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Topics, Trends & Updates
July 2016
Hot Topics
HCV
HIV
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Press Release
Policy Update

Governor Cuomo Announced 
that All HIV-Positive Individuals in
New York City Will Become Eligible
for Housing, Transportation, and Nutritional Support: Expanding Preventive Care is Vital
to the End the Epidemic Initiative
The New York State Department
of Health Issued a Policy Statement
Defining Program Eligibility by HIV Status, 
reiterating the guideline recommendation 
to initiate HIV-related care and treatment immediately upon diagnosis. 
Trends
The Conspicuous Gap Between HIV Care and HIV Public Health
By John G. Bartlett, MD, Medscape, June 20, 2016
 
" . . . HIV/AIDS was essentially an untreatable disease until 1996, when Dr Roy Gulick, in a stunning presentation, reported the results of the Merck 035 trial, which used "triple therapy" with indinavir, zidovudine, and lamivudine. It seemed clear then that we were well on the way to conquering this major modern plague. The subsequent progress was fast and impressive. . . . Yet, a humbling concern is that, although loaded with extraordinary gains, the past 20 years have been a big disappointment from a public health perspective. During that time, we have continued to see approximately 50,000 new HIV infections every year, and 155,000 HIV-positive persons in the United States are unaware of their infection. PrEP works well in trials, but implementation of this strategy has performed poorly, and attempts for a vaccine or cure continue to frustrate. This situation is unlikely to change in the foreseeable future without a major change in strategy." 
Update: What We're Reading

Blood Pressure Control and Medication Adherence among People Living with HIV

Christopher J. Hoffmann, MD, MPH, Johns Hopkins University

Hypertension is a common comorbidity among people living with HIV (PLH), affecting 20% to 43%. This proportion is likely to grow with the aging of the PLH population (see Okeke et al., CID 2016; PMID 27090989, for time trends in HTN diagnosis among PLH). Recent studies suggest the need to educate patients about the risks of uncontrolled hypertension (HTN).

The pivotal 2015 SPRINT study [NEJM 2015; PMID 26551272] quantified a reduction in mortality and cardiovascular outcomes with tight versus routine HTN control among individuals who were not HIV-infected. This large, randomized, controlled trial involved 9,361 individuals 50 years of age and older with a systolic blood pressure (SBP) between 130 and 180 mmHg (median 140 mmHg) and cardiovascular risk factors other than diabetes. Participants were randomized to one of two arms, with results reported after a median 3.3 years of follow-up. Results are summarized in the table below.
 
 
Treatment Arm
Participants
Standard
Intensive
Number
4,683
4,678
Target SBP mmHg
<140
<120
Median no. HTN meds
1.8
2.8
Serious adverse events
2.5%
4.7%
No. reaching primary clinical outcome*
319
243








*Hazard ratio = 0.75, p < 0.001

The primary clinical outcome was defined as one of the following: myocardial infarction, acute coronary syndrome, stroke, heart failure, or cardiovascular death. All-cause mortality was also substantially lower (hazard ratio = 0.73, p = 0.003) in the intensive treatment arm. Approximately 38% of participants in each arm experienced side effects, although serious adverse events, such as hypotension, syncope, electrolyte abnormalities, and acute kidney injury, were higher in the intensive treatment arm. In all, the SPRINT study demonstrated that a goal of SBP<120 mmHg reduced mortality and cardiovascular outcomes among individuals over the age of 50.

The PLH population already on antiretroviral therapy (ART) has experience with multiple medications and with regimens that require adherence as strict as those for HTN. 

Weiss and colleagues [JAIDS 2016; PMID 27171742] recently studied the effects of adding both medications and exhortations for strict adherence to the treatment regimens of HIV-infected participants. The researchers recruited 117 participants with HIV and HTN and 37 participants with HIV and chronic kidney disease (CKD) and followed them with health belief surveys and electronic monitoring of adherence to HIV, HTN, and CKD medications. At the 10 week follow-up, 88% of participants had virologic control and 60% had HTN control (SBP<140 mmHg). However, there was no difference in adherence to ART and HTN medications.

ART adherence was associated with participants' reports of greater understanding of HIV, the perception of greater severity of HIV, and the view that ART medications are more necessary than medications for other conditions. This study suggests that HTN control is worse than virologic control among PLH, even though adherence to the two types of medication may be similar.

Taken together, the results of these two studies suggest that clinicians caring for PLH may need to intensify efforts to educate patients about HTN and its consequences and the potential benefit of a blood pressure even lower than the standard <140 mmHg. 
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New York State Department of Health AIDS Institute
In collaboration with JHU School of Medicine, Division of Infectious Diseases
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