Hot Topics in HIV Comorbidities and Treatment
In this multidisciplinary video roundtable discussion, Jeffrey Kwong, DNP, MPH, ANP-BC, interviews pharmacist Milena Murray, PharmD, MS, psychologist David Vance, PhD, MGS, MS, and internist Jonathan Appelbaum, MD, about new results from the Swiss HIV Cohort Study released at CROI 2023, trends in neurocognitive issues and aging with HIV, and the movement towards long-acting agents for the treatment of patients with HIV.
- Surial B, Chammartin F, Damas J, et al. Impact of integrase inhibitors on cardiovascular events in persons starting ART, Talk presented at: Conference on Retroviruses and Opportunistic Infections (CROI) 2023; February 19-22, 2023; Seattle, WA. Accessed March 10, 2023. https://www.croiconference.org/abstract/impact-of-integrase-inhibitors-on-cardiovascular-events-in-persons-starting-art/
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Jeffrey Kwong, DNP, MPH, ANP-BC, is a professor in the division of advanced nursing practice at Rutgers School of Nursing (Newark, New Jersey) and a practicing clinician at Gotham Medical Group (New York, NY).
Milena Murray, PharmD, MS, is an associate professor of pharmacy practice at Midwestern University College of Pharmacy and a system-level HIV/ID clinical pharmacist at Northwestern Medicine (Chicago, IL).
David Vance, PhD, MGS, MS, is a professor and psychologist at the University of Alabama at Birmingham School of Nursing.
Jonathan Appelbaum, MD, Chair of the Department of Clinical Sciences and professor of internal medicine at Florida State University College of Medicine (Tallahassee, FL).
Jeffrey Kwong, DNP, MPH, ANP-BC: Hello everyone and welcome to our Multidisciplinary Roundtable discussion on HIV management. I'm your moderator Dr Jeffrey Kwong, and I'm a nurse practitioner and a professor in the Division of Advanced Nursing Practice at Rutgers University in Newark, New Jersey, and a practicing clinician at Gotham Medical Group in New York City.
Joining me today are three distinguished colleagues, Dr Jonathan Applebaum is a physician who is chair of the Department of Clinical Sciences, and a professor of internal medicine at Florida State University College of Medicine in Tallahassee, Florida.
Dr Milena Murray is a pharmacist and associate professor of pharmacy practice at Midwestern University College of Pharmacy, and a System-Level HIV/ID pharmacist at Northwestern Medicine.
And finally, Dr David Vance is a psychologist and professor at the University of Alabama and Birmingham School of Nursing, and is a leading researcher in the field of neurocognitive effects of HIV.
Thank you all for joining me today. So for this segment, we'll be focusing on the role of chronic conditions and mental health, and aging in persons with HIV. As many people know, people are doing very well these days on antiretroviral therapy and are aging into older adulthood. In fact, the estimates are that, in the next decade or so, more than 70% of persons with HIV will be 50 years or older, and that has a lot of implications for us as HIV providers, primary care providers, and geriatric providers.
And one of the things that I think comes to mind, is really the issue of managing other chronic conditions such as heart disease, metabolic disorders, as well as mental health disorders, which are becoming more and more important.
One of the chronic conditions that people are concerned about is cardiovascular disease, and the question of whether potentially, integrase inhibitors affect cardiovascular risk, has been uncertain. And I know that there was some recent data presented at CROI 2023, recently from the Swiss HIV cohort study that might have shed some light in terms of the risk or non-risk of integrase inhibitors and cardiovascular disease. John and Milena, what are your thoughts on the recent core data on CVD risk and INSTI use?
Jonathan Appelbaum, MD: It was kind of interesting. The poster I think, or the abstract generated a lot of buzz. This is my take on it, the raw data showed that there in fact, was an increase in cardiovascular events in patients who took integrase inhibitors. But then, if they drilled down the data and did I think a nice job of trying to eliminate some of the confounding factors and in that final data, actually, the integrase inhibitors did not have an increase in cardiovascular risk. The cohort that they looked at who was on integrase inhibitors, also had a higher use of drugs like Abacavir. And so whether or not that played a role, we all know about the issue with Abacavir.
