (MSM). These include depression, intimate partner violence, and poly drug use. Based on survey data gathered from MSM, Parsons et al. concluded that sexual compulsivity is an additional component of this psychosocial syndrome and is positively related to HIV seropositivity and high-risk sexual behavior. The authors suggest that “HIV prevention interventions should consider the overlapping and compounding effects of psychosocial problems, including sexual compulsivity.”
Source; Parsons JT, Grov C, Golub SA. Sexual compulsivity, co-occurring psychosocial health prolems, and HIV risk among gay and bisexual men: further evidence of a syndemic. Am J Public Health 2012;102:156–162.
Protease Inhibitor Use and Sudden Death Risk
Despite concerns that the use of HIV protease inhibitors may affect cardiac conductivity, causing prolonged QT and PR interval durations, a recent study reports no significant association between current or recent exposure to protease inhibitors and either sudden death or nonhemorrhagic stroke. The authors did find that the risk of such an event increased as cumulative exposure to these agents increased and that this association remained significant after adjusting for potential confounding factors. This finding, they note, “is more consistent with our previously reported results indicating that PI exposure may lead to the development of ischemic coronary disease, which, in turn, may result in sudden death.” The study was not sufficiently powered to test for associations with specific protease inhibitors.
Source: Worm SW, Kamara DA, Reiss P, et al. Evaluation of HIV protease inhibitor use and the risk of sudden death or nonhemorrhagic stroke. J Infect Dis 2012;205:535–539.
Hepatitis Virus Infection
Combined Antiviral Therapy Shows Promise in Chronic HCV
Direct-acting antiviral agents given alone or in combination with conventional peginterferon and ribavirin therapy can lead to a sustained virologic response in patients with chronic hepatitis C virus (HCV) genotype 1 infection. A group of patients with chronic HCV who did not respond to conventional treatment received a combination of two antiviral agents—daclatasvir (60 mg once daily, an NS5A replication complex inhibitor) and asunaprevir (600 mg twice daily; an NS3 protease inhibitor) either alone or in combination with peginterferon and ribavirin for 24 weeks, as part of a phase 2a clinical trial. At 12 and 24 weeks after the end of treatment, 4 of 11 (36%) patients who received the antiviral drugs alone had a sustained virologic response; 10 of 10 (100%) patients taking all four drugs had a sustained virologic response at 12 weeks (and 9 of 10 at 24 weeks).
Source: Lok AS, Gardiner DF, Lawitz E, et al. Preliminary study of two antiviral agents for hepatitis C genotype 1. N Engl J Med 2012;366:216-224.
Viral Hepatitis Burden Rises in U.S.
Mortality data collected from the National Center for Health Statistics for the time period 1999–2007 show that recorded deaths from hepatitis C virus (HCV) in the United States increased significantly, while deaths from HIV declined. By 2007, HCV had surpassed HIV as a cause of death in the U.S. Deaths from HCV and hepatitis B virus (HBV) disproportionately affected middle-aged persons. HIV co-infection, alcohol-related conditions, chronic liver disease, and either HBV co-infection or HCV co-infection were associated with an increased risk of HCV- or HBV-related deaths, respectively. The New York Times (Bakalar N. Awareness: hepatitis C death rate creeps past AIDS, February 27, 2012) quotes Dr. John W. Ward, director of the division of Viral Hepatitis at the CDC as saying, “The declines in HIV reflect the accomplishments in building a public health response to the epidemic that improved screening and provided means of access to effective treatment.”
Source: Ly KN, Xing J, Klevens RM, et al. The increasing burden of mortality from viral hepatitis in the United States between 1999 and 2007. Ann Intern Med 2012;156:271–278.
Merck Warns of Drug Interactions
Boceprevir (Victrelis™, Merck, Whitehouse Station, NJ), an oral NS3/4A protease inhibitor indicated for the treatment of chronic HCV genotype 1 infection, is not indicated for use in patients with chronic HCV who also are HIV-infected, and if given in combination with ritonavir-boosted HIV protease inhibitors may lead to drug interactions that compromise the efficacy of both drugs. Merck reported the results of a pharmacokinetic study in healthy volunteers that assessed concomitant administration of boceprevir and ritonavir (Norvir®) in combination with atazanavir (Reyataz®) or darunavir (Prezista®), or of boceprevir with lopinvir/ritonavir (Kaletra®). According to the company, co-administration of boceprevir with ritonavir-boosted HIV protease inhibitors “resulted in reduced exposures of the HIV medicines and Victrelis.” These drug interactions may have clinical significance due to the reduced effectiveness of the medications.
Source: Merck press release: Merck Informs U.S. Physicians of Results of Drug Interaction Study of Co-Administration of VICTRELIS with Ritonavir-Boosted HIV Protease Inhibitors. February 8, 2012.