Willingness to Take PrEP for HIV Prevention: The Combined Effects of Race/Ethnicity and Provider Trust.

Blacks and Hispanics/Latinos are disproportionately burdened by HIV compared to non-Hispanic Whites, as evidenced by higher HIV incidence, prevalence, and deaths attributable to AIDS. Increasing the use of novel prevention techniques such as Truvada for pre-exposure prophylaxis (PrEP) could greatly help in reducing these disparities by lowering HIV incidence among these higher risk groups. Trust in providers, which may differ by race and ethnicity, may influence willingness to take PrEP. This study explores the moderating effect of race/ethnicity on trust in one's primary care provider (PCP) on PrEP willingness. This study found a significant association between PCP trust and PrEP willingness, with those with greater trust having 3.24 times the adjusted odds of being willing to try PrEP. Results regarding the effects of race and ethnicity on these outcomes, however, were inconclusive. Results indicate the importance of fostering trust between PrEP-prescribing PCPs and their patients.

Medicare Part D drug benefit and HIV/AIDS: questions and answers.

This newly enacted legislation has the potential to expand access to needed medications for persons with HIV/AIDS and actually improve care by making medication more affordable. This is particularly true for patients who are currently enrolled in ADAPs with limited or restricted formularies. The benefit of the Part D program in states with more generous ADAP formularies, such as New York and California, is not as clear. Choosing a drug plan can also be complex. Providers and case managers should have knowledge of the plans that are offered in their areas. While a program such as this has the potential to improve access to drugs, providers should expect the unexpected, especially with a newly implemented program that is wide in scope and subject to change over time. In the end, we need to work to avoid interruptions in treatment for our patients.

Humoral Dysregulation Associated with Increased Systemic Inflammation among Injection Heroin Users.

BACKGROUND: Injection drug use is a growing major public health concern. Injection drug users (IDUs) have a higher incidence of co-morbidities including HIV, Hepatitis, and other infections. An effective humoral response is critical for optimal homeostasis and protection from infection; however, the impact of injection heroin use on humoral immunity is poorly understood. We hypothesized that IDUs have altered B cell and antibody profiles. METHODS AND FINDINGS: A comprehensive systems biology-based cross-sectional assessment of 130 peripheral blood B cell flow cytometry- and plasma- based features was performed on HIV-/Hepatitis C-, active heroin IDUs who participated in a syringe exchange program (n = 19) and healthy control subjects (n = 19). The IDU group had substantial polydrug use, with 89% reporting cocaine injection within the preceding month. IDUs exhibited a significant, 2-fold increase in total B cells compared to healthy subjects, which was associated with increased activated B cell subsets. Although plasma total IgG titers were similar between groups, IDUs had significantly higher IgG3 and IgG4, suggestive of chronic B cell activation. Total IgM was also increased in IDUs, as well as HIV Envelope-specific IgM, suggestive of increased HIV exposure. IDUs exhibited numerous features suggestive of systemic inflammation, including significantly increased plasma sCD40L, TNF-α, TGF-α, IL-8, and ceramide metabolites. Machine learning multivariate analysis distilled a set of 10 features that classified samples based on group with absolute accuracy. CONCLUSIONS: These results demonstrate broad alterations in the steady-state humoral profile of IDUs that are associated with increased systemic inflammation. Such dysregulation may impact the ability of IDUs to generate optimal responses to vaccination and infection, or lead to increased risk for inflammation-related co-morbidities, and should be considered when developing immune-based interventions for this growing population.

Risk factors for hepatic decompensation in patients with HIV/HCV coinfection and liver cirrhosis during interferon-based therapy.

OBJECTIVE: Hepatic decompensation was reported from two recent trials (APRICOT and RIBAVIC) assessing interferon (IFN)-based treatment of hepatitis C virus (HCV) in HIV/HCV-coinfected patients. This paper identifies risk factors associated with hepatic decompensation in APRICOT. METHODS: APRICOT is a randomized, partially-blinded, controlled trial comparing treatment with peg-IFN alpha-2a 180 microg once weekly plus ribavirin/placebo 400 mg twice daily with IFN alpha-2a 3 million units three times weekly plus ribavirin 400 mg twice daily for 48 weeks in a total of 859 patients. Multiple logistic regression analysis was performed comparing the baseline characteristics of those cirrhotic patients who experienced decompensation with those of the other cirrhotic patients enrolled. RESULTS: Fourteen patients, all cirrhotic, experienced hepatic decompensation during the study. The incidence in the cirrhotic subgroup of the study was 10.4% (14/134). Six of the 14 patients died as a result of hepatic decompensation. The risk factors associated with hepatic decompensation were increased bilirubin, decreased haemoglobin, increased alkaline phosphatase or decreased platelets, and treatment with didanosine. Markers of viral replication, histological activity, cellular immune status or HCV-therapy, treatment with ribavirin and pegylated versus non-pegylated IFN were not associated with hepatic decompensation. CONCLUSIONS: The results from APRICOT indicate that the overall risk of hepatic decompensation in HIV/HCV-coinfected patients without cirrhosis receiving IFN-based treatment is low. In contrast, patients with markers of advanced cirrhosis, despite the absence of a history of hepatic decompensation, should be monitored closely during IFN-based therapy, because they are at risk of hepatic decompensation. Treatment with antiretrovirals such as didanosine may increase the risk further.

Expanding role of conformulations in the treatment of HIV infection: impact of fixed-dose combinations.

Fixed-dose combination therapy is more convenient than combination therapy with the same drugs taken separately and can improve adherence. Improved adherence is often associated with enhanced outcomes, which, in turn, can reduce the cost of care. In addition, the lower costs of generic fixed-dose combinations in resource-poor areas can extend treatment to larger numbers of patients who would otherwise have no access to antiretrovirals at all. In any setting, fixed-dose combinations reduce the number of pills, simplify the dosing regimen; are easier to take; ensure that the correct dosage of each component is taken; and are more cost effective.

The HIV specialist improves quality of care and outcomes.

HAART has raised the bar for standards of care for HIV/AIDS. As patient outcomes improve, efforts are under way to address the infrastructure needed to continue to provide high-quality HIV care. Standards of care and treatment guidelines are updated regularly in an effort to keep up with our rapidly evolving understanding of HIV medicine. Two professional organizations have been formed in the past several years to address the needs of HIV care providers and patients. While there is slight variation between the 2 groups, both organizations define the HIV specialist in terms of clinical experience and continuing education and recognize that HIV care providers are a diverse group committed to managing this critical and constantly evolving epidemic. Several states have also developed initiatives that address the importance of health care quality and outcomes for people with HIV/AIDS. New York and California lead the way, and surely other states will follow. To ensure quality of care and continued good outcomes for our patients, managed care organizations and other providers of HIV care can now measure their own competence against these existing standards.

HIV disease management: new technologies improve outcomes and contain costs.

HIV disease presents a continuous learning curve as we move from managing a fatal illness to treating a chronic disease. Even though the HIV epidemic is more than 20 years old, our understanding of the disease and its management are constantly evolving. New technologies are an important part of this learning curve. As they are introduced, providers and managed care organizations need to develop policies and procedures that reflect the state of the art in HIV care to continue to build on the good outcomes seen since the advent of HAART. While this model of care is "expensive," it is less expensive long-term than the poorer outcomes and costs associated with increased hospitalization, drug resistance, and preventable morbidity in HIV disease.