Studies Highlight Role of Primary Care in HIV-Positive Population

The overall management of HIV-infected patients need no longer be strictly in the hands of infectious disease experts; primary care physicians have a greater role to play in the management of this patient population, suggest two papers in the April 25 Archives of Internal Medicine.

Conventionally, individuals with HIV infection have been managed by infectious disease specialists. But with the simplification of antiretroviral regimens, the increased ease of viral-load testing, and the subsequent reduction in opportunistic infections and HIV-associated malignancy rates, the management of HIV is far more feasible outside of infectious disease settings, Dr. Mitchell H. Katz said in an accompanying editorial (Arch. Intern. Med. 2011;171:719-20).

Today, the "most common reason for a patient’s condition not being fully suppressed while receiving one of the conventional regimens is nonadherence, a primary care problem if ever there was one," said Dr. Katz of the Los Angeles Department of Health Services.

He added that if "specialty care is less needed than it used to be for HIV-infected patients, it turns out that primary care is more needed. Owing to the advances in HIV treatment, our patients are no longer dying: They are aging!"

In the first paper (an analysis of two cohort studies of veterans), HIV infection was associated with an increased risk for heart failure (HF), independent of conventional risk factors for the heart condition.

Dr. Adeel A. Butt, director of the VA Pittsburgh Healthcare System’s infectious disease/HIV clinic, studied 8,486 patients who did not have prevalent coronary heart disease (CHD), angina, HF, or cancer at baseline. Of those, 2,391 were HIV infected and 6,095 were uninfected. Over a median follow-up of 7.3 years, there were 286 incident HF events and 1,096 deaths. Of the 7,104 patients who did not develop HF or die, 87% completed follow-up (Arch. Intern. Med. 2011:171:737-43).

The median age was 48 years in both groups, and all subjects were male. (Women were excluded because of low numbers.) The age- and race/ethnicity–adjusted rates of incident HF were 7.12 per 1,000 person-years for HIV-infected patients and 4.82 per 1,000 person-years for HIV-uninfected patients. Compared with HIV-uninfected patients, those who were HIV infected had a significantly increased risk of HF after adjustment for conventional risk factors including race, current smoking, body mass index, hypertension, diabetes, and a diagnosis of alcohol abuse or dependence (hazard ratio, 1.81).

Moreover, those with HIV infection who had baseline HIV-1 RNA levels of 500 or more copies/mL had a significantly higher risk of HF than did those who did not have HIV infection (HR, 2.28). However, the HIV-infected patients with HIV-1 RNA levels less than 500 copies/mL did not have an increased risk of HF, Dr. Butt and his associates reported.

Additional analysis excluding patients who developed CHD and/or alcohol abuse or dependence during the follow-up period prior to the HF diagnosis showed that the relationship between HIV and HF persisted, with a hazard ratio of 1.96 for those who developed neither condition, they said.

The exact mechanism by which HIV infection is associated with HF is not well understood. Possible mechanisms include direct effects of the HIV, comorbidities associated with HIV infection, antiretroviral therapy leading to an increased risk of CHD and subsequent HF, nutritional deficiencies, and immunologic damage to the myocardium.

These findings have major clinical implications. "If HF is a major cardiovascular consequence of HIV infection rather than atherosclerotic heart disease, different approaches to manage such consequences are warranted. Cardiovascular risk factor reduction and antiplatelet agents are the mainstay in the management of atherosclerotic heart disease. However, these strategies, plus aggressive blood pressure control and the treatment of the HIV infection, may also be required to prevent development of HF in this population," they concluded.

In the second study, 550 individuals were assigned to a health-promotion intervention that addressed multiple health-related behaviors, and 520 to an HIV/STD risk-reduction intervention. Both interventions consisted of eight weekly, structured, 2-hour sessions delivered by cofacilitators and incorporating brainstorming, games, videos, experiential exercises, discussions, and skill-building activities to increase self-efficacy, outcome expectancy, behavioral skills, and risk-reduction knowledge, said Nabila El-Bassel, Ph.D., professor of social work at Columbia University, New York, and her associates.

Those in the health behavior–intervention group were encouraged to exercise throughout the week, including at least 30 minutes of moderate-intensity physical activity on 5 days or at least 20 minutes of vigorous intensity physical activity on 4 days and strength-building activity on at least 2 days. Dietary activities addressed adherence to a diet of five to nine servings of fruits and vegetables daily, including addressing barriers such as cost of fresh produce, taste, and availability (Arch. Intern. Med. 2011;171:728-36).

Sessions also focused on the importance of breast and prostate cancer screening. The health risks of excessive alcohol use, particularly for those infected with hepatitis C, was also covered.

