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European Researchers Issuing Guidelines on Bone Disease
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Jules Levin
Capetown, IAS Conference July 19 2009 7pm
It's 6pm in Capetown, I just came from the GSK satellite meeting and the Conference Opening Session is in 1 1/ hours from now at 7:30. But i am writing to discuss the discussions that just took place at the GSK satellite and my discussions with researchers after the meeting in the hallways with regards to aging, comorbidities, cognitive impairment and mortality. Of note european researchers told me they have been meeting to put together revised european treatment, EACS, guidelines with regards to bone disease and other comorbidities. They are reviewing the new guidelines and will be releasing them at the EACS european AIDS meeting in Cologne, Germany in november 2009. Why have european researchers been working on this but USA researchers have not and ACTG & NIAID leaders have not either? The new EACS guidelines will address screening and monitoring patients for bone disease. It will present an algorithm for screening and monitoring bone disease that includes using the FRAX algorithm and recommendations for bone dexas, so again why has the USA not addressed this or even started a process to begin to address these issues for patients??
At the INSIGHT START meeting where they were discussing inflammation I raised the issue of senesence, immune activation by saying that senescence & immune activation are the root causes of inflammation & comorbidities and onsequent death and several researchers agreed with me. I also said that the NIH and NIAID has neglected the research questions related to these crucial issues and Jeff Nadler and another person from NIAID tried defending themselves by saying that they can only respond to research inqiries FROM researchers, in other words researchers should be submitting requests to them. I said in response, NO, the NIH & NIAID should be bringing investigators into the room to discuss these issues and help to move along research of these questions.
At the GSK satellite meeting Paddy Mallon did a talk on bone disease and Scott Letendre talked about cognitive impairment. Rates for osteopenia are 60% among HIV+ and osteoporosis 15%, stunningly at the average age of about 45 yrs. This is not new, I have been reporting this for 2 years. Studies have found HIV causes bone loss and HIV is associated with low vitamin D. Studies have found PIs and NNRTIs and certain nukes are associated with bone loss. Not to mention that HIV+ individuals have tons of the traditional risk factors: smoking, alcohol use, skinny, low testosterone and others. However, we need much more research to better understand the details. At the GSK satellite meeting Mallon reviewed guidelines for doctors and care providers regarding screening, monitoring, and treatment for bone disease in HIV. I went to the microphone and said the problem is that none of this is being implemented in the clinic by doctors and care providers, we need guidelines and education for care providers. Of course after the satellite meeting in talking with european researchers I found european researchers are preparing guidelines for release at EACS. BUT USA researchers and the NIH have not, why?
I have discussed this before so I will be brief in summing this up. Scott Letendre talked about cognitive impairment and how despite successful HAART we are experiencing a significant of patients experiencing cognitive impairment. As patients reach their late 50s and early 60s cognitive impairment will worsen, frailty will worsen, and bone loss gets worse. A 60 year old patient with untreated osteoporosis who may experience a fall due to ognitive impairment and fracture a bone, and studies show a bone fracture in HIV-neg elderly leads to early mortality. That's what we are facing in the near future. Letendre discussed his research in identifying a score of ART drugs in a regimen that reflects CSF penetration by the individual drugs in a regimen that results in a CPE score of the regimen and whether this score can preict improved cognitive impairment. 3 preliminary studies have been conducted with 2 showing a higher CPE score improves cognitive function & 1 study did not show it. Letendre said we need more research to understand these issues and that is true. He also mentioned that darunavir has a very high rate of CSF penetration.
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