On the other hand, both cohorts were pretty well randomized to other risk factors like smoking, hypertension, diabetes, and hyperlipidemia. So I think it's interesting data. Like anything, it's the first time we've seen data like this and I think all the other large data sets, NA-ACCORD and some of the other ones, DAD, will probably be looking at their own data. And I suspect that in the coming year or two, we're going to see other cuts of their data on this.
Milena Murray, PharmD, MS: So my interpretation would be, and John so nicely outlined the conclusions from it, I think this is where we really have to think about beyond undetectable. So we know that pretty much whatever medication regimen we choose, we're going to see undetectability unless there's some other issue with resistance or adherence. So I think that this data helps to open up our own personal algorithms to say, "Okay, this person in front of me, do they have those risk factors? Do they not have risk factors? What would push me one way or the other?" Because I don't think we can say with a blanket statement, "Oh, this drug does not cause, this drug does cause this." Because even with the evidence, we have to look at the person that's sitting in front of us. So I think this helps to tailor our personal algorithms, but I think that we are just at the tip of the iceberg with all of these metabolic issues with many of our regimens, and trying to really figure out what is going to be the best for the person sitting in front of you, is going to be very important.
Dr Kwong: Any of this information impacts the information that you share with patients or how you might approach a patient who has concerns about INSTI use? John?
Dr Appelbaum: I actually, was going to pose the question to Melina and you kind of posed it. I guess the bottom line is, is this going to change what we're already doing? I think there are so many advantages to using integrase inhibitors that with this data, I'm personally not going to change my practice. It does give me pause to think that maybe there might be other anchor drugs that potentially, may be also a viable option. And so the question comes up whether Doravirine, which so far seems to be a fairly clean drug, maybe a possibility for a patient where you're really concerned about their cardiovascular risk.
But personally, we have come a long way in caring for our patients with HIV, and the integrase class, I guess in my opinion, can't be bested as far as potency and virtual lack of significant side effects.
Dr Murray,: In terms of patient counseling, I think we do need a little bit of a culture shift. With some of our older agents, we know we were really letting people know what was going to happen, right? You're going to have diarrhea, you're going to have foggy memory, eta. And then we sort of moved into the era of integrase inhibitors and now we're looking at clinical trial data and we're seeing very, very low percentages. But I think what's important to remember is that some people will experience these things and so, depending on the percentage, we really should let them know. And I think it should be a shared decision-making process with the person, especially knowing what's important to them. Obviously, if they're performing a job like a bus driver and they can't get off the bus to find a bathroom or something like that, it's a different story for someone who maybe works an office job. I think there's just more, again, of that individualized counseling per person.
I think in terms of the data though, that again, it really is going to depend on if I have someone in front of me, what are the options, and really what's the worst-case scenario? So if we swing the one way and think this is going to cause an event, have they already had two MI's, myocardial infarctions, or something like that? I think the data overall, I agree, I think the integrase inhibitors are a very safe and effective drug class, but I think we just have to remember that sometimes, you do have that person in front of you, who if they do get an upset stomach, they're going to want to stop their meds. So, we really have to let them know and talk to them, without giving too much information or scaring them from taking the drug.
Dr Appelbaum: And I agree, Melina and I think we're already doing that, at least I'm already doing it. I'm sure you are, regarding weight gain. And clearly, women, particularly African-American women, are more likely to have significant weight gain. That's part of my informed consent with my patients who may suffer that side effect. So, I think you're right. I think we will have to disclose that we're not sure, but there may be a signal of cardiovascular risk and then look at the individual cardiovascular risk for the patient who's sitting in front of us.
Dr Murray: And one more thing I'll throw out there is, for all the clinicians who are in school or in early training, is to really think about things like this. Because I think now that education is, oh, there are no side effects, there's no anything with these newer drugs, and I don't think that that's true. So I think it is really important for us to be educated as well.
