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This Month in HIV: A Podcast of Critical News in HIV
  
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This Month in HIV: Top 10 HIV Medical Stories of 2006 Summary

January 2007

This podcast is a part of the series This Month in HIV. To subscribe to this series, click here.

Please note: These files can be quite large. Allow some time for them to download.

Summary of Interview

The End of Treatment Interruptions?

What It Was: One of the largest HIV treatment studies of all time. More than 5,000 people with HIV from around the world were split into two groups: One group started HIV treatment and continued without any interruption for the duration of the study. The other group took HIV treatment until their CD4 count climbed to 350, then stopped treatment until their CD4 count dropped to 250. The study conclusively found that the treatment-interruption strategy was worse for people's health than the continuous-treatment strategy. In fact, the results were so conclusive, that the researchers stopped the study early.

Why It Matters: This study shook the HIV medical establishment when the results were first announced in January 2006. "It teaches us that interrupting therapy, and tolerating low CD4 cell counts, in the history of bad ideas, is a pretty bad idea," Dr. Wohl said. "This study really puts a chill on any notion of doing treatment interruptions."

For more information on this study, click here.
For more on structured treatment interruptions, click here.

To read this section of the interview with Dr. David Wohl, click here.
 To listen to this section of the interview with Dr. Wohl, click here (6 min.). To download an MP3 of this part of the interview, click here.

Battle of the Titans: Kaletra vs. Sustiva (ACTG Study A5142)

What It Was: These popular, potent, first-line antiretrovirals were pitted against one another for the first time in this study which was funded by the U.S. National Institutes of Health-funded AIDS Clinical Trials Groups (ACTG) study. The results were unexpectedly mixed: People on Sustiva (efavirenz, Stocrin) were more likely to have an undetectable viral load. People on Kaletra (lopinavir/ritonavir) tended to have a higher CD4 count increase. And, to everyone's surprise, people had the same overall risk of side effects regardless of which med they took -- even when it came to lipid levels (like triglycerides), although many experts had predicted that people who were taking Kaletra would fare worse on that front.

Why It Matters: While neither drug can be crowned the champion, the match-up has taught us a lot about the pluses and minuses of these two powerhouse meds. "On the whole of it, we see that these two drugs have some strengths and weaknesses, relative to each other," Dr. Wohl said. "People are going to have to decide: 'What's more important to me?' Different people will come up with different answers."

For more on The Body's coverage of this study, click here.

To read this section of the interview with Dr. David Wohl, click here.
 To listen to this section of the interview with Dr. Wohl, click here (9 min.). To download an MP3 of this part of the interview, click here.

A Potpourri of Comparative HIV Treatment Trials: KLEAN, BMS-089 and Gilead 934

What They Were: The KLEAN study was a head-to-head battle of Kaletra versus Lexiva (fosamprenavir) in people who were just starting treatment; it found that Lexiva is virtually identical to Kaletra in terms of effectiveness, side-effect profile and drug-resistance risk.

The clinical trial known as BMS-089 compared unboosted Reyataz (atazanavir) with Reyataz boosted with Norvir (ritonavir) in a treatment regimen. The main difference they found is that when Norvir is added, side effects become more likely -- particularly those that impact lipid levels (like cholesterol).

Finally, the Gilead 934 study provided conclusive evidence that the combination of Emtriva (emtricitabine, FTC) plus Viread (tenofovir) -- two meds that are available together in the combo pill Truvada -- works just as well as Combivir (AZT/3TC) for people who are starting their first HIV treatment regimen.

Why They Matter: Collectively, these three studies help us better understand our options when it comes to HIV treatment for people who are starting on their first regimen. KLEAN helped secure Lexiva a preferred spot on the U.S. government HIV treatment guidelines alongside Kaletra and Sustiva.

BMS-089 shed a much-needed light on something that was previously not known: "For people who are really interested in their cholesterol -- as many, many patients are -- it was good to understand just exactly what Reyataz plus Norvir does to lipids," Dr. Wohl said.

And Gilead 934 "shows us that Truvada certainly deserves its place as a preferred agent, up there along with Combivir," Dr. Wohl notes.

