Important note: Information in this article was accurate in May 1999. The state of the art may have changed since the publication date. | The online version of HEPP News displays the main article only, to view the entire newsletter download the following PDF:
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Last month we brought you reports on immunology and new treatments from the 6th Conference on Retroviruses and Opportunistic Infections. This month we continue our synopsis with reports on HIV care utilization, viral load monitoring, and warnings about new clades and drug resistant HIV isolates.
Dr. Sam Bozzette presented his data from a national consortium of HIV providers 1. The HIV Cost and Services Utilization Study (HCSUS) 2, described the impact of HIV care on health, and the cost of that care in the "outside world". Delivery of care "outside" may directly impact correctional HIV care due to its effect on the health of HIV infected inmates arriving in correctional facilities.
Bozzette used information published by the New York State Department of Correctional Services (NYSDOCS) on the reduction in HIV-related mortality to illustrate his first point: HAART has had an impressive impact on AIDS mortality (see graph, pg. 5) 3. To support this point, he referenced three other studies that describe how HIV morbidity and mortality rates have been reduced when good HIV care, expert consultation, and HAART have been made available to patients. One study showed that hospitals "experienced" in HIV care had a 21% lower death rate for Pneumocystis Carinii Pneumonia (PCP) than hospitals that were less experienced 4. A second study showed that HIV infected patients in the care of experienced providers had a 31% lower AIDS mortality rate than patients in the care of other providers 5. A third study proved that patients in clinics with more than two HIV "services" had a 36% lower adjusted odds of developing PCP than those in clinics with one or none 6.
Bozzette reported some dramatic facts gleaned from studies of the large cohort of 3,072 HIV infected patients followed by the HCSUS HIV providers. He and his collaborators found that the proportion of persons living with T cell counts less than 200 has decreased nationally from 35% to 17% between 1996 and 1998. The number of persons with CD4 T cells above 200 has increased, suggesting that HAART is "arresting" the national rate of progression to AIDS. These researchers extrapolated from their study sample to estimate that about 335,000 persons attended HIV clinics in the past year, representing only about half of the 600,000 to 900,000 persons thought to be currently living with HIV, according to the CDC 7.
The HCSUS group found that the distribution of HIV patients in care was skewed towards lower CD4 T cell counts. This suggests that most of the patients who are not in care are in the early stages of HIV. Bozzette raised concern about identifying these individuals and getting them into treatment, since, for some patients, the best time to begin treatment to prevent the advancement of HIV disease may be during the early stages of infection.
Not all of the patients in Bozzette's study received specialty care in HIV clinics. While 50% of patients obtained care in HIV specialty clinic settings, another 23% used emergency rooms as one of their primary sources of health care. Perhaps as a result, 30% of those with a CD4 count less than 200 were not on PCP prophylaxis 1. Many measures of HIV care utilization differed by race and ethnicity. Compared to non-Hispanic whites, Hispanics and Blacks had fewer clinic visits, more IDU use, less ART, less PI, and less PCP prophylaxis. Access to HAART was also linked to race, income, active drug use, gender, risk behavior, geography, attitudes and beliefs about HIV care, and whether the HIV care provider for the patient focused primarily on HIV care or was involved in other aspects of health care. These findings come as no surprise to the correctional HIV provider. Providing HIV specialty care and related services in the correctional environment is one means of improving access to HIV treatment for these under-served populations.
Adherence in the HCSUS study population was fairly poor: 57% of patients reported that they were adherent 7 days a week, 19% reported that they were adherent 6 days a week 1. These self-reports may also over estimate actual adherence, raising grave concerns about the evolution of drug resistant virus in the HIV-infected patient population at large.
Bozzette and colleagues estimated that there were 2 million outpatient visits, 100,000 Emergency Room (ER) visits, 900,000 hospital days and 85,000,000 days of antiretroviral therapy in the first six months of 1996 1. The cost of this HIV care was about $6.7 billion per year, which was less than 1% of the total US expenditure on health care during 1997 1. In contrast, HIV-AIDS was the cause of 7% of total lives lost during the same year.
Bozzette also evaluated the impact of HAART on total HIV care costs. Most of the cost of treating HIV/AIDS in his cohort related to pharmaceutical expenditures. He found that drug expenditures and clinic visits have increased, but ER visits and hospitalization have decreased, and the total cost of caring for HIV/AIDS patients was no different after these adjustments. During a post-presentation interview, Bozzette indicated that similar figures for the impact of HAART in the correctional setting were not available.
