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Transcript

 

Lee Tetreault:

Hello, and welcome to Frequently Asked Questions from the session, HIV for the Clinician in Practice. We are joined today by Dr. Stephen Symes, Associate Professor of Medicine. Doctor, before we start today, would you like to share any key pointers from your session to the audience? 

Stephen Symes: 

Sure. Thank you and it's a pleasure to be here. The session will focus on the following, reviewing the pathogenesis and clinical presentation of HIV and associated diseases. We'll go through some common challenges in management that clinicians are likely to see and especially to talk a little bit more about emerging issues especially with an aging population.

Lee Tetreault:

Great. So let's get into some of these frequently asked questions, doctor. First, decades into HIV epidemic, what are challenges that you're seeing in diagnosis and prevention? 

Stephen Symes: 

Well, I think one of the things that we have realized is that there's still a lot of stigma out there surrounding HIV and this is actually really a fascinating area. Treatment is widely available, testing is widely available and very efficient and effective. We can know within five minutes with rapid testing if individuals are HIV positive or not. And now there's actually good preventative measures which are available including tablets to help to prevent you from catching HIV if your partner's positive or if your partner's at risk. But I think one of the big, big issues is people are still scared, they don't know what's out there and they don't know who to ask. And I think this is a big issue. We're hoping, again, that primary care providers and all the healthcare providers can be a gateway to help to alleviate and allow people to get access to both testing, as well as prevention.

Lee Tetreault:

So with the increasingly successful therapy you discuss, why is it still difficult for patients to stay in care? 

Stephen Symes: 

So once, actually, you are diagnosed, you can get on treatment and treatment is very effective, easy to take, very different from in the past, when you know, you had to take multiple different medications. Now it's down to one tablet a day. And yet after a while, we still see patients drop out of care occasionally. We still see patients having trouble keeping up with their medications. I think it is a chronic disease and we have to treat it that way. We have to expect, again, that people are gonna start treatment and be on it for the next 30 years. We have to realize it's a chronic disease, just like hypertension is, like diabetes is, until, again, individuals, until we do actually have a cure. And because of that, a chronic illness, again, we have to make sure again that their mechanisms in place to motivate patients to come and that they actually get this to be a regular part of their behavior.

Lee Tetreault:

Can clinicians stay up to date with more complex medications and co-management? 

Stephen Symes: 

So I think what I would say is that if you have a panel of patients, just like anything else, who are HIV positive on treatment, you'll stay up to date on care. If you're going to try and do this intermittently or off the cuff, it's really challenging, even again if you were well trained before. And I think that's true almost whatever your practice. You see a lot of hypertension, you'll get really good at managing it. You see a lot of patients again who have bronchitis, musculoskeletal disorders, you'll get really good at it. If you have a panel of patients and this has been well documented in your practice of at least 50 patients who have HIV, you'll get good at managing and keeping up with the trends, keeping up with the medications, the side effects and knowing what to do and what to handle with it, and I think that's really a reality.

Lee Tetreault:

So the newer combination meds are an advantage for all, but what do we still need to worry about? 

Stephen Symes: 

So, again, as we progress from older medications with lots of side effects and taking up to 18 tablets a day to newer medicines, one tablet a day, that are easier to take, less side effects, what we've seen is, again, even the newer medications, you have to be cautious in some cases with anti-coagulation medications, seizure medicine, other things, again, that can interact. And I think that's what it's, you know, is one of the challenges that we have to always keep an eye out for. The other thing is that, when the newest medication comes out, the one tablet a day, easy to take, a lot of times, again, we have to be careful that two years, four years down the line, we're not avoiding or not up to date on long-term side effects that take a long time to manifest and show themselves. We saw this, for instance, with some of the Viread preparations that over times were excellent drugs, but caused bone marrow toxicity, caused bone toxicity, kidney damage. And I think that's one thing again that practitioners have to keep an eye on.

Lee Tetreault:

And as patients get older, will there be additional pitfalls to overcome? 

Stephen Symes: 

So right now, we know that over 50% of individuals in United States are what we would call middle-aged or older, older than 50 years of age, and that's really fascinating. A lot of the younger patients who were diagnosed with HIV two decades ago, taking their medicines, doing work, continuing life and they're aging and getting older. The other thing is that older patients who have unprotected sex, a lot of times, are not viewed by practitioners as being at risk for HIV and so testing older individuals actually is not as facile or easy to do, or we don't think of it as often as we do, say, test our younger patients or college-aged students or someone. But this is something which is really important because older patients have more kidney damage and less kidney reserve, have more liver damage, less liver reserve and a lot of these medications are metabolized and cleared through the liver and kidney. So there's a potential for also more side effects. So I would say, again, you have to keep a closer eye on your older patients. And also you have to think about your older patients in terms of prevention. They do have sex, they should be tested, alright? And they should be counseled on effective ways of preventing them from even contracting HIV.

Lee Tetreault:

And lastly doctor, what interventions and practices hold the most promise for the future of HIV care? 

Stephen Symes: 

Well, there are national programs now which are going on, which are focusing on trying to test as many people as we can, trying to, for those people who are tested positive to get them into treatment as fast as we can and then last, to maintain the ones who are on treatment with non-detectable viral loads so that they're not at risk of passing on the virus to anyone else. So you can almost think of this as the 90% rule in terms of those three things, right? We wanna make sure that we test 90% of all the individuals out there who are HIV positive. We wanna get 90% of those who test positive into care and we wanna get 90% of those who we get into care to get to non-detectable viral loads. If we can do that, we know that we can decrease the risk of transmission to other people. You can be HIV positive, your partner HIV negative, if your virus is under control, you will not transmit the virus to your partner, which is something really amazing. And that's even again, having unprotected sex.

Also, again, there's medications out there if you're at higher risk where you can prevent yourself from contracting HIV from a partner, whether or not they're HIV positive or not. But this all depends, again, on you having that knowledge and having that ability to access, again, treatment. The last thing which is really fascinating is that there's actually been two people who have been cured, completely cured from HIV. The mechanism by which that happened which is, both those patients had cancers that required bone marrow transplants, right? Eradicating the immune system and then rebuilding it again. They were not treatment modalities that we can offer to most patients, but they offer a pathway on how to do this, and how it might work. And so I think these are some of the interesting things which are now developing in terms of HIV care that we need to keep an eye on for the future.

Lee Tetreault:

This is great information, doctor. Thank you so much for your time today. 

Stephen Symes: 

My pleasure.