For more on the KLEAN study, click here.
For more on BMS-089, click here.
For more on Gilead 934, click here.
To view a PDF of the U.S. government's preferred HIV regimens, click here.

To read this section of the interview with Dr. David Wohl, click here.
 To listen to this section of the interview with Dr. Wohl, click here (11 min.). To download an MP3 of this part of the interview, click here.

Circumcision as an HIV Prevention Method

What It Was: A new tool for HIV prevention made big headlines this year: circumcision. After years of conjecture, a set of three large clinical trials in Africa finally gave us solid proof that circumcision can halve the risk that a man will get HIV when having unprotected sex with a woman. The results of the trials were so dramatic, in fact, that the trials were stopped early, and all of the men in the study were offered circumcisions.

Why It Matters: Although it was huge international news when this story broke, the upshot of these findings is a little more complicated. For one thing, circumcision is clearly not a foolproof prevention method: It "doesn't offer you great protection, but it might offer a little bit more protection," Dr. Wohl says. There's also the matter of ensuring that circumcisions are done by trained medical professionals, with adequate follow-up care to make sure the penis heals properly -- care that is by no means guaranteed in the developing world. In addition, there's the possibility that circumcision doesn't actually do anything to change the behavior (unsafe sex) that puts men at risk for HIV in the first place. "I think we have to take this all with a grain of salt," Dr. Wohl says. "This is not going to be a major, major preventive measure. But it adds to the ones we have now."

For more on the recently halted circumcision studies in Kenya and Uganda, click here.
To read more on circumcision as HIV prevention, click here.

To read this section of the interview with Dr. David Wohl, click here.
 To listen to this section of the interview with Dr. Wohl, click here (6 min.). To download an MP3 of this part of the interview, click here.

The Benefits of HIV Treatment -- and the Price Tag

What It Was: We all know HIV treatment is expensive. But in this study, researchers tackled a mind-boggling question: How much will doctor's visits, hospital stays and HIV medications cost over the entire lifetime of someone with HIV? According to the researchers, a hypothetical HIVer beginning treatment with a CD4 count below 350 will require treatment costing about $385,200. Whether it intended to or not, the study also attracted a lot of attention by providing an updated estimate of how long the average HIV-positive person can expect to live after their diagnosis: 24.2 years.

Why It Matters: The 24-year figure got a lot of media play, but it's not a cutoff, Dr. Wohl explains. "If people come in with a little bit higher CD4 cell count, who basically can follow through, who can come to their clinic appointments, listen to most of what I say and take care of themselves, I tell them I expect them to get old and gray, that they can live, really, literally, for decades." Meanwhile, the study's monetary findings noted something pretty important: "As the CD4 cell count drops, the costs increase," Dr. Wohl says. "In fact, when you look at people who start HIV therapy right after infection, even though you're treating people longer, the cost goes down." The upshot? Dr. Wohl is blunt: "We need to start supporting HIV therapy for everybody."

For more on the economics of HIV, click here.

To read this section of the interview with Dr. David Wohl, click here.
 To listen to this section of the interview with Dr. Wohl, click here (7 min.). To download an MP3 of this part of the interview, click here.

Value of HIV Viral Load in Predicting CD4+ Cell Count Decline

What It Was: We've long believed that people with a high HIV viral load will see their CD4 count drop more quickly than people with a low viral load. However, this study partly disproved that assumption. It found that viral load works sort of like the seasons: In winter, for instance, it's generally colder than in summer, but there will be winter days that are quite warm. Similarly, this study found that a high viral load generally results in a faster CD4 count drop, but that many HIVers with a high viral load may not experience a fast CD4 count decline.

Why It Matters: The main takeaway from this study, Dr. Wohl says, is that it reminds doctors that they can't take a cookie-cutter approach to HIV treatment. In other words: Every HIV-positive person is different, and needs to be treated that way.

To read an abstract of this study, click here.
For more on HIV monitoring tests, click here.

To read this section of the interview with Dr. David Wohl, click here.
 To listen to this section of the interview with Dr. Wohl, click here (3.5 min.). To download an MP3 of this part of the interview, click here.