The HIV/STD risk-reduction intervention was structurally similar to the health promotion intervention; however, it focused on the participants as members of couples rather than as individuals.

The mean participant age was 43 years, and the HIV-positive partner was female in 60% of the couples. Attendance at the eight sessions of both interventions was excellent, with a retention rate of 88% at 12 months post intervention, Dr. El-Bassel and her associates reported.

Health promotion–intervention participants were more likely to report consuming five or more servings of fruits and vegetables daily (rate ratio, 1.38) and adhering to physical activity guidelines (RR, 1.39) compared with the HIV/STD intervention participants. In the health promotion intervention, compared with the HIV/STD intervention, participants consumed fatty foods less frequently (mean difference, –0.18), more men received prostate cancer screening (RR, 1.51), and more women received a mammogram (RR, 1.26). Alcohol use did not differ between the intervention groups.

One possible explanation for the lack of an effect of the health promotion intervention on alcohol use is that the HIV/STD intervention also covered the subject, cautioning that alcohol use could be a trigger for unsafe sexual behavior, they noted.

"We are optimistic that the present study offers an approach that may help reduce the disproportionately high morbidity and mortality rates from chronic diseases in African Americans," Dr. El-Bassel and her associates concluded.

Dr. Katz agreed. "Although serodiscordant couples are a highly specialized population, there is no reason to believe that their intervention would not work among other HIV-infected persons. Certainly, this study should encourage others to attempt group health promotion classes because, as I often tell my HIV-infected patients with diabetes, liver disease, or uncontrolled hypertension, ‘It’s not HIV that’s going to kill you.’ "

Neither Dr. Katz nor any of the investigators in either study reported financial disclosures.

The overall management of HIV-infected patients need no longer be strictly in the hands of infectious disease experts; primary care physicians have a greater role to play in the management of this patient population, suggest two papers in the April 25 Archives of Internal Medicine.

Conventionally, individuals with HIV infection have been managed by infectious disease specialists. But with the simplification of antiretroviral regimens, the increased ease of viral-load testing, and the subsequent reduction in opportunistic infections and HIV-associated malignancy rates, the management of HIV is far more feasible outside of infectious disease settings, Dr. Mitchell H. Katz said in an accompanying editorial (Arch. Intern. Med. 2011;171:719-20).

Today, the "most common reason for a patient’s condition not being fully suppressed while receiving one of the conventional regimens is nonadherence, a primary care problem if ever there was one," said Dr. Katz of the Los Angeles Department of Health Services.

He added that if "specialty care is less needed than it used to be for HIV-infected patients, it turns out that primary care is more needed. Owing to the advances in HIV treatment, our patients are no longer dying: They are aging!"

In the first paper (an analysis of two cohort studies of veterans), HIV infection was associated with an increased risk for heart failure (HF), independent of conventional risk factors for the heart condition.

Dr. Adeel A. Butt, director of the VA Pittsburgh Healthcare System’s infectious disease/HIV clinic, studied 8,486 patients who did not have prevalent coronary heart disease (CHD), angina, HF, or cancer at baseline. Of those, 2,391 were HIV infected and 6,095 were uninfected. Over a median follow-up of 7.3 years, there were 286 incident HF events and 1,096 deaths. Of the 7,104 patients who did not develop HF or die, 87% completed follow-up (Arch. Intern. Med. 2011:171:737-43).

The median age was 48 years in both groups, and all subjects were male. (Women were excluded because of low numbers.) The age- and race/ethnicity–adjusted rates of incident HF were 7.12 per 1,000 person-years for HIV-infected patients and 4.82 per 1,000 person-years for HIV-uninfected patients. Compared with HIV-uninfected patients, those who were HIV infected had a significantly increased risk of HF after adjustment for conventional risk factors including race, current smoking, body mass index, hypertension, diabetes, and a diagnosis of alcohol abuse or dependence (hazard ratio, 1.81).

Moreover, those with HIV infection who had baseline HIV-1 RNA levels of 500 or more copies/mL had a significantly higher risk of HF than did those who did not have HIV infection (HR, 2.28). However, the HIV-infected patients with HIV-1 RNA levels less than 500 copies/mL did not have an increased risk of HF, Dr. Butt and his associates reported.

Additional analysis excluding patients who developed CHD and/or alcohol abuse or dependence during the follow-up period prior to the HF diagnosis showed that the relationship between HIV and HF persisted, with a hazard ratio of 1.96 for those who developed neither condition, they said.

The exact mechanism by which HIV infection is associated with HF is not well understood. Possible mechanisms include direct effects of the HIV, comorbidities associated with HIV infection, antiretroviral therapy leading to an increased risk of CHD and subsequent HF, nutritional deficiencies, and immunologic damage to the myocardium.

