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C5 Case Study Session of Three Long-Term Survivors with HIV Disease Mondy

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  • Slide #29: ACTG A5164: Immediate Versus Deferred HAART in the Setting of Acute AIDS-Related OI ACTG A5164 is a phase 4, 48-week, strategy trial to determine the optimal timing of HAART initiation in the setting of acute AIDS-related OI or serious bacterial infection (BI). 1 Randomized arms included immediate HAART (initiated at time of acute OI) and deferred HAART (initiated after treatment for acute OI was completed). 1 There were no restrictions on what type of HAART regimens were used, although the study investigators recommended regimens comprising ritonavir-boosted PI or NNRTI plus 2 NRTIs. 1 Most hospitalizations were due to PCP (63%), and TB was excluded. HAART was started after a mean of 12 days from hospital entry. 1 Reference Zolopa A, Andersen J, Koparow L, et al. Immediate vs deferred ART in the setting of acute AIDS-related opportunistic infection: final results of a randomized strategy trial, ACTG A5164. Program and abstracts of the 15 th Conference on Retroviruses and Opportunistic Infections; February 3-6, 2008; Boston, Massachusetts. Abstract 142.
  • Slide #30: ACTG A5164: Final 48-Week Results Immediate HAART was associated with fewer deaths/AIDS progressions (20 versus 34 events), a longer time to death/AIDS progression, and shorter time to achieving a CD4 cell increase of >50 and >100 cells/mm 3 than deferred HAART in treatment-naïve patients hospitalized with acute OIs. 1 Based on these data, the investigators recommended initiating HAART within 14 days following an acute OI event, as opposed to delaying therapy, absent any contraindications. 1 Reference Zolopa A, Andersen J, Koparow L, et al. Immediate vs deferred ART in the setting of acute AIDS-related opportunistic infection: final results of a randomized strategy trial, ACTG A5164. Program and abstracts of the 15 th Conference on Retroviruses and Opportunistic Infections; February 3-6, 2008; Boston, Massachusetts. Abstract 142.
  • Additional studies evaluated the timing of ART in the setting of acute OIs. At last year’s CROI, results of ACTG 5164 were presented, demonstrating that early ART was associated with a reduced risk of AIDS progression or death compared with waiting until 4-6 weeks later. In this analysis, investigators evaluated the occurrence of IRIS and risk factors for mortality among these highly immunosuppressed patients. IRIS occurred in only 7.6% of pts, a lower rate reported in retrospective studies, and did not differ whether ART was given early or later. When IRIS occurred, it happened a median of 33 days on ART, and was associated with a more rapid HIV RNA decline but interestingly not a rise in CD4. Steroids (given in 5164 frequently as adjunctive therapy for PCP) delayed the onset of IRIS but did not prevent it. Those with lower CD4 cell counts had a higher risk of death – showing that CD4 cell counts have prognostic value even in the setting of acute OIs.
  • results from recent MERIT study (Maraviroc versus Efavirenz in Treatment-Naive Patients) study
  • for cd4 350-500, 55% strong recommendation, 45% moderate recommendations
  • CV, cardiovascular; OI, opportunistic infection.   At the 2010 CROI, additional data were presented to support these recommendations, including studies demonstrating that the CD4+ cell count nadir was predictive of an increased risk of HIV-associated neurocognitive disorders, arterial stiffness as a marker of cardiovascular risk, and increased risk of bone fractures. All of these findings were independent of current CD4+ cell count or HIV-1 RNA level, suggesting that they reflect how badly the immune system has been affected by the disease. In these analyses, CD4+ cell count nadir is presumably a surrogate for the effect of ongoing viremia during the course of an infected individual’s life and appears to predict these outcomes even in patients who initiated therapy and responded well.   In addition, studies examining patients with acute opportunistic infections showed a higher risk of clinical progression in patients who deferred therapy vs patients who initiated treatment immediately. In addition, earlier therapy was associated with improved immunologic outcomes, which is consistent with the randomized, controlled ACTG 5164 that showed benefits associated with therapy initiated early during the course of an acute opportunistic infection. [1]   Reference 1. Zolopa A, Andersen J, Powderly W, et al. Early antiretroviral therapy reduces AIDS progression/death in individuals with acute opportunistic infections: a multicenter randomized strategy trial. PLoS One. 2009;4:e5575.   For more information, go online to: http://clinicaloptions.com/HIV/Conference%20Coverage/Retroviruses%202010/Tracks/Podium/Capsules/128.aspx
  • Silverberg also presented data from a second study (abstract 28), this one focusing on HIV positive participants in the Kaiser Permanente health system, which cares for more than 6 million people in California. A total of 19,280 HIV positive patients (90% men) were matched with 202,313 HIV negative participants of the same sex and age. The cohort was followed from first Kaiser enrollment after 1996 through 2007, or until they were diagnosed with cancer or lost to follow-up. Cancer rates were determined using the National Cancer Institute's Surveillance Epidemiology and End Results (SEER) registry. Cancer risk among HIV positive participants was stratified according to recent CD4 cell count and HIV viral load.
