The Evolution of Antiretroviral Therapy for HIV - Episode 1
Peter L. Salgo, MD: Hello, and thank you for joining us for this MD Magazine® Peer Exchange® entitled, “Optimizing Outcomes in the Treatment of HIV.” Substantial advances have been made in using antiretroviral therapy for prevention and treatment of HIV infection. Newly available regimens are safer, more effective, and more convenient than ever before. In this MD Magazine® Peer Exchange® panel discussion, I am joined by a panel of infectious disease specialists who are experts in treating HIV infection. Together, we’re going to talk about the most recent recommendations for long-term management of your patients who are at risk for, or are already infected with, HIV. In addition, we’re going to talk about emerging agents that are coming to the clinic soon.
My name is Dr Peter Salgo. I’m a professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons and an associate director of Surgical Intensive Care at New York-Presbyterian Hospital.
Joining me for this discussion are: Dr Eric Daar, chief of the Division of HIV Medicine at Harbor-UCLA Medical Center and professor of medicine at the David Geffen School of Medicine at UCLA in Los Angeles, California; Dr Joseph Eron, professor of medicine at the University of North Carolina [at] Chapel Hill in North Carolina; Dr Ian Frank, professor of medicine at the Hospital of the University of Pennsylvania in Philadelphia; and Dr Paul Sax, clinical director for the Division of Infectious Disease at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School in Boston, Massachusetts.
Guys, thank you for joining. I’m going to start right now with our first question, which is the obvious one: what are the most recent recommendations for HIV screening? Who wants to start us off? Ian?
Ian Frank, MD: The CDC has created some guidance for HIV testing in the United States. They recommend that everybody between the ages of 13 and 64 be tested for HIV at least one time if you live in a neighborhood where the HIV prevalence is not less than a tenth of 1%—which I don’t think exists in the United States.
Peter L. Salgo, MD: Yes. I was going to say that for me, as somebody who was in practice at the beginning of the HIV epidemic (which was not an HIV epidemic then), it was whatever you wanted to call it. That’s an astounding statement. Basically, they want to test everybody. Why?
Paul E. Sax, MD: There are a couple of reasons why the CDC decided to do that. One of them is obvious: you want to be able to find people who are infected before they get sick. That way, they can get life-saving therapy and not transmit the virus to other people. But the other reason they did it was actually kind of more psychological. They said that if we test everyone, the stigma around getting tested will be reduced. And that’s actually been very effective, because when you look at, it’s more important to test high-risk people than it is to test everybody. This was kind of a de-stigmatizing effort by the CDC.
Peter L. Salgo, MD: I remember that in the early days, you would say, “Well, I know who to test. I can tell.” Right?
Joseph Eron, MD: Sure. We don’t know who it is now.
Peter L. Salgo, MD: You never knew.
Joseph Eron, MD: We don’t know who to test, and the range is a little funny. It’s not really clear why you should stop, because older people can get HIV. In fact, we’re seeing that. But I think Paul made a critical point, which is that people who are at highest risk need to be tested more often. In fact, we were trying to get away from what’s called “targeted testing,” but that’s exactly what we need. And that’s what’s missing. We need to consider the younger people who don’t touch healthcare. They’re not in healthcare. They don’t touch the system.
Peter L. Salgo, MD: So, I’m going to screen everybody in the United States, which is effectively what I heard you say. Is it cost-effective?
Paul E. Sax, MD: It’s cost-effective when you’re testing people above a certain background prevalence.
Peter L. Salgo, MD: But that’s not what he said. He said pretty much everybody.
Paul E. Sax, MD: The bottom line is that the test is very inexpensive, and the years of life that can be saved from finding an undiagnosed case of HIV are so huge that it ends up being cost-effective.
Joseph Eron, MD: And the other point, too, is that the tests are exquisitely sensitive and specific. It’s not like a test where you get a whole bunch of false-positives and you waste a whole bunch of money doing prostate ultrasounds.
Eric S. Daar, MD: There’s another benefit, though, that’s really important. It’s not just for the individual, too. There’s always been this concern that 15% to 20% of people in the United States are infected and don’t know it and that those people may be disproportionately driving the current epidemic.
Peter L. Salgo, MD: I heard that number.
Ian Frank, MD: That number, though, is much improved compared to the number 5 years ago.
Eric S. Daar, MD: Right now it’s probably about 15% of the people infected in the United States don’t know it. And the only reason they don’t know it is because they’ve never been tested.
