The Changing Landscape of HIV Treatment

The infectious disease landscape has been evolving, largely due to advancements in treatment and technology. The CDC estimates that more than 1.2 million Americans are living with HIV. In the hepatitis C virus (HCV), between 130 and 150 million individuals worldwide have chronic HCV, of whom, approximately 700,000 will die each year from HCV-related liver diseases.

In part 1 of a 4-part exclusive interview with Specialty Pharmacy Times, Ron Nahass, MD, MHCM, FACP, FIDSA, discusses the impact of antiretrovirals and new blockbuster HCV drugs, challenges in the field, patient adherence, telehealth, and more.

Dr Nahass has been practicing infectious disease medicine for almost 30 years. He has had a long career in clinical research, and education in the area of chronic viral diseases, including HCV, hepatitis B, and HIV. He currently serves on the American Association for the Study of Liver Disease (AASLD) panel HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C.

SPT: Why did you choose to specialize in infectious diseases?

Dr Nahass: As a specialty in medicine, it’s one that is not organ-based. For example, cardiologists focus on the heart, neurologists focus on the brain, pulmonary doctors focus on the lung, gastroenterologists focus on the GI tract. [With] infectious disease doctors, I like to say we don’t own an organ because infections can infect all the organs. I’ve always been a fan of all the organs, not just one. So it was a way for me to continue to be very much involved in all aspects of human health as it relates to all body functions, and still have a specialty.

SPT: How has the development of antiretrovirals changed the HIV landscape?

Dr Nahass: If you go back to the mid-1990s and early 2000s, you would see somewhere around 50,000 to 60,000 deaths per year, and we’re now down to under 10,000 deaths per year; it’s really quite remarkable. It just shows, in about 1995 when these drugs became available, that death rates just plummeted. It’s really a dramatic decline.

SPT: Were you involved during the outbreak of the 1980s AIDS epidemic?

Dr Nahass: The AIDS epidemic really was from mid-1980s and really, it continues, the epidemic hasn’t stopped. Deaths may have dramatically declined but we’re still in the midst of an epidemic. The first case of AIDS that I saw was in 1982, maybe in 1981. I’ve certainly seen patients with AIDS throughout the 80s and 90s. The peak in the epidemic in the US was in 1995.

SPT: When you saw your first patient, did you have an inkling that this was going to become an epidemic?

Dr Nahass: Yeah, pretty quickly you realize. There was patient after patient in that period of time in the early 80s. I mean, it was just one after the other after the other of patients with an unknown diagnosis, with an unknown disease that all had the same symptoms and the same problems. So, you said something’s going on, you knew something was wrong that was just going to end up being identified at some point in time. I don’t think anybody, including myself, knew what the magnitude was going to be.

SPT: Do you work with specialty pharmacies? What has your experience been working with them?

Dr Nahass: Yes, we do work with specialty pharmacies. It would be almost impossible to do this without them. Most of the work with the specialty pharmacists though, are done by my staff. After we make the treatment decision, it’s a lot of work quite frankly.

SPT: What is the most challenging aspect of your job?

Dr Nahass: It’s [working] with the insurance companies. You asked about working with specialty pharmacies, I mean getting drugs approved for patients with hepatitis C is really challenging and that’s a big hassle and a big frustration. I think that dealing with the evolution of the documentation from a paper record to an electronic record is a big hassle, so that’s a challenging part for all of us. I think it’s important that we do that, but it is a challenge and it is very frustrating.

I’ll give you 3 frustrations: one is dealing with the insurance companies and getting approvals; two is the electronic health record; and three is the changing landscape for reimbursement for our services is creating additional challenges, stress, and angst for a lot of physicians, including myself.

We’re moving away from what’s called a pay for service to a pay for value, and I’m all for that, but there’s a lot of pain in changing things. Just like there is pains in moving from a paper record to an electronic record, they don’t have that figured out. They also don’t have it figured out how to do the pay for value model of reimbursements, and that’s a challenge.