C.A.R.E. Knowledge Blog

Missed Appointments with Your Care Provider

 

I thought this video update from CROI was worth re-posting here. The data that they talked about has to do with the relationship between missed clinical appointments and health outcomes. What was interesting is that the study was done by Kaiser-Permanente, so the population with HIV had health care. For patients who missed visits in the first year after their diagnosis, there was a two-fold increase in mortality. Missing a visit had a greater impact than having a CD4 count under 100. 

As we move into the era of "Test and Treat," we need to stay focused on everything necessary to keep people in care. What they refer to in the video as the treatment cascade is essentially this: 

Not everyone who tests positive gets enrolled in care, and of those enrolled, some aren't getting lab work done. In the old guidelines for treatment, providers often waited until CD4 counts dropped, so some weren't eligible for anti-retroviral therapy. Another barrier not shown is that doctors are often reluctant to offer HIV medications to people who are dealing with untreated mental health issues, housing problems, and illegal drug use. Then there are issues around people sticking to their regimen through the fist bumpy weeks of immune reconstitution and short-term side effects. Then there are the issues that can arise in anyone's life--loosing a job or health insurance, personal problems, and more that can play havoc with adherence. We'll need to look at all these issues, identify barriers, and find ways to overcome them if we expect the pills to do their work.

 

HIV: Thirty Years and Counting

 
The mainstream media are starting to cover stories on HIV and AIDS as we approach the 30th anniversary of the first reports of a handful of gay men in Los Angeles showing symptoms of an opportunistic infection. A few days after the June 5th anniversary, forty of the world's leaders will gather at the United Nations to address the progress made--along with the unmet need. 

To put things in perspective, if we had an AIDS quilt for everyone living or dead from HIV it would cover all of Washington DC instead of just the grass along the Capitol Mall. One of the highlights of the past few weeks is the news that getting HIV-positive folks on medication greatly reduces the risk of transmission. But to get treatment to play a role in prevention, we would need the one in four who are positive and don't know it, to get tested. 

Here at the CARE program we offer free confidential testing for HIV Monday through Friday from 9:00 am to 4:00 pm by appointment. Our number is (562) 624-4900. We use Ora-Quick testing, so you'll have your results in 20 minutes and because it's an oral test for HIV, there's no needles. 

 

New Support Group for HIVHep-C Co-Infected in Long Beach

The CARE Progam now has an education and support group for individuals co-infected with both hepatitis C and HIV. With the approval of new therapies, and a new co-infected HCV/HIV clinic at the CARE Program, now is an opportune time to look into treatment options, voice concerns, and hear from others who are contemplating hep-C treatment, or are on treatment and looking for support and information on ways to manage side effects, and those who have successfully completed their course of therapy. 

The group meet the 2nd and 4th Wednesday of the month from 1:30 to 3:15pm at the CARE Clinic, 1043 Elm Avenue, Suite 300, Long Beach, CA 90813. The group includes an education component along with peer discussion and support. 

For more information, contact Paul Lovely at 562-624-4963.

When to Start HIV Therapy

Of course, the decision to start HIV therapy is a personal one, taking to account current medical information, the reccommendation of your health care provider, and your own ablility to stick with a pill taking regemin for the rest of one's life.

The two main laboratory factors are your viral load and CD4 or T-cell count, used as an indicator of your current level of immune function and the speed at which the disease progresses. When I was at the International AIDS Conference in Geneva a researcher used a train approaching a broken bridge as a metaphor for the two numbers. When the train (a metaphor for a person living with HIV) reaches the broken tracks, they are at a point more suseptible to illness; in terms of a CD4 count, that would be around 200 or less, when one becomes at risk for opportunistic infections. The higher the CD4, the further the train is away from the edge. The speed of the train is the viral load; the higher the viral load, the faster you move to the edge.

Once someone begins HIV therapy, the train slows down, stops, then begins to back away from the edge. Since effective therapies have been only been around for fifteen years, we don't know what the long-term effects will be. If missed doses didn't lead to treatment failure and if the drugs were side-effect free, the CDC would probably recommend that everyone with HIV should start on meds. With our current knowledge, the recommendation is to start on meds when the CD4 count drops below 500. In the EU, their more cautious recommendation is to start at 350. 

But is it better to start sooner or later? In the April 19, 2011 issue of The Annals of Internal Medicine researchers compared data from multiple studies in the United States and Europe. As it turns out, significantly reduces HIV patent's risk of progressing to AIDS. In an accompanying editorial, the authors point out that in addition to fewer AIDS-defining illnesses, starting more people on therapy sooner will reduce the number of new cases of HIV. In addition to the personal health benefit, starting early on HIV meds benefits the community.

