Prevention of HIV-related Cardiovascular Disease: an enewsletter Series

Transcription

1 Prevention of HIV-related Cardiovascular Disease: an enewsletter Series Final Outcomes Report Gilead Grant ID: ZZ03-16 Data reflective through October 6, 2017

2 Series Landing Page

3 Overview Activity: enewsletter Series (4) Credit:.50 AMA PRA Category 1 Credit(s) TM per activity Sponsored by: The Academy for Continued Healthcare Learning (ACHL) Supported by: Supported by an educational grant from Gilead Sciences, Inc. Intended Audience: Cardiologists, infectious disease specialists, primary care physicians, and other clinicians interested in the management of patients with HIV-related cardiovascular disease. Activity Series Landing Pages: ACHL: freecme: Outcomes Methodology: Activity-related changes in clinician knowledge and competence were evaluated by assessing learner s initial areas of strength and weakness based on the responses provided from questions and case vignettes. The analysis assesses change in ability of the learners to use knowledge and attitudes obtained through the activity in a clinical capacity.

4 Executive Summary: Levels 1-2 Participation 8153 learners across the series and 1555 certificates issued Serial Learning 200 learners participated in at least two activities Participant Satisfaction Objectivity and balance rated as good/excellent by 94% of learners Learning Objectives 94% of learners strongly agree or agree that all learning objectives were met, with an average rating of 3.32/4.0 Faculty Drs. Myerson and Overton were highly rated with an average rating of 3.33/4.0

5 Executive Summary: Levels 3-4 These activities increased learner awareness of CVD risks in HIV-infected individuals, including the roles of HIV infection and inflammation, and the application of available tools for assessing CVD risks. Appropriate use of statin therapy in the setting of ART improved with learners demonstrating competence in the selection and identification of statins with the highest and lowest potential for drug-drug interactions; learners also demonstrated increased knowledge of REPRIEVE and its goals. Changes made from this series will impact up to 17,116 patients each month. Cost, patient compliance issues, and lack of experience were reported as the most common barriers to implementing changes in practice. Learners reported an interest in additional education on strategies for primary prevention in HIV-infected individuals.

6 Considerations for Future Education Application of available assessment tools across diverse HIV-infected patients to guide interpretation Case-based activities of complex patients requiring multiple therapies to reduce CVD risk while receiving ART Selection of therapy to minimize drug-drug interactions Results of the REPRIEVE clinical trial as they become available, including primary prevention with statin therapy and correlation of clinical factors and biomarkers with CVD risk

7 Level 1: Participation Participants Certificates Participation by Specialty Participation by Clinician Type Cardiology Critical Care Physician Physician Assistant Nurse/NP Technologist Other 28% 14% 27% 18% Emergency Medicine Family Practice/Primary Care Gen. Practice/Int. Medicine Surgery Other 49% 19% 2% 4% 8% 13% 5% 13% Other clinicians include: Laboratory Scientist, Administrator, Case Manager, Hospitalist, Pharmacist, Resident. Other specialties include: Infectious Disease, Microbiology, Nephrology, Pain Management, Pathology, Pharmacy.

8 Series Details Activity enewsletter Title & Activity Description Faculty Launch Date Expiration Date Learners (1800 guaranteed per activity) Certificates (400 guaranteed per activity) 1 HIV-related Cardiovascular Disease Reviews CVD risks in HIV-infected individuals and discusses the roles of traditional CVD risk factors and approaches to determining risks via available screening tools. Dr. Merle Myerson September 22, 2016 Expired September 22, 2017 Guarantee Exceeded 3151 Guarantee Exceeded A Deep Dive into HIV Infection as a Contributor to Cardiovascular Disease Reviews the contributions of chronic inflammation, immune activation, and other factors to increased CVD risk in HIV-infected individuals. Dr. E. Turner Overton November 30, 2016 November 30, 2017 Guarantee Exceeded 2506 Guarantee Exceeded Antiretroviral Therapy and Cardiovascular Risks in HIV Reviews the benefits of antiretroviral therapy on cardiovascular risks and selection of therapy for HIV-infected individuals with dyslipidemia Dr. E. Turner Overton February 28, 2017 February 28, Primary Prevention Strategies for HIV-related Cardiovascular Disease Reviews modification of traditional CVD risk factors in HIV-infected individuals with a focus on primary prevention and statin therapy Dr. Merle Myerson May 31, 2017 May 31, *See Appendix for additional recruitment tactics

9 Serial Learning Instances of Serial Learning Individual serial learners Physician Attendance Amongst Serial Learners Cardiology Specialty Amongst Serial Learners 2 activities % 3 activities 70 22% 4 activities 32 16% 53% A proportion of learners participated in more than one activity and were exposed to diverse educational content at different timepoints.

