Summer 2013 - Yale School of Medicine

Summer 2013
VACS Patient Newsletter
Vol. 1 Issue 4
VACS IN THE NEWS

A Geriatrics and Palliative Care Blog (GeriPal), in
April, discussed Meredith Greene’s “Management of
HIV infection in advanced age” article (See publicity
page 3).

The University of Pittsburgh compiled a summary of
press coverage on Matthew Freiberg's "HIV Infection
and the Risk of Acute Myocardial Infarction" article. It
has received an estimated total of 135 media hits as
of March 11, 2013. This included coverage in outlets
in Pakistan, Canada, India, UK, Australia, South
Africa, and New Zealand.

A capsule summary was put together by Clinical Care
Options (CCO), on Keri Althoff’s oral presentation at
th
the 20 Conference on Retroviruses and
Opportunistic Infections (CROI). The presentation
was entitled, “Increased risk for MI, ESRD, and nonAIDS-defining cancers in HIV-infected vs HIVuninfected adults, but similar age at events.”
VA CT Healthcare System West Haven, Coordinating Center
of the Veterans Aging Cohort Study.
PLACE PHOTO HERE,
OTHERWISE DELETE BOX
About VACS
James J. Peters VA Medical Center (Bronx), featured site
Why is Participation Important?
The advances the VACS study has made over the course of
its existence are very substantial; however there is still a
long way to go. It is not only important to know about the
conditions that may go along with HIV infection, but also
how to treat such conditions and ultimately improve quality
of life. The information from our Veterans has allowed us to
gain a vast amount of insight into aging with and without HIV
infection, and we hope for their continued support and
participation that will allow us to provide the best care
possible.
Veterans Aging Cohort Study
950 Campbell Ave (11ACSL-G)
Building 35A
West Haven, CT 06516
www.vacohort.org
E: angela.consorte@va.gov
P: 203-932-5711 ext. 3541
F: 203-937-4926
The Veterans Aging Cohort Study (VACS) is an observational
study that compares HIV-positive and HIV- negative veterans
in care in the United States. The purpose of this study is to
better understand HIV infection and how outside forces, such
as alcohol use, smoking, and other diseases and infections,
can influence the people living with HIV. The study consists of
two cohorts, a “virtual cohort” that uses data from over
120,000 veterans, and a “living cohort” of over 7,000 veterans
that actively participate and receive medical care at one of our
nine
VACS
locations:
Atlanta,
Baltimore,
Bronx,
Brooklyn/Manhattan,
Dallas, Houston, Los Angeles,
Pittsburgh, and Washington DC. The information received
from these cohorts has played a large role in increasing
knowledge about HIV infection and the lives of those infected.
We cannot thank our Veterans enough for their continued
participation in this study.
Summer 2013
VACS Patient Newsletter
Vol. 1 Issue 4
Sheldon T. Brown
PI – Bronx Site
Dr. Brown is the Principal Investigator at
VACS Bronx, a position he has held
since the study’s inception. He is
currently the Chief of Infectious
Diseases at the James J. Peters VA
Medical Center (Bronx) where he
oversees clinics managing the primary
care of HIV, the Viral Hepatitis Clinics,
inpatient and outpatient ID Consultation,
and the Infection Control Program. He is
Associate Professor of Medicine in the
Division of Infectious Diseases at the
Icahn School of Medicine at Mt. Sinai
and Clinical Assistant Professor of
Medicine, Division of General Medicine,
Columbia University Medical Center. He
is the VA liaison and past Chairman of
the New York State (NYS) AIDS
Institute Adult Medical Criteria of Care
Committee. Dr. Brown has been an
active investigator in NIH and VA
sponsored studies of HIV disease and
its complications for over 25 years.
James J. Peters VA Medical Center (Bronx), featured site
Anatoly Ponomarenko
Coordinator
Anatoly Ponomarenko joined
VACS in 2008, bringing experience
from his time assisting pioneering
liver disease researcher Dr.
Charles Lieber. Anatoly is the lead
coordinator at the Bronx site and
also coordinates EXHALE, a VACS
sub-study. He enjoys fishing and
spending time with his grandson.
