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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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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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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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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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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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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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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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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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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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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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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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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.