September 28, 2012

HIV Therapy Universally Effective

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By Michael Smith, North American Correspondent, MedPage Today

Published: September 28, 2012

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

HIV therapy is equally effective regardless of race, ethnicity, sex, or economic class -- as long as patients can be engaged and retained in care.

The finding -- apparently at odds with reports of major disparities in HIV across the U.S. -- comes from a 15-year analysis of data from a long-standing and highly regarded Baltimore clinic.

Over that time, outcome differences along race, sex, or economic lines have steadily fallen, according to Richard Moore, MD, and colleagues at Johns Hopkins University.

By 2010, the proportion of patients getting triple-drug therapy, the average viral load, the rate of opportunistic infections, the average count of CD4-positive T cells, and the risk of dying were all similar across all demographic and HIV risk categories, Moore and colleagues found.

And a 28-year-old patient in care in 2009 in the Johns Hopkins HIV/AIDS Service could expect an additional 45 years of life, the researchers reported online and in the Nov. 1 issue of Clinical Infectious Diseases.

"What we have found is very optimistic," Moore told MedPage Today. "Our treatments really can work for everyone who's HIV-infected."

The catch is overcoming barriers that prevent patients from remaining in care, Moore said. Most disparities in outcomes arise from a failure to retain patients, and the current study only applies to the 6,366 patients who were engaged in care at Johns Hopkins from 1995 to 2010.

But in many cases, he said, "I think it would generalize" -- especially to other specialized centers that have been able to use federal money available under the Ryan White Care Act, to overcome patient barriers to care.

Using that resource, the Baltimore clinic is able to offer -- along with HIV care -- primary care, specialties such as substance abuse and mental health, and supportive services, including nutrition, treatment adherence, emergency services, and transportation.

In 2010, 92% of the clinic's patients were low-income and 75% were black -- two groups that are hardest-hit by HIV.

Indeed, the "remarkable outcomes" in Baltimore and similar centers are likely a result of Ryan White support, commented Michael Saag, MD, of the University of Alabama at Birmingham.

In an accompanying editorial comment, he noted that Ryan White support can be used to cover the cost of outpatient care and medications, including such things as psychology/psychiatry, substance use treatment, adherence counseling, and social services.

Most other disease-specific and primary care clinics don't have such extra support, Saag noted, "and this is likely a fundamental reason why the poor and disadvantaged in the U.S. have health disparities that cause disproportionately worse clinical outcomes than those with means."

Moore said other factors also play a role -- including improved treatments and better clinical understanding of HIV. But the absence of Ryan White support, he said, "would be a big blow to our program" assuming there were no compensating changes to healthcare.

The Ryan White act is due for reauthorization next year, Saag noted. The entire healthcare system needs an overhaul, he said, but until then "we will desperately need the support from (the act) to continue filling the holes in our primary care safety net for HIV patients."

Moore and colleagues reported that, as of 2010:

  • 87% of their patients were receiving antiretroviral therapy.
  • The median serum viral load was less than 200 copies of HIV RNA/mL.
  • The median CD4 was 475 cells/mm2 of blood.
  • The rate of opportunistic illnesses was 2.4 per 100 patient-years.
  • The mortality rate was 2.1 per 100 patient-years.

By and large, they reported, there were no differences by demographic or HIV risk group. The exception was that people infected through injection drug use had a lower CD4 count and a higher viral load than other risk groups.

The researchers cautioned that the study focused on a single center and may not apply more widely. In any case, they added, the results "certainly do not generalize to HIV-infected people in the U.S. who have not engaged in HIV care."

"Nevertheless," they concluded, "we believe that our results are an important demonstration of what can be achieved by contemporary HIV care in patients who are retained in care."

The study was supported by the National Institutes of Health. The journal said the authors reported no potential conflicts.

The journal said Saag reported no potential conflicts.

Primary source: Clinical Infectious Diseases
Source reference:
Moore RD, et al. "Improvement in the health of HIV-infected persons in care: Reducing Disparities" Clin Inf Dis 2012; DOI: 10.1093/cid/cis654.

Additional source: Clinical Infectious Diseases
Source reference:
Saag MS. "Viva no différence!" Clin Inf Dis 2012; DOI: 10.1093/cid/cis656.

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