COMPLICATIONS
Sharon Stancliff, MD, FAAFP, FASAM

Using Supervised Injection Facilities to Reduce Harm and Improve Access to Care

As clinicians traditionally involved in the treatment of HIV become increasingly involved in efforts to treat and cure hepatitis C, it is important that we all know about and are able to advocate for advances in harm reduction. Harm reduction, such as needle exchange, has already demonstrated the power of this approach in lowering the risk HIV transmission in people who inject drugs. Another successful harm reduction approach, taken in a number of other countries but yet to openly be practiced in the USA, is the establishment of medically supervised injection facilities in communities where public injection of illicit drugs, particularly opioids, is a problem. Supervised injection facilities have been shown to reduce overdose fatalities, improve linkage to care, and may also help reduce transmission of infectious diseases such as hepatitis C and HIV. Don’t miss this cutting-edge presentation from Dr. Sharon Stancliff, Director of the Harm Reduction Coalition.

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Stephen E. Goldstone, MD, FACS

Update on Common Anorectal Disorders in HIV Medicine

Patients in all primary care practices have anorectal complaints, but when they do, are we asking the right questions, and are we doing an adequate physical exam? Too often, both patients and providers may prefer to skip the exam, which slows or prevents the diagnosis and treatment of common problems, some of which may be sexually transmissible or lead to cancer. Don’t miss this important update by Steve Goldstone on anorectal problems in HIV medicine, and what you can do to help.

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Andrew G. Sikora, MD, PhD

Integrating Immunotherapy with the Standard-of-Care for HPV-related Head and Neck Cancer in HIV Patients

The major cause of throat cancer used to be environmental carcinogens, such as smoking, but now it is human papillomavirus (HPV) that is transmitted through orogenital sex. In fact, HPV-related cancer is the fastest growing cause of head and neck cancer in the general population. This risk is even greater in HIV-coinfected people, and antiretroviral therapy does not reduce the risk. Unlike anogenital cancer, we do not have screening cytology tests for early detection of throat cancer. The good news is that, even when diagnosed late, HPV-related cancers of the head and neck have a much more favorable prognosis than tobacco-related cancers have had in the past. This program will help acquaint you with the various types of immunotherapy that are increasingly being used in combination with standard-of-care chemoradiotherapy for HPV-related oropharyngeal cancer in HIV–positives.

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Todd T. Brown, MD, PhD

Optimizing Bone Health in the HIV-infected Patient

Are you evaluating your patients for osteoporosis aggressively enough? Bone loss begins in early adulthood in both men and women, so it is important for clinicians to evaluate risk factors for bone loss in both genders. But HIV infection increases this risk, resulting in the significantly higher prevalence of fracture in HIV-positive men and women as they age. Fortunately, there are antiretroviral treatment strategies you can recoomend to reduce the impact on bone, and there are other treatments you can offer to improve bone health in your patients. Don’t miss this important update on evaluating bone health in your HIV-positive patients and steps you can take to help them avoid disabling fractures.

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Elizabeth C. Verna, MD MS

Non-alcoholic Fatty Liver Disease and Steatohepatitis in HIV Disease

You are probably aware that iiver disease is the leading cause of non-AIDS-related death in our HIV-infected patients, but did you know that non-alcoholic fatty liver disease (NAFLD) is the most common liver abnormality in the absence of viral hepatitis? And that NAFLD is more common in HIV-positives than in HIV-negatives? This important program will help you recognize and stage NAFLD as part routine metabolic monitoring, and you will also learn about novel treatment strategies that in clinical trials, and treatments that may soon be available for your highest risk patients.

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Sara E. Dolan Looby, PhD, ANP-BC, FAAN

Coronary Heart Disease Risk in HIV: Clinical Research and Clinical Implications

HIV is associated with persistent inflammation that can impact cardiovascular disease (CVD) risk directly or indirectly through multiple pathways, especially in our aging patients. And this risk may be further exacerbated in our postmenopausal patients. The SMART Study showed that viral suppression with uninterrupted antiretroviral therapy can reduce non-AIDS associated illness including CVD. But what else can be done? A lot; so don’t miss this important program on the multifaceted approach to reducing CVD risk, including information about the REPRIEVE Trial-- the first large-scale randomized clinical trial to test a strategy utilizing statin therapy for preventing heart disease in people living with HIV, and the Follow YOUR Heart Campaign that will assess the relationship between reproductive aging, immune activation, cardiovascular disease risk and risk reduction among HIV-infected women with reduced ovarian reserve.

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Christine M. Durand, MD

HIV to HIV Transplantation: Hope in Action

There is a growing need for liver and kidney transplants in our HIV-positive patients, and wait-lists can be frustrating. But after passage of the HIV Organ Policy Equity (HOPE) Act, it is now possible to use HIV-positive organ donors for HIV-positive candidates in need of solid organ transplant. Christine Durand, from the HOPE in Action study team, and principal investigator of the first pilot study of HIV-to-HIV kidney and liver transplant at Johns Hopkins, is also leading a national consortium of more than 30 transplant centers in organizing efforts to study HIV-to-HIV transplant at sites across the country. Learn more about the management challenges for both recipients and donors in this important program.

