Heart disease, HIV treatment success, and PrEP news By Warren Tong

The following reports were among the most attention-grabbing at IDWeek 2017, held October 4–8 in San Diego, California. Go to idsociety.org for more conference news.

Prescriptions of PrEP increase almost 1,000% in New York City, but disparities remain

PrEP (pre-exposure prophylaxis) prescriptions in New York City increased by 974% between 2014 and 2016, though mostly in younger white males, according to a study presented by Paul Salcuni, MPH, at IDWeek 2017.

New York City has one of the highest rates of new HIV transmissions, with nearly 2,500 new diagnoses in 2015. These new cases were disproportionately occurring in specific communities, including men who have sex with men (58%), Black and Latina women (16%), and individuals living in high-poverty neighborhoods (53%).

Research has already shown that oral PrEP when taken consistently reduces the risk of sexual HIV transmission by 92%. Therefore, New York City has been making a concerted effort to scale up PrEP prescription and use, with a particular focus on the priority populations mentioned above.

The study looked at PrEP prescribing data among a sample of 602 New York City ambulatory care practices. PrEP prescription rate per 100,000 patients seen in these practices increased from 38.9 in 2014 to 418.5 in 2016, an increase of almost 1,000%.

Looking at some of the subgroups, male PrEP prescription rate per 100,000 patients increased from 89.5 to 1,036.4, while female PrEP prescription rate per 100,000 patients increased from 7.4 to 32.4, both statistically significant increases. However, Salcuni noted the overall gap between male and female prescriptions got wider. In 2014, men were 4.6 times more likely to be prescribed PrEP than women, and in 2016 that number increased to 13.5 times, highlighting the need to reach and prescribe PrEP to more women who may need it.

Among males, young males were more likely to be prescribed PrEP than older males. In 2014, for males between the ages of 18 and 29, PrEP prescription rate per 100,000 was 131.4 and in 2016 that rate increased to 2,297.1. For males over 30, the rate was 82.1 in 2014 and increased to 805.1 in 2016. By 2016, young males were 2.8 times more likely to be prescribed PrEP than their older counterparts.

Looking at race and ethnicity for males, all races (including white, black, Latino, Asian, and others) saw an increase in PrEP prescription rates from 2014 to 2016. However, the increase was much higher in white males. By 2016, men of color were about half as likely to be prescribed PrEP as white males.

Overall, by 2016, men made up 95% of PrEP prescriptions. Among males, PrEP prescription was associated with: younger age, white race, Manhattan practice location, community health centers vs. independent practices, onsite infectious disease specialist, and lower proportion of patient population from high-poverty neighborhoods.

The study results suggest that campaigns that promote PrEP for patients and PrEP prescribing by providers may be successful at increasing PrEP uptake. However, the disparity seen between male and female prescriptions suggest that the focus needs to shift to women and their primary care providers, including OB/GYNs, Salcuni said.

Moreover, Salcuni noted that the low prescribing rates seen in men of color compared to white men, despite men of color being disproportionately affected, needs to be addressed.

Additionally, continued outreach is needed for practices outside of Manhattan, independent practices, non-ID specialists, and practices seeing patients from high-poverty neighborhoods.

“These results show that educating healthcare providers can really help improve the rate of PrEP prescribing, but it’s apparent we need additional programs to ensure equitable access,” Salcuni concluded in the study press release.

Missed opportunities for preventing cardiovascular disease among patients living with HIV

Cardiovascular disease risk factors need to be addressed among people living with HIV, even those doing well on treatment with undetectable viral loads, according to a study presented by the Ryan White-funded Palmetto Health clinic at the University of South Carolina in Columbia.

The retrospective study, which was led by Michael Kacka, MD, MPH, analyzed clinic data and found that there were missed opportunities for screening and preventing cardiovascular disease among some patients living with HIV—despite the fact that people living with HIV have a high prevalence of atherosclerotic cardiovascular disease (ASCVD) risk factors, including hypertension (high blood pressure), dyslipidemia (high cholesterol or fats), diabetes, high body mass index (BMI), smoking, physical inactivity, and poor diet, the study authors noted.