Yelena Ponomarenko
Co-PI Bronx Site
Dr. Ponomarenko has been a coprincipal investigator in the Bronx for
the VACS since 2009. She is currently
an Attending Physician at the James
J. Peters VA Medical Center (Bronx).
She is Assistant Professor of Medicine
at both Mt. Sinai and Division of
General Medicine, Columbia
University Medical Center. Dr.
Ponomarenko has been an active
investigator in NIH and VA sponsored
studies of liver disease prevention for
over 10 years. Dr. Ponomarenko also
has a PhD in cardiology and a number
of peer-reviewed publications.
Fletcher Fernau
Coordinator
Fletcher Fernau has been a study
coordinator at the James J Peters
VA Medical Center (Bronx) since
2009. For VACS he acts as the
regulatory coordinator as well as
managing patient visits. In addition
to VACS, he has coordinated
studies investigating C. difficile
infection, norovirus, and influenza.
FEATURED SITE: BRONX
The Bronx location is one of our nine VACS sites across the country, and is located within the James J.
Peters VA Medical Center. Dr. Sheldon Brown is the Principal Investigator, and works with Dr. Yelena
Ponomarenko, Co-Principal Investigator, and Site Coordinators, Anatoly Ponomarenko and Fletcher
Fernau. The Infectious Disease Program at this site serves a clinic population of over 400 patients with
HIV.
Summer 2013
VACS Patient Newsletter
Vol. 1 Issue 4
Publicity: The VACS Index has gained recognition on a national and international level. Our most recent publications
are listed below. (Links to articles located on next page)
 HIV Infection and the risk of acute myocardial infarction. Freiberg MS, Chang CC, Kuller LH, Skanderson M,
Lowy E, Kraemer KL, Butt AA, Goetz M, Leaf D, Oursler KA, Rimland D, Rodriguez-Barradas M, Brown S,
Gibert C, McGinnis K, Crothers K, Sico J, Crane H, Warner A, Gottlieb S, Gottdiener J, Tracy RP, Budoff M,
Watson C, Armah KA, Doebler D, Bryant K, Justice AC. JAMA Intern Med 2013 Apr; 173(8):614-622.
This
paper
investigated
whether HIV is associated
with an increased risk of acute
myocardial infarction (AMI).
Participants with baseline
: cardiovascular disease were
eliminated from this analysis.
After analyzing data from
82,459 study participants, we
found that during a median
follow-up of 5.9 years, there
were 871 AMI events. Across
three decades of age, AMI
events per 1,000 personyears, were consistently and
significantly higher for HIVpositive
compared
with
uninfected
veterans
(see
Figure at right). In conclusion,
HIV is associated with a 50%
increased risk of AMI.
25
12
10
20
8
15
AMI Rates per
1000 persons- 6
years
10
4
Uninfected
Uninfected
HIV
Infected
Infected
5
2
0
<30
40-49 40-49
50-59 60-69
80-89 70-79
>89
<30 30-39
30-39
50-59 70-79
60-69
Age
Figure adapted from Freiberg M et al. JAMA Intern Med 2013 article Table 2. Rates of
AMI by HIV Status and Age Group
 Management of HIV infection in advanced age.
Greene M, Justice AC, Lampiris HW, Valcour V.
JAMA 2013 Apr; 309(13):1397-1405.
HIV infected patients treated with antiretroviral
therapy now have increased life expectancy and
develop chronic illnesses that are often seen in
older HIV uninfected patients. In this analysis,
factors associated with end-of-life care were
reviewed. We found that HIV is no longer a fatal
disease. Management of multiple comorbid
diseases is a common feature associated with
longer life expectancy in HIV infected patients.