These findings have major clinical implications. "If HF is a major cardiovascular consequence of HIV infection rather than atherosclerotic heart disease, different approaches to manage such consequences are warranted. Cardiovascular risk factor reduction and antiplatelet agents are the mainstay in the management of atherosclerotic heart disease. However, these strategies, plus aggressive blood pressure control and the treatment of the HIV infection, may also be required to prevent development of HF in this population," they concluded.

In the second study, 550 individuals were assigned to a health-promotion intervention that addressed multiple health-related behaviors, and 520 to an HIV/STD risk-reduction intervention. Both interventions consisted of eight weekly, structured, 2-hour sessions delivered by cofacilitators and incorporating brainstorming, games, videos, experiential exercises, discussions, and skill-building activities to increase self-efficacy, outcome expectancy, behavioral skills, and risk-reduction knowledge, said Nabila El-Bassel, Ph.D., professor of social work at Columbia University, New York, and her associates.

Those in the health behavior–intervention group were encouraged to exercise throughout the week, including at least 30 minutes of moderate-intensity physical activity on 5 days or at least 20 minutes of vigorous intensity physical activity on 4 days and strength-building activity on at least 2 days. Dietary activities addressed adherence to a diet of five to nine servings of fruits and vegetables daily, including addressing barriers such as cost of fresh produce, taste, and availability (Arch. Intern. Med. 2011;171:728-36).

Sessions also focused on the importance of breast and prostate cancer screening. The health risks of excessive alcohol use, particularly for those infected with hepatitis C, was also covered.

The HIV/STD risk-reduction intervention was structurally similar to the health promotion intervention; however, it focused on the participants as members of couples rather than as individuals.

The mean participant age was 43 years, and the HIV-positive partner was female in 60% of the couples. Attendance at the eight sessions of both interventions was excellent, with a retention rate of 88% at 12 months post intervention, Dr. El-Bassel and her associates reported.

Health promotion–intervention participants were more likely to report consuming five or more servings of fruits and vegetables daily (rate ratio, 1.38) and adhering to physical activity guidelines (RR, 1.39) compared with the HIV/STD intervention participants. In the health promotion intervention, compared with the HIV/STD intervention, participants consumed fatty foods less frequently (mean difference, –0.18), more men received prostate cancer screening (RR, 1.51), and more women received a mammogram (RR, 1.26). Alcohol use did not differ between the intervention groups.

One possible explanation for the lack of an effect of the health promotion intervention on alcohol use is that the HIV/STD intervention also covered the subject, cautioning that alcohol use could be a trigger for unsafe sexual behavior, they noted.

"We are optimistic that the present study offers an approach that may help reduce the disproportionately high morbidity and mortality rates from chronic diseases in African Americans," Dr. El-Bassel and her associates concluded.

Dr. Katz agreed. "Although serodiscordant couples are a highly specialized population, there is no reason to believe that their intervention would not work among other HIV-infected persons. Certainly, this study should encourage others to attempt group health promotion classes because, as I often tell my HIV-infected patients with diabetes, liver disease, or uncontrolled hypertension, ‘It’s not HIV that’s going to kill you.’ "

Neither Dr. Katz nor any of the investigators in either study reported financial disclosures.

The overall management of HIV-infected patients need no longer be strictly in the hands of infectious disease experts; primary care physicians have a greater role to play in the management of this patient population, suggest two papers in the April 25 Archives of Internal Medicine.

Conventionally, individuals with HIV infection have been managed by infectious disease specialists. But with the simplification of antiretroviral regimens, the increased ease of viral-load testing, and the subsequent reduction in opportunistic infections and HIV-associated malignancy rates, the management of HIV is far more feasible outside of infectious disease settings, Dr. Mitchell H. Katz said in an accompanying editorial (Arch. Intern. Med. 2011;171:719-20).

Today, the "most common reason for a patient’s condition not being fully suppressed while receiving one of the conventional regimens is nonadherence, a primary care problem if ever there was one," said Dr. Katz of the Los Angeles Department of Health Services.

He added that if "specialty care is less needed than it used to be for HIV-infected patients, it turns out that primary care is more needed. Owing to the advances in HIV treatment, our patients are no longer dying: They are aging!"

In the first paper (an analysis of two cohort studies of veterans), HIV infection was associated with an increased risk for heart failure (HF), independent of conventional risk factors for the heart condition.

Dr. Adeel A. Butt, director of the VA Pittsburgh Healthcare System’s infectious disease/HIV clinic, studied 8,486 patients who did not have prevalent coronary heart disease (CHD), angina, HF, or cancer at baseline. Of those, 2,391 were HIV infected and 6,095 were uninfected. Over a median follow-up of 7.3 years, there were 286 incident HF events and 1,096 deaths. Of the 7,104 patients who did not develop HF or die, 87% completed follow-up (Arch. Intern. Med. 2011:171:737-43).

