2002

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Hopkins HIV Report

Medical Management of HIV Infection

Hopkins HIV Report

November

Report from ICAAC: New Drugs and Antiretroviral Therapy for Naïve Patients: Joel E. Gallant, M.D., M.P.H.; Antiretroviral news was sparse at the 42nd ICAAC, presumably because it followed the International AIDS Conference in Barcelona by only 2 months. Now that we have a yearly international conference once again (the International AIDS Conference alternating with the International AIDS Society Conference), ICAAC may play a less important role as a forum for HIV-related data.
International HIV Workshop on Management of Treatment-Experienced Patients: John G. Bartlett, M.D.; This pre-conference workshop, directed by John Mellors and Julio Montagner, took place September 26 and 27 in San Diego. A summary of the presentations addressing the state-of-the-art for treatment experienced patients follows.
HIV Notes from the 40th Annual Meeting of the Infectious Diseases Society of America: Emily J. Erbelding, M.D., M.P.H., Gregory M. Lucas, M.D., and Rajesh T. Gandhi, M.D.; While IDSA is generally not the venue for breaking HIV treatment data, there was some new information regarding laboratory monitoring strategies for resource-poor countries, rising HIV risk behaviors, adherence, complications of therapy, and vaccines presented at this year's conference in Chicago.
Report on Adherence From the XIV International AIDS Conference in Barcelona: Beulah Perdue Sabundayo, Pharm.D., M.P.H.; Investigators and clinicians continue to be interested in predicting, measuring, and improving adherence to highly active antiretroviral therapy (HAART). However, new information was sparse at the International AIDS conference in Barcelona in July, despite the presentation of over 60 abstracts on the subject.
Women's Health Issues: News from the XIV International AIDS Conference in Barcelona: Jean Keller, P.A.C., Judy Lee, M.D., and Jean Anderson M.D.; Attention to HIV's devastating effect on the lives of women around the globe continues to grow, and women's issues were well represented at the XIV International AIDS Conference.This article presents highlights from the conference (complete coverage can be found on the Johns Hopkins AIDS Service website.

September

Antiretroviral Therapy: When to Start & What to Start With: Timothy R. Sterling, M.D.; There were several abstracts at the meeting on the controversial topic of when to start therapy in asymptomatic individuals. There appears to be a consensus that therapy should be initiated based primarily on CD4 count rather than viral load, and that the CD4 count should be between 200 and 350 cells/mm3. However, the optimal CD4 count and timing within this range remains unclear.
Drug Resistance and the Treatment of Experienced Patients: Joel E. Gallant, M.D., M.P.H.; The most exciting and eagerly awaited data presented in Barcelona pertained to the treatment of naïve patients. Patients starting therapy for the first time can choose among a number of simple, well tolerated, and highly potent combinations, and those who adhere to therapy shouldn’t have to worry about issues such as drug resistance and salvage therapy for a long time. Nevertheless, treatment failure and drug resistance remain a big concern, especially for highly experienced patients with diminishing options for therapy. A number of interesting presentations on drug resistance and approaches to the treatment of experienced patients were presented in Barcelona.
Pharmacology and Drug Interactions: A Progress Report: Adriana Andrade, M.D., M.P.H. and Charles Flexner, M.D.; At the XIV International AIDS Conference in Barcelona, there were only six oral presentations and approxi-mately 30 posters on pharmacology and drug interactions. A number of the studies presented had potential relevance to resource poor countries, a theme that resonated throughout the conference.
Antiretroviral Treatment in Developing Countries: Jean Nachega, M.D., M.P.H.; The debate over prevention versus treatment efforts took center stage at the XIV International AIDS Conference in Barcelona, Spain, July 7-12, 2002.
The Global HIV/AIDS Pandemic 2002: A Status Report: Thomas C. Quinn, M.D.; On the eve of the XIV International AIDS Conference in Barcelona, UNAIDS released its “Report on the Global HIV/AIDS Epidemic, 2002.” This is the most comprehensive and detailed report on the epidemic that has ever been released by either the World Health Organization or UNAIDS.
Management of Hepatitis C: A Review of the NIH Consensus Development Conference: Kelly A. Gebo, M.D., M.P.H. and John G. Bartlett, M.D.; The National Institutes of Health (NIH) convened a Consensus Development Conference June 10-12, 2002. The primary sponsors of the meeting were the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the Office of Medical Applications of Research (OMAR) of the NIH.
Drug Profile: PEG-Interferon 2b (PEG-Intron): Paul Pham, Pharm.D., BCPS

