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Studies Highlight Role of Primary Care in HIV-Positive Population


 

FROM THE ARCHIVES OF INTERNAL MEDICINE

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).

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