10 Level 2: Learning Objectives Please rate the following objectives to indicate if you are better able to: Activity 1 N=612 Analysis of Respondents Rating scale: 4=Strongly Agree; 1=Strongly Disagree Activity 2 N=395 Activity 3 N=262 Discuss the risk of CVD in HIV positive patients Perform a CVD risk assessment in patients living with HIV Outline the contributions of HIV infection to cardiovascular risks Evaluate potential drug interactions between cardiovascular medications and ART, as well as CVD-related adverse effects of certain ART Identify the most appropriate statins for patients with HIV and CVD risk factors based on the current ART Discuss the high rates of smoking, obesity, diabetes, and hypertension in the HIV population and opportunities to manage these conditions with medication and lifestyle changes. Activity 4 N= % of learners across the series strongly agree or agree that all learning objectives were met, with an average rating of 3.32.

11 Level 2: Faculty Evaluation Please rate the faculty on the criteria listed Rating scale: 4=Excellent; 1=Poor Merle Myerson, MD, EdD, FACC, FNLA Activities 1 and 4 N=785 E. Turner Overton, MD Activities 2 and 3 N=657 Ability to effectively convey the subject matter Expertise on the subject matter The faculty were rated good or excellent across all areas by 94% of learners, with an average rating of 3.33 (N=1442).

12 Level 2: Objectivity & Balance Did you perceive any bias? 9% 91% Yes No N=1442 Activity was perceived as objective, balanced and non-biased.

13 Activities 1/2: Confidence How confident are you in assessing CVD risk in your patients with HIV? A. Very confident B. Somewhat confident C. Minimally confident D. Not at all confident Prior to participating in the first two enewsletters, more than one-half of learners were only somewhat or minimally confident in their ability to assess CVD risk in their HIV patients. After participation, the number of learners reporting being very or somewhat confident increased: from 53% to 85% in Activity 1 and from 55% to 81% in Activity 2. This increase in confidence may be attributed to faculty discussion of risk factors and assessment tools in these activities. Activity 1 Pre (N=695) Activity 1 Post (N=612) 55% 38% % 17% 11% 5% A B C D Activity 2 Pre (N=494) Activity 2 Post (N=395) 53% 36% 28% 28% 19% 14% 17% 4% A B C D

14 Activities 3/4: Confidence How confident are you in selecting therapies to decrease CVD risk in your patients with HIV? A. Very confident B. Somewhat confident C. Minimally confident D. Not at all confident Activity 3 Pre (N=346) Activity 3 Post (N=262) 51% 31% 25% 17% 14% 18% 4% A B C D Activity 4 Pre (N=225) Activity 4 Post (N=173) Confidence in selecting therapy to decrease CVD risk increased after participation in these activities, from 57% to 82% and from 63% to 84% in activities 3 and 4, respectively. This may be attributed to content related to ART and statin use for managing dyslipidemia. 46% 38% 23% 17% 12% 4% A B C D

15 Activities 1/2: Discussing CVD Risks Which of the following best describes your CURRENT approach vs. how you now PLAN to approach discussing CVD risks in your HIV-infected patients? 5 54% 43% Activity 1/2 Pre (N=1189) Activity 1/2 Post (N=1007) 3 29% 3 18% 1 11% 1 5% I regularly/will regularly discuss their CVD risks I refer/will refer my patients to a specialist for CVD risk assessment and management I rely/will rely on other members of my team to discuss CVD risks I wait/will wait until a patient brings up their risks The percentage of learners reporting that they intend to add discussions of CVD risk into conversations with their HIV-infected patients post-activity increased approximately twofold. Prior to participation, more learners referred their patients to a specialist.