  • ARV, antiretroviral; CI, confidence interval.   As mentioned earlier, the guidelines have suggested that one might consider earlier therapy to protect the uninfected partner in a serodiscordant relationship. While awaiting completion of a randomized controlled trial that is specifically addressing this question, there are several cohort studies that have examined the impact of antiretroviral therapy on HIV transmission risk in serodiscordant couples.   In one particular study reported at the 2010 CROI, investigators followed a group of individuals in heterosexual serodiscordant relationships (3381 couples) in Africa. During the course of follow-up, some of the infected partners met the criteria for initiation of antiretroviral therapy based on CD4+ cell counts or the development of symptoms. Because the study enrolled both the infected and uninfected partners, the investigators were able to genetically characterize the virus in individuals who had incident infection to make sure that the virus they acquired was from their primary partner. Approximately one third of the incident infections were with viruses that were not from the primary partner. When the analysis was limited to the 103 individuals with incident infections that were genetically linked to the primary partner, they found that 102 of the 103 cases had partners who were not receiving antiretroviral therapy, suggesting in an adjusted analysis a 92% lower risk of HIV transmission in these African serodiscordant couples when the HIV-infected partner had been initiated on antiretroviral therapy. It is important to note that this is a cohort study and not a randomized controlled trial, but it shows strong evidence that being on therapy may confer a reduced risk of HIV transmission to uninfected partners.   For more information, go online to: http://clinicaloptions.com/HIV/Conference%20Coverage/Retroviruses%202010/Tracks/Podium/Capsules/136.aspx
  • In a second study presented at CROI, researchers found an increased risk for fragility fractures in relatively young HIV patients (age range, 25 to 54 years), compared with the general population. The researchers analyzed data from 5826 HIV patients from the HIV Outpatient Study, an open prospective study that began in 1993 and includes patients from 10 clinics in 8 American cities. Fracture rates between 2002 and 2008 were compared with those recorded during the same time period in the National Hospital Discharge Survey, which includes data from urgent care, emergency care, and inpatient settings. The researchers found that fracture rates were 4.3 times higher in HIV patients than in the general population, and fragility fractures were also more common. Rates of fracture in HIV patients increased over time. Among HIV patients, a CD4 count of less than 200 cell/mm3 (hazard ratio [HR], 1.60), comorbid diabetes (HR, 1.62), hepatitis C infection (HR, 1.61), and substance abuse (HR, 1.52) were independently associated with increased fracture risk. A third study presented at CROI of male veterans also found an increased risk for fragility fractures in those with HIV, although the increased risk was "modest," according to lead researcher Julie Womack, PhD, from the Veterans Administration Connecticut Healthcare System in West Haven. In that study, the researchers analyzed data from the Veterans Aging Cohort Study, a prospective observational cohort, in which HIV-infected men were matched with uninfected veterans from 1997 to 2009. During the 8-year follow-up, the researchers found an increased prevalence of fragility hip fractures in HIV-infected men, compared with uninfected men. The mean age at fracture was 55 years. When the researchers evaluated the incidence of hip and vertebral fractures in both the infected and uninfected groups, they found that the increased risk (HR) for fragility fractures among HIV-infected men was 1.53. But when the researchers adjusted for established risk factors for fragility fractures, the increased risk dropped to 1.38. "While the effect of HIV on fragility fracture risk is modest, it's significant and independent of other variables," Dr. Womack told Medscape HIV/AIDS .
  • Transcript

    • 1. HIV Cases
    • 2. Case 1
      • 36-year-old AA male, healthy in the past with no prior hospitalizations
      • Presents to ER with
        • 2 week history of cough with clear sputum production
        • Dyspnea on exertion, progressive
        • Associated with subjective fevers
        • Myalgias, fatigue; weight loss 5-10 pounds last month
        • 4-5 loose BMs per day last few weeks
      • PMH
        • Genital herpes
    • 3. Case 1
      • Social history: lives with a friend, unemployed, no recent travel or sick contacts; not sexually active for the last 2 months; smokes marijuana occasionally; social alcohol; no tobacco.