July

New CDC STD Treatment Guidelines: Emily J. Erbelding, M.D., M.P.H.; In May, the Centers for Disease Control and Prevention (CDC) released a new version of their guidelines for the diagnosis and management of STDs [MMWR 51; RR06, 2002]. The previous version was released in 1998. These guidelines are reviewed and updated by expert consensus panels every 4-5 years, and they represent the standards for the clinical management of STDs in the U.S.
WHO Draft Guidelines for ART in Resource Limited Settings: Lisa A. Spacek, M.D., Ph.D.; On April 22, 2002, the World Health Organization (WHO) approved draft treatment guidelines for HIV-infected people in resource limited settings and recommended that 12 antiretroviral drugs be added to the Essential Medicines List. The primary purpose of the guidelines is to serve as a framework for health care policy leaders in developing nations as they begin to implement HIV treatment programs.
Acute Neuromyopathy Syndrome: Justin McArthur, MBBS, M.P.H.; In the last three years a new form of HIV associated neurological disease has been described, often occurring in association with lactic acidosis in patients with prolonged use of stavudine (d4T, Zerit). While the clinical and pathological features are still being defined, the severity of this syndrome and its apparent high mortality rate warrant a discussion of what we know now.
Peripheral Neuropathy and HIV: Michael J. Polydefkis, M.D.; Peripheral nerve damage is one of the most common neurological complications of HIV infection and its treatment. Of these, the distal sensory neuropathies, which occur in the advanced stages of HIV disease, are the most common, affecting approximately 30% of AIDS patients. It is important, however, to recognize that other forms of peripheral nerve disease occur in HIV infection.
Substance Abuse and HIV: Jeffrey H. Hsu, M.D.; Since 1989, approximately one-third of all AIDS cases in the United States have been among active or former injection drug users (IDUs). Although the major risk factor for HIV infection in the United States among men is same-sex contact, the major risk factor among women with AIDS is either IDU or heterosexual contact with an injection drug user.

May

Update on Women and HIV: Jean Keller, PA-C, Brenda Ross, M.D., and Jean R. Anderson, M.D.; Although new information presented about issues relevant to reproductive health and pregnancy in HIV-infected women was sparse at the 9th CROI, there were a few key presentations and a number that add important emphasis to previous observations.
HLA B57 and Abacavir Hypersensitivity: Charles Flexner, M.D.; The sequencing of the human genome has focused much attention on finding genetic causes for both common and uncommon diseases. The field of pharmacogenetics (or pharmacogenomics) identifies genes associated with drug responsiveness. So far, this field has produced little of real clinical consequence.
IQ’s, VIQ’s, and NIQ’s: Are We Smart Yet?: Charles Flexner, M.D.; Therapeutic drug monitoring (TDM) for antiretrovirals remains one of the most interesting and controversial topics in HIV pharmacology. Several presentations at the 9th CROI reflected recent progress in thinking about how to make TDM clinically useful.
TB and HIV: Challenges and Progress: Richard E. Chaisson, M.D.; Tuberculosis took center stage at the 9th CROI, but there was little good news to report. In a special symposium, four speakers addressed important new scientific developments in the area of TB and its control. Dr. Nulda Beyers of the University of Stellenbosch, S. Africa, reported on the innovative epidemiologic research her group has been carrying out, largely in HIV-negative patients.
Update on Opportunistic Infections: John G. Bartlett, M.D.; At present, discontinuation of primary prophylaxis for PCP, toxoplasmosis, and MAC after an adequate response to HAART is recommended as safe (AI recommendation) according to the 2001 USPHS/IDSA guidelines (available at http://www.hivatis.org). Secondary prophylaxis refers to the use of prophylactic agents to prevent a recurrence of disease once a patient has been adequately treated for the primary episode.
Adolescents and HIV: Jonathan M. Ellen, M.D.; Adolescence is a stage of life typically characterized by good health, with healthcare encounters focused on health maintenance and issues surrounding prevention of STDs, drug use, and unwanted pregnancy. Adolescent health care providers in geographic regions hard hit by HIV are now faced with two important trends.