The good news for correctional healthcare providers who manage HIV patients is that there has been a slight decrease in HIV care costs and improvement in service utilization from 1996 up until now. That means that more of our patients will have been tested and treated with HAART before they arrive at a correctional setting. The bad news is that the number of patients who adhere to their regimens is much less than would be desirable. The most important impact of new HIV treatments has been on mortality; death rates have dropped dramatically. Setting aside tangible financial benefits, the intangible emotional benefits of HAART are palpable both inside and outside corrections.
Full time blood donors are screened for HIV-risk behaviors; blood is also screened for evidence of HIV infection before use. Information from blood-donor screenings was presented by the CDC 11 giving a novel perspective on the actual incidence of HIV infection among a group of individuals who do not consider themselves at risk. The relevance of this topic to corrections is that it expands the ability to identify HIV infected persons who may not have reported standard "HIV risks.”
The average rate of acquisition of HIV infection among full time US blood donors was 8 per 100,000 person years, much lower than among higher risk groups 11. Studies have found, however, a higher prevalence of HIV than the donors may have expected. Persons in Southeastern states (20-26 new infections per 100,000), persons of color (25-30 fold higher HIV incidence rate than whites), and persons in the 22 to 45 age range who do not consider themselves to be HIV infected (2 fold higher than persons older or younger than that age group) may have a higher risk of HIV infection than previously thought.
In a substudy of 31 recently infected blood donors, researchers found evidence, in one patient, of acquisition of a clade A virus. All of the other new infections appeared to cluster with B strains. This report of a non-clade B virus (the usual strain of virus transmitted in the US) suggests that the US is not immune to invasion of other strains of HIV that dominate the epidemic in other parts of the world.
The most important finding in this study is related to drug resistance: 18 out of the 31 infections among blood donors had changes related to drug resistance. Resistance to protease inhibitors predominated. The take-home message for corrections was that drug resistance can be widespread in "free world" populations. Therefore, patients on HAART should be monitored for response to treatments and intensification of regimens should be considered if response is inadequate. As discussed in the last issue of HEPP News, viral resistance testing (genotypic anti-retroviral resistance testing, or GART) is a tool that expands our ability to make better-informed decisions on treatment.
The "Inside" View: Extrapolating HCSUS Data to CorrectionsBozzette's data are relevant to correctional HIV care providers because they give us a rough estimate of the proportion of the national HIV infected population that is under our care. The National Bureau of Justice Statistics (BJS) recently estimated that there are 35,000 to 47,000 patients with HIV infection in the nation's prisons and jails 8. Comparing this figure to Bozzette's estimates, prisons and jails are providing care for approximately one tenth of the total number of HIV infected individuals that are accessing health care. The HCSUS study also permits some budgetary contrasts. Allowing for some differences in budget estimates, current expenditures on HIV care in correctional settings may be in the same range as expenditures in the "free world". These estimates run counter to public sentiment that "too much money" is spent on correctional HIV care. For example, recent estimates of HIV/AIDS related expenditures reported by the New York State Department of Correctional Services (NYSDOCS) were $10.8 million directly spent on medical services, and 45.8 million on AIDS programs for approximately 3,000 inmates that are currently accessing HIV care in the NYSDOCS 9. The Florida State DOC reported spending $19 million in 1998 on HIV medications alone for approximately 2,100 HIV infected patients. Just as Bozzette observed for his community patients, HIV infected patients in the correctional setting seem to be unwilling or unable to access HIV care: less than 50% of the estimated 7,500 to 8,500 HIV infected individuals in the NYSDOCS population are participating in clinical care 10. While some of these HIV infected individuals may be avoiding HIV care because they are not yet personally "ready" or willing to participate in HIV treatment, some individuals may be actively avoiding HIV care because of the nature of the correctional setting. Since we now know that early intervention can preserve immune function and reduce morbidity, efforts to identify HIV infected patients and encourage them to participate in HIV care inside the correctional environment are critically important. Some methods that are believed to increase inmate participation in HIV care include: peer education, provider and correctional officer education on HIV risk factors (critical pathways), multiple opportunities to access HIV testing, confidential test results, improving HIV care quality, and reducing barriers to accessing HIV care. Due to the concentration of individuals who have HIV infection or are at risk of HIV infection in correctional settings, correctional providers have a unique opportunity to get at-risk individuals tested and engaged in treatment. |
Dr. R.Lyles presented information on the "natural" progression of viral load in a subset of 270 men enrolled in a large study called the Multicenter AIDS Cohort Study (MACS)12. This cohort has been described in detail in previous publications 13. For this report, Dr. Lyles and co-workers stratified the patients by viral load and examined progression to AIDS. Patients who had lower viral load (less than 10,000 copies/ml) at the outset of the study, had slower progression to AIDS than patients who had a higher viral load (averaging around 100,000 copies) at the outset (progressing to AIDS within the first three years). Patients who did not progress to AIDS within 7 years of the first viral load had no change in the viral load over time; and those who were AIDS free after 9 years or more had a slight decrease in the MRNA level over time. Dr. Lyles provided data showing that progression to AIDS could be extrapolated given data points covering about 1.5 years.