      • Current meds: none
      • Temp 39.7; Pulse 114, BP 148/62, RR 22, O2 sat 88% RA
      • Exam notable for bilateral basilar rhonchi
        • Otherwise unremarkable
    • 4.  
    • 5.  
    • 6.
      • Nasopharyngeal swab negative for influenza/other viruses
      • Sputum gram stain reveals few PMNs, no organisms
      • Strep. pneumonia and legionella antigens negative
      • Rapid HIV ELISA +
      • HIV WB also +
          • p17/18 + p51/55 +
          • p24 + p66 +
          • p31 + gp120/160 +/+
          • gp41 +
    • 7. Patient started empirically on ceftriaxone and zithromax for community-acquired pneumonia, but has not improved a day later. What should be the next step in management?
      • Send CD4 cell count, HIV viral load and genotype; await results before changing therapy
      • Above answer + send sputum for PCP testing and start bactrim + steroids empirically
      • Add additional antibiotic therapy to cover MRSA and Pseudomonas
      • All of the above
    • 8. Patient had been started empirically on ceftriaxone and zithromax for community-acquired pneumonia, but has not improved. What should be the next step in management?
      • Send CD4 cell count, HIV viral load and genotype; await results before changing therapy
      • Above answer + send sputum for PCP testing and start bactrim + steroids empirically
      • Add additional antibiotic therapy to cover MRSA and Pseudomonas
      • All of the above
    • 9.
      • Patient is started on bactrim and steroids; fever and oxygenation improve
      • CD4 count 4 c/mm3 (1%)
      • HIV RNA 63,100 cp/mL
      • Genotype
          • PROTEASE GENE
            • Primary mutations: None.
            • Secondary mutations: None.
          • REVERSE TRANSCRIPTASE (RT) GENE
            • Mutations: K101Q, Y181C, G190A.
    • 10. Do you want to start antiretroviral therapy now?
      • Yes, but not until patient has completed his pneumonia treatment (concern for Immune Reconstitution Syndrome)
      • Start therapy now with truvada/ritonavir/darunavir
      • Start therapy now with truvada/efavirenz (atripla)
      • Defer therapy until patient has established HIV care and compliance to follow-up can be assessed as an outpatient
    • 11. Do you want to start antiretroviral therapy now?
      • Yes, but not until patient has completed his pneumonia treatment (concern for Immune Reconstitution Syndrome)
      • Start therapy now with truvada/ritonavir/darunavir
      • Start therapy now with truvada/efavirenz (atripla)
      • Defer therapy until patient has established HIV care and compliance to follow-up can be assessed as an outpatient
    • 12. ACTG A5164: Immediate Versus Deferred HAART in the Setting of Acute AIDS-Related OI
      • 48-week, strategy trial
        • Determine the optimal timing of HAART initiation in the setting of acute AIDS-related OI or serious bacterial infection (BI)
      • Randomized arms
        • Immediate HAART
          • Initiated at time of acute OI
        • Deferred HAART
          • Initiated after treatment for acute OI is completed
      • HAART
        • No restrictions on initial regimen
        • Study recommended ritonavir-boosted PI or NNRTI plus 2 NRTIs
      Zolopa A, et al. 15 th CROI. Boston, 2008. Abstract 142. Baseline Characteristics Immediate (n=141) Deferred (n=141) Male (%) 85 86 HIV RNA (log 10 copies/mL) 5.07 5.08 No prior HAART 93 91 Median CD4 (cells/mm 3 ) 31 28 Mean time to start HAART after OI/BI diagnosis (day) 12 45 OIs (%) PCP Serious BI Crypto/Histo Toxoplasmosis Other 62 12 14 6 6 63 12 18 3 4
    • 13. ACTG A5164: 48-Week Final Results Recommendation: Initiate “immediate HAART” (within 2 weeks of OI/BI diagnosis) in the setting of acute-AIDS related opportunistic infections/serious bacterial infections, absent any major contraindications Zolopa A, et al. 15 th CROI. Boston, 2008. Abstract 142. Low frequency of IRIS (6% to 8%) and no difference in IRIS observed. 70% of PCP patients received steroids. Immediate HAART (n=141) Deferred HAART (n=141) Odds Ratio (95% CI) P Value Death/AIDS progression (number of events) 20 34 0.51 (0.23, 1.15) 0.035 Time to AIDS progression/ death (weeks) 116 94 0.53 (0.25, 1.09) 0.023 Time to CD4 target (weeks) >50 cells/mm 3 >100 cells/mm 3 4.0 4.3 8.1 12.1 -- -- <0.001 <0.001 HIV RNA <50 copies/mL with no progression (%) 47.5 44.7 -- 0.215
    • 14. IRIS and Mortality when ART Given with OIs A5164 Follow up (N=282 median CD4 29 cells/mm 3 )
      • Early vs. deferred therapy with an OI
        • IRIS in 7.6% of patients after median of 33 days on ART
          • Lower than estimates in retrospective studies
        • HIV RNA decline at week 4 predicted IRIS;
          • CD4 change did not
        • Steroids delayed but did not prevent IRIS
        • No difference in rates of IRIS whether treatment started early or later
        • Overall mortality in trial linked to lower absolute CD4 ( P =0.04)
      Grant P, et al. 16th CROI; Montreal, Canada; February 8-11, 2009. Abst. 775 .
