This Month in HIV: Top 10 HIV/AIDS Medical Stories of 2006
Number six is a really technical article, and I think it was really important. I think it's going to spark a lot of conversation. The bottom line for this study is: we know that viral loads are important. They're not like CD4 cell counts; viral loads are different. A viral load's use is that it can help us understand what's the likelihood that someone's T-cell count is going to drop. When someone comes into [the] clinic, we get a viral load and CD4 cell count. If your CD4 cell count is 400, and your viral load is high, your doctor gets a little bit worried because that means that likely, over the next year or two, your CD4 cell count's going to drop quicker than someone who comes in that same day, has a CD4 cell count of 400, and has a very low viral load.
We think about the viral load as sort of the engine that's driving the CD4 cell count decline. The more virus you [have], the worse it is. I tell my patients: foxes and rabbits. Your T cells are rabbits, your virus: foxes. The more foxes you [have], the quicker the rabbits are going to disappear. We've got to get rid of the foxes.
That was sort of the paradigm that we'd been following for a long time, sort of the model. It's based upon some data that are almost 10 years old now. Well, in this study, they looked at the viral load before people started therapy, and looked at T-cell counts in a bunch of individuals from different clinics across the country, but mostly from California.
They found [that], when you group people into big categories, the viral load does seem to predict what happens to people [in general] -- but not individual patients -- very well. What they found was that when you look at people who have a viral load that's high, and a viral load that's low: some of the people who have a viral load that's low saw their T-cell count drop really quickly. Some of the people who had a high viral load: their T-cell counts didn't drop that quickly. There was a lot of overlap between patients. For any one individual patient, the viral load didn't do very well at predicting how quickly the T-cell count would drop.
"They found [that], when you group people into big categories, the viral load does seem to predict what happens to people [in general] -- but not individual patients."
What it did is, if you took a whole bunch of patients who had a similar viral load, generally their CD4 cell count dropped at a different rate than another group of people who had a viral load of a certain amount. So if you had a group of people -- 20, 30, 40 people -- who had a high viral load, they would tend to have their CD4 cell count drop quicker than people who had -- a group of 40 patients or so -- a low viral load, on average. But when you start breaking it down and looking at individuals, that kind of falls apart. [To read an abstract of this study, click here.]
This is a really important study because this helped clinicians understand: We cannot be putting as much stock into viral load; applying the viral load that we've got, looking at groups of patients, to the one individual patient in front of us. I think that that is sort of a very, very interesting concept, and there's going to be a lot more discussion. There will be other studies that will come out from this one that I think we'll have to look at, and see if this holds up. But this is a well-done study.
Number seven. This gets back to the issue of body shape that we talked about before. There's another AIDS Clinical Trials Group, the ACTG national group (the U.S. government group), another trial that they sponsored, [which] looks at changes in body shape and lipids, and a whole bunch of other things in patients who were assigned to either be on a protease inhibitor, Viracept [known generically as nelfinavir], Sustiva, or a combination of the two.
Then there were also patients who were getting Combivir with those, or Zerit and Videx [generically called didanosine or ddI]. [To read more coverage from The Body on this study, click here.] There's a complicated sort of scheme of how the patients were handled in the study. But the bottom line for this particular study is: They were able to collect data, body shape data and other types of data related to metabolics, on patients over a long period of time, over 144 weeks. They were able to look at how people did, as far as their body shape.
The thing that I really liked about this study was that they looked at people who were just on Combivir -- not the Zerit and the Videx, which we know can [cause the] fat in your limbs to waste. When you just stuck with Combivir, which, like we talked about before, most people don't consider Combivir offensive to arm and leg fat (although there are some people who feel that it could, like we talked about with the Gilead study). When you looked at people who were on Combivir and the protease inhibitor Viracept: They did see decreases in their limb fat over time, whereas people on Combivir and Sustiva didn't [see this decrease in limb fat]. Now, these are not huge, huge numbers of patients, but I think it really indicates that there may be some difference between the effects you see with a drug like Combivir, depending on what it's coupled with. When it's taken with a protease inhibitor, things seem a lot worse than [for] people who take it with Sustiva.
Now, this is not just an isolated result. There had been other studies, including some from Australia. The Australians were really on top of this before anyone else was -- showing that when people took Zerit and a protease inhibitor, they had more fat waste than when people didn't take a protease inhibitor.
So I think these are important results, and they may make us qualify what we say about Combivir. As I said: I was guilty, as well, of saying, well, I think the AZT and Combivir can cause fat wasting. I'm a little bit more cautious about saying that right now. I think it's true, but I think it also depends upon what [drug or drugs] it's coupled with. [To read more about body fat changes and metabolic complications, click here.]
"No matter which [HIV] therapies they took, truncal fat -- that's the fat around the trunk, the belly -- that increased."
The other part of the study that I think is really interesting is that no matter which [HIV] therapies they took, truncal fat -- that's the fat around the trunk, the belly -- that increased. No matter if you took a protease inhibitor, no matter if you took Sustiva, no matter if you took Combivir, or you took Zerit. We saw increases in body fat in the belly, in every study that's bothered to look at body fat and look at belly fat; in specific, [every study] on people who are starting HIV therapy has found the same thing. So they all do it.
So be prepared for body fat changes if you're going to take HIV meds?
The majority of people get some weight gain. They get some return to health. Something happens. I mean, look at people, again, in the aggregate. This is not every individual. There are some people who won't [gain weight]. There are some people who will lose. There are some people who will gain. But when you look at it, groups of people tend to gain fat around their trunk.
