Brian R Wood MD Assistant Professor of Medicine University of Washington Medical Director NW AETC ECHO March 5 2015 ECHO CROI Reviews 2015 3515 31215 31915 Brian Wood Primary Care ID: 1033167
Download Presentation The PPT/PDF document "CROI 2015: Hot Topics in HIV Primary Car..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
1. CROI 2015: Hot Topics in HIV Primary CareBrian R. Wood, MDAssistant Professor of Medicine, University of WashingtonMedical Director, NW AETC ECHOMarch 5, 2015
2. ECHO CROI Reviews 20153/5/153/12/153/19/15Brian Wood: Primary CareShireesha Dhanireddy: New TreatmentsNina Kim: HCV CoinfectionRuanne Barnabas: Prevention Issues
3. CROI 2015: Primary Care TopicsCancer risk and lung cancer screeningBenefits of statins beyond cholesterol reduction
4. “Cancers in Young and Old and Lung Cancer in HIV”CROI 2015
5. Cancer Risk in HIV+ Over 65 Years OldCase-cohort study5% Medicare registry sample All cancers in people over 65 in large cancer registryAssociation between HIV and cancer incidenceAdjusted for age, race, sex, calendar yearYanik El et al. Abstract 725.Cancer TypeHazard Ratio Comparing HIV+ to HIV- (95% CI)Kaposi sarcoma79.2 (42.9-146)Non-Hodgkin lymphoma3.01 (2.24-4.05)Diffuse large B cell5.56 (3.69-8.39)Burkitt lymphoma21.8 (6.91-68.5)Other specified1.16 (0.67-1.99)Unspecified6.78 (3.93-11.7)Anus32.4 (21.6-48.5)Hodgkin lymphoma9.96 (4.89-20.3)Liver3.83 (2.46-5.97)Lung1.52 (1.21-1.91)Colorectal0.97 (0.69-1.36)Breast0.96 (0.56-1.65)Prostate0.78 (0.61-0.99)
6. Cancer Risk in HIV+ Over 65 Years Old5-year cumulative incidence (%)
7. CD4 Count as a Predictor of Lung Cancer Risk and Prognosis26,065 HIV+ in VACSIncident non-small cell lung cancer casesCox regression models for lung cancer risk, CD4 countAdjusted for: age, sex, race, smoking, h/o pneumonia or COPDCompared survival based on HIV status, CD4 +/- 200Sigel K et al. Abstract 728.CD4 AnalysisHazard Ratio (95% CI)12-month lagged value<2001.6 (1.2-2.2)200-5001.2 (0.9-1.5)12-month moving average<2002.0 (1.4-2.7)200-5001.4 (1.1-1.8)24-month moving average<2001.7 (1.2-2.4)200-5001.3 (1.1-1.7)
8. Smoking Outweighs HIV-Related Risk Factors for Non-AIDS-Defining CancersAdults in NA-ACCORDNon-AIDS-defining cancersHIV-related risk factors and smoking≈40K adults, ≈160K person-yearsMost common cancers: lung (17%), anal (16%), prostate (10%), 9% HL, 7% liver, 7% breast Source. Althoff KN et al. Abstract 726.Population attributable risk (PAF), %Including lung cancerExcluding lung cancer
9. US Preventive Services Task Force (USPSTF) Lung Cancer Screening RecsAnn Intern Med. 2014;160:330-338.
10. Lung Cancer Screening in HIV+ Smokers14 French clinical centers; single low-dose chest CTInclusion: age >40, ever smoked in last 3 years, >20 pack-years, CD4 nadir <350, current CD4 >100442 subjects:Median age: 49.8, nadir CD4: 168, last CD4: 57490% with last viral load <50Median smoking pack-years: 3094 subjects (21%) had a significant finding18 diagnostic procedures in 15 subjectsMakinson et al. Abstract 727.
11. PatientScreen DetectedHistologyStageAgePack yearsViral loadLast CD4Nadir CD41YesAdenoIA4530<406371602YesAdenoIV4852<405971323YesAdenoIIA4945<403783214YesAdenoIV502761590605YesAdenoIV5235<405682366YesAdenoIA5260438592147YesSquamIA5428<40345718YesAdenoIB5634<204802019YesNo histoIA5821<2057321810NoSmall cellExtended5040<404481Conclusions: Screening is safe and effective; USPSTF guidelines may miss early CAQuestions: When to start screening? Which criteria- Age? Pack-years? CD4 nadir?Lung Cancer Screening in HIV+ Smokers
12. Benefits of Statins Beyond Cholesterol ReductionCROI 2015
13. 1) Overton ET et al. CID, May 2013. 2) Galli L et al. AIDS, Oct 2014.
14. Statin Reduces Non-Calcified Coronary Plaque BurdenDouble-blind, placebo-controlled, single-center, RCTAtorvasatatin vs. placebo40 subjects, no known CAD, LDL 70-130, subclinical atherosclerosis (plaques) on CTA, stable on ARTAfter 12 months, atorvastatin reduced non-calcified coronary plaque volume (-19.4% vs. +20.4%, p = 0.009)Reduced overall plaque volume, # of high-risk plaques, Lp-PLA280% progression with placebo vs. 35% with atorvastatinLo J et al. Abstract 136.
15. More Potential Statin BenefitsRosuvastatin arrests progression of carotid intima media thickness (Longenecker CT et al. Abstract 137)Simvastatin protects human aortic endothelial cells from oxidative damage (Panigrahi S et al. Abstract 298LB)Atorvastatin partially reverses the HIV-mediated reduction of heme oxygenase (HO-1) in macrophages and may have benefit in HAND (Duncan MR et al. Abstract 502)Statins improve SVR and reduce fibrosis progression and HCC among HCV+ persons (Butt AA et al. Abstract 643)Statins have initial benefit for BMD over placebo but benefit doesn’t persist at 96 weeks and has detrimental effects on insulin resistance (Erlandson KE et al. Abstract 771)
16. Weigh benefits against risks: hepatotoxicity, myopathy, drug interactions, polypharmacy, costJustice A et al. Lancet HIV, January 2015.
17. ConclusionsHIV infection raises risk of non-AIDS-defining malignancies, though smoking outweighs HIV-related risk factorsLung cancer screening should be considered for those at high risk, but need to define best criteria for HIV+Statins have many potential benefits, including reduced progression of subclinical high-risk coronary plaquesWe need better guidelines for assessing CAD risk and statin initiation for HIV+ persons(A5332; reprievetrial.org)