The researchers randomly selected 100 complete charts from patients living with HIV who were over 40 years old, did not have a previous diagnosis of cardiovascular disease, had three or more visits in the past three years, with at least one visit in the last year. Forty percent were between 40–49 years old, 44% were between 50–59 years old, 15% between 60–69 years old, and less than 5% were over 70. Thirty-one percent were female and 69% were male, while 36% were black and 64% were white. About 85% had an undetectable viral load.

Of the complete charts, 66% had a high enough BMI to be overweight or obese, but less than 30% received a diagnosis or received an intervention for diet, exercise, or weight loss.

Hypertension was diagnosed in 42% of the patients, but only 52% of those diagnosed had their hypertension adequately controlled. An additional 4% met the criteria for hypertension, but were never diagnosed.

Documented diagnosis of diabetes was less than 5%, which the authors noted was surprisingly low. For patients who were eligible to be prescribed a statin (a medication that lowers cholesterol and helps reduce cardiovascular disease risk), less than 25% were prescribed one. More alarmingly, none of the patients with very high cholesterol, which is a low-density lipoprotein (LDL) cholesterol level over 190 mg/dL, or with diabetes received a prescription for statin therapy.

Thirty-one percent of the patients were current smokers and the majority were receiving a smoking cessation intervention. However, nurses had assessed smoking in 100% of the patients.

Overall, despite 85% of the patients having an undetectable viral load, there were multiple missed opportunities to identify risk factors and help prevent cardiovascular disease, including identifying and controlling hypertension and diabetes, assessing and giving interventions to promote healthy diet and exercise, and statin therapy for those who may need it under current guidelines.

While the study does call attention to the overlooked cardiovascular disease risk factors, it was limited by small sample size, incomplete records or documentation, and unavailable information on statin allergy or intolerance.

Integrase inhibitors lead to higher rates of undetectable viral loads after 6 months of treatment

For people living with HIV who are starting treatment, regimens containing an integrase inhibitor (INSTI) led to the highest rate of viral suppression after six months of treatment, and were the fastest in terms of days to viral suppression when compared to regimens containing other drug classes, according to a study which analyzed data from 155 treatment-naive patients (individuals who had never been on treatment before) who had started treatment between 2013–2016. About 29% were female and 71% male. The mean age was 41.3 years and mean viral load before starting treatment was 293,974.

About 46% started a regimen containing an integrase inhibitor, about 37% started a regimen containing a non-nucleoside reverse transcriptase inhibitor (NNRTI), and 17% started a regimen containing a protease inhibitor (PI).

Overall, about 52% of patients achieved an undetectable viral load, with the median time to viral suppression being 105 days. Patients on INSTI-based regimens were more likely to achieve an undetectable viral load by six months (93.2%), compared with NNRTI-based regimens (69.7%) and PI-based regimens (30.8%). Patients on INSTI-based regimens also experienced a lower median time to viral suppression (62.6 days), compared with NNRTI-based regimens (140.5 days) and PI-based regimens (154.5 days). Both these findings were statistically significant.

The authors note that their data support previous studies that have highlighted faster time to viral suppression using INSTI-based regimens. And while current guidelines define virologic failure as having a viral load over 200 after 24 weeks of treatment, perhaps this definition should be changed for those starting INSTI-based regimens to as early as 12 weeks.

The study, led by Karen Jacobson, MD, MPH, also has important implications for situations where individuals would benefit from shorter time to viral suppression, such as for pregnant women, the authors noted.

The study was limited by incomplete patient records which led to a small sample size, non-uniform timing of viral load measurements after treatment initiation, and lack of CD4 count data.

References at positivelyaware.com

Warren Tong is a freelance health and science journalist, with an extensive background writing about HIV and hepatitis C. Follow Warren on Twitter: @warrentong.