March

When to Start HAART: Still a Controversy: Timothy R. Sterling, M.D.; There were several presentations at the CROI on the controversial issue of when to initiate highly active antiretroviral therapy (HAART) in asymptomatic HIV-infected patients. Although HAART significantly decreases clinical disease progression, currently available drugs are unlikely to eradicate HIV infection.
Antiretroviral Toxicities Take Center Stage at the 9th CROI: Gregory M. Lucas, M.D.; As the natural history of HIV disease in developed countries has become synonymous with the natural history of combination drug therapy, clinicians who care for HIV-infected patients are increasingly becoming acquainted with the long-term adverse effects of antiretroviral therapy, which include both subtle and dramatic toxicities.
HIV and Hepatitis C: Kelly Gebo, M.D.; HIV/hepatitis C (HCV) co-infection was a particularly hot topic at the 9th CROI. Cohort studies continued to produce data regarding the long-term complications of HCV infection as well as the interaction of HAART and HCV, and treatment trials with both pegylated and non-pegylated interferon alpha with ribavirin were presented.
Treatment of Antiretroviral-Experienced Patients and Immune-Based Therapy: Gregory M. Lucas, M.D.; The treatment of antiretroviral therapy experienced patients is critically linked to using available data to construct a new regimen with adequate potency and tolerability. This article will review data presented at the 9th CROI on: The efficacy of new drugs in experienced patients, the meaning of "blips" and low level viremia in treatment experienced patients, and the role of immune-based therapies (notably IL-2) and therapeutic vaccines in treating HIV-infected patients.
New Drugs in Clinical Development and Treatment of Naïve Patients: Joel E. Gallant, M.D., M.P.H.; TMC 125 is a second-generation NNRTI from Tibotec-Virco that demonstrates in vitro activity against HIV that carries high-level resistance to the three currently available NNRTIs. At ICAAC in December, we heard exciting results from a phase 2 trial in which antiretroviral therapy-naïve patients taking TMC 125 monotherapy experienced an astonishing 1.92 log drop in viral load after only 7 days.
New Drugs: Attacking Chemokine Receptors: Charles Flexner, M.D.; There is concern that the growing list of approved antiretrovirals will discourage pharmaceutical and biotechnology companies from investing in the discovery and development of new drugs. The short list of new investigational agents in the antiretroviral classes at the 9th CROI seems to confirm that fear. However, there were several important advances.

January

Antiretroviral News from the 41st ICAAC: Joel E. Gallant, M.D., M.P.H.; The 41st Interscience Conference on Antimicrobial Agents and Chemo-therapy (ICAAC), held in Chicago from December 16 to 19, had been postponed due to the events of September 11, 2001. As a result of the awkward timing, attendance was somewhat sparse. Antiretroviral news was somewhat sparse, as well, which probably has more to do with the growing number of conferences at which data pertaining to HIV infection and its treatment are presented.
Report from ICAAC: Update on Opportunistic Infections: Joel E. Gallant, M.D., M.P.H.; Henry Masur from the NIH [Abstract 586] reviewed selected topics in the category of opportunistic infections (OIs). He noted that the incidence of all OIs has decreased substantially. The incidence began to fall in the late 1980’s with the advent of nucleoside analog therapy and prophylaxis of opportunistic infections, and dropped more dramatically with the introduction of HAART in the mid to late 90’s.
Update from the 3rd International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV: Joseph Cofrancesco, Jr., M.D., M.P.H.; The 3rd International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV, held in Athens, Greece on October 23-26, presented a number of well conducted studies that provide further hints into the pathogenesis of antiretroviral complications.
HIV Notes from the 39th Annual Meeting of the Infectious Diseases Society of America: Gregory M. Lucas, M.D.; Bioterrorism clearly took center stage at this year’s IDSA meeting. Only one slide session was devoted to HIV-related issues, and, as in previous years, head-turning new data on antiretroviral therapy were sparse. However, there were some interesting abstracts presented on the pathogenesis early of HIV infection in women, opportunistic infections (OIs), and response to vaccinations.
IDSA Update: Sexually Transmitted Infections and HIV: Emily J. Erbelding, M.D., M.P.H.; Though bioterrorism was clearly the issue of the day at the 39th Annual Meeting of the IDSA, new observations regarding the important epidemiologic interactions between sexually transmitted diseases (STDs) and HIV were brought to the fore at this conference as well.
TB Update from the 39th Annual Meeting of the IDSA: Timothy R. Sterling, M.D.; At the Tuberculosis Workshop that preceded the IDSA meeting, Philip Hopewell, M.D., of the University of California, San Francisco discussed the revised tuberculosis treatment guidelines of the American Thoracic Society, Centers for Disease Control and Prevention, and the IDSA. The most recent treatment guidelines were published in 1994; the revised guidelines should be published in 2002.