Humberto Jimenez, PharmD, BCPS, AAHIVP, on Managing Comorbidities and Polypharmacy in HIV
Do comorbidities and polypharmacy lead to virologic failure in all populations living with HIV? This was the focus of recent research presented at IDWeek 2018. Lead author of the study, Humberto Jimenez, answered our questions about his research and what the results mean for infectious disease and HIV specialists.
Humberto Jimenez, PharmD, BCPS, AAHIVP, is a clinical assistant professor in the Pharmacy Department at the Ernest Mario School of Pharmacy at St. Joseph's University Medical Center in Paterson, New Jersey.
Infectious Diseases Consultant: Your study assessed whether HIV comorbidities and their associated polypharmacy affect the success of HIV management. Can you tell us a little bit more about your study and what you found?
Humberto Jimenez: We wanted to determine whether our patients with multiple comorbid conditions and/or an associated high pill burden had different rates of reaching virologic control than our patients without such factors. Our hypothesis was that with the added complexities of our managing additional diseases, drug-drug interactions, and so on, these patients would be more likely to have detectable virus. To our initial surprise, patients with multiple comorbidities were more likely to have virologic response than patients with no other concomitant illness or those with only one other condition.
ID CON: What role did age and race/ethnicity play in HIV management?
HJ: Age was an important factor, as older patients were statistically more likely to be virogically undetectable. Patients in the multiple comorbidities arm were significantly older than those with only one comorbidity or with HIV only (55 vs 48 vs 40 years of age, respectively). Just over half of our patients were Black (non-Hispanic) and one-third were Hispanic. However, there were no differences between the arms based on race or ethnicity. Interestingly, women were significantly more likely be older and have multiple comorbidities than men patients.
ID CON: Your study concluded that multiple comorbidities and a greater pill burden increase the likelihood for achieving virologic suppression. How do these results translate into clinical practice?
HJ: Although our finding may not represent other clinics or communities, it appears that our patients with multiple comorbidities and polypharmacy were more ingrained or invested in the health care system. They often have more follow-ups for primary-care-related issues, and conversations about antiretroviral therapy centered mostly around simplification or switch strategies to offset some of the untoward effects that may be exacerbating those very same primary care issues. If this phenomenon is the reason for the improved virologic control, we must identify ways to engage our younger patients more into their health, even if they have been generally asymptomatic. Thanks to great efforts in HIV testing and awareness in our community, patients are being diagnosed earlier than ever. Thus, initiating care with asymptomatic (or subacute) disease has possibly led to decreased fear of the classic AIDS-related consequences of HIV and nonadherence.
ID CON: How can HIV specialists better care for their patients with HIV and comorbidities?
HJ: As infectious diseases specialists, we have focused on the challenges surrounding virologic success. For our patients, particularly as they age and those living in underserved communities, we should strive to be more proactive at ensuring primary care issues are addressed. Recent data have shown that people living with HIV are less likely to take a statin or baby aspirin when indicated.
Another important focus for specialists in this population is navigating simplification and switch strategies, particularly when patients are clearly receiving medications targeting a side effect of an antiretroviral. For example, we have many patients receiving fenofibrate or gemfibrozil. Whether these were initiate due to older hypertriglyceridemia guidelines or due to protease inhibitor therapy, re-evaluation of this medication may lead to discontinuation or a switch to statin-based therapy.
ID CON: In your opinion, what steps need to be taken to ensure a higher rate of HIV remission is achieved in the United States?
HJ: Greater engagement of disenfranchised communities, particularly young men of color. This must involve continued cultural shifts, such as destigmatizing sexual orientation, desensitizing sex, and comprehensive sex education in our schools.
ID CON: What is the key takeaway from your study that HIV and infectious disease specialists should keep in mind?
HJ: That patients with multiple complicating illnesses and a high pill burden are not necessarily more challenging with regard to achieving virologic control. In contrast, additional efforts may be needed to maintain treatment success in people living with HIV who are otherwise in good health and, subsequently, maximize our efforts in curbing the epidemic by preventing new infections.
Reference:
Jimenez H, Stevens T, Suh J. Do comorbidities and polypharmacy lead to virologic failure in all populations with HIV? Paper presented at: IDWeek 2018; October 3-7, 2018; San Francisco, CA. https://idsa.confex.com/idsa/2018/webprogram/Paper71549.html. Accessed November 7, 2018.