    • 15. Case 2
      • 27 y.o. Caucasian woman referred from ER after positive rapid HIV test (came for sutures to laceration suffered in bike accident)
      • No other medical conditions
      • Risk factor: unprotected sex with men
      • No tobacco; social ETOH; no illicit drugs
      • Works as a waitress; lives with 2 roommates; no kids
      • Interested in starting meds for HIV
      • Baseline labs performed (2 months ago)
        • CD4 525 c/mm 3 , VL 35,000, no mutations by genotype
        • RPR negative, Urine GC/CT negative
        • HCV Ab negative, HBV sAb positive, HAV Ab positive
        • CBC and metabolic panels normal, U/A normal
        • Last week: CD4 510 c/mm 3 (20%), VL 33,000
    • 16. Which selection would be a poor choice?
      • Defer therapy at present
      • Initiate therapy with Truvada/Efavirenz (atripla)
      • Initiate therapy with Ritonavir-boosted PI (darunavir or atazanavir) and 2 NRTIs
      • Initiate therapy with Raltegravir and 2 NRTIs
      • Initiate therapy with Maraviroc and 2 NRTIs
    • 17. Which selection would be a poor choice?
      • Defer therapy at present
      • Initiate therapy with Truvada/Efavirenz (atripla)
      • Initiate therapy with Ritonavir-boosted PI (darunavir or atazanavir and 2 NRTIs
      • Initiate therapy with Raltegravir and 2 NRTIs
      • Initiate therapy with Maraviroc and 2 NRTIs
    • 18. Recommendations for Initiating ART * Treatment with fully suppressive drugs active against both HIV and HBV is recommended. DHHS. Available at: http://aidsinfo.nih.gov/Guidelines.
    • 19. New Studies Supporting Earlier Antiretroviral Therapy
      • Low CD4+ nadir associated with
        • Increased rates of HIV-associated neurocognitive disorders [1]
        • Arterial stiffness contributing to CV risk [2]
        • Increased risk of fracture [3]
      • Patients with acute opportunistic infection
        • 2-fold higher risk of clinical progression in patients who deferred HAART vs those started immediately [4]
        • Improved immunologic outcomes in patients starting early vs deferred HAART during acute opportunistic infection [5]
      1. Ellis R, et al. CROI 2010. Abstract 429. 2. Ho J, et al. CROI 2010. Abstract 707. 3. Dao C, et al. CROI 2010. Abstract 128. 4. Miro J, et al. CROI 2010. Abstract 529. 5. Sanchez A, et al. CROI 2010. Abstract 509.
