Download Characteristics of Native Americans with HIV and

Characteristics of Native Americans with HIV
and implications for care
Christina Connel, PharmD, BCPS, Jeffrey S. Stroup, PharmD, BCPS, Johnny R. Stephens, PharmD,
and Erica Martin, PharmD, BCPS
Limited data have been published about HIV infections and response to
antiretroviral therapy in the Native American population. We reviewed
baseline characteristics of 112 Native American patients to determine if
there were any shared characteristics that would dictate the best treatment for this population. Metabolic diseases and psychiatric disorders
were common findings among our patients. Native American patients
should be monitored and screened as appropriate for comorbid conditions, and these disease states should be considered when choosing an
antiretroviral regimen.
IV rates vary across ethnic groups in the United States.
Data from 2009 estimated that approximately 3000
Native Americans were living with an HIV diagnosis
in the United States (1). While Native Americans represent <1% of persons living with HIV, the rates of diagnosis
increased in this population from 2007 to 2010 (1). In 2010,
the estimated rates of HIV per 100,000 population of Native Americans was 9.7, which is higher than that for Asian or
Caucasian populations, although lower than that for African
American or Hispanic populations (1). HIV has not been well
studied in the Native American population, leading to limited
data for treatment specific to this group. The present study assessed the baseline characteristics and treatment of patients with
HIV and Native American heritage. Our goal was to determine
if there were any common variables among this population that
would dictate the best treatment options for them. This study
was conducted at a Ryan White clinic that cares for approximately 1100 HIV-positive patients.
H
METHODS
This retrospective study evaluated the baseline characteristics of HIV-positive Native American patients >17 years
of age at their initial visit to the Oklahoma State University Internal Medicine Specialty Clinic. Native American
heritage was defined as either patient-reported ethnicity or
a record of medical care through Indian Health Services.
Data collected included patients’ age at transmission, gender, HIV genotype, baseline CD4 count and viral load,
renal function, home medications (including antiretroviral therapy regimen), comorbid conditions, and mode of
Proc (Bayl Univ Med Cent) 2014;27(2):103–105
transmission of HIV. Use of the clinic electronic medical
record identified 149 patient charts meeting inclusion criteria for the study. Upon review, 21 patients had incomplete
initial documentation, and 16 did not have documentation
of Native American heritage. These charts were excluded,
and 112 charts were reviewed for baseline characteristic data.
Descriptive statistics of the patient population were used to
analyze the data gathered.
RESULTS
Patients’ baseline characteristics at the first visit are shown
in Table 1. Viral loads and CD4 counts of patients already controlled on antiretroviral therapy are not reported. Twenty-seven
patients (24%) entered care with a diagnosis of AIDS based on a
CD4 cell count <200/μL at the time of entry; however, previous
AIDS-defining illnesses were not assessed in this study. Most
patients (83%) were men, and the average age of diagnosis was
33 years. Ages of transmission ranged from birth to 65 years.
One patient had vertical transmission and the other 111 patients
received a diagnosis of HIV at the age of 18 or older. As shown
in the Figure, the most frequent mode of transmission was men
having sex with men, followed by heterosexual intercourse. Two
patients reported intravenous drug use in addition to sexual
activity as a possible mode for acquisition of HIV. Those reporting heterosexual intercourse as the form of transmission were
more likely to be female.
Thirty-five patients (31%) entered the clinic already on
antiretroviral therapy; 20 of them had an undetectable viral
load at entry into care. Eleven patients were continued on
regimens despite evidence of undetectable viral loads, two
did not have viral load recorded, and four had a viral load
<500 copies/mL.
Baseline HIV genotypes were collected when available.
Unfortunately, only nine patients (8%) had resistance
From the Department of Pharmacy Services (Connel, Martin) and the Department
of Medicine (Stroup, Stephens), Oklahoma State University Medical Center, Tulsa,
Oklahoma.
Corresponding author: Jeffrey S. Stroup, PharmD, Chief Pharmacy Officer,
Oklahoma State University Medical Center, Associate Professor of Medicine,
Oklahoma State University Center for Health Sciences, 717 S. Houston Avenue,
3rd Floor, Tulsa, OK 74127 (e-mail: [email protected]).
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Table 1. Baseline demographics in 112 Native American
HIV-positive patients
Variable
Table 2. Comorbid conditions in 112 Native American
HIV-positive patients
Mean (range)
Comorbid condition
n (%)
Age at diagnosis (years)
33 (0–65)
Psychiatric disorder
34 (30%)
Men
93 (83%)
Viral load (copies/mL)
CD4 (cells/μL)
Serum creatinine (mg/dL)
137,807 (43–750,000)
374 (2–1142)
0.95 (0.61–1.51)
Height (cm)
175 (150–198)
Weight (kg)
80 (45–182)
Depression
24 (71%)
Anxiety
18 (53%)
Bipolar disorder
2 (6%)
Schizophrenia
1 (3%)
Attention deficit hyperactive disorder
17 (15%)
Dyslipidemia
17 (15%)
Diabetes mellitus
profiles at baseline. Six patients, all of whom were treatment naive, were sensitive to all antiretroviral agents, while
three were resistant to at least one agent. Of the three, one
was treatment naive with conferred resistance to lamivudine.