16 Activities 2/3/4: CVD Risk & Therapy Selection* How often do you factor/plan to factor CVD risk into selection of therapy for your HIV-infected patients? 45% 35% 3 37% 29% 35% 32% Activities 2/3/4 Pre (N=1065) Activities 2/3/4 Post (N=830) 25% 21% 17% 18% 15% 1 11% 5% Always Often Rarely Never The percentage of learners self-reporting that they always or often factor CVD risk into selection of therapy for their HIV-infected patients increased from 5 pre-activity to 72% after participation. In conjunction with other outcomes metrics, these data suggest an increased awareness of CVD risks in infected-individuals. *This topic was not discussed in Activity 1

17 Activities 2/4: REPRIEVE Trial* Activity 2 N=494 pretests N=449 posttests Activity 4 N=225 pretests N=207 posttests Pre-activity Post-activity Recognition of the primary endpoint of the REPRIEVE clinical trial increased in learners who participated in the enewsletters. Knowledge of the trial goals may encourage learners to enroll eligible patients and seek information on available and emerging primary prevention strategies for their HIV-infected patients. *Similar question posed across two enewsletters.

18 Activities 3/4: Drug-Drug Interactions* Activity 3 N=346 pretests N=315 posttests Activity 4 N=225 pretests N=207 posttests Pre-activity Post-activity Learner competence with the selection of appropriate statin therapy to avoid potential drug-drug interactions with ART improved post-activity. Responses across these questions indicate increased awareness of statins with the highest and lowest likelihood of interaction with ART. *Similar question posed across two enewsletters.

19 Activity 3: Managing CVD Risks Which of the following best describes your CURRENT approach vs. how often you now PLAN to approach managing CVD risks in your HIV-infected patients? 5 42% 52% 44% Pre (N=346) Post (N=262) 3 23% 25% 14% 1 I regularly/will regularly manage their CVD risks I refer/will refer my patients to a specialist for CVD risk management I rely/will rely on other members of my team to manage CVD risks The percentage of learners who intend to manage CVD risks on their own rather than refer to a specialist increased approximately twofold post activity.

20 Activity 1: Pretest vs. Posttest Overview of Correct Responses Pre Post Topic % Change 10 88% 9 Guidelines on CVD Risk Factors and HIV 471% 8 CVD Risks 10 44% 31% Risk Assessment Tools 19 7% Topic 1 Topic 2 Topic 3 Learner knowledge and competence increased across all pre/posttest questions for this activity.

21 Level 3-4: Pre vs. Post Guidelines on CVD Risk Factors and HIV Activity 1 Pre (N=695) Activity 1 Post (N=625) Which guidelines include a dedicated and specific section on managing CVD risk factors in patients with HIV-infection? A. Primary Care Guidelines for the Management of Persons Infected With HIV: 2013 Update by the HIV Medicine Association of the Infectious Diseases Society of America B. American College of Cardiology/American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults C European Guidelines on Cardiovascular Disease Prevention in Clinical Practice D. Part 2 of the National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia 5 45% 35% 3 25% 15% 1 5% 46% 36% 23% 17% 11% 7% A B C D The percentage of learners correctly identifying available guidelines increased from 7% to after participation in the activity. However, these data suggest that additional education is needed on the guidance from the National Lipid Association.

22 Level 3-4: Pre vs. Post CVD Risks Activity 1 Pre (N=695) Activity 1 Post (N=625) SD, a 27-year old man who initiated ART 2 years previously after being diagnosed, presents as a new patient after relocating to the area. He is surprised that he may be at risk for CVD and does not recall being screened by his prior provider. How would you describe his CVD risk to SD? A. His CVD risk is generally comparable to the general population B. His HIV positive status increases his CVD risk C. The use of ART increases his CVD risk D. A lipid panel is necessary to determine if his risk is increased compared to the general population % 44% 18% 21% 17% 3% 6% 3% A B C D There was a 10 increase in the percentage of learners correctly identifying that HIV infection translates into an increased CVD risk. These data suggest that learners gained increased appreciation of CVD risks, even in young HIV-infected patients.

