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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Raising The Bar In The Care Of Patients With Hiv: Expanding Treatment Strategies And Limiting Transmission


GOAL
To provide HIV/AIDS physicians with up-to-date information on the treatment and management of patients with HIV/AIDS.

TARGET AUDIENCE
This activity is designed for HIV/AIDS physicians. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, participants should be able to:

  • Discuss the prevalence and continued impact of HIV/AIDS.
  • Define and adopt new approaches to address prevention of HIV/AIDS in minority groups.
  • Develop skills to manage women and other minority patient populations, given the unique clinical and therapeutic issues.
  • Demonstrate a better comprehension of the appropriate uses, considerations, and potential medication-induced comorbidities where pharmacologic agents for HIV/AIDS are concerned.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity. The estimated time to complete this educational activity: 2 hours.

Release date: March 15, 2006.
Expiration date: March 15, 2008.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Bristol-Myers Squibb.

Full Disclosure Policy Affecting CME Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

John G. Bartlett, MD
Professor, Department of Medicine
Chief, Division of Infectious Diseases
Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Bartlett reports serving as a consultant on the HIV Advisory Board for Abbott Laboratories, Bristol-Myers Squibb, and GlaxoSmithKline.

PARTICIPATING FACULTY

Myron S. Cohen, MD
J. Herbert Bate Distinguished Professor
Medicine, Microbiology and Public Health
Chief, Division of Infectious Diseases
Director, The University of North Carolina Center for Infectious Diseases
The University of North Carolina
Chapel Hill, North Carolina
Dr Cohen reports having no significant financial or advisory relationships with corporate organizations related to this activity.

Roy M. Gulick, MD, MPH
Associate Professor of Medicine
Weill Medical College of Cornell University
New York, New York
Dr Gulick reports receiving grants/research support from Abbott Laboratories, Boehringer-Ingelheim, Merck & Co., Inc, Pfizer Inc, Schering, and Tibotec; serving as a consultant for Abbott Laboratories, Boehringer-Ingelheim, Bristol-Myers Squibb, Gilead, GlaxoSmithKline, Monogram, Pfizer Inc, and Tibotec; and receiving honoraria from Gilead.

Kenneth E. Sherman, MD, PhD
Gould Professor of Medicine
Director, Division of Digestive Diseases
University of Cincinnati College of  Medicine
Cincinnati, Ohio
Dr Sherman reports receiving grants/research support from Idenix, Roche, Schering, and SciClone; serving as a consultant for SciClone; and receiving honoraria from Abbott Laboratories, Roche, and Schering.

Paul Volberding, MD
Professor and Vice Chair
Department of Medicine
University of California, San Francisco
Co-Director, Gladstone Institute of Virology and Immunology Center for AIDS Research
San Francisco, California
Dr Volberding reports serving as a consultant for Bristol-Myers Squibb, Gilead, Incyte, Merck & Co., Inc, and Pfizer, Inc; receiving honoraria from Bristol-Myers Squibb, Gilead, Merck & Co., Inc, and Roche; and receiving other financial or material support from Immune Response.

Notice: The audience is advised that articles in this CME activity contain reference(s) to unlabeled or unapproved uses of drugs or devices.

Dr Gulick–multiple investigational antiretroviral agents.
Dr Sherman–pegylated interferon a-2b.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Raising the Bar in the Care of Patients with HIV: Expanding Treatment Strategies and Limiting Transmission
John G. Bartlett, MD

Randomized, controlled clinical trials continue to define new treatment strategies that improve viral suppression, increase CD4 cell counts, and prolong survival in patients with HIV infection. The mortality rate associated with HIV infection increased throughout the 1980s, reached a peak in 1995, and began to decline thereafter.1 Acording to HIV surveillance data from the US Centers for Disease Control and Prevention, the number of AIDS-related deaths in the United States decreased by 8% between 2000 and 2004.2 As a result of these improvements in HIV care, more than 1 million people now live with HIV in the United States.3 Although these are encouraging trends, significant challenges remain in the recognition and management of HIV infection. Despite the commitment of significant healthcare resources to prevent the spread of HIV, approximately 40 000 new infections and 18 000 deaths still occur each year in the United States.2 For women and men, approximately 80% of cases of HIV infection are the result of sexual contact.3 New approaches to identify individuals with HIV infection and to prevent the transmission of the virus are still needed, in addition to new approaches to suppress viremia in individuals with chronic HIV infection.