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N. Patrick Hennessey, MD

35 Years of Looking at HIV/AIDS Through the Skin, and How To Diagnose and Treat Dermatological Manifestations of HIV Today

How often does a patient ask “Oh by the way can you take a look at something I noticed on my skin?” In primary care, skin complaints are common, and in HIV medicine, can be a sign of underlying coinfections and complications. With over 30 years of diagnosing and treating skin disorders in people living with HIV, Pat Hennessey has some important clinical tips for providers dealing with skin complaints in HIV medicine today.

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Christina M. Wyatt, MD

The Kidney in HIV Treatment and Prevention: Current Considerations

Kidneys. We all need them, but both acute and chronic kidney disease and their associated adverse outcomes are more common in HIV-positive patients. How can we help prevent or reduce kidney disease in our patients through diet and better management of antiretroviral therapy and other drugs? When should we be referring our patients for kidney biopsy? And how can we improve options and outcomes for our patients who may need dialysis or transplant? Don’t miss this important update on the prevention and management of kidney disease by Dr. Christina Wyatt.

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Joel Palefsky, MD, FRCP(C)

Prevention of Anal Cancer in HIV-positive Men and Women: Testing the Paradigm

The risk for HPV-related anal cancer is much higher in our HIV-coinfected patients, despite the many advances in HIV antiretroviral therapy. If given, the HPV vaccines will help prevent anal cancer in our younger patients, but our older patients need help too. Anal cytology and treatment of high-grade squamous intraepithelial lesions (HSIL) may help, and the ANCHOR study, which is now enrolling, is designed to test this hypothesis. Don’t miss this important presentation by Joel Palefsky on ways that you can help your patients prevent this grave complication.

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Christopher T. Coad, MD, and Donald P. Kotler, MD

AIDS-defining CMV Retinitis & Colitis

Older clinicians in our audience remember the horror of diagnosing and managing AIDS-defining CMV colitis and retinitis in the pre-HAART era, which have now become rare, thanks to the prevention of severe immune deficiency through early initiation of combination antiretroviral therapy for HIV. But severe complications of cytomegalovirus coinfection still happen in people with undiagnosed and/or untreated HIV/AIDS and we must forever be prepared to suspect, swiftly diagnose, and treat both HIV and the many manifestations of CMV in the setting of immune deficiency.

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Missak Haigentz, Jr., MD

Addressing the Rise of Non-AIDS Defining Cancers: Implications for Cancer Screening & Treatment

Since the beginning of the HAART era, and as our patients age with HIV disease, we are seeing more non-AIDS defining cancers (NDACs). In fact, HIV infection is associated with an increased risk for some NDACs. But there are some things we can do right now to prevent some of these cancers, including smoking cessation, hepatitis B vaccination, age-appropriate HPV vaccination, and treatment of hepatitis C. Join us for this important presentation on current challenges in the prevention, screening and treatment of NDACs in HIV-positives, with a special focus on lung cancer, prevention, and research.

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Peter W. Hunt, MD

HIV and Aging

From the horrors of AIDS we know so well from the not-so-distant past, aging while on treatment for HIV disease seems like a blessing. But are there surprises awaiting us in this journey? And are there ways that we can prevent complications and improve life expectancy in our patients as they continue to age? For a better understanding of the risks our patients face, and research that is underway to improve the aging process in HIV disease, don’t miss this important lecture by Peter Hunt.

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Anne K. Monroe, MD, MSPH

Diagnosing and Managing Diabetes in HIV-infected Patients

With an estimated prevalence of up to 14% in HIV-infected patients, diabetes is a leading cause of cardiovascular disease, blindness, end-stage renal disease, amputations, and hospitalizations for our patients. Regular screening for diabetes is important, and extra diagnostic caution must be taken in people living with HIV. When diagnosed, changes in lifestyle are critical, and medical management requires individualization. This clinically oriented lecture focuses on therapeutic options including recently approved drugs from new classes of drugs for glycemic control, as well as treatment strategies for optimal management of diabetes and prevention of diabetic morbidities in HIV medicine.

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Dan R. Drozd, MD

Update on Cardiovascular Disease Risk, Management and Prevention in HIV

HIV disease is likely associated with a 50% increased risk for cardiovascular disease, but independent HIV-related risk factors suggest that early and continuous antiretroviral therapy may reduce atherosclerotic cardiovascular disease risk in HIV, especially type 1 myocardial infarctions caused by atherosclerotic plaque rupture. In addition to the direct relation of HIV disease to atherosclerotic disease, questions about reported associations of certain antiretroviral drugs with myocardial infarctions, and the potential use of statins to decreased inflammation and promote plaque regression are discussed in this important program.

