Assessment of HIV Comorbidities

1. Assessment of HIV Comorbidities Andrew Carr, MBBS, MD, FRACP, FRCPA HIV, Immunology and Infectious Diseases Unit Clinical Research Program, Centre for Applied Medical Research St. Vincent’s Hospital and University of New South Wales Sydney, Australia

2. Disclosures • Research funding: Baxter, Gilead, MSD, Pfizer, ViiV • Consultancies: Gilead, MSD, ViiV • Lectures: BMS, Gilead, Janssen, MSD, Roche, ViiV • Advisory boards: Gilead, MSD, ViiV • Travel: BMS, Gilead, MSD, ViiV

3. Key Principles Why comorbidities matter • More common cause of morbidity and mortality than AIDS in patients on ART • ART accelerates comorbidities that are common, eg, CVD, CKD, fractures • Increase complexity of care • reduce ART adherence • reduce ART options • increase in polypharmacy for those ages 45+ • Reported in only ~25% of initial ART trials, and underassessed in routine care, so underappreciated Gifford AL, et al. J Acquir Immune Defic Syndr. 2000;23(5):386-395; Presented by DAD study group at IAC. July 2010. Vienna, Austria. Hasse B, et al. Clin Infect Dis. 2011;53(11):1130-1139; Krentz HB, et al. Antivir Ther. 2012;17(5):833-840; Presented by Lee, et al. ADAP Data Report Workshop. 2012; Presented by Shahmanesh M, et al. ADAP Data Report Workshop. 2013.

4. Key Principles When and Who • Pre-ART and pre-ART change in all patients • On ART • every patient once stable (about 3 months) • test interval variable and proportional to ART type and to underlying risk in individual patient • don’t order a test • if you don’t know what to do with the result • if the result will not change management • So, likely that most useful screening will be most useful in older HIV+ adults

5. Cardiovascular Disease How Framingham risk score DAD risk score http://hp2010.nhlbihin.net/atpiii/calculator.asp http://www.cphiv.dk/tools/dadriskequations/tabid/437/default.aspx

6. Potential disadvantages source data only from USA patients not HIV+ Cardiovascular Disease Who: ASCVD risk estimator Potential advantages • more current data • includes diabetes and race • provides 10-year and lifetime estimates, including risks postintervention http://tools.cardiosource.org/ASCVD-Risk-Estimator/

7. Cardiovascular Disease Variable results with different equations • 50-year-old white man on LPV/r for 5 years • Total cholesterol = 5.5 mmol/L (99 mg/dL), HDL-C = 1.1 mmol/L (20 mg/dL) • Systolic BP = 125 mm Hg • Nonsmoker • Diabetes mellitus controlled

8. Kidney Disease How http://www.eacsociety.org/Portals/0/Guidelines_Online_131014.pdf

9. Kidney Disease How: assessing decline in eGFR • Assess other CKD risk factors, including: • NSAID use • HCV, HBV • hypertension • diabetes • Cobicistat/dolutegravir effects appear confined to initial 4 weeks • Falling eGFR after week 4 may be due to TDF • urinary glucose/phosphate + • no dehydration • no creatine supplement • no active additional risk factors http://www.eacsociety.org/Portals/0/Guidelines_Online_131014.pdf

10. Fracture Risk How http://www.shef.ac.uk/FRAX; McComsey et al, Clin Infect Dis 2010; http://www.eacsociety.org/Portals/0/Guidelines_Online_131014.pdf

11. Fracture Risk Who McComsey GA, et al. Clin Infect Dis. 2010 Oct 15;51(8):937-946.; http://www.eacsociety.org/Portals/0/Guidelines_Online_131014.pdf

12. Neurocognitive Disease - HAND How Mind Exchange Working Group. Clin Infect Dis. 2013;56(7):1004-17

13. Neurocognitive Disease - HAND Who: HAND vs other causes of dementia Mind Exchange Working Group. Clin Infect Dis. 2013;56(7):1004-17

14. Cancer Who and How http://www.eacsociety.org/Portals/0/Guidelines_Online_131014.pdf

15. Symptomatic/Visible Toxicities Who

16. HIV Comorbidity Assessment Summary