    • 20. Immunodeficiency, HIV-1 RNA, and Risk of Non-AIDS–Defining Cancers
      • Recent HIV-1 RNA levels not significantly associated with non-AIDS–defining cancer risk (infection related or non-infection related)
      Silverberg M, et al. CROI 2010. Abstract 28. *Adjusted for age, sex, smoking, overweight, alcohol/drug abuse, viral hepatitis; reference = uninfected cohort. † P < .001 relative to uninfected. ‡ P < .05 relative to uninfected. Adjusted HR* HIV Infected, CD4+ Cell Count, cells/mm 3 < 200 201-499 ≥ 500 P Value Any infection related 12.8 † 5.9 † 3.2 † < .001 Anal 164.2 † 83.1 † 34.2 † < .001 Hodgkin’s lymphoma 55.0 † 11.0 † 11.6 † < .001 Oral/pharyngeal 3.1 † 1.9 ‡ 0.8 .030 Any infection unrelated 1.8 † 1.2 1.1 .002 Melanoma 1.3 1.9 ‡ 1.9 ‡ .71 Lung 2.1 ‡ 1.0 1.2 .083 Colorectal 2.2 ‡ 1.0 0.9 .050
    • 21. HIV Transmission Risk in Heterosexual Serodiscordant Couples Initiating ARV
        • 92% lower risk of HIV transmission in African serodiscordant couples when HIV-infected partner receiving antiretroviral therapy
          • 102 of 103 cases of confirmed HIV transmission occurred in couples with HIV-infected partner not receiving ARV therapy
        • Unadjusted relative risk: 0.17 (95% CI: 0.004-0.94; P = .037)
        • Adjusted relative risk: 0.08 (95% CI: 0.002-0.57; P = .004)
          • Adjusted for visit and CD4+ cell count at initiation
      Donnell D, et al. CROI 2010. Abstract 136.
    • 22. Case 2
      • 1 year later (therapy had been deferred)
        • CD4 375 c/mm 3
        • VL 36,000 cp/mL
      • Asymptomatic
    • 23. What would you do?
      • Defer therapy at present, continue to monitor CD4 every 3-4 months
      • Initiate therapy
      • Initiate therapy, but since asymptomatic now can stop when CD4 again greater than 500
    • 24. What would you do?
      • Defer therapy at present, continue to monitor CD4 every 3-4 months
      • Initiate therapy
      • Initiate therapy, but since asymptomatic now can stop when CD4 again greater than 500
    • 25. CASE 3
      • A 48 y.o. HIV-infected white male presents to you for treatment
      • He weights 140 lbs and is 5’11” tall
      • He smokes 1 ppd and drinks moderately
      • He presents with an HIV-1 RNA of 110,000 copies per mL and a CD4+ cell count of 210 cells/mm 3
      • He wants to start antiretroviral treatment
    • 26. What is his risk of underlying osteopenia and osteoporosis?
      • < 1%
      • 5-10%
      • 20% to 40%
      • 50-70%
      • > 90%
    • 27. What is his risk of underlying osteopenia and osteoporosis?
      • < 1%
      • 5-10%
      • 20% to 40%
      • 50-70%
      • > 90%
    • 28. ACTG 5224 Baseline characteristics Baseline prevalence of osteopenia/osteoporosis 35% McComsey G, et al. CROI 2010. Abstract 106LB. N=269 * Age, median (IQR) 38 (31,44) Male (%) 85% White non-Hispanic Race (%) 47% HIV RNA log 10 c/mL, median (IQR) 4.62 (4.24,4.90) HIV RNA ≥ 100,000 c/mL (%) 41% CD4 cells/mm 3 , median (IQR) 233 (106,334) CD4 < 200 cells/mm 3 (%) 43% Lumbar spine T score ≤-1 (%) 35% BMI, Median (IQR) 24.9 (21.8, 28.2) Limb fat kg, Median (IQR) 7.4 (4.7,10.1)
    • 29. Osteopenia related to HIV itself: Bones in HAART-naïve HIV individuals Powderly et al. CROI 2005, Abstract 823. 16% -1 Gilead Study 903, pre-HAART TDF+3TC+EFV (n=299) D4T+3TC+EFV (n=301) Total (n=600) Normal 221 (74%) 206 (68%) 427 (71%) Osteopenia 70 (23%) 83(28%) 153(26%) Osteoporosis 8 (3%) 12 (4%) 20 (3%)
    • 30. Would you do a DEXA scan before starting antiretroviral therapy?
      • Yes
      • No
      • I do not know
    • 31. Would you do a DEXA scan before starting antiretroviral therapy?
      • Yes
      • No
      • I do not know
    • 32. NOF: Indications for BMD Testing for General Population
      • Women > 65 and men > 70 years of age
      • Younger women and men (50 to 69 y of age) at risk
        • Women in the menopausal transition if there is a specific risk factor
        • Adults who have a fracture after 50 y of age
        • Adults of any age with fragility fracture
        • Adults with a condition (eg, rheumatoid arthritis) or taking a medication (eg, glucocorticoids) that predispose them to osteoporosis. I would include HIV here.
        • Anyone being considered or on treatment for osteoporosis. Women that discontinue estrogens.
      National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Available at: http://www.nof.org/professionals/pdfs/NOF_ClinicianGuide2009 v7.pdf.
