Journal Article Annotations
2017, 4th Quarter
Annotations by John Grimaldi, MD, and Mary Ann Cohen, MD, FAPM
Also of interest:
In this opinion piece from the JAMA, Anthony Fauci argues that the Joint United Nations Program on HIV/AIDS (UNAIDS) and the World Health Organization’s goal to end the AIDS pandemic by 2030 will require an effective HIV vaccine along with an accelerated robust research effort to support its development. While acknowledging the central importance of full implementation of the UNAIDS “90-90-90” strategy to significantly reduce transmission, he identifies several gaps that a vaccine would fill. Despite the remarkable achievement of providing roughly half of all HIV-infected individuals with antiretroviral therapy, there remain 17 million in need of treatment. Meeting this need will come at considerable cost and exists against a backdrop of falling donor-government HIV funding. Additionally, modeling studies suggest that a sizable proportion of this group will be difficult to reach due to geographic dispersion. Dr. Fauci believes that recent advances in vaccine research suggest that a moderately effective HIV vaccine is a realistic goal.
This NEJM Perspective describes the scope of and potential solutions to the growing problem of HIV drug resistance in the developing world. Defined as resistance to nonnucleoside reverse transcriptase inhibitors (NNRTIs), a core component of therapy in low- and middle-income countries, data from surveys compiled by several organizations including the World Health Organization (WHO) and Center for Disease Control and Prevention (CDC) suggest an increase in drug resistance prevalence from 11% to 29% since 2001. In over half of countries surveyed, the rate of pretreatment resistance exceeded 10%. The WHO has responded with a multipronged community, programmatic and patient-level approach. Core features include an expansion of the capacity for viral load monitoring, improved engagement in care and adherence to therapy as well as programmatic enhancements to insure uninterrupted drug availability and timely access to care. The authors propose additional measures to mitigate the risk of drug resistance. In the treatment of naïve patients, nonnucleoside reverse transcriptase inhibitors could be replaced by integrase inhibitors, as part of the initial regimen, due to their higher genetic barrier to resistance, lower cost and better tolerability. Evidence exists for the effectiveness of dolutegravir specifically, combined with one fully active nucleoside reverse transcriptase inhibitor, in patients with acquired NNRTI resistance. The authors also caution that the use of injectable, long-acting cabotegravir for pre-exposure prophylaxis (PrEP) may result in resistance to integrase inhibitors, including dolutegravir in individuals who subsequently acquire HIV. They conclude with a warning about the potential negative impact of federal funding cuts on efforts to reverse current trends in prevalence of HIV drug resistance.
Type of study: A case control study examining the effect of three interventions on HIV testing rates
The finding: This observational study of patients admitted to an acute inpatient psychiatric unit examined the impact of 3 sequential, overlapping interventions intended to increase rates of HIV antibody testing from 2006-2012: 1) advocacy by an administrative champion, 2) an on-site HIV counselor, and 3) advocacy by a clinical champion. Using a general estimating equation model, retrospective analysis of demographic, length of stay and HIV testing data found that rates of HIV testing increased significantly from 6.5% prior to any intervention to 30.1% following full implementation of the 3 interventions, representing an almost 5-fold increase. The largest increase, from 7.2% to 25.1% occurred after a full-time HIV test counselor was added to the inpatient team. Patients who were white or had a longer duration of hospital stay were more likely to receive an HIV test than were black or Asian patients or patients with a shorter length of stay. Over the duration of the study, 1.6% of all patients tested HIV-positive.
Strength and weaknesses: The interventions were tested in a real-world setting and in a population with a significant HIV seroprevalence. The study utilized 2 low-cost interventions thus increasing the applicability to a wide range of settings. The time-limited high-intensity intervention, on-site HIV counseling, was followed by ongoing lower intensity interventions, further demonstrating the feasibility of replicating the interventions in other settings. The study is limited in several respects. No information is provided regarding the patients who tested HIV-positive and efforts to link them to care. The study also did not characterize the 70% of patients who were not tested beyond demonstrating an association between lower testing rates and being black or Asian or having a shorter inpatient stay. This is especially relevant given unequal access for blacks to HIV testing, prevention and treatment services in larger studies. Likewise, a significant proportion of the study population was admitted involuntarily for up to 72 hours of observation, leading to shorter stays and greater likelihood of refusing all bloodwork. Interestingly, few patients specifically refused HIV testing. The study was retrospective in design, relied on administrative data and occurred on a single inpatient psychiatry service in a major urban area. Because interventions overlapped, determining the individual impact of each intervention was not possible.
Relevance: This study is relevant for several reasons. Studies have consistently demonstrated higher than expected HIV prevalence in psychiatric populations, especially dually-diagnosed psychiatric inpatients. Similarly, psychiatric disorders are overrepresented among HV-infected clinical samples. Yet studies also show consistently low rates of HIV testing and HIV-related risk assessment on inpatient psychiatric services. Given this situation, it’s not surprising that the literature and CDC offer clinicians and administrators limited guidance and best practices for HIV testing in psychiatric inpatient as well as ambulatory care settings. This study demonstrates that HIV testing in the inpatient setting can be effective and is feasible with limited investment of resources. This message is even more compelling in light of higher mortality and poorer access to general medical care among individuals with severe mental illness. This vulnerable population should be among the beneficiaries of what is now known about the advantages of early HIV diagnosis and engagement in care.