Thinking back to the early days of the epidemic--before medications and HIV testing--they way we slowed transmission was to protect ourselves and protect each other. It seems that caring for the community at large is a good idea whose time has come again. 

Serosorting and HIV Transmission

Two interesting research papers came across my desk this week. The first, Characteristics of HIV epidemics driven by men who have sex with men and people who inject drugs (Wilson et al) used innovative mathematical modeling techniques to evaluate various strategies for reducing the number of new HIV infections in adversely affected subpopulations. Since the first signs of the virus in the early eighties, we’ve learned to identify and test for HIV, determine the body fluids and behaviors that contribute to a higher probability for transmission, and then develop behavioral interventions that would reduce risk. In the early years—before it was even possible to test for HIV—the mantra was, “Since we don’t know who’s infected, assume all your partners are positive, or that you may be positive yourself.” The underlying morality of this model was showing care and respect for ourselves along with showing care and respect for the consenting adults we had sex with.

Over the years, educational programs, counseling and testing, outreach, safer-sex workshops and the like have met with varying degrees of success. Just having a gander at our fellow residents struggling with obesity, addiction, and other preventable health problems should make it evident that changing behavior isn’t simple or easy. With the advent of effective therapies for HIV in the mid-nineties, and the resulting reduction in viral load and transmissibility of the virus, another model for reducing new cases of HIV emerged. Currently known as Test and Treat, the underpinning idea is to identify those who are infected through easy access to regular testing, and then get those who test positive on medication. By reducing the community’s viral load, less transmission will occur, and the number of new cases will go down.

In the Wilson paper they look at serosorting, which is based on the idea of choosing a partner with the same HIV status. The logic behind this is that if two HIV-negative persons have sex, there is no HIV to transmit, and if two HIV-positive partners have sex, no new cases of HIV will occur. One issue noted with this practice is that it can create a type of “viral apartheid,” and labels like “disease-free, you be too,” can exacerbate stigma for those who are living with the virus. The other fly in the ointment becomes those individuals who have never tested and those who have had a previous negative test, but later became infected. Since they see themselves as still being a part of the negative camp, limiting oneself to other “negative” partners can be fraught with peril. Wilson modeled the acquisition of HIV associated with serosorting and found that,

 “… (It) is only beneficial when the percentage of undiagnosed HIV-infected MSM is below 20%. These modeling studies are consistent in their findings and have assessed sero-sorting to be effective at the population level in developed setting with high testing rates such that there are a minority of HIV infections which are undiagnosed. However, in most parts of the world serosorting with casual partners is likely to increase risk of HIV acquisition.”

 The other paper, Predictors of Unrecognized HIV Infection among Poor and Ethnic Men Who Have Sex with Men in Los Angeles (Young et al) notes that approximately 25 – 48% of HIV+ people may be unaware that they are positive. The percentage of persons unaware of there HIV positive status is much higher in younger age cohorts than persons over 35. Here in Long Beach, County epidemiologists estimate that one out of four infected people don’t know they’re positive. Young’s paper also notes that when subjects were assessed for homonegativity (that means negative perceptions and feelings about homosexuality) higher negative feelings were associated with not being aware of one’s HIV-positive serostatus.

In places like San Francisco where Community Viral Load is monitored, and the Test and Treat model is aggressively promoted by public health officials, the number of new HIV infections has fallen by half, while the rates of other STD continued to climb.

Taken together, these two papers point out the need for more HIV testing, and regular testing for those most at risk. Choosing a partner because of their perceived or posted negative status may actually increase one’s risk of acquiring HIV.

Here at the CARE Program, we offer free confidential testing for HIV, with results in twenty minutes. Call for an appointment at (562) 624-4900. We test Monday though Friday from 9:00 to 11:30 and 1:15 to 4:00. If you test positive, CARE offers comprehensive medical, dental, mental health, and social services. We can also help you enroll in benefit programs to help pay for your care.  

 

HIV and Hep C Research Update

Coming up in May, Dr. Eric Daar from Harbor-UCLA will be presenting an update on the latest advances in treatment, prevention and care. By the middle of this year there will be two new drugs available for the treatment of hepatitis C, both which show better treatment outcomes when added to the existing two drug therapy. For some patients it may allow for a shorter course of treatment, halving the time from one year to six months. 

The community forum will be taking place at the Long Beach Courtyard Marriott, located at 500 East First Street, Long Beach, CA 90802. The update is from 6:00 to 8:00 pm on Thursday, May 19th, 2011 and dinner will be served.

To reserve your place, call Paul Lovely, the CARE Program's Treatment Advocate at (562) 624-4963.