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Biomedical subjects

P Volberding

Publications and source records attributed to P Volberding.

At least 19 recordsLinked to original sources
PubMed2000

Consensus statement: anemia in HIV infection--current trends, treatment options, and practice strategies. Anemia in HIV Working Group.

BACKGROUND: Despite important advances in antiretroviral therapy, anemia remains a problem in many HIV-infected patients. Although the incidence of anemia in these patients has decreased, its prevalence appears to have stabilized or decreased only slightly. Anemia has a deleterious effect on both functional capacity and quality of life, and has been associated with shortened survival. OBJECTIVE: The Anemia in HIV Working Group, an expert panel of physicians and researchers involved in the care of HIV-infected patients, met to determine the impact of anemia in this patient population; to develop practice strategies for the clinician treating HIV-infected patients with anemia; and to identify future research directions. METHODS: The proposed practice strategies are based on results of the available clinical trials (as identified through a MEDLINE search), a review of the literature, and the clinical experience and expert opinion of the panel. The present report is based on meetings held in February and June of 1998; as further experience with various treatment options accumulates and the impact of highly active antiretroviral therapy becomes clearer, the panel will reconvene to develop evidence-based guidelines. RESULTS: The working group considers HIV-associated anemia to be an important contributor to the morbidity and mortality of this infection. Recent reports indicate that recovery from anemia is associated with improved quality of life and survival. CONCLUSIONS: As HIV-infected persons live longer, maintaining quality of life becomes an increasingly important goal of treatment. When planning treatment strategies, clinicians should consider the quality-of-life decrement caused by anemia. Transfusions should be used when rapid recovery is required, and underlying conditions causing anemia should be treated, if possible. Recombinant human erythropoietin (rHuEPO) therapy is appropriate in certain HIV-infected persons and should be considered to maintain hemoglobin concentrations. The target hemoglobin level is 12 g/dL for men and 11 g/dL for women. Weekly rHuEPO dosing is suggested, initiated at 40,000 U, as has been established in patients with cancer.

Anemia↗
PubMed2000

When and where to start: guidelines for the initiation of antiretroviral therapy.

Although several sets of treatment guidelines recommend when antiretroviral therapy should begin, no overall consensus has emerged. Factors that must be weighed in deciding when to start include not only CD4+ cell count and viral load but also the stage and tempo of the disease and the commitment of the patient. Evidence suggests that a first-line, triple-nucleoside regimen may not be the best option, especially for people with more advanced disease. Although deciding between a protease inhibitor (PI) regimen and a non-nucleoside regimen is more difficult, some data indicate that PIs may exert beneficial effects not seen with other antiretrovirals. Simplifying regimens by combining agents with longer half-lives, or by combining two PIs, can make antiretroviral therapy easier to take and more tolerable. But no current regimen will be durable without the utmost adherence by the patient.

Adult↗
PubMed1999

Adherence communication: a qualitative analysis of physician-patient dialogue.

OBJECTIVE: To explore how HIV/AIDS care physicians communicate with HIV-positive patients about the need for adherence to antiretroviral treatment regimens. DESIGN: Semi-structured, face-to-face interviews, a qualitative research method. SETTING: A comprehensive, multidisciplinary, HIV/AIDS practice at San Francisco General Hospital. PARTICIPANTS: Fifteen physicians, most of whom (73%) were board certified in internal medicine and/or infectious diseases; all were involved in HIV continuity care. RESULTS: Most physicians engaged in both pre- and post-prescription phases of adherence communication with their patients. During the pre-prescription phase, physicians made decisions about offering prescriptions to patients, often based on their beliefs about the patient's likelihood of adhering to therapy. During the post-prescription phase, physicians asked patients questions about if/how they were adhering to the regimens. Physicians' practices, such as the length of time spent in the pre-prescription phase, the timing of the 'check-ins' in the post-prescription phase, and the overall content of both phases, varied significantly. CONCLUSIONS: Physicians have diverse ways of communicating with patients regarding adherence to antiretroviral medications. The effect of such communication on treatment outcomes needs to be assessed; however, the potential benefit suggests that training programs should be developed to improve physicians' skills in this area. Further studies should be done to assess how generally applicable these findings are to other groups of physicians.

Adult↗
PubMed1999

Perceptions of health care professionals and patients about the risk of HIV transmission through oral sex: a qualitative study.

We explored health care professionals' beliefs and methods for counseling patients about risks for transmitting human immunodeficiency virus (HIV) through oral sex and HIV-seropositive patients' beliefs and practices regarding oral sex behavior. Health care professionals used divergent counseling strategies, avoided specific recommendations, and expressed ambivalence about recommending barrier protection for oral sex. Patients expressed differing beliefs about oral sex risk; the majority have engaged in unprotected oral sex since diagnosis. Few professionals or patients mentioned oral sex risk for other sexually transmitted diseases (STDs), which can be cofactors for HIV. Although scientific evidence indicates a potential risk for transmitting HIV via oral sex, and patients in our sample want more information about this risk, the health care professionals we interviewed have adopted a largely noncommittal approach to communicating potential risk to patients. Health care professionals should consider discussing more specifically with patients the oral sex risk for transmission of HIV and other sexually transmitted diseases.