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Wafaa El-Sadr, MD, MPH

Confronting Ebola: Lessons from HIV

The recent outbreak of Ebola in West Africa and the fear it caused worldwide are a vivid reminder of reactions to the AIDS epidemic years ago. Both infections are of zoonotic origin, and capable of producing stigma, discrimination, fear and denial. In this program, Dr. El-Sadr discusses how lessons learned in the early years of the HIV epidemic, including community mobilization, human rights measures, workforce innovations, laboratory systems and outreach activities have contributed to a rational and science-based response to contain and control Ebola transmission.

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Todd T. Brown, MD, PhD

Update on Hypogonadism in Aging HIV-infected Men

Is testosterone replacement for hypogonadism overprescribed in the United States? Is it safe? The diagnosis of hypogonadism is not uncommon in aging HIV-infected men. So understanding the optimal screening recommendations as well as the potential risks and benefits of testosterone therapy, particularly in older men, is extremely important to their well-being. Join us for this important update by Todd Brown.

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David J. Back, PhD

Drug-drug Interactions in HIV and HCV in an Aging Population

Awareness of drug-drug interactions between agents used to treat HIV, coinfections such as hepatitis C, and co-morbidities such cardiovascular, renal, respiratory and metabolic disease, has never been more important. And the risk of adverse interactions of polypharmacy will increase as our patients age and their problem lists get longer. This comprehensive view from David Back, known world-wide for his extensive work in drug interactions at the University of Liverpool, is a must for anybody caring for people living with HIV.

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Christina M. Wyatt, MD

Update on the Kidney in HIV Treatment and Prevention

Who, among your HIV-positive patients, may be at higher risk for kidney disease? And what about your HIV-negative patients who have started or are thinking about PrEP? This program will help you recognize the limitations of current screening tests for kidney disease in your patients with and at risk for HIV disease, and understand the diagnosis and management of antiretroviral-associated nephrotoxicity.

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Robert J. Kaner, MD

Effects of HIV on the Lung

Pulmonary complications of HIV are not what they used to be, but they are no less important. The rapidly progressive opportunistic lung infections that were seen so often in the pre-HAART era, are rare now that earlier treatment of HIV is standard. But non-AIDS-defining bacterial pneumonias, malignancy and pulmonary hypertension continue to be serious problems, and accelerated emphysema is a growing concern due to the high prevalence of smoking in HIV-positives. In this program Rob Kaner discusses all of these issues and will help you improve early diagnosis of emphysema and COPD, critical to improved management and quality of life, and when possible, referral to appropriate research studies.

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Stephen E. Goldstone, MD, FACS

Anything Butt: Common Anorectal Disorders in HIV Medicine

In this lecture Dr Golstone discusses common complaints, workup, diagnosis, treatment and prevention of common anorectal problems in HIV medicine. If your patients ever complain about rectal pain or bleeding, do not forget to do cultures, a digital anorectal exam and if needed, anoscopy, or you may miss something important, something infectious, and something you can treat effectively in your office. To learn more about the skills you will need, as well as practical tips for preventing anorectal problems, please see this important and useful video presentation.

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Fabienne Laraque, MD, MPH

A Public Health Approach to Hepatitis C in NYC

As clinicians caring for people living with HIV, we are already aware of the increased risk of sexual transmission of hepatitis C in HIV-positive MSM, but we may also care for people born between 1945-65, for people with a recent or past history of intravenous drug use, tattoos, piercings, or who had a medical procedure with anesthesia from a multidose vial. With new rapid tests for HCV that are easily performed at the point-of-care, and all-oral interferon-free treatments for hepatitis C that are more effective and better tolerated, the role of the primary care provider in diagnosing HCV has never been more important. In this presentation, Fabienne Laraque discusses the epidemiology of HCV in New York City, and resources that will help all primary-care clinicians improve diagnosis and linkage to care.

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Joel M. Palefsky, MD, CM, FRCP(C)

Anal Cancer Prevention: Moving Forward, New Hope

Human papillomavirus is, by far, the most common sexually transmitted disease, but in HIV medicine there is a higher risk for HPV-related complications. Why? In addition to high risk of oral and anogenital HPV infection through shared sexual behavioral risk, HIV reduces the immune response to HPV, and direct interactions between HIV and epithelial cells potentiate new HPV infection. So, both primary and secondary prevention efforts, as well as early diagnosis and treatment are critical to the long-term health of our patients with and at-risk for HIV and HPV coinfection. Learn more about the epidemiology, preventive vaccines, physical exam, laboratory assessment, and treatment of HPV-associated complications in this video of Joel Palefsky’s presentation to PRN.

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Naomi Jay, RN, NP, PhD

Anal Cancer Screening and Prevention: Diagnosis, Treatment and Helpful Tips for HIV Providers

Anal cancer secondary to human papillomavirus (HPV) is an increasing problem, especially in HIV-positive men and women, despite successful treatment of HIV. But just like cervical cancer, anal cancer can be prevented if providers caring for people living with HIV promote and master anal cancer screening and prevention techniques. Following the inaugural meeting of the newly-formed International Anal Neoplasia Society (IANS), Naomy Jay journeyed from San Francisco to New York to share clinical tips and insights with our PRN audience, and has declared 2014 to be “The Year of the Anus.” We are certain that you will find this video of her lecture both engaging and helpful in the care of your patients.