The World's Best Metabolic Study: ACTG 5005s

What It Was: Doctors still don't fully understand what causes HIV-positive people to experience body-shape changes. This study didn't resolve our questions, but it does give us a better understanding of the effect certain HIV meds have on body fat. The main verdict: Well-known villains like Retrovir (zidovudine, AZT) and Zerit (stavudine, d4T) aren't the only culprits, and the combination of meds could be as important as the meds themselves in impacting body fat.

Why It Matters: This study is an incremental gain in our knowledge of body-fat changes in HIVers. Dr. Wohl pointed out that it helped make him change his own opinions about some HIV meds: "I was guilty ... of saying, well, I think AZT [Retrovir] and Combivir can cause fat wasting. I'm a little bit more cautious about saying that right now." Another important takeaway from this study: "No matter what anyone took," Dr. Wohl noted, "people's belly fat increased." Was it because of the HIV meds, or was it just because people were regaining the fat they lost as a result of their HIV infection? That's for future studies to reveal.

To read The Body's coverage of this study, click here.
For more on metabolic complications and lipodystrophy, click here.

To read this section of the interview with Dr. David Wohl, click here.
 To listen to this section of the interview with Dr. Wohl, click here (6.5 min.). To download an MP3 of this part of the interview, click here.

Brave, New HIV Testing Recommendations From the CDC

What It Was: About a million Americans are HIV positive, and as many as a quarter of them don't know it. In the past, HIV testing has always been voluntary -- you need to agree to be tested -- and it was generally offered only to people who healthcare providers considered "high risk" due to various factors such as their sexual preference. But in a move that instantly stirred controversy within the HIV community, the U.S. Centers for Disease Control and Prevention (CDC) turned two decades of HIV testing on its head: They now recommend that HIV testing be offered to everyone between the ages of 13 and 64 and that it be made a routine part of every American's health care.

Why It Matters: Many HIV advocates came down against the CDC's new rules, because they recommend dropping a lot of consent and counseling requirements that have been in place for many years. Dr. Wohl disagrees: "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.'" Beyond the hope of catching more infections, Dr. Wohl says, "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 just deciding to test me just because that's the public policy.' ... So I think there could be some tremendous benefit."

For more on U.S. HIV testing policy, click here.

To read this section of the interview with Dr. David Wohl, click here.
 To listen to this section of the interview with Dr. Wohl, click here (4 min.). To download an MP3 of this part of the interview, click here.

Updated U.S. HIV Treatment Guidelines

What It Was: Every six months or so, the U.S. Department of Health and Human Services releases updated guidelines on how healthcare providers should treat people with HIV. The latest version includes a recommendation that HIV drug-resistance testing be routinely done before people start taking HIV meds. It also includes a reorganized list of recommended first-line meds that reads like a menu for a combination platter: Choose one from column A, one from column B.

Why It Matters: "I think the new guidelines are a breath of fresh air," Dr. Wohl says. As he explains it, the latest incarnation represents an evolution from HIV treatment guidelines that have always been a bit behind the times into guidelines that are state of the art. "The important thing about the new guidelines is, they've really encompassed therapies that clinicians are using now in the clinic," Dr. Wohl explains. The addition of meds like Norvir-boosted Lexiva and Norvir-boosted Reyataz to the list of "preferred" meds attests to this. The drug-resistance testing recommendations are also a major step up. "It's a great document, and all clinicians need to know about that," Dr. Wohl says.

To read this section of the interview with Dr. David Wohl, click here.
 To listen to this section of the interview with Dr. Wohl, click here (4 min.). To download an MP3 of this part of the interview, click here.

The Next Generation of HIV Meds

What It Was: In 2006, only one new HIV medication was approved in the United States: the protease inhibitor Prezista (darunavir, TMC114). But the story of 2006 wasn't so much about the new meds that were approved; it was more about the new meds that are about to be approved: the integrase inhibitor MK-0518, the NNRTI TMC125 and the CCR5 antagonist maraviroc.

