Special Considerations in HIV Management - Episode 2
Peter L. Salgo, MD: Thank you for joining this AJMC® Peer Exchange® regarding special considerations in the management of HIV. HIV has become more of a chronic disease thanks to advances in the therapeutic armamentarium. However, improved survival has highlighted the need for longer-term management strategies. Throughout this AJMC® Peer Exchange®, a panel of experts in infectious disease and managed care are going to discuss today’s management of HIV, including the need for individualized care and the role for newer treatment options.
I’m Dr. Peter Salgo. I’m a professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons, and an associate director of Surgical Intensive Care at New York-Presbyterian Hospital. Participating today on our distinguished panel are Dr. Jeffrey Dunn, vice president of Pharmacy for Magellan Rx Management of Salt Lake City, Utah; Dr. Elly Fatehi, director of Clinical Pharmacy for Amida Care of New York, New York; and Dr. Michael Sension, medical director and specialist in HIV medicine with CAN Community Health in Fort Lauderdale, Florida. I want to thank all of you so much for being with us. We’ve got a lot to cover. It has been quite an eventful ride with HIV.
Michael Sension, MD: It sure has.
Peter L. Salgo, MD: Tremendous interesting stuff going on. Let’s talk about some history here. Talk about some historical perspectives on the success of HIV antiretroviral therapy over the past 2 decades. Where do you want to even start? I remember in the beginning of this disease, we had nothing. Nothing. And here we are. How did we get from there to here?
Michael Sension, MD: You’re absolutely right. In the very beginning, we weren’t even sure what was causing it and that’s how the word “AIDS” got coined: Acquired immune deficiency syndrome. We knew people weren’t born with it so it was acquired, and they were dying of diseases that resulted in a severely deficient immune system. And we weren’t sure if it was environmental factors. It wasn’t until a virus was discovered in the early 80s when we actually attributed this to a virus. And then for the next 10 years or so, our attempt to manage or intervene with medications, we were really in the dark ages. We were attempting to treat HIV with the first medications without being able to measure HIV. So, it would be like trying to treat hypertension without being able to measure high blood pressure.
Peter L. Salgo, MD: You know, somebody asked me back then did I think we’d ever have, (a) an effective treatment or (b) a cure. And I said—I thought responsibly—never in the history of the human race have we cured a viral disease. We have vaccines but no cures. And we’ve never really been able to control them either. So, then what happened?
Michael Sension, MD: Well, the technology advanced as well as our understanding of HIV, and it wasn’t until the mid-90s or so when the very first protease inhibitors were approved, and they were approved right about the same time the technology allowed us to actually measure the virus. Prior to that, we were giving people medicines. We could measure their immune system and we could say the studies were clinical endpoint studies where somebody would get a drug and other people would get a placebo, and if at the end of a period of time less people died and less people got sick, we said it worked.
Peter L. Salgo, MD: How about endpoint?
Michael Sension, MD: Right. Fortunately, we now have a surrogate endpoint and that is we can measure HIV. We take that for granted now, but in the early days, we could not measure HIV.
Peter L. Salgo, MD: Now we have longer life expectancies for people who have HIV infections. I’m going to go out on a limb and say that as I view the landscape, not being an ID doctor, we have normal life expectancies for people who continue their therapies who happen to be infected with HIV. There was a pause. How far off am I?
Michael Sension, MD: You’re pretty close, actually.
Peter L. Salgo, MD: Phew, that was a relief.
Michael Sension, MD: Modeling data come pretty close to that. There have been some modeling data that suggest that a young person in their 20s who gets linked into care, gets hooked up with a provider, is prescribed antiretroviral therapy, takes it regularly, and achieves virologic suppression, that that individual has very close to the same life expectancy as a person his age who never catches HIV.
Peter L. Salgo, MD: I just want people to stop for just a moment and think about that. This was a disease that was killing people left and right. It was mowing people down across America, and now we’re talking about normal life expectancy. So, let me ask you another question, and the whole panel can jump in on this one. Remember that AIDS is a syndrome and HIV is simply a virus. Should anybody really get AIDS today?
Elly Fatehi, PharmD, MPH: Absolutely not, not with the medications that we have.
Michael Sension, MD: It’s really sad if somebody does progress to advanced HIV disease and gets sick, given what we have available to us.
Jeffrey Dunn. PharmD: I was going to say that’s assuming that we’re all doing the right thing collectively.
Michael Sension, MD: Absolutely.
Jeffrey Dunn, PharmD: There are still systemic issues.
Peter L. Salgo, MD: Well, there was a condition in there.
Jeffrey Dunn, PharmD: Right.
Peter L. Salgo, MD: But in the best of all possible scenarios, HIV.
Jeffrey Dunn, PharmD: There’s no excuse clinically.
Peter L. Salgo, MD: HIV does not correlate to invariable AIDS. In fact, it shouldn’t ever if you do it right.
Michael Sension, MD: But that’s dependent upon us identifying everyone who has HIV, getting them into care, and getting them the proper medication to suppress their virus, and there are some gaps along the way as we attempt to do that.
Peter L. Salgo, MD: Would you have, back in the early 80s, ever thought we’d be having this conversation this way? There are some gaps and that’s what we have to close.
Michael Sension, MD: No. I honestly can’t say I would have thought that.
Peter L. Salgo, MD: It’s insane. Insanely great, but insane. But there are real challenges, not the least are financial.