The other two patients reported having previously been
on therapy, and genotyping showed resistance to nelfinavir
and nucleoside/nucleotide reverse transcriptase inhibitors
(NRTIs), respectively.
The most common comorbid conditions were psychiatric disorders (depression and anxiety being the most
common), hypertension, dyslipidemia, diabetes mellitus,
alcohol abuse, tobacco abuse, and hepatitis (Table 2). Based
on home medication lists, these conditions were being
treated 33% to 50% of the time. Twenty-seven patients
entered our clinic with a CD4 count <200/μL, and nine
of these patients had lower CD4 counts of <50/μL. Prophylaxis for pneumocystis pneumonia and mycobacterium
avium complex was continued or initiated in 70% and
56%, respectively.
1 (3%)
Hypertension
8 (7%)
Alcohol abuse
11 (10%)
Tobacco abuse
29 (26%)
Hepatitis B
4 (4%)
Hepatitis C
9 (8%)
DISCUSSION
Disease states found in our HIV-positive Native
American patients refl ect those reported in national data
for Native American patients. However, there was a lower
prevalence of hypertension, diabetes mellitus, and cardiac
disease than would be anticipated. This could be due to the
overall younger age of the study patient population. Data
including all ethnicities has shown a higher frequency of the
metabolic syndrome among patients between 45 and 64 than
in younger populations (2). Nevertheless, due to the known
increased risk in the Native American population for metabolic disease, patients should be closely monitored for this
disease state and screened as
appropriate. Serum glucose
levels should be monitored
80
with the initiation/change
of antiretroviral therapy and
70
every 6 months thereafter;
60
monitoring should be more
frequent if abnormalities
50
are found (3). The NRTIs
didanosine, stavudine, and
40
Male
zidovudine as well as some
Female
protease inhibitors, particu30
larly those that are ritonavir
20
boosted, have been found to
increase the risk of diabetes
10
mellitus and insulin resistance (3–5). Non-nucleoside
0
reverse transcriptase inhibiMSM
Heterosexual
IVDU
Not
Other
tors (NNRTI) and integrase
Documented
inhibitors do not appear to
Figure. Modes of transmission among 112 Native American HIV-positive patients. MSM indicates men having sex with alter insulin resistance and
men; IVDU, intravenous drug use.
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Baylor University Medical Center Proceedings
Volume 27, Number 2
would be better choices in a patient with diabetes or a patient
at risk for diabetes.
Adult HIV guidelines list NRTIs (stavudine, zidovudine,
abacavir), the NNRTI efavirenz, and all ritonavir-boosted protease inhibitors as having the risk of increasing lipid levels (3).
A baseline fasting lipid profile should be drawn prior to therapy
initiation, and the risk of dyslipidemia should be assessed. Lipid
levels should be monitored annually, and it is not unreasonable
to check a fasting lipid profile 4 to 8 weeks after starting a new
regimen (3). Due to the risk of cardiovascular disease in Native
Americans, it may be prudent to avoid the above regimens if
possible; however, HIV should be treated despite the risk of
vascular disease (5).
When choosing a regimen for a Native American HIVpositive patient, it is important to assess possible adverse effects as
they will affect or precipitate comorbid conditions (6). Currently,
three of the four preferred regimens supported by adult HIV
treatment guidelines contain a component that could precipitate
diabetes mellitus, dyslipidemia, or psychiatric comorbid issues.
The preferred integrase inhibitor regimen and the alternative
non-efavirenz-containing NNRTI regimens appear to be favorable regimens to use in patients at risk for these conditions. The
risk of precipitating a comorbid adverse event should not deter
treatment of HIV. Monitoring should be done in accordance
April 2014
with current guidelines to reduce and prevent medication complications. Newer therapies on the market, such as elvitegravir/
cobicistat or dolutegravir, may also have a role in these patients.
Centers for Disease Control and Prevention. HIV Surveillance Report 2010.
Atlanta, GA: CDC, March 2012. Available at http://www.cdc.gov/hiv/
topics/surveillance/resources/reports/.
2. Schiller JS, Lucas JW, Ward BW, Peregoy JA. Summary health statistics
for U.S. adults: National Health Interview Survey, 2010. Vital Health Stat
2012;10(252):1–207.
3. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and
Adolescents. Rockville, MD: US Department of Health and Human
Services. Available at http://www.aidsinfo.nih.gov/contentfiles/
lvguidelines/adultandadolescentgl.pdf.
4. Bozzette SA, Ake CF, Tam HK, Chang SW, Louis TA. Cardiovascular and
cerebrovascular events in patients treated for human immunodeficiency
virus infection. N Engl J Med 2003;348(8):702–710.
5. Brown TT, Cole SR, Li X, Kingsley LA, Palella FJ, Riddler SA, Visscher
BR, Margolick JB, Dobs AS. Antiretroviral therapy and the prevalence
and incidence of diabetes mellitus in the multicenter AIDS cohort study.
Arch Intern Med 2005;165(10):1179–1184.
6. De Wit S, Sabin CA, Weber R, Worm SW, Reiss P, Cazanave C, El-Sadr
W, Monforte Ad, Fontas E, Law MG, Friis-Møller N, Phillips A; Data
Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study. Incidence and risk factors for new-onset diabetes in HIV-infected patients: the
Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study.
Diabetes Care 2008;31(6):1224–1229.
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Characteristics of Native Americans with HIV and implications for care
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