Why It Matters: All three meds hold the promise of significantly impacting the way HIV is treated. MK-0518 and maraviroc work in a fundamentally different way from every other HIV medication on the market, while TMC125 appears to work in people who already have some resistance to other NNRTIs, such as Viramune (nevirapine) and Sustiva. All three meds have pretty good side-effect profiles, but the real kicker here is how widely they expand treatment options for people with HIV drug resistance: Thanks to these new meds, "People who ... have multidrug-resistant HIV now have enough drugs where they can make a new regimen that can really work," Dr. Wohl points out. "It really holds out a new lease on life for a lot of people."

For more on HIV medications in development, click here.

To read this section of the interview with Dr. David Wohl, click here.
 To listen to this section of the interview with Dr. Wohl, click here (5.5 min.). To download an MP3 of this part of the interview, click here.

Honorable Mentions

HIV Sorely Neglected in U.S. Prisons

What It Was: In 2006, we saw a stream of reports, studies and articles highlighting the urgent need for more effective HIV prevention, screening and care in prison systems throughout the world, including the United States. Editorials appeared in several medical journals, including The Lancet and the New England Journal of Medicine, and a notable study in Georgia identified dozens of prisoners who had been infected with HIV after entering the correctional system.

Why It Matters: "We have to take our head out of the sand and recognize that prisons are a neglected area in our consciousness when we think about HIV," Dr. Wohl says. Estimates show that one fifth of HIV-positive people in the United States pass through a jail or prison every year, which points to the extraordinary potential there is for prisons to serve as a focal point for HIV prevention and treatment efforts -- efforts that, if successful, could help curb the epidemic throughout the country.

For more on the Georgia study, click here.
For more on the recent New England Journal of Medicine article on HIV and the U.S. prison system, click here.
For more on the recent report in The Lancet examining HIV in prison systems throughout the world, click here (free registration at thelancet.com is required).
For more on HIV/AIDS in prisons, click here.

HIV Treatment Works, Even in World's Poorest Regions

What It Was: HIV treatment access is finally ramping up in developing countries -- but just how great an impact does it have on the survival of people with HIV? A study published in the New England Journal of Medicine followed 1,004 people with AIDS in Port-au-Prince, Haiti, who had never received treatment. Nearly 90 percent of them were still alive a year after beginning HIV treatment -- a survival rate three times higher than among Haitians with AIDS who did not receive treatment.

Why It Matters: In the past, policymakers skeptical of HIV treatment programs in the developing world have implied that there was little point to prescribing complex treatment regimens to people living in impoverished areas. However, the Haiti study is the latest to prove that "people can take HIV therapy in places where they don't wear watches," Dr. Wohl says. This evidence makes it even more urgent that we improve the world's access to HIV medications.

For more on this study, click here.
For more on HIV/AIDS treatment in the developing world, click here.

Surgeons Shouldn't Hesitate to Operate on People With HIV

What It Was: Researchers in northern California matched 332 pairs of HIV-positive and HIV-negative people who were receiving similar surgeries and then watched how well they recovered after their procedures. The researchers found that, although HIV-positive people were more likely to die in the year following surgery, that excess death risk wasn't related to the surgeries themselves. The researchers noted, however, that people with a CD4 count below 50 or a viral load above 30,000 were more likely to have complications from their surgery.

Why It Matters: Surgeons are often reluctant to operate on people with HIV, even for relatively minor procedures. This study should help convince them that there's no cause for concern when it comes to people with HIV who are otherwise healthy. "I think we can feel a little bit more comfortable saying to patients, 'Yes, if you need your carpal tunnel repair, if you need to have this elective surgery, you can have it. Go for it,'" Dr. Wohl says.

For more on this study, click here.

To read this section of the interview with Dr. David Wohl, click here.
 To listen to this section of the interview with Dr. Wohl, click here (4 min.). To download an MP3 of this part of the interview, click here.


To ask TheBody.com's experts about any of these studies, click here.
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Copyright © 2007 Body Health Resources Corporation. All rights reserved. Podcast disclaimer

This podcast is a part of the series This Month in HIV. To subscribe to this series, click here.


  
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This article was provided by TheBody.com. It is a part of the publication This Month in HIV.
 

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