Assessment of HIV Comorbidities Andrew Carr, MBBS, MD, FRACP, FRCPA HIV, Immunology and Infectious Diseases Unit Clinical Research Program, Centre for Applied Medical Research St. Vincent’s Hospital and University of New South Wales Sydney, Australia
Assessment of HIV Comorbidities. Andrew Carr, MBBS, MD, FRACP, FRCPA. HIV, Immunology and Infectious Diseases Unit Clinical Research Program, Centre for Applied Medical Research St. Vincent’s Hospital and University of New South Wales Sydney, Australia. Disclosures. - PowerPoint PPT Presentation
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Assessment of HIV Comorbidities
Andrew Carr, MBBS, MD, FRACP, FRCPAHIV, Immunology and Infectious Diseases UnitClinical Research Program, Centre for Applied Medical ResearchSt. Vincent’s Hospital and University of New South WalesSydney, Australia
Why comorbidities matter• More common cause of morbidity and mortality than AIDS in patients on ART• ART accelerates comorbidities that are common, eg, CVD, CKD, fractures• Increase complexity of care
– reduce ART adherence– reduce ART options– increase in polypharmacy for those ages 45+
• Reported in only ~25% of initial ART trials, and underassessed in routine care, so underappreciated
Gifford AL, et al. J Acquir Immune Defic Syndr. 2000;23(5):386-395; Presented by DAD study group at IAC. July 2010. Vienna, Austria. Hasse B, et al. Clin Infect Dis. 2011;53(11):1130-1139; Krentz HB, et al. Antivir Ther. 2012;17(5):833-840; Presented by Lee, et al. ADAP Data Report Workshop. 2012; Presented by Shahmanesh M, et al. ADAP Data Report Workshop. 2013.
Key Principles
When and Who• Pre-ART and pre-ART change in all patients• On ART
– every patient once stable (about 3 months)– test interval variable and proportional to ART type and to underlying risk in
individual patient– don’t order a test
if you don’t know what to do with the result if the result will not change management
• So, likely that most useful screening will be most useful in older HIV+ adults
Calculator Period Outcome(s) Risk (%)Current Optimal
Framingham 10 years
myocardial infarction (MI) 5 ..
D:A:D 5 years MI 5 ..
ACC-AHA10 years
MI, ischemic stroke or CV death 8.1 2.1
Life-time
MI, ischemic stroke or CV death 50 5
Variable results with different equations
Cardiovascular Disease
• 50-year-old white man on LPV/r for 5 years• Total cholesterol = 5.5 mmol/L (99 mg/dL), HDL-C = 1.1 mmol/L (20 mg/dL)• Systolic BP = 125 mm Hg• Nonsmoker• Diabetes mellitus controlled
What IntervalOrgan CVD ACC-AHA (including diabetes) 1-2 years Renal eGFR / UProt:Cr / other causes 6 months Bone DXA / FRAX / other causes 2-5 years CNS Cogstate?; LP / MRI if symptomatic 12 monthsCancer Breast / bowel / lung / liver As in HIV-
Pap smear 1-2 yearsDrug d4T / AZT Lipoatrophy / fat accumulation 6 months PI GI symptoms every visit EFV CNS symptoms every visit RAL Muscle pain / weakness every visit