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Todd T. Brown, MD, PhD

Osteoporosis in HIV: Is HIV Bad to the Bone?

Fractures are likely to be a major source of morbidity in people aging with HIV disease. Although the etiology is multifactorial, initiation of antiretroviral therapy has been associated with clinically significant bone loss. When and how can we best screen our patients for primary and secondary causes of osteoporosis? If found, how can we best treat patients with osteopenia or osteoporosis? In this program, Todd Brown discusses the causes, workup, management, and prevention of complications secondary to osteoporosis in HIV disease.

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Markella V. Zanni, MD

Immune-mediated Mechanisms of Heightened Cardiovascular Disease Risk in HIV: Clinical Research and Clinical Implications

In aging HIV-positive population, the percentage of deaths due to non-AIDS-defining illness, including cardiovascular disease, is on the rise. And the risk of myocardial infarction is 1.5 to 2 times higher in HIV-positive patients on antiretroviral therapy than in uninfected people, but why? In this presentation Markella Zanni discusses a new paradigm for conceptualizing elevated MI risk in HIV-- the paradoxical state of immune suppression and activation in HIV disease resulting in increased atherogenicity, and potential future immune-modulatory therapeutic strategies to mitigate this risk.

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Daniel R. Kuritzkes, MD

HIV Drug Resistance and Low-level Viremia

Persistent low-level viremia, when HIV RNA is detectable but less than 1000 copies/mL on repeated measurements, has been associated with new drug-resistance mutations when compared to prior genotyping. Providers should consider repeating genotypic testing especially if the viral load rises to 500 copies/mL or higher, because early detection and appropriate regimen switches may prevent further accumulation of resistance mutations. In this program, Dan Kuritzkes discusses virologic suppresson, incomplete virologic responses, blips, persistent low-level viremia, virologic rebound, virologic failure, and how to use this information to optimize antiretroviral therapy.

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Todd T. Brown, MD, PhD

Managing Diabetes in HIV-infected Patients: Current Concepts

Diabetes is common in HIV-infected populations, and prevalence is increasing. Early diagnosis and management of this complication can help prevent cardiovascular disease, blindness, end-stage renal disease, amputations, and hospitalizations. In this presentation Todd Brown discusses regular screening and diagnosis of diabetes HIV-positives, a step-wise approach to individualizing diabetes treatment, and lifestyle changes that can help prevent complications in this aging population.

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Timothy Wilkin, MD, MPH

Building Capacity to Prevent and Manage HPV-related Neoplasia in HIV-positive Patients

Human papillomavirus (HPV) is the most common sexually transmitted infection and HPV-associated anal cancer is an increasing concern, especially for HIV-infected patients. Anal HPV infection and associated anal intraepithelial neoplasia (AIN) are highly prevalent in HIV-infected men and women. Due to this increased risk, screening programs for AIN in all HIV-infected individuals, and routine vaccination of HIV-infected patients 9-26 years of age, should be strongly considered. Further research is needed to expand our treatment and prevention options for this life-threatening complication.

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Missak Haigentz, Jr., MD

Prevention and Management of Cancer in HIV-infected Individuals

With effective antiretroviral therapy, people with HIV are living longer and the burden of cancer in this population continues to increase. Malignancies are more common and occur earlier in HIV-positives than in the general population. The increased risk for both AIDS-defining and non-AIDS-defining cancers in HIV positive populations have clear implications for cancer prevention, screening and evidence-based therapies, yet patients with HIV and cancer have historically been under-represented on cancer clinical trials.

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David R. Boulware, MD, MPH, CTropMed

HIV Immune Reconstitution Inflammatory Syndrome: Pathogenesis and Pearls for Clinical Management

What are the risk factors for immune reconstitution inflammatory syndrome (IRIS) and how can you differentiate IRIS from other conditions that present in similar ways? In this program, David Boulware discusses clinical tips in the diagnosis of this important complication as well as its management and treatment.

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Christina M. Wyatt, MD

Preventing and Managing Kidney Disease in HIV-infected Patients

Who, among your HIV-positive patients, may be at higher risk for kidney disease? And how can you identify them? This program will help you recognize the limitations of current screening tests for kidney disease and nephrotoxicity in HIV-infected individuals, and understand the diagnosis and management of antiretroviral-associated nephrotoxicity.

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Samir K. Gupta, MD, MS

What Do We Really Know About Cardiovascular Disease in the HIV-infected Population?

Are our patients with HIV disease more likely to develop heart disease than the general population? And if so, is it HIV that increases cardiovascular risk or the medications we use to treat HIV? In this program, Samir Gupta discusses these issues as well as interventions that may reduce the increased risk of cardiovascular disease that many of our patients face.

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N. Patrick Hennessey, MD

Primary-care Diagnosis and Treatment of Common Dermatological Problems in HIV Medicine

Skin problems are common in primary care, and in HIV medicine they can be especially challenging. With 30 years of experience caring for people with HIV and AIDS as both an internist and dermatologist, Pat Hennessey shares his library of images and extensive clinical insight regarding everything from Kaposi's sarcoma to itchy red bump disease.

