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“I like the ISHEID meeting because of its intimate character,” he said. “There are many chances to discuss projects alongside the formal sessions and it is also a good marketplace for collaborations, in which you start discussing with people and come up with ideas for cooperations which can be very fruitful.” He added that the ISHEID congress also provided an excellent opportunity for young investigators to present. “We need conferences that allow fellows to discuss their work in an oral presentation, which is different from a presentation made standing in front of a poster. ISHEID closes an important gap in this respect.”
View the preliminary program here.
He explained that highly effective treatments in recent years had instigated a sea change in patients’ outlooks towards their disease.
“HIV patients can no longer be viewed as one uniform group,” he said. “The reflection of a consciousness within the gay community, for example, that people have to stand side by side and defend themselves against the disease threat to their community, that has gone. I still see HIV ‘veterans’ who have been infected for 25 years or so, but even among them, with more effective treatment available today, despite having received 15 or more years of therapy, there is no longer a feeling of this being something you have to stand up and fight against every single day. Life is not as limited as you might have perceived it.”
He said that the profound psychological shock experienced by a patient when testing positive to HIV was certainly life-changing, but that once the sufferer became accustomed to the news the attitude was replaced by a pragmatic management approach in most patients. “HIV starts to become one of their health problems,” Pr Stellbrink explained. “It is not necessarily their most important problem. And for more recently diagnosed patients it is a well treatable disease. It is not nearly as devastating as before if you are infected.”
In this new HIV landscape there it is a fact that some sufferers will undergo Highly Active Antiretroviral Therapy (HAART) for decades, though adherence remains a challenge. “People especially have decreases in adherence when they have private crises,” Pr Stellbrink has observed. “We have to realize that we will rarely see a patient who adheres perfectly well for all of his life. But what are the consequences? If they are taking a ritonavir-boosted protease inhibitor-based regimen it is not a catastrophe. Boosted PIs are very forgiving in terms of resistance development, but even with efavirenz-containing regimens, a few missed doses appear not to be very problematic. If people fail, their treatment efficacy would not be severely limited. Regimens have to be chosen with this in mind, because that’s actually different for other drugs.”
All the same, Pr Stellbrink believes that when efavirenz becomes generic, as is scheduled in the near future, preferences for first-line therapy may change, with its central nervous system side effects nevertheless remaining a problem. “We don’t know to what extent the daily constraint of a patient’s neuro-psychologic performance is caused by efavirenz,” he said. “Not everyone has the same reactions. Should we switch people who haven’t really complained just because they are tired? (One side effect of efavirenz can be insomnia.) Other drugs do not have this side effect, but economic considerations might be considered more important once efavirenz becomes generic.”
While the transition of a patented drug to generic means cheaper access for all, it can also potentially result in dangerous compromises in medical quality. “Sometimes in developing countries there is less monitoring,” Pr Stellbrink said. “People can also be started with drugs of different qualities and you can’t be sure that you are always getting what is written on the packet. We will see people fail, which results in an important question – do they get access to secondary drugs? First line therapy is reasonably good in most countries but what happens when that fails? Secondary drugs are very expensive in the western world. Maybe a reasonable approach is to let the companies make money from the sales in high-income countries in order to ensure drug availability at low prices in developing countries.”
The notion of setting a ‘gold standard’ of international guidelines is also fraught with complexity, although Pr Stellbrink feels that some direction is needed. “Common guidelines would be appropriate, but rather in terms of defining a minimum standard, especially in resource-constrained settings, where standards sometimes vary in terms of drug availability and health care providers’ education,” he said.
Because no two healthcare systems are the same, he believes it would be difficult to implement sweeping guidelines, given the vast differences between practices, patient needs, local cultural issues and available resources in HIV-affected countries.
“There are choices to make in providing the most economic and appropriate treatment for the largest number of patients and these factors vary. For example, drugs in the US are reimbursed by insurance, so they have to make rules for allowing patients to get reimbursements. In Germany patients are automatically reimbursed. People in these two systems are working under very different pressures, so there will continue to be a need for national or regional guidelines.”
Finally, Pr Stellbrink spoke of the unique opportunity for infectious disease clinicians to provide broad and ongoing health advice to their patients, in areas that might not necessarily be initially considered part of HIV primary care. “In the general physician population there is the notion that cholesterol concerns are exaggerated for cardiovascular risk,” he said. “But our patients teach us that there is a very realistic danger of increase. We have to be ahead of this. We must be very strict and reinforce behavioural changes. Up until a couple of years ago we all thought the same as the GPs on this issue. But in general medicine you don’t see the patients so frequently, and you are more likely to miss what happens to them.”
He said that the HIV specialists had an advantage in being able to convince patients via their ‘bed-side manner’. “Some people cannot be convinced to change. It depends on the communication skills of the doctor, to create a kind of pressure so that the patient doesn’t want to ‘escape’,” he said. “We usually have a good relationship with our patients that has grown over years of contact. Our patients will trust us, which is different from the occasional patient who visits a GP once a year, gets cholesterol measured and doesn’t follow up. The next time you see that person could be in intensive care. We see our patients every three months at least so we have a unique chance to exploit that trusting relationship to reduce the risks.”
If you want to join the debate and hear the latest on global HIV treatments join us for the ISHEID Congress in Marseille, 23-25 May 2012.
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