23 Level 3-4: Pre vs. Post Risk Assessment Tools Activity 1 Pre (N=695) Activity 1 Post (N=625) Which of the following best describes the use of the National Cholesterol Education Program Adult Treatment Panel III Framingham Risk Score to estimate CVD risk for a patient such as SD? A. This tool is not recommended for use in this population B. This tool has been validated and is recommended for use in this population C. This tool may over- or underestimate risks in HIV-infected patients and is recommended, but has not been validated, in this population D. This tool overestimates risks in HIV-infected patients with comorbidities, but it can be applied in HIV-infected patients without comorbidities % 31% 18% 3% 3% 4% A B C D The number of learners who correctly recognized the drawbacks and recommendations for using available risk assessment tools in HIV-infected patients increased by 193% after the activity. This may translate into appropriate use and interpretation in clinical practice.

24 Activity 2: Pretest vs. Posttest Overview of Correct Responses Pre Post Topic % Change 10 85% Use of Biomarkers 88% 8 74% 66% 45% CVD Risks 174% 27% 25% REPRIEVE Clinical Trial 164% Topic 1 Topic 2 Topic 3 Participants demonstrated improved knowledge and competence on all pre/posttest questions for this activity.

25 Level 3-4: Pre vs. Post Use of Biomarkers Activity 2 Pre (N=494) Activity 2 Post (N=449) Which of the following best describes available research on IL-6 in HIVinfected individuals? A. ART decreases IL-6 levels, comparable to those in uninfected controls B. Elevated IL-6 does not correlate with increased risk of fatal CVD events C. Elevated IL-6 is associated with risk of death after an MI, stroke, or CVD event D. Methotrexate decreases IL-6 levels and reduces risks of CVD events comorbidities % 45% 27% 18% 1 7% 4% 4% A B C D The percentage of learners correctly identifying research on IL-6 increased from 45% to 85%. Although such biomarkers are not currently used in practice, learners may have increased appreciation for the role of inflammation in HIV-associated CVD.

26 Level 3-4: Pre vs. Post CVD Risks in HIV-infected Individuals Activity 2 Pre (N=494) Activity 2 Post (N=449) BD is a 36-year old man diagnosed with HIV infection 3 years previously. He has been receiving a stable regimen of ART and is interested in joining a clinical trial examining CVD risks in asymptomatic HIV-infected patients. To be included in the trial, he undergoes CT angiography. Based on existing data, BD s coronary CT will most likely reveal: % A. Significant coronary stenosis (>5) B. Calcified coronary plaque 3 28% 29% 27% C. Non-calcified coronary plaque D. Smooth muscle cell rich plaque with lipid accumulation 1 6% 1 16% 1 A B C D The number of learners correctly selecting subclinical signs of CVD typically observed in the setting of HIV infection increased by 174% from pre- to post-activity. As a result, learners may now have increased appreciation of atherosclerotic progression in HIV-infected patients.

27 Level 3-4: Pre vs. Post REPRIEVE Clinical Trial Activity 2 Pre (N=494) Activity 2 Post (N=449) The goal of the ongoing REPRIEVE clinical trial is to evaluate: 7 66% A. The benefits of suppressing chronic inflammation with methotrexate in HIV-infected adults B. Primary prevention using pitavastatin to reduce the risk of CVD in HIV-infected adults C. The effects of specific ART regimens on plaque volume in HIVinfected adults D. The time to first major CVD event in HIV-infected patients receiving ART and aggressive management of traditional risk factors % 9% 25% 26% 15% 21% 1 A B C D Baseline knowledge of the REPRIEVE clinical trial was low. These data demonstrate increased awareness of the intervention, goals, end primary endpoint.

28 Activity 3: Pretest vs. Posttest Overview of Correct Responses Pre Post Topic % Change 10 Selecting Therapy for CVD Risks 186% 8 66% 61% 73% Drug-Drug Interactions 134% Drug-Drug Interactions 204% 23% 26% 24% Topic 1 Topic 2 Topic 3 Participants demonstrated improved knowledge and competence on questions related to therapy and potential drug-drug interactions.

29 Level 3-4: Pre vs. Post Selecting Therapy for CVD Risks Activity 3 Pre (N=346) Activity 3 Post (N=315) WT, a 50-year old man has been receiving a stable ART regimen with full virologic suppression. Hypertriglyceridemia was diagnosed during his annual fasting lipid panel. In addition to providing counseling on lifestyle modifications, what would be your next steps for this patient? A. Switch to another ART regimen B. Add a fibrate % 36% C. Add niacin D. Add a statin % 23% 8% 17% 11% 15% A B C D Learner competence in the selection of therapy for this theoretical HIV patient with hypertriglyceridemia increased from 23% to 66%. Despite this increase, additional education on the management of dyslipidemia in this population may be warranted.