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Todd T. Brown, M.D., Ph.D.

Hypogonadism in Older HIV-infected Men: Current Concepts and Controversies

Hypogonadism in HIV-positve men of all ages is a common problem, and the long-term management of hypogonadism is of special concern as men age. Todd Brown returns to PRN to speak on this important endocrine abnormality, and if you have male patients nearing or over the age of 50, you will find this especially interesting and useful.

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Donald P. Kotler, MD

Gastrointestinal Disease in HIV Infection

Before the introduction of HAART, bowel disorders including KS, CMV, and diarrhea with wasting were more common, but understanding these complications can still be helpful, and even life-saving, if you recognize them. Don Kotler's knowledge and experience in the diagnosis and treatment of gastrointestinal disease from the very beginning of the HIV epidemic qualifies him to speak not only about the more common GI problems today, but also the less frequent complications we must consider, and never forget.

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Charles Flexner, MD

Learning From HIV: Pharmacology's Role In The Management Of Hepatitis C

Clinicians managing HIV disease have long been aware of  drug interactions that affect therapeutic levels or increase risk of toxicity. And now, the introduction of  antiretroviral drugs for the treatment of hepatitis C, called directly acting agents (DAA), demands a similar awareness of potential drug interactions, especially when treating HIV and HCV coinfection. Charlie Flexner, well known for his work in HIV drug-drug interactions, returned to PRN to discuss this emerging therapeutic challenge.

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Michelle Roland, MD

Update On Solid Organ Transplantation In People With HIV Infection

A true leader in access to liver and kidney transplants for HIV-infected patients with end-stage liver and kidney disease, Michele Roland returns to PRN to discuss all that has been learned since she first spoke on this subject at PRN in 2000.

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Marion Peters, MD

New Insights In Hepatitis B And HIV Coinfection

Hepatitis B coinfection should either be prevented through vaccination, or diagnosed and treated with HIV disease. Due to an increased risk for severe liver disease, drug resistance and hepatic flair in HIV-HBV coinfection, understanding the laboratory diagnosis and work-up for liver disease in our patients is essential. Marion Peters returns to PRN for an update on the diagnosis and co-management of these viral infections.

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Joel Palefsky, MD, CM, F.R.C.P.(C)

The Path To Anal Cancer Prevention: Where We Are And Where We’re Going

With increasing awareness of human papillomavirus (HPV) infection and its link to anal cancer, and the even greater risk for HIV-positive men and women, HPV prevention and treatment is an integral part of HIV medicine. Joel Palefsky returns to PRN to review what is known about anal neoplasia and preventing anal cancer.

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Stephen E. Goldstone, MD, FACS

Clinical Diagnosis And Treatment Of Common Anorectal Disease In MSM

The anorectal exam is a routine element of any comprehensive physical exam, but in the examination of MSM with or at risk for HIV disease, it is essential. In this lecture Steve Goldstone shows numerous photos of anorectal pathology and tells us what we can do about it.

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Donald P. Kotler, MD

Update from the 7th International Workshop on Adverse Reactions and Lipodystrophy in HIV

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Todd T. Brown, MD, PhD

Selected Endocrine Topics in HIV: Osteoporosis and Adrenal Insufficiency

The care of HIV-infected patients has become increasingly complex. Endocrine problems, such as osteoporosis and AI, have been frequently reported in the HAART era. Additional considerations may be required regarding the etiologies, diagnosis, and treatment compared with the general population. Further research is required to understand the intricacies of these problems in HIV-infected patients in order to provide optimal care.

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Alejandra Gonzalez-Duarte, MD, Katia Cikurel, MD and David M Simpson, MD

Selected Neurologic Complications of HIV and Antiretroviral Therapy

Despite the marked benefits of highly active antiretroviral therapy (HAART), up to 70% of patients with HIV develop neurologic complications of the central or peripheral nervous system. Neurologic consequences of HIV can be divided into primary and secondary disorders. The primary neurologic complications include HIV dementia in adults, encephalopathy in children, HIV-associated (vacuolar) myelopathy, and distal peripheral polyneuropathy. Secondary disorders are due to opportunistic infections resulting from HIV immunosuppression. The focus of the presentation and this article is limited to complications in adults.

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Justin McArthur, MBBS, MPH

Update on the Neurological Manifestations of HIV

With the continued widespread use of combination antiretroviral therapy, the incidence of various neurological complications of HIV disease seems to be declining. However, some complications continue to have a serious impact on the lives of HIV-infected patients, and the diagnosis of these neurological complications has become even more complex in recent years. Adverse events, stemming from the long-term use of antiretroviral therapy, can lead to neurological complications. And as HIV-positive people continue to live longer because of antiretroviral therapy, the risk of neurological complications stemming from comorbidities increases. In his presentation to the Physicians' Research Network (PRN), Dr. Justin McArthur discusses some of the most common neurological complications in the setting of HIV, most notably HIV-associated dementia, neurological opportunistic infections, neoplasms and peripheral neuropathy.