It is important to emphasize that much of the data derived from the MACS cohort was derived prior to the widespread use of HAART. When questioned about the impact of HAART on these results, the researchers suggested that the impact of access to care, treatment, and adherence was summarized in the viral load measurements, and therefore felt that their results were still accurate.
Dr. Kathryn Anastos and co-workers compared patients enrolled in the Women's Interagency HIV Study (WIHS) and MACS (a similar study of men) 14. They evaluated the HIV RNA levels of women in WIHS who had not initiated ART at the beginning of therapy, and contrasted their viral loads to a comparable subset of men in the MACS cohort.
In the final analysis, the HIV RNA among women in this study was 20% lower than the viral burdens in men with the same CD4 T cell count who were enrolled in the MACS. After adjustments for age and racial differences in the cohort, Dr. Anastos found that the viral load at which equivalent rates of progression to AIDS occurred was as much as 35% lower for women than the rates observed for men. If anything, these estimates, according to Dr. Anastos, underestimate the true differences between women and men. In response to a question from the audience, she replied that we don't know, as of yet, whether we should initiate HAART at lower viral loads for women than for men. She suggested that a controlled, prospective study of gender differences in viral loads would allow researchers to better control for confounding factors, such as access to health care and adherence.
The lack of reports directly related to correctional HIV care at the Retrovirus Conference reflected a disconcerting lack of interest by academic researchers about the impact of HIV on inmates. Since as many as 10% of the nation’s HIV infected population may be accessing care in a correctional setting, it seems appropriate for a shift in focus. One means to accomplish this might be for correctional HIV providers to conduct clinical studies in their facilities, and to submit their reports to national meetings.
For information on submitting research to the 7th Conference on Retroviruses and Opportunistic Infections, contact the Retrovirus Conference Secretary at 703/684.4876. Abstracts available at the conference website at http://www.retroconference.org/99/
1. Markson L, et al." Who receives highly active antiretroviral therapy? Data from a nationally representative sample." 6th Conference on Retroviruses and Opportunistic Infections, Abstract 105.
2. Bozzette, SA, et al. "The care of HIV-infected adults in the United States. HIV Cost and Services Utilization Study Consortium." N Engl J Med 1998 Dec 24;339(26):1897-904.
3. MMWR 1999 Jan 8; 47(51&52): 1115-7. Paella, et al., "Declining morbidity and mortaliy among patients with advanced HIV." NEJM 1998 March 26, 338(3) 853-60.
4. Bennett CJ, et al. "U.S. Hospital Care for HIV infected persons and the role of public, private, and Veterans Administration hospitals." J Acquir Immune Deficiency Syndr Hum Retroviral 1996 Dec 15; 13(5) 416-21.
5. Kitahata et al, "Physicians experience with the acquired immune deficiency syndrome as a factor in patients' survival." N Engl J Med 1996 Mar 14;334(11):701-6.
6. Turner BJ, et al. " Clinic HIV-focused features and prevention of Pneumocystis Carinii Penumonia." J Gen Intern Med 1998 Jan; 13(1): 16-23.
7. www.cdc.gov/nchstp/hiv_aids/stats
8. Hammett TM, Harmon P , Rhodes W. "The burden of infectious disease among inmates and releaees from correctional facilities." Unpublished paper prepared for the National Commission on Correctional Health Care, December, 1998.
9. Sharp V. New York AIDS Advisory Council. Report of the Subcommittee on Criminal Justice. February 1999. For a copy of the report, call the AIDS Institute at 518.473 2903.
10. Personal communication, Lester Wright, Assoc. Commissioner/Chief Medical Officer of NYSDOCS.
11. Busch MP, et al.,"Demographic correlates of HIV incidence among US blood donors." 6th Conference on Retroviruses and Opportunistic Infections, Abstract 272.
12. Lyles R, et al. "Natural history of HIV-1 Viremia after seroconversion in the Multicenter AIDS Cohort Study."6th Conference on Retroviruses and Opportunistic Infections, Abstract 273.
13. Detels-R; et al. "Effectiveness of potent antiretroviral therapy on time to AIDS and death in men with known HIV infection duration." Multicenter AIDS Cohort Study Investigators. JAMA.1998 Nov 4; 280(17): 1497-503.
14. Anastos K, et al., Women's Interagency HIV Study (WIHS) and the Multicenter AIDS Cohort Study (MACS). " Gender specific differences in quantitative HIV-1 RNA levels." 6th Conference on Retroviruses and Opportunistic Infections, Abstract 274.
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