The median age was 48 years in both groups, and all subjects were male. (Women were excluded because of low numbers.) The age- and race/ethnicity–adjusted rates of incident HF were 7.12 per 1,000 person-years for HIV-infected patients and 4.82 per 1,000 person-years for HIV-uninfected patients. Compared with HIV-uninfected patients, those who were HIV infected had a significantly increased risk of HF after adjustment for conventional risk factors including race, current smoking, body mass index, hypertension, diabetes, and a diagnosis of alcohol abuse or dependence (hazard ratio, 1.81).

Moreover, those with HIV infection who had baseline HIV-1 RNA levels of 500 or more copies/mL had a significantly higher risk of HF than did those who did not have HIV infection (HR, 2.28). However, the HIV-infected patients with HIV-1 RNA levels less than 500 copies/mL did not have an increased risk of HF, Dr. Butt and his associates reported.

Additional analysis excluding patients who developed CHD and/or alcohol abuse or dependence during the follow-up period prior to the HF diagnosis showed that the relationship between HIV and HF persisted, with a hazard ratio of 1.96 for those who developed neither condition, they said.

The exact mechanism by which HIV infection is associated with HF is not well understood. Possible mechanisms include direct effects of the HIV, comorbidities associated with HIV infection, antiretroviral therapy leading to an increased risk of CHD and subsequent HF, nutritional deficiencies, and immunologic damage to the myocardium.

These findings have major clinical implications. "If HF is a major cardiovascular consequence of HIV infection rather than atherosclerotic heart disease, different approaches to manage such consequences are warranted. Cardiovascular risk factor reduction and antiplatelet agents are the mainstay in the management of atherosclerotic heart disease. However, these strategies, plus aggressive blood pressure control and the treatment of the HIV infection, may also be required to prevent development of HF in this population," they concluded.

In the second study, 550 individuals were assigned to a health-promotion intervention that addressed multiple health-related behaviors, and 520 to an HIV/STD risk-reduction intervention. Both interventions consisted of eight weekly, structured, 2-hour sessions delivered by cofacilitators and incorporating brainstorming, games, videos, experiential exercises, discussions, and skill-building activities to increase self-efficacy, outcome expectancy, behavioral skills, and risk-reduction knowledge, said Nabila El-Bassel, Ph.D., professor of social work at Columbia University, New York, and her associates.

Those in the health behavior–intervention group were encouraged to exercise throughout the week, including at least 30 minutes of moderate-intensity physical activity on 5 days or at least 20 minutes of vigorous intensity physical activity on 4 days and strength-building activity on at least 2 days. Dietary activities addressed adherence to a diet of five to nine servings of fruits and vegetables daily, including addressing barriers such as cost of fresh produce, taste, and availability (Arch. Intern. Med. 2011;171:728-36).

Sessions also focused on the importance of breast and prostate cancer screening. The health risks of excessive alcohol use, particularly for those infected with hepatitis C, was also covered.

The HIV/STD risk-reduction intervention was structurally similar to the health promotion intervention; however, it focused on the participants as members of couples rather than as individuals.

The mean participant age was 43 years, and the HIV-positive partner was female in 60% of the couples. Attendance at the eight sessions of both interventions was excellent, with a retention rate of 88% at 12 months post intervention, Dr. El-Bassel and her associates reported.

Health promotion–intervention participants were more likely to report consuming five or more servings of fruits and vegetables daily (rate ratio, 1.38) and adhering to physical activity guidelines (RR, 1.39) compared with the HIV/STD intervention participants. In the health promotion intervention, compared with the HIV/STD intervention, participants consumed fatty foods less frequently (mean difference, –0.18), more men received prostate cancer screening (RR, 1.51), and more women received a mammogram (RR, 1.26). Alcohol use did not differ between the intervention groups.

One possible explanation for the lack of an effect of the health promotion intervention on alcohol use is that the HIV/STD intervention also covered the subject, cautioning that alcohol use could be a trigger for unsafe sexual behavior, they noted.

"We are optimistic that the present study offers an approach that may help reduce the disproportionately high morbidity and mortality rates from chronic diseases in African Americans," Dr. El-Bassel and her associates concluded.

Dr. Katz agreed. "Although serodiscordant couples are a highly specialized population, there is no reason to believe that their intervention would not work among other HIV-infected persons. Certainly, this study should encourage others to attempt group health promotion classes because, as I often tell my HIV-infected patients with diabetes, liver disease, or uncontrolled hypertension, ‘It’s not HIV that’s going to kill you.’ "

Neither Dr. Katz nor any of the investigators in either study reported financial disclosures.