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Jeffrey S. Roth, MD, PhD

Restorative Treatment Approaches for HIV-Associated Lipoatrophy

For numerous HIV-infected patients, facial lipoatrophy has become a frustrating reality. While not typically life-threatening, it can lead to comorbidities and is one of the most stigmatizing complications of HIV. And because facial lipoatrophy is believed to be an adverse effect of antiretroviral therapy, it can significantly affect a patient’s “relationship” with his or her regimen, potentially resulting in poor adherence or termination of therapy altogether, even if the regimen is achieving a desired effect on viral load and CD4+ cell counts. Although the mechanism(s) by which lipoatrophy occur have not been concluded, progress is at hand. For example, a number of cosmetic modalities are being explored—and used—for the correction of facial lipoatrophy. For Dr. Jeffrey Roth, who has consulted with numerous HIV-infected patients dealing with lipoatrophy, the selection of the right product has been something of a difficult task and requires knowledge of the advantages and drawbacks of each approach.

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Scott Letendre, MD

Methamphetamine, HIV, and the Human Brain

Nearly all primary care providers in the United States, especially those with sizeable HIV practices, are aware of the very real dangers of crystal methamphetamine use. When it comes to methamphetamine and HIV, there are potentially multiple levels of interaction. First and foremost is the increased risk of acquiring HIV and other sexually-transmitted infections. Various research teams have documented that, when crystal meth is used in association with sexual activity, condoms are more likely to be abandoned, numerous sex partners are more likely to be had, and trauma to the lining of the anus and/or vagina is more likely to be experienced. In his presentation to the Physicians' Research Network, Dr. Scott Letendre of the University of California, San Diego, discusses significant research involving the effects of methamphetamine on central nervous system function in HIV-positive people.

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Liza King, MPH and Shama Ahuja, MPH

TB and HIV Coinfection: Current Trends, Diagnosis, and Treatment Update

The impact that HIV has on the pathogenesis of tuberculosis (TB) is clear. It is one of the most important risk factors associated with an increased risk of latent TB infection progressing to active TB disease. HIV-infected people have an annual risk of 5% to 15% of developing active TB once infected. TB is the most common opportunistic infection in people living with HIV worldwide. It is also the most common cause of death in HIV-positive adults living in developing countries, despite being a preventable and treatable disease. This paper describes the global epidemiology of TB and HIV coinfection with an emphasis on its relevance to New York City’s large immigrant population, followed by diagnosis and treatment challenges in these patients.

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Stephen J. Ferrando, MD

Managing Depression in HIV Disease, Viral Hepatitis, and Substance Abuse

Rates of depression and other psychiatric disorders are elevated in HIV-positive patients. Various studies have demonstrated high rates of depression in patients chronically infected with the hepatitis C virus. Substance abuse can cause depressive symptoms. Evidence exists for the efficacious treatment of depression. The risk of clinically significant drug interactions is outweighed by the risk of underdiagnosed and undertreated depression in HIV patients.

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Edward V. Nunes, Jr., MD and Allan Clear

HIV, Substance Use and Abuse: Treatment and Harm Reduction

An integrated approach to healthcare is needed when dealing with injection drug users. Clinicians can help reduce the risk of blood-borne viruses and soft-tissue infections by prescribing clean needles and educating users about safer injection methods. Other treatments include overdose prevention, medication therapies, methadone maintenance and buprenorphine therapy. Patient education and dialogue are important components to treatment

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Steven K. Grinspoon, MD

Use of Androgens in HIV-Infected Men and Women

Endocrine abnormalities—specifically testosterone deficiency—are nothing new among HIV-positive patients. Their significance came to light in the earlier days of the AIDS epidemic, particularly as a leading contributor to AIDS-related weight loss and wasting syndrome. While these complications are much less common today, thanks to the restorative benefits of antiretroviral therapy, androgen deficiency is still an issue that many HIV-positive individuals continue to grapple with. Fortunately, there have been a number of studies reported in recent years evaluating the safety and effectiveness of androgen replacement therapy in both men and women. Dr. Steven Grinspoon has played no small role in many of these studies, and thus was considered to be the ideal candidate to address the Physicians’ Research Network in NYC.

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Donald P. Kotler, MD

Lipodystrophy, What's Going On?

The etiology and pathogenesis of antiretroviral therapy-associated morphologic complications—most notably loss of subcutaneous fat and truncal obesity—remain something of a mystery. However, research continues to move forward. To bring PRN members up to date on the various work that is being done to better understand and manage the fat redistribution that is synonymous with HIV-associated with lipoatrophy, Dr. Donald Kotler took the podium at PRN to review some of the newest, most important data that will likely guide clinical research in this arena in the months and years to come.

