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As CROI 2007 drew to a close, we asked David Wohl, M.D., Associate Professor at University of North Carolina-Chapel Hill, and Co-Director of HIV Services for the North Carolina Department of Corrections to discuss what he felt was the most interesting research presented at the conference. Dr. Wohl is also an expert at The Body's Ask the Expert forums.

What have been the highlights of this conference for you?

Thank you, Bonnie. I think this is a really difficult conference in which to pick out one or two or three top things. Certainly it's a little bit easier than the international conference [on AIDS in Toronto], where there was just so much. This [conference] is much more refined; there are fewer presentations. I think, increasingly at this conference we're seeing less and less that's relevant to HIV care in the United States, because there's more and more information coming from other parts of the world.

There are several things that I found really fascinating here as a clinician that treats people. The big study, of course, I think, is ACTG [AIDS Clinical Trial Group] 5142. Coincidentally we've just done with TheBody.com and TheBodyPRO.com is, we've just completed the top ten stories of 2006. A lot of the seeds of those stories are kind of germinating here at this conference. So we saw 5142: [the] big HIV trial of efavirenz [EFV, Sustiva, Stocrin] versus lopinavir/ritonavir [Kaletra]. Now we get the metabolic data from that study. Again, it's surprising. When you look at lipids, surprisingly, there's not that much difference between efavirenz and lopinavir/ritonavir; most people would have bet there would be. When you look at body shape: [there were] completely off-the-wall results, where we don't see lipoatrophy [the depletion of subcutaneous fat stores, especially in the limbs and cheeks] in people who are on lopinavir/ritonavir but we do see it in people who are on efavirenz, except when lopinavir/ritonavir and efavirenz are put together.

[These results have] got a lot of people scratching their heads. I think this is actually healthy for us, because it makes us [understand] that protease inhibitors don't cause body shape changes, or they don't cause lipoatrophy. We're learning that the data are much more important than the dogma. I think that's really refreshing. We may not understand everything, but I actually think that this is healthy for us, and it makes us drop our assumptions so we can figure out what's really going on. I really liked that study, in particular.

There's more data that's coming out from these large cohorts. There was a D:A:D study [presented]. D:A:D is this mega-cohort of people who are being followed in North America and Europe. The big story out of D:A:D has always been cardiovascular disease, that the longer you're on PI [protease inhibitor] therapy, the greater your chance of having a heart attack, even though the number of people with heart attacks is rather small. [For coverage on this study, click here.]

Well, we're learning that malignancies are also something that they're able to track pretty well. There's a report here on fatal malignancies that developed during D:A:D [Click here for study abstract] and there are almost as many fatal malignancies as there were heart attacks in the study. There have been, like, 360 heart attacks and there were 305 fatal malignancies. So it's just as important ... and these are fatal, so it doesn't even include the malignancies that were not fatal.

The big take home messages were: (1) That non-AIDS-associated -- what we consider non-AIDS-associated malignancies -- were responsible for over 60% of the malignancies that developed and killed people in that cohort.

Can you specify the malignancies?

Yes. There were a number of different ones that kind of sliced up the pie. Lung cancer was a big one. Genitourinary cancer, [cancers of the urinary tract and male genital tract] which I think probably means mostly prostate cancer, maybe some bladder cancer, was a big one. I think there were some other solid organ tumors that kind of rounded out the list.

The other part of that was: that not only are traditionally non-AIDS-associated malignancies more common than AIDS-associated malignancies in this cohort of people with HIV, but the lower your CD4+ cell count went, the greater your risk of having a non-AIDS-associated malignancy. I think this really changes maybe what we think is called a non-AIDS-related malignancy. My friend, Joe Bick [Chief Medical Officer of the California Medical Facility, a correctional facility in Vacaville, California], who is here in California; he said we really just have to think maybe these are AIDS-associated malignancies. I think that's completely accurate.

Are you saying they are AIDS-related associated malignancies because they are associated with HIV-positive people with low CD4+ cell counts?

Yes. I think we're learning that the immune system does a lot more than just protect us from germs. It protects us also from malignancies. When there's a cell that goes aberrant and it becomes malignant, our immune system says that's foreign, and it attacks it just like it would a germ. So I think there's a really important role there.

This has implications for how we think about screening people for cancer who have HIV. I think that, [regarding] prostate cancer screening: we're going to have to look really hard at that in the setting of HIV. Maybe HIV is sort of a big risk factor for prostate cancer, such as being African American or having a first-degree relative -- maybe it's of that importance.

I think those are things we are going to have to answer. Certainly, it really redoubles our efforts to get people [with HIV] to stop smoking. We have better technologies now, better efforts. I think all HIV doctors have to learn how to help people stop smoking. We have to become smoking cessation experts, because a large proportion of these people die from lung cancer. So this was another [big surprise at this conference!]. I certainly didn't come here knowing that.

Is the incidence of smoking is very high in the HIV-infected population.

Incredibly high. In the studies that we've seen here and elsewhere, we're talking about 40% of people, or more. We're seeing way too many smokers. If you're HIV positive and you're taking HIV medicines and you continue to smoke, it's a push-pull. The smoking actually does have negative effects on your ability to live with this infection.

Were there any other data that you thought was interesting at the conference?

Well, I think there's a bunch of information that's more of, like, a smattering, but kind of collectively tell a story. There are more and more posters here about testing, about how we have to expand testing and the benefits from expanding testing. [Click here to view some of these studies.] We're missing opportunities. I think that [with] expanded testing, the positives certainly outweigh the negatives. We're seeing more and more of that. You know, you just don't want to miss someone with HIV when you see them before you [at a clinic], or when they come to an emergency room, or when they come in for routine care and they get admitted to the hospital for something else. We have to make this much more routine.

Even though we can't afford the treatment and have people on waiting lists in the U.S.?

Well, maybe we can afford the treatment. How much are we spending a week in Iraq? We can afford it; we can do it. This is one country where people get their HIV medicines, by and large. There are certainly horrible examples of people who don't, but we could rise to the occasion. I don't think that should deter us from not identifying people who otherwise would maybe die from their infection. The cost of care actually is more expensive when we don't diagnose it earlier. There's a nice report [from Bruce R. Schackman et al] -- it's in the top ten -- about prognosis of living with HIV infection, and the cost of care [Click here to read the summary]. It turns out if patients start HIV therapy at a higher CD4+ cell count; it costs less money over time than it does if they start with a low CD4+ cell count. So I think that's also really important stuff.

Those are some of the things that I think, really, are important, besides the things that everyone's going to talk about [after CROI]. Everyone will certainly talk about the new drugs [presented at CRIO]. I'm glad we have new drugs. New drugs are needed for patients who have gone through all the different regimens, and burned bridges, and have not much left. This is a new lease on life for them, so I think that's exciting and we want to see more of that.

I think this has been a productive conference. More will come out of it during the next few days when we sit down with all the data and we can say, well, this study really was important; and I didn't see this, but someone else did [and they tell you about it]. So a lot of data sharing goes on after the conference is over.