Peter L. Salgo, MD: So, again, you test everybody to avoid stigmatizing the people that you really should be testing more often?
Paul E. Sax, MD: That’s true.
Peter L. Salgo, MD: It’s not a bad idea, frankly, if it’s cheap and it’s easy.
Joseph Eron, MD: Plus, you do find people. But it’s just not a very efficient find. In North Carolina, the number of tests increased by 2- to 2.5-fold. And the number of new diagnoses went up around 10%. But you do find people, so it’s valuable to find them.
Paul E. Sax, MD: We did a study in our emergency room of testing people in whom testing would not otherwise be indicated. We were actually screening everyone, and the yield was understandably very low. We did find a few. Interestingly, we found a couple who were actually already known to be infected but had “forgotten,” or were in denial. So, it was actually quite useful.
Ian Frank, MD: Before we move on, I think we should talk about who should be tested, rather than just suggest that we test everybody.
Peter L. Salgo, MD: That was my next question, anyway, because you did allude to this. There are some people that you really want to drill in on, if you will—high-risk individuals. How would you define those?
Ian Frank, MD: I think we would define them as men who have sex with men, individuals with multiple concurrent sexual partners, individuals who do intravenous drugs, or folks who have certain indicator diseases that can be associated with HIV that are often overlooked—psoriasis, herpes zoster, tuberculosis.
Joseph Eron, MD: Zoster is a big one. We just had a woman with zoster a year ago—a young woman who came in with HIV, a low CD4 with PCP (pneumocystis jirovecii pneumonia).
Ian Frank, MD: Anyone who’s had a sexually transmitted infection?
Paul E. Sax, MD: Thrombocytopenia. There are a whole bunch of conditions that normally are not thought to be HIV-related and yet are early clues.
Peter L. Salgo, MD: De novo, so-called idiopathic thrombocytopenia, patients should get an HIV test done.
Paul E. Sax, MD: Absolutely.
Joseph Eron, MD: That should be, unequivocally, part of the workup.
Peter L. Salgo, MD: So, those are your high-risk individuals. Of course, if you know that they’re thrombocytopenic, you’ve tested them for something else anyway.
Eric S. Daar, MD: The current guidelines are targeting people who are encountering the healthcare system for other reasons. Certainly, everyone is encouraged to seek out testing sites, but the guidelines are really focusing on people who encounter the healthcare system for any reason.
Peter L. Salgo, MD: We have 2 kinds of compliance here, right? There’s the compliance of people who present and would like to be tested. You offer them the test. Then, you’ve got compliance for primary care physicians or other physicians who should be proactively offering it. Why don’t we divide that into 2 groups? How do we get people to want to be tested? Anybody have a brilliant idea?
Joseph Eron, MD: You have to get the word out of how effective therapy is. That is number one. Because you add 30, 40 years of life to someone who is 20 years old. If they weren’t treated or weren’t diagnosed, they might live 20 years. Instead, they can live 50 or 60 years and can, essentially, have a normal life expectancy. So, that’s one obvious way. I think de-stigmatizing the test is really important.
Paul E. Sax, MD: In infectious disease practice, the way we do it is we say to people who come in who haven’t been tested, “We test everyone,” and they go, “Okay,” because they’re everyone. They’re part of that.
Peter L. Salgo, MD: But does every doctor do that? Is it part of every doctor’s practice?
Eric S. Daar, MD: The recommendations are over 10 years old, and clearly everybody isn’t doing it.
Peter L. Salgo, MD: Why not?
Eric S. Daar, MD: It’s sort of an unfunded mandate, if you will. There’s no money that came with it. It takes a lot of effort, although they tried to make it easier. They got rid of the consent process, which was huge. All of the pre- and posttest counseling that used to take up a lot of time, they got rid of all of that. But not everybody has the ability to spend the time with the patients and simply say “We’re going to do this as part of routine care.” And then the other big thing is dealing with the fallout when you find a positive. A lot of centers, whether it’s a private doctor’s office or even an emergency department, have got to move on to the next patient. They’re not looking for new problems.
Ian Frank, MD: But I think some of it is just assumptions that we make. You’ve been taking care of this gentleman for many years, and you think you know their sexual habits, and you say, “Oh, they’re not at risk for HIV.” And I think that that’s what happens. Like Paul said, if your approach is that we test everybody for HIV infection, when you’re ordering any kind of test (eg, routine blood work), you can say, “Hey, it’s our standard practice to test everybody.” The counseling doesn’t need to be more complicated than that. It doesn’t need to take a lot of time.
Transcript edited for clarity.