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Tim Horn

Restorative Treatment for HIV-Associated Lipoatrophy: A Report from the 6th International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV

Lipodystrophy, which is peripheral lipoatrophy with or without central fat accumulation, is a side effect of HIV and antiretroviral therapy. Several presentations focused on restorative modalities for lipoatrophy at the 6th International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV. This article reviews poly-L-lactic acid (Sculptra), polyalkylimide (Bio-Alcamid), polymethylmethacrylate (PMMA), and autologous fat transfer (ATF).

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François Clavel, MD

Mechanisms of HIV Drug Resistance: A Primer

Resistance of HIV to antiretroviral drugs is one of the most common causes for therapeutic failure in people infected with HIV. Sadly, the emergence of drug-resistant HIV variants is a common occurrence—even under the best of circumstances—given that no antiretroviral drug combination studied as of yet is completely effective in shutting down viral replication. And there is no shortage of data indicating that the emergence of HIV drug resistance is clearly associated with adverse treatment outcomes.

Fortunately, the availability of drug-resistance testing has improved the ability of clinicians to deal knowledgeably with HIV drug resistance head on. On the research front, drug-resistance testing has enabled investigators to more effectively develop and study both novel and older therapeutics for the sake of tailoring treatment for patients with varying resistance profiles. In this respect, therapy can now be individualized, based on our evolving knowledge of drug resistance, drug-resistance testing, and state-of-the-art treatment approaches.

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Daniel R. Kuritzkes, MD

HIV Drug Resistance: New Insight and Updated Practices

Significant amounts of data presented at scientific conferences have shed additional light on the mechanisms and clinical significance of antiretroviral drug resistance. These include new reports from studies evaluating the incidence and lingering consequences of transmitted drug-resistant HIV, the significance of the K65R mutation in reverse transcriptase, the persistence of minor HIV variants harboring drug-resistance mutations, the selection of TAM pathways, as well as some heartening data indicating that lamivudine retains some activity against HIV carrying the M184V mutation.

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Joel Palefsky, MD, FRCP(C)

Diagnosis and Management of HPV-Associated Anogenital Dysplasia in HIV-Infected Men and Women

For clinicians involved in the management of HIV-infected individuals, human papillomavirus (HPV) coinfection and its sinister sequelae--squamous intraepithelial lesions and invasive cervical or anal carcinoma--are proving to be a significant challenge. This article reviews the epidemiology, pathogenesis, diagnosis, monitoring, and management of cervical and anal dysplasia in the setting of HIV. “Data continue to emerge, supporting the diagnosis and management of cervical and anal dysplasia in HIV-infected patients,” said Dr. Joel Palefsky, who returned to PRN to discuss recent advances in the study and clinical care of HIV/HPV coinfection.

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Marshall J. Glesby, MD, PhD

HIV and Cardiovascular Disease: Responding to the Risk

Dr. Marshall Glesby discusses the potential long-term adverse effects of HIV infection and its therapies, including the risk of cardiovascular disease. There have been high rates of metabolic and morphologic abnormalities seen in HIV-infected individuals taking antiretroviral therapy. However, there is confusion about whether or not the high prevalence of cardiovascular disease risk factors has actually resulted in a higher incidence of acute cardiovascular events, particularly myocardial infarctions and strokes. Dr. Glesby reviews the cardiovascular disease risk factors in HIV-infected patients, epidemiology of coronary heart disease and subclinical atherosclerosis, monitoring and management of cardiovascular risk factors, as well as the increased long-term risk of atherosclerosis.

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Sharon Stancliff, MD

Buprenorphine and the Treatment of Opioid Addiction

Illicit opioid addiction, which is no stranger to the HIV-infected population, is a complex illness, with relapses possible even after long periods of abstinence. With the passage of the Drug Addiction Treatment Act of 2000 and the recent approval of buprenorphine for the treatment of opioid addiction, primary care clinicians now have the ability to closely follow and treat their opioid-addicted patients.

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Isaac B. Weisfuse, MD, MPH, Kent A. Sepkowitz, MD, and Yehuda L. Danon, MD

Bioterrorism and Smallpox Vaccination: Experience and Considerations

Smallpox, which is believed to have originated over 3,000 years ago in India or Egypt, is one of the most devastating diseases known to humanity. For centuries, repeated smallpox epidemics swept across continents, decimating populations in their wake. The disease, for which no effective treatment was ever developed, killed as many as 30% of those infected. Between 65% and 80% of survivors were marked with deep-pitted pockmarks, most prominent on the face. Blindness was another complication. In 18th century Europe, a third of all reported cases of blindness were because of smallpox.

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Hélène C.F. Côté, Ph.D

Mitochondrial Toxicity in HAART

Mitochondrial toxicity has been associated with the use of NRTIs. Dr. Hélène Côté and her colleagues at the Vancouver B.C. Centre for Excellence in HIV/AIDS use a validated quantitative mitochondrial DNA assay to study the link between antiretroviral treatment and mitochondrial damage. Researchers use venous lactate measurements to study the relationship between hyperlactatemia and mitochondrial toxicity. Physicians may want to consider using routine venous lactate determinations in the monitoring of patients on NRTI-containing antiretroviral therapy.

