Comorbidities and Treatment Optimization

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The HCPLive Peer Exchange: Optimizing Outcomes in HIV Treatment features insight and opinion on the latest developments in HIV research, diagnosis, and management from leading physician specialists.

This Peer Exchange is moderated by Paul Doghramji, MD, who is a family physician at Collegeville Family Practice in Collegeville, PA, and Medical Director of Health Services at Ursinus College, also in Collegeville, PA.

The panelists are:

• Alfred A. DeLuca, MD, Infectious Disease Specialist at CentraState Healthcare System in Manalapan, NJ
• Ian Frank, MD, Director of Anti-Retroviral Clinical Research and Director of Clinical Core at Penn Center for AIDS Research, and Professor of Medicine at the Hospital of the University of Pennsylvania in Philadelphia, PA
• Paul Sax, MD, Associate Professor of Medicine at Harvard Medical School and Clinical Director of the Division of Infectious Diseases and the HIV Program at Brigham and Women's Hospital, in Boston, MA

Also participating via video is Amir Qaseem, MD, Director of Clinical Policy for the American College of Physicians, based in Philadelphia, PA.

In this segment, the panelists discuss comorbid conditions often seen in patients with HIV (eg, hypertension, hyperlipidemia, metabolic syndrome, and COPD) and talk about how this affects medication selection and other aspects of treatment.

Dr. DeLuca says this “is not a small consideration, given the possibility of drug interactions.” He cites the example of hypertension in this population, noting that these patients “have increased risk of cardiovascular disease in HIV especially, and the drugs that you’re going to use to treat those other conditions are going to potentially interact and have their own side effects.”

Dr. Sax says it is important that patients be involved in making decision about their treatment, and that he tries to assist that process by narrowing the choices down to two or three options and explaining the features and potential side effects of each medication.

Dr. Doghramji concurs with this approach, noting that “when it comes to shared decision making, patients are much more likely to be compliant and compliance is such a key factor in patients having the best outcomes” in HIV treatment.

Returning to the topic of comorbidities in patients with HIV, Doghramji asks the panel for their opinions on which clinicians on the treatment team should be responsible for screening for these comorbid conditions when devising a treatment plan.

Dr. Frank says it is important to understand how the patient is going to receive their care, noting that “some patients are going to be co-managed with a primary care provider. Sometimes the HIV provider is the primary care provider. All of the providers need to take responsibility to make sure that the patient is on the right medication for their conditions. So the HIV specialist may need to educate the primary care provider about drug-drug interactions, but the HIV provider needs to be aware of comorbidities that may influence their treatment decision. So they need to be aware of cardiovascular disease, diabetes, hepatitis co-infection, or other factors which may influence choosing one combination versus another.”

It’s important to screen for comorbidities and incorporate that information into the treatment plan for patients with HIV because in many cases patients’ mortality risk is actually higher from those conditions than from HIV. Dr. DeLuca says, “We’re seeing an awful lot of deaths from hepatic failure, cirrhosis. There’s even increased incidence of liver cancers and hepatomas. There’s increased cardiovascular deaths, stroke, and heart attack and peripheral arterial disease as well.”

One comorbid condition in particular has become less of a concern as treatment options have improved: hepatitis C.

Dr. Frank says, “We’re entering a very new era in hepatitis C treatment. Hepatitis C is now an easy disease to manage, very easy, well tolerated regimens that are available with a very high rate of cure. So the importance of hepatitis C being a co-factor in choosing an antiretroviral regimen or influencing the outcomes of HIV treatment is less now than it has been. With the newer drugs there are fewer drug-drug interactions between the antiretrovirals and the hepatitis C direct-acting agents. And so you can choose almost among all of the initial preferred antiretroviral combinations for the HIV treatment of the co-infected patient.”