At the 2008 Conference on Retroviruses and Opportunistic Infections in Boston, David Evans talks with Douglas Ward, MD, about success in controlling AIDS-related complications and progress still to be made. To see the video click here.
David Evans: Good morning. I’m David Evans with AIDSmeds.com and POZ magazine, and we’re here at the 2008 Conference on Retroviruses and Opportunistic Infections in Boston, Massachusetts. With me today is Dr. Douglas Ward who’s with the Dupont Circle Physicians Group in Washington, D.C., and we’re going to be talking a little bit about the illnesses that are affecting people with HIV as we move forward in the epidemic. You know, before the introduction of combination antiretroviral therapy, we saw a lot of illness; we saw things like Kaposis Sarcoma, PCP pneumonia, dementia, and wasting. For the most part, we’re seeing less of that now. I’m wondering if you can tell us a little bit about that, and where we’ve been successful.
Douglas Ward, MD: Well I think the reason for that dramatic decline in the morbidity and the mortality in HIV is directly related to the use of the antiretroviral drugs. And with the truly effective regimens that came out approximately ten years [ago], we’ve done a very good job of controlling the virus, and therefore as a consequence of that, controlling the complications of viral infection. If we suppress the virus, the immune system gets better, and with a better immune system, we can control these complications. In this morning’s session at CROI on morbidity and mortality associated with this, looking at a number of databases over the last ten years, the incidence of HIV death and complications has improved dramatically and continues to improve, and this is associated with the increased use of highly active antiretroviral therapy.
DE: I’ve heard though that there are some diseases and conditions that are emerging as problems for people as we go further into the epidemic. Can you tell me a little bit about that?
DW: As Andrew Phillips, who gave this morning’s session, points out, all causes of death in the HIV infected population have decreased; both directly AIDS associated deaths and non-AIDS associated deaths. But the non- AIDS associated deaths, including things like malignancies, liver disease, heart disease, kidney disease have not gone down as much, so that they now represent a higher proportion of the complications that we see.
DE: So it’s not so much that those things are on the rise as much as they just haven’t gone down as much as the others?
DW: Exactly. And there is data emerging that those complications have decreased also, and that some of this decrease may also be associated with antiretroviral medications.
DE: With liver disease, which compared to other things is a problem in HIV, are the deaths that we’re seeing that are attributable to the liver and liver disease, are they mostly in people who are infected with hepatitis C and B, or is it other things?
DW: Liver deaths, absolutely, are by and large in those people who are co-infected with hepatitis B and C and HIV. It’s a complicated question. There is definitely data that HIV treatment improves the outcome with hepatitis B or C. There is a slower progression of disease, lower risk of complications from those coinfections. On the other hand, HIV medications may have liver toxicity. So it’s a double-edged sword.
DE: With cognitive disorders… you know, at AIDSmeds.com, our visitors to our site, when they’ve made comments on our stories or in our forums, have made complaints about feeling mentally fuzzy or having trouble concentrating. I’m wondering, what are we seeing in terms of neurological problems in people with HIV now?
DW: Once again, a complicated question; I think there are numerous causes for that mental cloudiness, memory problems, etc. There is at least one HIV medication, efavirenz, or Sustiva, that is the most commonly prescribed medication, which definitely can cause some mental clouding. For most people that is a side effect that occurs initially and gets better with time, but in a significant minority of patients may persist, and is something that I feel very strongly if a patient is getting mental side effects from a drug, there are other perfectly good drugs that don’t have those side effects. We also see patients who have been on medications long term; they may have some low level complications of those medications that just cause some fatigue, mental cloudiness, etc. Then there is the complication of a direct effect of HIV on the brain, HIV dementia; it was an uncommon side effect, but there is certainly good data that HIV does effect the brain to varying degrees in different patients. And even sometimes in patients who are doing well, with undetectable viral loads, may have mental memory side effects or problems, and it’s hard to determine what is causing them, and frequently, for a lack of anything else, we have to blame it on the HIV infection itself getting into the brain.
DE: In people that are maintaining really high CD4 cells though, do you see less of that kind of cognitive problem?
DW: Absolutely. We used to feel that that was a complication that you only saw in very advanced disease, so that nowadays, with patients doing very well, high T cells, you don’t expect to see it. But personally, I have a couple of patients who are doing quite well, good T cells, who are unable to function, because of some of those side effects. It’s very difficult to differentiate HIV dementia from depression, from other factors effecting concentration, memory, but sometimes that’s the only explanation you have.
DE: What actions can people with HIV and their doctors take to further avoid some of these complications and illnesses that we’re seeing in people now, now that we have effective antiretroviral therapy.
DW: I think that that’s an area that we certainly need more research in. There’s absolutely no question that the HIV medications we have now have done an extremely good job in controlling the virus, reducing death, and reducing other complications. But now we have to look at, are some of the complications related to the medications themselves, can we modify treatment regimens in order to make them less toxic, and also the question of when should you start therapy. I think there is data that the earlier you start, you may be able to reduce the risk of some of these non-directly HIV related complications. And this is an area that needs to be looked into. The question of where to start, when to start, involves not just a direct HIV outcome, but also these non-directly HIV associated symptoms.
DE: That helps a great deal. Thank you so much for agreeing to be interviewed today, and I look forward to more of the conference.
DW: Thank you very much, my pleasure.