Adult↗
PubMed1999

Physicians' transmission prevention assessment and counseling practices with their HIV positive patients.

Physicians can help prevent transmission of HIV by assessing HIV positive patients for risky sexual and needle-sharing behaviors, and by providing risk reduction counseling. From 1995 to 1997, we gathered data on the HIV transmission prevention assessment and counseling practices of 44 San Francisco Bay area physicians in face-to-face, semistructured interviews. A refined coding scheme and constant comparative analytic method were used. Although physicians varied in their responses to coded items, two styles of engagement, at the extremes, emerged from the data: "consultant" and "collaborator." Consultants conducted transmission prevention assessment and counseling during initial visits or upon medical cues (e.g., presence of sexually transmitted diseases) and viewed themselves primarily as information sources, whereas collaborators regularly conducted transmission prevention counseling and viewed themselves as actively helping patients reduce transmission risk. Physicians who fell between the two styles generally did not conduct regular counseling themselves, but many used referrals to health educators. The findings suggest that consultant and collaborator styles may influence patients differently, and offer insight into the role that physicians can play in transmission prevention with HIV positive patients.

Adult↗
PubMed1996

Zidovudine side effects as reported by black, Hispanic, and white/non-Hispanic patients with early HIV disease: combined analysis of two multicenter placebo-controlled trials.

The objective of this study was to determine whether HIV patients' subjective tolerance of zidovudine differs by racial or ethnic grouping by conducting a post hoc analysis of reported symptoms in two multicenter, placebo-controlled trials of zidovudine monotherapy for early HIV disease. Ratios of rates of developing new or worsening symptoms as reported by patients assigned to active drug or placebo were compared in groups of white/non-Hispanic, black, or Hispanic origin. Patients were included in the study if they had asymptomatic HIV disease and entry absolute CD4 lymphocyte counts below 500 cells/microL and were enrolled in National Institute of Allergy and Infectious Diseases AIDS Clinical Trials Group (ACTG) protocol 019 or had mild symptoms of HIV disease, were enrolled in ACTG protocol 016, met protocol eligibility criteria for the respective trial, and were categorized at entry as white/non-Hispanic (N = 1801), black (N = 195), or Hispanic (n = 214). The primary outcome measure was development of a new or worsening symptom of any severity. Among patients treated with zidovudine compared with placebo, the estimated risk for developing a new or worsening symptom was not significantly greater for blacks or Hispanics than for white/non-Hispanics for any of the most frequently reported symptoms (p > 0.05 after adjustment for the multiple comparisons performed). Our analysis of 195 black and 214 Hispanic patients did not reveal a significantly increased risk of subjective zidovudine intolerance compared with white/non-Hispanic subjects. If there is an increased risk of such intolerance in minority groups compared with white/non-Hispanics, it is not likely to be clinically important.

Acquired Immunodeficiency Syndrome↗
PubMed1995

The need for additional options in the treatment of human immunodeficiency virus infection.

Current therapy for human immunodeficiency virus (HIV) infection is inadequate to control the progression of the disease. Although existing nucleoside analogues, such as zidovudine, have clear benefits, they also have drawbacks, including toxicity and the possibility of drug resistance. In addition, the timing of therapy and the use of monotherapy versus combination therapy as initial treatment have not been definitively established. HIV drugs currently in development include newer nucleoside analogues, such as stavudine and lamivudine, nonnucleoside reverse transcriptase inhibitors, and protease inhibitors. The addition of these agents to the antiretroviral armamentarium will expand the treatment options available to clinicians who treat patients with HIV infection.

Antiviral Agents↗
PubMed1995

The value of the CD4+ count of 500 cells/microliters.

The CD4+ cell count is a surrogate marker used for evaluating the efficacy of therapies for HIV infection and for estimating the prognosis of patients with HIV infection. However, there is no single CD4+ count that can be used to indicate likely clinical outcome or the optimal time of treatment initiation. Protocol 019 of the AIDS Clinical Trials Group (ACTG) investigated the efficacy of zidovudine monotherapy in asymptomatic patients with HIV infection. Following results showing zidovudine to be significantly more effective than placebo in delaying the progression to AIDS in HIV-infected patients with CD4+ counts < 500 cells/microliters, further analysis of data from this trial showed that immediate zidovudine significantly delayed the time to reach a CD4+ count of 500 cells/microliters in patients with > 500 cells/microliters compared with deferred therapy. However, there was no additional advantage in terms of delayed onset of AIDS or death compared with deferred treatment. Based on the available evidence, our group believes that the threshold for initiating zidovudine monotherapy should be a CD4+ count of 500 cells/microliters. However, we also strongly advocate additional research to confirm the value of early treatment with zidovudine in asymptomatic patients. Continuing educational and collaborative research efforts will further clarify optimal therapeutic strategies in asymptomatic patients with HIV infection.

