Veterans in Cities More Likely to Use New HIV Drugs

Urban veterans with HIV may be more likely than their rural counterparts to be early adopters of new HIV therapies, a recent study suggests.¹

For the study, researchers in Iowa City, IA,  performed a retrospective cohort study to determine rural-urban variation in adoption of raltegravir — the first HIV integrase inhibitor — in Veterans Affairs healthcare.

“Adoption of raltegravir, an important advance in antiretroviral therapy, is an informative case-study in diffusion of innovation in HIV therapy,” the researchers wrote.

The researchers analyzed data from VA’s national Clinical Case Registry of veterans in care for HIV infection from 1996 through December 2009. There were 1,222 veterans with clinical indication for raltegravir therapy at the time of its FDA approval in October 2007, of whom 223 resided in rural areas.

The researchers found that urban dwellers were more likely than rural to initiate raltegravir within 180 days (17.3% vs. 11.2%) and 360 days (27.5% vs. 19.7%), though this gap narrowed slightly at 720 days (36.3% vs. 31.8%). In multivariable analysis adjusting for patient characteristics, urban residence predicted raltegravir adoption within 180 days (odds ratio 1.72, 95% CI 1.09-2.70) and 360 days (OR 1.63, 95% CI 1.13-2.34), but not 720 days (OR 1.26, 95% CI 0.84-1.87).

“Among veterans who are living with HIV infection who had an indication for a newly approved medicine, raltegravir, veterans living in rural areas showed slower adoption of the new medication compared to veterans living in urban areas,” Michael Ohl, MD, the lead author for the study, told U.S. Medicine.

The findings did not surprise Ohl.

“The reason we hypothesized this would be the case is that we know that rural persons who are living with HIV infection face barriers to obtaining high-quality HIV care, including a perception of greater stigma surrounding HIV infection in a local environment that might discourage healthcare seeking, fewer resources for obtaining information about new HIV therapies, such as contacts with peers who may also be living with HIV infection, as well as poorer access to healthcare providers with expertise in HIV medicine,” he said.

Ohl acknowledged the study focused on the adoption of one new HIV therapy and that further research would need to be done to determine whether general adoption of new HIV therapies is slower among veterans living in rural areas.

“We view this as the first study, the first to ever look at this question of whether there may be differences in the rate of adoption among rural persons to say that this is a potentially important area of further study. I think that the questions remaining are, ‘Is this a generalizable pattern across therapies in general?’ If so, what specific barriers are causing this?” he said.

The researchers also said a central question is whether their findings generalize outside VA care.

Future studies should “explore patient, provider and care site characteristics that are associated with rapid adoption of ongoing innovations in HIV therapy and that may explain rural–urban disparities in access to new therapies,” according to the researchers.

“This will inform interventions to reduce geographic disparities in access to advances in HIV therapy,” the authors concluded.

1. Ohl M, Lund B, Belperio PS, Goetz MB, Rimland D, Richardson K, Justice A,

Perencevich E, Vaughan-Sarrazin M. Rural Residence and Adoption of a Novel HIV

Therapy in a National, Equal-Access Healthcare System. AIDS Behav. 2011 Dec 29.

[Epub ahead of print] PubMed PMID: 22205324.

VA Study Looks at HIV Role in Kidney Disease

In a recent study, researchers sought to identify traditional and HIV-related risk factors for End Stage Renal Disease (ESRD) in HIV-infected individuals and compare ESRD risk by estimated glomerular filtration rate (eGFR) and proteinuria levels.¹

“Despite improvements in survival with human immunodeficiency virus (HIV) infection, kidney disease remains an important complication. Few studies have evaluated risk factors associated with the development of end-stage renal disease (ESRD) in HIV-infected individuals,” the researchers wrote.

For the retrospective cohort study, the researchers studied 22,156 HIV-infected veterans without pre-existing ESRD receiving healthcare in the VA medical system between 1996 and 2004. Using the VA’s electronic record system, the researchers identified the predictors of hypertension, diabetes, cardiovascular disease, hypoalbuminemia (serum albumin <3.5 mg/dL), CD4 lymphocyte count, HIV viral load, hepatitis C virus coinfection, proteinuria and eGFR

The researchers found 366 cases of ESRD, corresponding to 3 cases/1,000 person-years. Hypertension, diabetes and cardiovascular disease were associated independently with ESRD risk in multivariate-adjusted models, as were CD4 lymphocyte count <200 cells/μL, HIV viral load ≥30,000 copies/mL, hepatitis C virus coinfection and hypoalbuminemia.

“Compared with persons without chronic kidney disease, defined as eGFR >60 mL/min/1.73 m(2) and no proteinuria, lower eGFR and higher proteinuria categories were associated jointly with exponentially higher ESRD rates, ranging from 6.6 events/1,000 person-years for persons with urine protein excretion of 30-100 mg/dL and eGFR >60 mL/min/1.73 m(2) to 193 events/1,000 person-years for persons with urine protein excretion ≥300 mg/dL and eGFR <30 mL/min/1.73 m(2),” the authors wrote.

In HIV patients, ESRD risk appears “attributable to a combination of traditional and HIV-related risk factors for kidney disease. Combining eGFR and proteinuria for chronic kidney disease staging is most effective for stratifying the risk of ESRD,” the study concluded.

1. Jotwani V, Li Y, Grunfeld C, Choi AI, Shlipak MG. Risk Factors for ESRD in HIV-Infected Individuals: Traditional and HIV-Related Factors. Am J Kidney Dis. 2011 Dec 27. [Epub ahead of print] PubMed PMID: 22206742.

No Allergic Reactions to Shellfish-Derived Bandage

In 2005, the Office of the Army Surgeon General mandated that every soldier carry a HemCon bandage in 2005. Made from chitosan, a polysaccharide derived from shrimp shells, this bandage is designed to stop bleeding.

In a recent study, researchers prospectively studied the safety of the HemCon bandage in a group of shellfish allergic patients.

“The need to ensure the safety of this bandage is significant, as over 700,000 HemCon bandages have been distributed, and chitosan-based products are being applied for emergency and dental care,” the researchers wrote. “Interestingly, no case reports have been published regarding the use of this bandage in a soldier who has a concurrent shellfish allergy.”

The researchers recruited patients who reported shellfish allergy for the study. Nineteen participants were enrolled, and 10 completed the study. Nine (90%) reported a shrimp allergy history, and five (50%) reported multiple shellfish allergies.

The study researchers hypothesized that the subjects would not experience a reaction to chitosan “based on the extraction process.”

The researchers found that no study participant experienced an adverse reaction to the bandage.

“We found that all subjects tolerated the bandage without reaction,” the authors concluded. “Although larger cohort studies should be considered, the results from this study are encouraging and consistent with two previous studies demonstrating the safety of other chitin-derived products in patients allergic to shellfish.”

1. Waibel KH, Haney B, Moore M, Whisman B, Gomez R. Safety of chitosan bandages

in shellfish allergic patients. Mil Med. 2011 Oct;176(10):1153-6. PubMed PMID: 22128651.

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