    • 33. CROI 2010: Fracture studies HOPS cohort VA aging cohort Dao C, et al. CROI 2010. Abstract 128. Womack J, et al. CROI 2010. Abstract 129.
    • 34. CASE 3
      • The patient’s labs are otherwise normal
      • Genotype is wild type
      • He prefers a simple treatment
      • You prescribe atripla once daily
      • The patient tolerates his medicine well
    • 35. What do you expect to happen to his BMD after starting ART treatment?
      • It will increase because his level of chronic inflammation will be reduced
      • It will stay the same
      • It will decrease by 3%-5%
      • It will decrease by 10%
    • 36. What do you expect to happen to his BMD after starting ART treatment?
      • It will increase because his level of chronic inflammation will be reduced
      • It will stay the same
      • It will decrease by 3%-5%
      • It will decrease by 10%
    • 37. A5224s design: Metabolic substudy of A5202 A5224s
    • 38. Mean (95% CI) percent change in lumbar spine BMD * -linear regression No significant interaction of NRTI and NNRTI/PI components (p=0.63) * * McComsey G, et al. CROI 2010. Abstract 106LB. A5224s
    • 39. Mean (95% CI) percent change in hip BMD * * McComsey G, et al. CROI 2010. Abstract 106LB. A5224s
    • 40. Bone Conclusions of 5224s
        • HIV infection itself is associated with an increased risk of bone loss
        • All regimens appeared to produce an initial bone loss with subsequent stabilization or even improvement after Week 48
        • T DF/FTC led to greater BMD loss in hip and lumbar spine than ABC/3TC
        • ATV/r led to greater BMD loss in lumbar spine (but not hip) than EFV
        • Fractures were similarly distributed among study arms
      McComsey G, et al. CROI 2010. Abstract 106LB.
    • 41. CASE 3
      • After 4 years, he is doing well on his regimen
      • CD4+ cell count is now 526 cells/mm 3 and his viral load is undetectable
      • While walking his dog, he fell and fractured his wrist.
    • 42. Would you change his antiretroviral regimen?
      • Yes, definitely
      • No, this was a traumatic fracture
      • No, look first for secondary causes of osteoporosis
    • 43. Would you change his antiretroviral regimen?
      • Yes, definitely
      • No, this was a traumatic fracture
      • No, look first for secondary causes of osteoporosis
    • 44. Bone mineral density appears to improve/stabilize over time N=125; subjects on antiretrovirals for mean of 3.4 years; 46% with low BMD at baseline. Independent predictors of low BMD were history of smoking, steroid use, or wasting; low current weight, and longer duration of HIV infection ( p < 0.05 for all). Mondy et al. CID 2003;36:482-90
    • 45. Vitamin D and HIV Courtesy of Michael Yin, MD 25 OHD Study N Sex Age CD4 ARV Season Def Insuff Normal Stephensen (REACH, US) 2006 238 HIV+ 121 HIV- 25% M 10% W 20 ? ? Winter-Spring 87% 87% Yin (WIHS cohort) 2009 100 HIV+ 68 HIV- 100%F 29% W 38 438 59% All 81% 87% 19% 13% Bang (Sweden) 2004 115 HIV+ 100% M, 100% W 44 480 62% Fall-Winter 20% 36% 40% Rubin (NYC) 2005 62 HIV+ 100% M 34% W 48 540 92% Fall-Winter 42% 34% 24% Rodriguez (Boston) 2005 57 HIV+ 77% M, 60% W 46 430 81% Winter-Spring 48% ? ? Van Den Bout (Holland) 2008 252 HIV+ 75% M, 73% W 41 420 79% Jan-Aug 29% ? 71% Dao (SUN cohort) 2010 672 HIV+ 77% M 30% B 41 471 80% All 72% 38% Broderi (ICONA) 2010 856 HIV+ 71% M 95% Euro 36 ? 96% All 7% 54% 39% Mueller (Swiss cohort) 2010 211 HIV+ 75%M 88%W 37 226 100% Spring (Fall) 42% (14%) 53% (63%) 5% (23%)
    • 46. Case 3
      • DEXA scan results:
        • Hip T-score: -2.4
        • L-spine T-score: -2.2
      • Vitamin D: 12ng/mL
      • Initiated on high dose vit D and calcium
        • 50,000 IU/wk X 12 weeks THEN 2,000 IU/day
        • Optimizes nutrition/weight; stops smoking
      • 1yr later
        • Hip T-score: -1.5
        • L-spine T-score: -1.2