2012 International AIDS Congress: Messages for Primary Care Physicians

With more than 20,000 delegates from nearly 200 countries and upwards of 10,000 abstract submissions (3,600 of which were presented), the International AIDS Congress, which just wrapped up its first US appearance in more than 20 years, is huge. There’s no way to highlight everything of interest in one brief article.

Instead, we enlisted Antonio E. Urbina, MD, the associate medical director at the Center for Comprehensive Care at St. Luke’s Roosevelt Hospital in New York City, for his thoughts on the key takeaways for primary care physicians.

The overriding theme: The effects of HIV beyond the immune system. In particular, there is a growing understanding that HIV accelerates aging, even in patients who are perfectly controlled on antiretroviral therapy (ART). This occurs because the virus infiltrates the genome, Dr. Urbina explained, triggering the release of inflammatory cytokines that “grind down and wear down on end organs,” particularly the brain, heart, lungs, and kidneys.

“I think we saw data to show that HIV causes an increase in these inflammatory markers and that this leads to more non-AIDS comorbidities,” he said.

For instance, one study found that HIV-positive patients had a higher risk of ischemic stroke at a far younger age (on average, 15 years younger) than uninfected individuals. The authors suggest that the infection itself may increase the risk of stroke, regardless of traditional risk factors. Overall, researchers found the incidence of stroke in HIV patients had risen from 0.09% in 1997 to 0.15% in 2006, with an incidence of 5.27 per 1000 patient-years in infected individuals versus 3.75 per 1000 patient-years for those who are HIV negative.¹

Confounding clinicians’ ability to identify patients at high risk of stroke is the fact that the only two traditional risk factors for stroke in the study population were smoking and atrial fibrillation, with systolic blood pressure significantly lower in the HIV-infected cohort.

Traditional risk factors for cardiovascular disease, such as obesity, also seem to have a greater impact in people with HIV. A report from the Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy (SUN) found that obese individuals with HIV and a viral load less than 400 copies/ml exhibited higher levels of inflammatory and atherosclerotic markers, including significantly greater carotid artery intima-media thickness, than a similar, normal-weight, HIV-infected cohort.²

This is particularly concerning given the increasing rates of obesity seen in HIV-infected patients, said Dr. Urbina. For instance, since enrollment in the SUN study began in 2004, a third of the 700 HIV-infected patients have gone from normal weight to overweight, and 25 percent from overweight to obese. Another longitudinal study of 1682 patients with HIV, just 2% of whom were underweight at diagnosis and 46% of whom were overweight or obese, found that 62% gained weight after diagnosis. The gain was unrelated to ART therapy. Indeed, there is some evidence that weight gain may negatively impact response to ART.^3,4 

“We need to be more aggressive in managing these risk factors in people with HIV because estimates are that the virus accelerates aging by 10 to 15 years, and we need to start intervening with preventive strategies earlier,” Dr. Urbina noted.

One option is daily aspirin therapy. A study presented at the Congress found that a daily aspirin reduced markers of immune activation in as little as one week in HIV-positive patients.⁵ This highlights the importance for HIV-positive patients of following the US Preventive Services Task Force’s recommendation for daily aspirin in all men 49 to 79, and all women 55 and older.

Another study found that early initiation of ART therapy reduced immune activation markers within 48 weeks, possibly slowing the accelerated aging effects of the virus, he said.⁶

 “There is just more and more data to support that the longer one goes with untreated HIV, the more even after they start on therapy and get viral suppression, to experience more downstream complications, particularly for non-AIDS events,” Dr. Urbina added.

However, another study presented at the meeting pained a bleak picture of screening, treatment initiation, and viral suppression in the United States:⁷

• 18 percent of infected persons were unaware that they have HIV infection
• 67 percent of all infected persons were not receiving antiretroviral therapy
• 75 percent of all infected persons did not have suppressed HIV-1 RNA

Meanwhile, an analysis of data of 90 newly diagnosed individuals in Durham County, NC, also presented during the meeting, found that although most had been seen by a healthcare provider at least once in the 12 months prior to their diagnosis, just 10% of women and a third of men were diagnosed during that first visit.

The authors concluded that “despite recommendations for widespread testing, HIV diagnosis remains frustratingly delayed, even among those with frequent healthcare system interactions.”⁸

References:

References

1. Nigo N, et al. Stroke in human immunodeficiency virus (HIV) infected patients. Paper presented at: XIX International AIDS Conference; 2012; Washington, DC.

2. Conley L, et al. Obese HIV-positive persons have higher levels of select inflammatory markers and co-morbid illnesses. Paper presented at: XIX International AIDS Conference; 2012; Washington, DC.

3. Crum-Cianflone N, Roediger MP, Eberly L, et al. Increasing rates of obesity among HIV-infected persons during the HIV epidemic. PLoS One. 2010;5(4):e10106.

4. Crum-Cianflone NF, Roediger M, Eberly LE, et al. Obesity among HIV-infected persons: impact of weight on CD4 cell count. AIDS. 2010;24(7):1069-1072.5. O'Brien M, et al. Increased platelet activity and immune activation in HIV-positive subjects on antiretroviral therapy is attenuated with low-dose aspirin. Paper presented at: XIX International AIDS Conference; 2012; Washington, DC.

6. Markowitz M, et al. Very early initiation of combination antiviral therapy results in normal levels of markers of immune activation. Paper presented at: XIX International AIDS Conference; 2012; Washington, DC.

7. Hall HI, et al. Continuum of HIV care: differences in care and treatment by sex and race/ethnicity in the United States. Paper presented at: XIX International AIDS Conference; 2012; Washington, DC.

8. Chin T, et al. Missed opportunities for diagnosing HIV infection in healthcare settings in the southeastern U.S. Paper presented at: XIX International AIDS Conference; 2012; Washington, DC.