Acquired Immunodeficiency Syndrome↗
PubMed1995

An approach to antiretroviral treatment of HIV disease. Combined antiretroviral therapy: the emerging role.

Early, aggressive antiretroviral therapy may soon be considered state of the art. A new generation of antiretroviral agents will soon be available, many of them well tolerated and effective, particularly when used in combination with zidovudine and other nucleoside analogues. Combined antiretroviral therapy represents a significant step forward in the management of HIV infection.

Antiviral Agents↗
PubMed1994

Serum p24 antigen level as an intermediate end point in clinical trials of zidovudine in people infected with human immunodeficiency virus type 1. Aids Clinical Trials Group Virology Laboratories.

Serum p24 antigen levels were examined in subjects from three clinical trials of zidovudine to determine whether the pattern of change in serum p24 antigen during the first 8-16 weeks of therapy was associated with human immunodeficiency virus type 1 (HIV-1) disease progression or death. Among 406 patients with AIDS and a first episode of Pneumocystis carinii pneumonia, 65% had measurable pretreatment concentrations of serum p24 antigen (> or = 10 pg/mL). Changes during treatment were not associated with reduced mortality. In 637 mildly symptomatic patients, 24% had measurable concentrations, and changes were marginally associated with increased time until more advanced disease. Among 683 asymptomatic patients, 18% had measurable concentrations, and changes were not associated with increased time until progression. Despite the small number of clinical events and the low rate of serum p24 antigen positivity in the latter two studies, pretreatment serum p24 antigen levels were predictive of clinical outcome; subsequent measurements appear to be of limited use in evaluating zidovudine therapy.

AIDS-Related Complex↗
PubMed1994

Prevalence and patterns of use of concomitant medications among participants in three multicenter human immunodeficiency virus type I clinical trials. AIDS Clinical Trials Group (ACTG).

Data on the prevalence and patterns of use of concomitant medications among participants in three large phase III clinical trials of zidovudine (ZDV) in human immunodeficiency virus type 1 (HIV-1) infection were analyzed. Overall, 2,801 patients reported 43,331 uses of concomitant medications. Over 85% of clinical trial participants used one or more concomitant medications at some point during the study. Patients with acquired immune deficiency syndrome (AIDS) used an average of 7.1 drugs per month. Patients with AIDS-related complex (ARC) or who were asymptomatic used relatively fewer drugs: 3.1 and 2.7 per month, respectively. Fourteen percent of patients with AIDS used more than 10 concomitant medications per month. The three most commonly utilized classes of drugs were antiinfectives (57%), analgesics or antipyretics (55%), and vitamins (47%). A total of 17% of patients overall and 30% of AIDS patients used acyclovir while on trial. Consumption of prescription drugs was greater, and "over-the-counter" drugs less, among AIDS patients. Reported use of agents not approved by the Food and Drug Administration or approved drugs used for off-label indications was infrequent. Overall use of concomitant medications did not differ across demographic subgroups when corrected for disease stage at the time of enrollment. White, non-Hispanic, homosexual and bisexual men consumed significantly more antivirals and vitamins than other trial participants. Women in all three protocols took more analgesics or antipyretics than did men.(ABSTRACT TRUNCATED AT 250 WORDS)

AIDS-Related Complex↗
PubMed1993

Zidovudine response relationships in early human immunodeficiency virus infection.

OBJECTIVE: To examine predictors of magnitude of CD4+ response to treatment of human immunodeficiency virus (HIV) infection with zidovudine. METHODS: This was a post hoc analysis of randomized placebo-controlled clinical trial in a multicenter trial, 1423 asymptomatic HIV-positive subjects with CD4+ cell counts less than 500 mm-3 were given 500 mg/day zidovudine, 1500 mg/day zidovudine, or placebo. The main outcome measure was change in the CD4+ cell counts over time. RESULTS: This study suggests that earlier treatment with zidovudine results in a larger increment in the CD4+ cell count. In addition, the increment in CD4+ cell count is very long lived. However, drug exposure was not found to be a predictor of response to treatment in the dose range studied. CONCLUSIONS: A parametric model of disease progression can be estimated with use of data collected in a conventionally designed study. These parametric models may provide insight into the optimal use of drugs. This model suggests that zidovudine does not change the underlying course of HIV infection but simply delays the time course. The model also suggests that the magnitude of this delay is larger when treatment is begun earlier in the course of the disease.

Bayes Theorem↗