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David T. Scadden, MD

Lymphoma in the Setting of HIV Disease

Lymphomas have long been some of the most devastating and complex opportunistic diseases of HIV infection. Their epidemiologies, both before and after the widespread use of HAART, have not been fully elucidated, and their various treatments, both in the setting of underlying immune suppression and used concurrently with antiretroviral therapy, have not been officially standardized. As for their etiologies and pathogeneses, there is still much to understand, including the role of Kaposi's sarcoma-associated herpesvirus (KSHV/HHV-8) and the Epstein-Barr virus (EBV) in the transformation of B-cells into lymphomas in the setting of HIV disease. But this much is clear: Lymphomas remain the most lethal complications of HIV disease (Chaisson, 1998). Yet it is also true that the incidence of HIV-related lymphoma has decreased in recent years. What’s more, the immune recovery associated with antiretroviral treatment has enabled many more patients to better tolerate chemotherapy and to live longer, healthier, and cancer-free lives after receiving what is potentially a grim diagnosis.

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Tim Horn and James Braun DO

Sexually Transmitted Diseases in Review: The 2002 CDC STD Treatment Guidelines

Sexually transmitted diseases (STDs) are among the most common infectious diseases in the United States today, affecting more than 13 million men and women in this country each year. This article reviews six common STDs—genital herpes, syphilis, gonorrhea, chlamydia, trichomoniasis, and bacterial vaginosis—that can be considered in broad groups according to whether their major initial manifestations are 1) genital sores; 2) urethritis or cervicitis; and 3) vaginal discharge. The diagnostic and treatment recommendations, unless otherwise noted, reflect those specified by the CDC in the 2002 update.

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Vincent Soriano, MD, PhD

Liver Disease in HIV: An Update

In the United States, it is estimated that 30% of the 800,000 people living with HIV are coinfected with the hepatitis C virus (HCV). Similar rates have been documented in Western Europe, although the actual number of HIV-infected individuals in some countries is not well defined. The magnitude and potential ramifications of HIV/HCV-coinfection is even more alarming in Spain, where Dr. Vincent Soriano suggested that at least half of the 130,000 HIV-positive people in the country are coinfected with HCV (Soriano, 2000). In turn, Spain has become a hotbed for coinfection research and has yielded studies that have helped to address some of the most important questions regarding follow up and treatment facing clinicians today.

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Yuan Chang, MD

The Plot Thickens: KSHV and Molecular Piracy

Perhaps the greatest advance in the area of AIDS-related malignancies has been the identification of human herpesvirus-8 (HHV-8), also known as Kaposi’s sarcoma-associated herpesvirus (KSHV). Since its discovery by Drs. Yuan Chang and Patrick Moore and their colleagues almost eight years ago, KSHV has been identified in virtually all AIDS- and non-AIDS-related KS lesions. At the same time, several research teams have identified the virus in a subset of other less common pathologic conditions, including primary effusion lymphomas (PEL) and multicentric Castleman’s disease (MCD). But while a definitive link exists between KSHV and these specific malignancies, the precise role that it plays in their development is just now coming into focus.

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Wafaa El-Sadr, MD, MPH

HIV and TB Coinfection

Tuberculosis (TB) is one of the most dreaded diseases that afflict mankind, yet over 50 years after effective drug treatment was introduced, more people died of TB last year than in recorded history—2 to 3 million deaths, or 1 death every 10 seconds. New recommendations including more aggressive screening and early treatment approaches, particularly among those at the greatest risk for TB: persons living with HIV and AIDS. This discussion of HIV and TB coinfection by Dr Wafaa El-Sadr includes treatment recommendations, drug-drug interactions and paradoxical response to treatment caused by immune restoration inflammatory syndrome.

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Michele Roland, MD

Safety and Efficacy of Solid Organ Transplantation in HIV-positive Patients

The success of highly active antiretroviral therapy (HAART) can easily be gauged by the fact that fewer patients are dying of AIDS-related manifestations than ever before. However, there has been a relatively sharp increase in the number of deaths from other complications, including end-stage organ disease. For patients with end-stage liver and kidney disease—not to mention patients with end-stage lung and heart disease—transplantation may be the only option.

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Susan Morgello, MD, Alessandro Di Rocco, MD & David M. Simpson, MD

Current Views on Common Neurologic Manifestations of HIV

The neurological complications of HIV disease most commonly seen are peripheral neuropathy, HIV-associated dementia (HAD), and AIDS-associated myelopathy. This review by Susan Morgello, Alessandro Di Rocco and David Simpson, discusses the clinical diagnosis and management of these debilitating comorbidities of HIV disease.

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Jeffrey S. Roth, MD, PhD

Common Cutaneous Complications of HIV Disease

Skin disorders are more common and more aggressive in HIV disease. Dr. Jeffrey Roth discusses the diagnosis and treatment of warts, molluscum, seborrhea, scabies, herpes, Staphylococcus aureus, Kaposi's Sarcoma and bacillary angiomatosis in the setting of HIV and AIDS.

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