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


HIV Management in Challenging Populations


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

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, the participant should be able to:

  • Discuss the prevalence and continued impact of HIV/AIDS. 
  • Define and adopt new approaches to address the prevention of HIV/AIDS in minority groups and hard-to-reach populations.
  • Develop skills to manage women and other minority patient populations, given the unique clinical and therapeutic issues.
  • Formulate strategies to maximize management of patients with HIV disease, substance abuse, and mental illness.

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


PARTICIPATING FACULTY

Constance A. Benson, MD
Antiviral Research Center
University of California
San Diego, California
Dr Benson reports receiving grants/research support from Abbott Laboratories and Gilead; and serving as a consultant for Abbott Laboratories, Achillion Pharmaceuticals, Inc., Gilead, GlaxoSmithKline, Merck, Vertex Pharmaceuticals Incorporated, and Virologic.

Victoria A. Cargill, MD, MSCE
Director of Minority Research
Director of Clinical Studies
Office of AIDS Research
National Institutes of Health
Bethesda, Maryland
Dr Cargill reports having no financial or advisory relationships with corporate organizations related to this activity.

Kenneth H. Mayer, MD
Professor of Medicine and
Community Health
Brown University
Director, Brown University AIDS Program
Attending Physician, Infectious
Disease Division
The Miriam Hospital
Providence, Rhode Island
Medical Research Director
Fenway Community Health
Boston, Massachusetts.
Dr Mayer reports having no financial or advisory relationships with corporate organizations related to this activity.

Josiah D. Rich, MD, MPH
Professor of Medicine and
Community Health
Brown University
The Miriam Hospital
Providence, Rhode Island
Dr Rich reports having no financial or advisory relationships with corporate organizations related to this activity.

Glenn Treisman, MD, PhD
Associate Professor of Medicine
Johns Hopkins University School
of Medicine
Director of AIDS Psychiatry
Johns Hopkins Hospital
Baltimore, Maryland
Dr Treisman reports having no financial or advisory relationships with corporate organizations related to this activity.

Notice: 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.

Hiv Management In Challenging Populations
John G. Bartlett, MD

Since the first appearance of AIDS among urban homosexual men in 1981, HIV infection has become a global pandemic. During the past 2 decades, it has been estimated that HIV/AIDS has caused the deaths of 25 million people worldwide.1 According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), it is estimated that in 2005, approximately 40 million people worldwide are living with HIV infection, and that 5 million people globally are estimated to have been newly infected.1 In the United States, the management of HIV infection has evolved rapidly during the past decade, as several large, randomized controlled clinical trials have demonstrated significant clinical benefits with several multidrug antiretroviral regimens. These new treatment regimens have significantly reduced the progression to AIDS and HIV-related mortality; HIV surveillance data from the US Centers for Disease Control and Prevention (CDC) have suggested that the number of AIDS-related deaths decreased by 8% between 2000 and 2004.2 As a result, there are now more than 1 million people living with HIV infection in the United States.3

Despite these advances, the CDC estimates that approximately 40 000 new AIDS diagnoses per year still occur in the United States.3 As the treatment options for HIV have expanded, increasing attention has been focused on identifying and overcoming obstacles to HIV care among specific, and sometimes difficult-to-reach, patient populations. Among men who have sex with men, the incidence of HIV is estimated at 2 cases per 100 person-years.4 Although a great deal of effort has been focused on HIV prevention in this population, there are signs that the prevalence of high-risk sexual behaviors may actually be increasing.5 The incidence of HIV incidence among injection drug users is approximately 1 to 3.2 cases per 100 person-years, with significant regional variation and higher incidence among individuals who are not in drug treatment programs.4 In addition to needle sharing, these individuals often have poor rates of condom use, unstable housing situations, and other factors that increase their risk of infection with HIV and other infectious diseases.6,7

Although most cumulative HIV infections among women have occurred in traditionally high-risk groups, new infections among women are now mostly attributed to heterosexual transmission.8 Members of racial and ethnic minorities represent an increasing proportion of AIDS cases, with an especially high burden among African Americans.9-11 Finally, the widespread adoption of behaviors to reduce HIV risk among the population in general has created an increase in the proportion of persons with new infections who have psychiatric disorders.12 Individuals with depression, personality disorders, or cognitive impairments are least likely to adopt behavioral strategies to reduce their risk of contracting HIV, and also often have difficulties remaining adherent to complex antiretroviral treatment regimens.

This issue of Advanced Studies in Medicine provides an update for clinicians on the recognition and management of HIV infection in several patient populations in which HIV care poses special challenges. Kenneth H. Mayer, MD, of Brown University, describes recent trends in high-risk behaviors and patient characteristics that contribute to high rates of HIV infection, in addition to opportunities to improve HIV identification and treatment. Josiah D. Rich, MD, MPH, also of Brown University, describes issues in HIV management among injection drug users and individuals who are in or recently released from correctional institutions. Victoria A. Cargill, MD, MSCE, of the National Institutes of Health, discusses specific challenges faced by women with HIV infection and reviews the management of HIV infection during pregnancy. Glenn Treisman, MD, PhD, of Johns Hopkins University, describes special issues in the management of HIV, substance abuse disorders, and psychiatric disorders.

This educational activity will provide clinicians who care for patients with HIV infection an overview of recent research and expert opinion regarding strategies for the management of patients in these difficult-to-treat populations.


References

1. UNAIDS epidemiology page. Joint United Nations Programme on HV/AIDS. Available at: http://www.unaids.org/en/
resources/epidemiology.asp. Accessed November 28, 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.
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.
4. Karon JM, Fleming PL, Steketee RW, DeCock KM. HIV in the United States at the turn of the century: an epidemic in transition. Am J Public Health. 2001;91:1060-1068.
5. Katz MH, Schwarcz SK, Kellogg TA, et al. Impact of highly active antiretroviral treatment on HIV seroincidence among men who have sex with men: San Francisco. Am J Public Health. 2002;92:388-394.
6. Rusch ML, Farzadegan H, Tarwater PM, et al. Sexual risk behavior among injection drug users before widespread availability of highly active antiretroviral therapy. AIDS Behav. 2005;9:289-299.
7. Corneil TA, Kuyper LM, Shoveller J, et al. Unstable housing, associated risk behaviour, and increased risk for HIV infection among injection drug users. Health Place. 2006;12:79-85. Epub 2004 Dec 15.
8. Hader SL, Smith DK, Moore JS, Holmberg, SD. HIV infection in women in the United States: status at the Millennium. JAMA. 2001;285:1186-1192.
9. Rosenberg PS, Biggar RJ. Trends in HIV incidence among young adults in the United States. JAMA. 1998;279:
1894-1899.
10. Centers for Disease Control and Prevention. HIV/AIDS surveillance supplemental report: cases of HIV infection and AIDS in the United States, by race/ethnicity. MMWR Morb Mortal Wkly Rep. 1998-2002;10:1-38.
11. Adimora AA, Schoenbach VJ. Contextual factors and the black-white disparity in heterosexual HIV transmission. Epidemiology. 2002;13:707-712.
12. TreIsman GJ, Angelino AF, Hutton HE. Psychiatric issues in the management of patients with HIV infection. JAMA. 2001;286:2857-2864.


*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.





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