30 Level 3-4: Pre vs. Post Drug-Drug Interactions Activity 3 Pre (N=346) Activity 3 Post (N=315) DW, a 46-year old man who has been on a stable protease-inhibitor based ART regimen since his diagnosis 6 years ago undergoes a lipid panel during a routine visit. His low-density lipoprotein cholesterol (LDL-C) level has continued to increase over the past year and is 165 mg/dl. Which of the following statin therapies is NOT an option for this patient if he remains on his current ART regimen, due to an increased risk of statin side effects? % 61% A. Atorvastatin B. Pitavastatin C. Pravastatin D. Simvastatin 3 1 6% 21% 19% 18% 14% 26% A B C D Data from this theoretical case patient demonstrate increased competence with selection of statin therapy in patients receiving ART. The percentage of learners correctly recognizing that simvastatin poses the potential of drug-drug interactions with a protease inhibitor increased from 25% to 61%

31 Level 3-4: Pre vs. Post Drug-Drug Interactions Activity 3 Pre (N=346) Activity 3 Post (N=315) Your patient receiving a stable ART regimen elects to initiate statin therapy for his elevated LDL-C level. Which currently available statin does not appear to have drug-drug interactions with ART? % A. Atorvastatin B. Pitavastatin 5 C. Pravastatin D. Lovastatin 3 32% 24% 28% 1 9% 16% 1 8% A B C D Again, learner knowledge of potential drug-drug interactions between ART and statin therapy improved postactivity (from 24% to 73%). Learners recognized that pitavastatin has the lowest potential for interactions.

32 Activity 4: Pretest vs. Posttest Overview of Correct Responses Pre Post Topic % Change Drug-Drug Interactions % 8 85% Dyslipidemia Management 196% Drug-Drug Interactions 196% 23% 26% 27% 29% REPRIEVE Clinical Trial 193% Topic 1 Topic 2 Topic 3 Topic 4 Increased knowledge and competence was observed on all pre/posttest questions in this activity.

33 Level 3-4: Pre vs. Post Drug-Drug Interactions with ART 7 Activity 4 Pre (N=225) Activity 4 Post (N=207) DW, a 47-year old man receiving a stable antiretroviral (ART) regimen, was told that his blood pressure was elevated at a work health fair. During his most recent office visit, his blood pressure was 145/92 mmhg. Which class of antihypertensives would you recommend to avoid the potential for drug-drug interactions with his ART regimen? A. Calcium-channel blockers B. Beta-blockers C. Diuretics D. Angiotensin converting enzyme inhibitors % 6% 32% 8% 17% 26% 23% A B C D Learner knowledge of potential drug-drug interactions with ART also improved in the selection of an antihypertensive for this theoretical patient (23% to ). A portion of learners selected a diuretic which may be an option for some patients. These data underscore the complexities of selecting an antihypertensive and indicate that additional education on ART and selection of therapy for modifying CVD risks may be needed.

34 Level 3-4: Pre vs. Post Dyslipidemia Management Activity 4 Pre (N=225) Activity 4 Post (N=207) Which of the following best describes recommendations for managing dyslipidemia in HIV-infected individuals? A. Recommendations specific to HIV-infected individuals are not available at this time B. It is recommended that HIV-infected individuals achieve the same lipid goals as the general population % C. Moderate-high doses of statins are recommended for individuals infected with HIV due to their high risk for atherosclerotic cardiovascular disease D. Recommendations call for more aggressive lipid targets in HIVinfected individuals compared with the general populations % 6% 26% 28% 24% 8% 9% A B C D After participation in the activity, more learners correctly identified recommendations for managing dyslipidemia in HIV-infected patients. This may translate into better selection of appropriate lipid goals for this patient population.

35 Level 3-4: Pre vs. Post Drug-Drug Interactions Activity 4 Pre (N=225) Activity 4 Post (N=207) CB, a 54-year old man who has been on a stable protease-inhibitor based ART regimen for several years is referred due to an elevated low-density lipoprotein cholesterol level (165 mg/dl). Which of the following statin therapies would you recommend to reduce the potential for drug-drug interactions? A. Atorvastatin B. Pitavastatin C. Pravastatin D. Simvastatin % 27% 8 17% 21% 1 8% 6% 6% A B C D Similar to the results observed in activity 3, the percentage of learners correctly identifying pitavastatin as the statin with the least likelihood for drug-drug interactions increased (from 27% to 8). These data suggest that learners are aware of the mechanism by which statins may cause drug-drug interactions with ART regimens.