Now, the thing we don't have is what people look like before they got HIV infected, or when their T-cell counts were really high. We know from looking at lipids that we could be fooled, that people who start HIV therapy generally have low cholesterol relative to the way that they looked before they got HIV. A lot of times, people have lost weight by the time they start HIV therapy. So this may just be a return to the average American waistline. I don't know. Those are the kind of data that would be very helpful.
But when you look differentially between different treatment regimens, we're not seeing differences. That leads me to believe this is not a drug-specific problem, this fat accumulation; this is a phenomenon that we're seeing across the board, with different therapies -- as opposed to fat wasting, where we do see differences between different regimens.
But if you start therapy and you have 500 T-cells, wouldn't this be less likely to happen? Because you're already kind of healthy.
Maybe. I think this is really interesting. One of the ways we'll see how this pans out is looking at studies of patients who start therapy soon after they're infected, like acute HIV studies. Some of those studies are conducting metabolic evaluations. That's one way we could find out right away.
"There are studies that show that aerobic and anaerobic exercise combined -- sweating, lifting weights, that kind of thing, something that you could do that's very active -- and do that frequently -- along with diet modification (appropriate diet modification), has reduced inches from around the waist."
People who take these therapies when they're acutely [very recently] HIV infected -- when just a few weeks ago they were totally fine -- and we don't see changes in body fat, that will tell us right away. But if they do [gain weight], then there's some drug-specific thing going on. There are other ways to do this, and I think your idea is really a good one. We don't have the data yet, but that would be an excellent study. If it's found to be true, it would be another motivation for starting therapy earlier, rather than later.
Isn't it true that exercise can help? It's not inevitable that you'll get a fat belly?
Well, first, the other thing I should point out is that, yes. Don't be scared, because the kind of changes we're talking about may not be undesired. This may be: "Thank God I look healthy again," not "Look at my big fat tire around my waist." That's not what we're talking [about] here. A lot of these patients didn't have anything that was so horribly disfiguring.
In extreme cases, we do see that. But most people just get a little bit -- they gain a little weight. They just feel a little better. Yes. And if it gets to the point where it's not desirable, there are studies that show that aerobic and anaerobic exercise combined -- sweating, lifting weights, that kind of thing, something that you could do that's very active -- and do that frequently -- along with diet modification (appropriate diet modification), has reduced inches from around the waist.
Number eight gets us in kind of a different realm altogether, and what I thought was very important for [studies eight and nine is that] we're looking at policy changes. The big one here is that the CDC [U.S. Centers for Disease Control and Prevention] has released revised recommendations for how people should be screened for HIV in the United States. Previously, really, HIV screening was offered to people who were considered at high risk. Either the person considered themselves at high risk, or the clinician kind of thought: "You know, maybe based on what you're telling me, maybe you should get an HIV test." You know what? That didn't work very well. The incidence of HIV -- that's new infections every year -- hasn't really changed very much, and in some subgroups [it] is increasing. So that policy was a failure. [To read more about U.S. HIV testing policy, click here.]
"I can order a syphilis test right now on anyone I want ... without getting their informed consent in writing."
A much better policy would be offering HIV [testing] much more broadly. About one out of every 300 Americans is HIV positive, one out of every 300 people living in our country. This is not some very, very rare disease. Offering testing to people as they come into their routine clinic appointments, certainly when they go to STD clinics: Those types of things make a lot of sense. I think if we make it very routine, we sort of de-stigmatize the whole idea. "Well, my doctor's offering it to everybody; it's not just me. She's not making a judgment about me. She's just deciding to test me just because that's the public policy, the public health policy." And so I think there could be some tremendous benefit.
The other part of this, though, is that to make it easier, this whole process that we go through right now of counseling people before they get the test -- getting written, informed consent, and then doing counseling after the test -- has really turned out to be, although very well intentioned, an obstacle to getting HIV testing. When you ask doctors why they didn't order an HIV test on someone, oftentimes they'll say, "Well it was just too cumbersome, and I didn't have enough time to go over it, and I thought I'd do it next time, and we forgot about it."
So the whole sort of protections, built in, might have been actually having an effect where people just weren't getting tested because it was too onerous [on the part of the clinicians]. So the guidelines say you have to certainly tell people you want to test them, and they have to have an opportunity to say, "Please don't." But otherwise, you can get an HIV test just like we order other tests right now. I can order a syphilis test right now on anyone I want who comes in to see me, without getting their informed consent in writing. This is a way, I think, to make it a little bit more level for HIV screening and screening for other diseases.
So these are important guidelines. They also recommend that everybody aged 13 to 64 in our country get tested at least once.
Do you think we'll be able to handle all the new infections that are found?
Well, for one thing, there are very few places that have implemented this. So [anyone concerned] about a big surge in HIV cases tapping out our resources [should] remain calm. There are a lot of state laws regarding HIV testing and policies -- hospitals have policies; health departments have policies -- that will have to be tackled before this can really start up. I don't think we're going to see a huge surge. If we do see, in the short term, some increase in healthcare utilization, I think it's worth it. Because in the long term, what we're hoping is [that] we'll see less new infections. So I think this is an investment in the future, where short-term expenditures will lead to long-term dividends.
Copyright © 2007 Body Health Resources Corporation. All rights reserved. Podcast disclaimer.
This article was provided by TheBody. It is a part of the publication This Month in HIV.
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