Dr Kwong: Great, thank you. Switching gears just a little bit, from cardiovascular disease to brain health. David, one of the concerns that we're seeing as people age into older adulthood is the concern over cognitive changes. I know this is your area of research and specialty. Can you briefly tell us a little bit more about the current trends in HIV-associated neurocognitive disorder (HAND) and what we, as HIV providers or primary care providers can do to help address this?
David Vance, PhD, MGS, MS: Sure. There are a lot of emerging trends in the neurocognitive field. One of the ones that I think is pertinent here is the study of cognitive profiles. Before we would always think of people, who either have HAND or don't have HAND. HAND is an HIV-associated neurocognitive disorder, and we have to think about what HAND truly is. It's really not a disease. It's really just a classification of how well someone's performing on some cognitive tests. And so we're really looking at it more broadly now. We're looking at different profiles. For example, sometimes people may think, "Oh, if you have HAND, you forever have HAND." And that's just not the case. We know that many people who may meet the criteria for HAND today, may not meet it a year from now or vice versa. And just because someone has HAND doesn't mean they will progressively get worse.
What is a concern is, if people think that they have HAND. I really wouldn't worry about it if someone was diagnosed with HAND, unless it was much more severe. So I think one thing that clinicians can do is just, first of all, assuage everyone's fears. If you have some mental fog as you age, that's okay, as long as it's not really impacting your everyday functioning. Some of the work that we've done, we've shown that many older adults as they age with HIV believe that they're going to have some cognitive problems. That's just not necessarily the case. I think what we have also shown is that a lot of people don't know how to protect their cognitive functioning as they age. And there's a host of things that people can do.
We do a lot of work in cognitive training, a lot of those computerized cognitive training programs. But one of the best things you can do is physical exercise or reduce alcohol intake or things of that nature. Those are the sort of things that we really want to focus on. It's just general, overall good health will support overall brain health.
Dr Kwong: Great. And obviously, those things also help manage other chronic conditions like CVD ris k and metabolic concerns. So yes, the importance of exercise and diet nutrition and all of those things are so important. Really quickly, I know this is an exciting time for us regarding HIV treatment. We're really seeing this rise and shift towards long-acting antivirals. First with dapivirine and now, more recently with lenacapavir as a potential option for certain patients. Really quickly, I'll just go around the circle here. What are your thoughts on the movement towards long-acting agents and treatment and how do you think this fits in for persons with HIV, especially with older adults? John?
Dr Appelbaum: I'm excited. I think the more options there are, the better. It's not a one size fits all. I mean, back when all we had was boosted protease inhibitors, we saw what happened there. I think every patient has their individual lifestyle and desires. For some people, a pill once a day is fine, but for others, every day they take that pill reminds them that they're living with HIV. As we talked about earlier there are still a lot of stigmas. There are health disparities, there are socioeconomic issues, and access to care, all of the social determinants. I think that plays a role in what is the best treatment for the patient in front of you. And I think the more options we have, the better. And I think we're going to have even better options down the road.
Dr Murray: I am very excited as well. I think, especially from a pharmacist point of view, there is always room for more drugs in the treatment care continuum because we've got drug interactions, pharmacokinetic issues, just a lot of different things that we need to consider, in addition to what John mentioned. And also, we really have to branch out and reach all of our populations. So those who are unstably housed, obviously an injection is going to be wonderful because they don't have to worry about their pill bottles being stolen. People travel a lot and are always in different time zones. I mean, it's really endless to the number of different populations that we can reach with these new and exciting treatments.
Dr Vance: And I'm excited as well because for someone with memory problems, well, you don't have to remember to take your medication every day. So it's a win-win.
Dr Kwong: And I think the issue with polypharmacy, yes, HIV treatment is one pill a day, but it's on top of diabetes medications and hypertension medications. And so if we can eliminate or minimize some of that, I think that's always beneficial as well.
Well, thank you so much for all of your insight and expertise. I know this was quick, we touched on a lot of different topics, but I want to thank all of our audience members as well for joining us. And please join us again for other future multidisciplinary round table discussions.