36 Level 3-4: Pre vs. Post REPRIEVE Trial Activity 4 Pre (N=225) Activity 4 Post (N=207) The ongoing REPRIEVE clinical trial is: 9 85% A. Comparing the lipid-lowering ability of several different statins in HIV-infected adults B. Evaluating whether targeting specific inflammatory pathways can reduce CVD events C. Investigating primary prevention using pitavastatin to reduce the risk of CVD in HIV-infected adults D. Comparing the time to first major CVD event in HIV-infected patients receiving newer ART regimens % 22% 29% 17% 1 7% 7% A B C D 1% Again, baseline knowledge of the REPRIEVE clinical trial was low, but learners demonstrated increased awareness of the study and its primary endpoint. A similar increase was observed in activity 2.

37 Level 4: Patient Care Impact Number of patients affected by these changes each month: 7% 3% 2% 0 33% >50 55% Changes will impact up to 17,116 patients each month (average per activity). This assumes data in chart above is representative of all healthcare professionals in attendance (8,153), who indicated the content will assist in improving quality of care for their patients as a result of their participation in this activity (91%).

38 Level 4: Barriers Cost Patient compliance issues Lack of experience Lack of opportunity (patients) Lack of time to assess/counsel patients Lack of administrative support Lack of consensus or professional guidelines Reimbursement/insurance issues Other No barriers 4% 7% 1 11% 14% 18% 22% 21% 22% 5% 1 15% 25% Participants indicated cost (22%) as most common barrier to implementing changes in their practice, followed by patient compliance issues (21%) and lack of experience (). Of those who identified barriers, 38% will attempt to address the perceived barrier(s) in order to affect change. N=1442; multiple responses allowed

39 Contact Information Brittany Puster Director, Education Development Academy for Continued Healthcare Learning (ACHL) E: P: ext. 134

40 Appendix

41 Additional Recruitment Tactics Social Media will be utilized to post activity messaging on freecme and ACHL platforms, including Facebook, Twitter, and LinkedIn from November - February. freecme will send a November and December eblast to individuals who have noted a cardiology specialty and/or physician clinician type. freecme will continue hosting this series rectangle advertisement in the Recommended Courses section of their website home page through December 2017.

42 Topics of Interest Primary Prevention Strategies in Patients with HIV 42% Patient Cases 33% Management of Traditional CVD Risk Factors 32% Impact of ART on CVD Risks Primary prevention strategies was rated with highest interest for future education, followed by management of traditional risk factors, and case-based education. N=1442; multiple responses allowed

43 Level 4: Activity Impact Self-reported takeaways ACE inhibitors are safest in terms of drug interaction with ART. Always evaluate the risk of CVD in any HIV patient. Behavioral modification can be invaluable in advanced disease processes as well as among the general population. Better aware that everyone should be asked about their HIV status in relation to having a diagnosis of Hyperlipidemia. Better management of HIV comorbidities. Discuss prevention of CVD with all patients by review of lifestyle changes and annual review of lipid profiles along with suggested strategies. Drug-drug interactions with ART. Early intervention is vital. Elevated Il-6 association with CVD event; increases risk of death from cardiovascular events. Elite progressors have same risk for CVD as patients with symptomatic HIV disease. HIV-infected patients are unaware of their increased CVD risk due to being HIV positive even when on ART. HIV patients has higher risk for CVD. HIV patients have a fold increased risk of experiencing cardiovascular events. HIV patients have higher risk of cardiac arrest. HIV positive patients should be evaluated before and during HIV prescriptions to ensure CV needs are met. How to manage patients related to CVD and prevention strategies with HIV patients. I had no idea about the amount of inflammation and how it harmed those patients. I learned that certain comorbidities are more common in HIV positive populations. Importance of keeping labs checked and monitored I never realized choice of statin was important with respect to ART Importance of screening. Importance of risk assessment. Increased awareness of treatment options. Increased my knowledge in this patient population. Increased knowledge relationship of ART to statin drugs Increased risk for patients with and without use of ART.