 Medical intensive care unit (MICU) admission
diagnoses and outcomes in HIV-infected and
uninfected Veterans in the combination
antiretroviral era. Akgun KM, Tate JP, Pisani M,
Fried T, Butt AA, Gibert CL, Huang L, RodriguezBarradas MC, Rimland D, Justice AC, Crothers
K. Crit Care Med 2013 Jun; 41(6):1458-1467.
Patients on combination antiretroviral therapy
are longer living, but may have increased risk for
age-associated diseases, which may lead to
increasing critical care requirements. This paper
compared medical intensive care unit (ICU)
admission characteristics and outcomes among
HIV infected and demographically similar uninfected
patients, and looked at whether an index which
combines clinical biomarkers predicts a 30-day medical
ICU mortality. We found that medical ICU admission was
frequent, 30-day mortality higher, and mechanical ICU
admission was frequent, 30-day mortality higher, and
mechanical ventilation were more common in HIV
infected patients compared with uninfected.
 Physiologic frailty and fragility fracture in HIV infected
male veterans. Womack JA, Goulet JL, Gibert C, Brandt
CA, Skanderson M, Gulanski B, Rimland D, RodriguezBarradas MC, Tate JP, Yin MT, Justice AC. Clin Infect
Dis 2013 May; 56(10):1498-1504.
This analysis explored the association between
physiologic frailty, and fragility fracture as assessed by
the VACS Index. Hip, vertebral, and upper arm fractures
were identified in HIV infected patients and these were
accessed to determine fragility fracture risk factors.
These risk factors include age, hepatitis C status, FIB-4
score, glomerular filtration rate, hemoglobin, HIV RNA,
and CD4 count. We found that frailty, as measured by
the VACS Index, is an important predictor of fragility
fractures among HIV infected male veterans. The
components that were most strongly associated with
fracture risk were age, and hemoglobin level.
VACS Patient Newsletter
Summer 2013
Vol. 1 Issue 4
Article Links:
● GeriPal’s discussion of Greene M et al. JAMA 2013: http://www.geripal.org/2013/04/aging-with-hiv.html
● Freiberg M et al. JAMA Intern Med 2013 Press Coverage: http://www.vacohort.org/impact/75_150934_Media
%20Coverage%20Snapshot%20-%20HIV%20and%20Heart%20Attacks.pdf
● CCO’s Capsule Summary on Althoff K CROI oral presentation: http://www.clinicaloptions.com/HIV/Conference%20
Coverage/Retroviruses%202013/Comorbidities%20and%20Coinfection/Capsules/59.aspx
● Akgun K et al. Crit Care Med 2013: http://www.ncbi.nlm.nih.gov/pubmed/23507717
● Womack J et al. Clin Infect Dis 2013: http://www.ncbi.nlm.nih.gov/pubmed/23378285
● Greene M et al. JAMA 2013: http://www.ncbi.nlm.nih.gov/pubmed/23549585
● Freiberg M et al. JAMA Intern Med 2013: http://www.ncbi.nlm.nih.gov/pubmed/23459863
Affiliated Programs & Resources:
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Center for Interdisciplinary Research on AIDS: http://www.cira.med.yale.edu
Estimating Prognosis for Elders: http://www.ePrognosis.org
American Foundation for AIDS Research (AMFAR): http://www.amfar.org
National Institute of Health, Office of AIDS Research: http://www.nih.gov/od/oar
Project Inform: http://www.projectinform.org
National AIDS Treatment Advocacy Project: http://www.natap.org
US Department of Veterans Affairs: http://www.va.gov
National Institute on Alcoholism and Alcohol Abuse: http://www.niaaa.nih/gov
Funding and Affiliated Funding Sources:
VACS is funded primarily by the National Institute on Alcoholism and Alcohol Abuse, National Institutes of Health. The study
has a special focus on the role of alcohol use and abuse in determining clinical outcomes. This project is also funded in kind
by the US Department of Veterans Affairs and by supplemental support from the National Heart, Lung and Blood Institute,
National Institute of Allergy and Infectious Diseases, the National Institute of Mental Health, the National Cancer Institute
and the Medical Research Council.
QR Codes access the VACS Website and Index Risk Calculator:
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Homepage
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INDEX CALCULATOR-
QR Code for VACS
INDEX CALCULATORMOBILE APP
Funding and Affiliated Funding Sources:
Please visit the VACS website at www.vacohort.org
For any questions or concerns please contact Angela Consorte at
angela.consorte@va.gov or 203.932.5711 ext. 3541