In this issue of Advanced Studies in Medicine, experts in the treatment of HIV use recent research and case study examples to describe some of the most important and difficult challenges in current practice. Myron S. Cohen, MD, of the University of North Carolina, describes recent research regarding the biology and epidemiology of HIV transmission. The transmission of HIV varies considerably during the course of the illness and as a consequence of coinfection with other sexually transmitted diseases. Understanding the biology of HIV transmission suggests reasons why current prevention strategies are not as effective as they could be and may help to identify ways to improve the prevention of HIV infection, such as the identification of acutely infected patients and the use of antiretroviral drugs to prevent infection.

Kenneth E. Sherman, MD, PhD, of the University of Cincinnati, reviews important issues in the management of patients who are coinfected with hepatitis C virus (HCV) and HIV, in addition to other hepatic complications of HIV infection and its treatment. Hepatic complications account for considerable morbidity and mortality among individuals with HIV infection, as a result of drug toxicity, concurrent viral hepatitis, and other causes.4,5 Dr Sherman also describes recent studies that have examined interferons conjugated with polyethylene glycol for the treatment of HCV in HIV-coinfected individuals.

Paul Volberding, MD, of the University of California, San Francisco, provides an overview of important issues in selected patient populations, including the initial presentation of a patient with advanced disease, substance abuse and associated poor treatment adherence, postpartum treatment, and the cooccurrence of HIV infection and anemia. Dr Volberding also describes the recent New York City case, a patient who was infected and then had an unusually rapid progression with a drug-resistant strain of HIV.6

Roy M. Gulick, MD, MPH, of Weill Medical College of Cornell University, discusses treatment options for patients with extensive experience with several antiretroviral drugs. The success of antiretroviral therapy (ART) at improving survival has led to an ever-growing number of individuals who have undergone treatment for years or even decades. Many of these patients were treated with early regimens that are now known to be less than optimal and that may have contributed to the development of drug-resistant HIV variants. Dr Gulick describes the use of genotypic and phenotypic resistance testing to identify potential strategies that may be effective in patients who have long histories of ART. He also discusses the use of newer treatment approaches, such as the combined use of 3 protease inhibitors (PI; 'double-boosting'), the introduction of new PIs, and the clinical development of agents with novel mechanisms of action. The program concludes with a panel discussion with the audience.

This educational activity will provide healthcare providers who care for patients with HIV infection an overview of recent research and expert opinion regarding the biology of HIV transmission, its interaction with comorbid conditions, and management of infection in patients who are highly treatment experienced.

REFERENCES

1. Kates J, Wilson Leggoe A. The HIV/AIDS Epidemic in the United States. The Henry J. Kaiser Family Foundation; September 2005.
2. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2004. Vol. 16. Atlanta, Ga: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2005. Also available at: http://www.cdc.gov/hiv/stats/hasrlink.htm.
3. Glynn L. Estimated HIV prevalence in the United States at the end of 2003. Presented at: 2005 National HIV Prevention Conference; June 12-15, 2005; Atlanta, Ga. Abstract 595.
4. Reisler RB, Han C, Burman WJ, et al. Grade 4 events are as important as AIDS events in the era of HAART. J Acquir Immune Defic Syndr. 2003;34:379-386.
5. Neff GW, Bonham A, Tzakis AG, et al. Orthotopic liver transplantation in patients with human immunodeficiency virus and end-stage liver disease. Liver Transpl. 2003;9:239-247.
6. Markowitz M, Mohri H, Mehandru S, et al. Infection with multidrug resistant, dual-tropic HIV-1 and rapid progression to AIDS: a case report. Lancet. 2005;365:1031-1038.

*Professor of Medicine, Johns Hopkins University School of Medicine, Chief, Division of Infectious Diseases, Johns Hopkins Hospital, Baltimore, Maryland.
Address correspondence to: John G. Bartlett, MD, Professor of Medicine, Johns Hopkins University School of Medicine, Chief, Division of Infectious Diseases, Johns Hopkins Hospital, 1830 Building, Suite 437, 600 North Wolfe Street, Baltimore, MD 21287. E-mail:
jb@jhmi.edu.

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.





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