HIV and ID Observations

The last time I did one of these quick “musings” posts, I listed 21, and someone asked me, “Why 21?” The answer — obviously — is that I originally planned on writing 20, but then had to add a 21st, just because that’s exactly how many points you need to win a ping pong game.

So here are a bunch more, in honor of another important racquet sport, tennis, which this weekend will reach the culmination of its grueling season in the finals of the US Open. Stick around to the end to see how I tie it in.

1. Hepatitis B transmission occurred in a nursing home from a contaminated glucometer. As is commonly done, glucometers at the skilled nursing facility were shared among several residents. Even though the disinfection protocols were apparently followed appropriately, a person with chronic hepatitis B was the source of a transmission. In an era of near-universal hepatitis B immunization and dropping prevalence of chronic HBV, it’s worth remembering that among our blood-borne pathogens (HIV, HCV, HBV), HBV is by far the most contagious.

2. A strategy of two doses of dalbavancin 1 week apart for Staph aureus bacteremia was noninferior to 4-8 weeks of daily therapy. However, it was not superior based on the primary “desirability of outcome ranking,” or DOOR endpoint. I think noninferior for clinical endpoints is still important for something as transformative as just two doses, though cost remains a huge barrier for dalbavancin. And get ready for a bunch of studies that use this novel DOOR composite endpoint, which incorporates clinical success, infectious complications, safety complications, mortality, and health-related quality of life.

3. Alpha-gal syndrome is tick-related, is increasingly common — but no, it’s not an infectious disease. Raise your hand if, as an ID doctor, you have been asked anyway to comment on the diagnosis or management of this allergic reaction to the sugar molecule galactose-alpha-1,3-galactose. Here’s the chemical structure, in case you’d like to synthesize it during your free time.

4. I thought you couldn’t put the toothpaste back in the tube. Tell me — who would buy this gizmo? Even for only 10 dollars, I just can’t see the use case.

5. Two-drug initial therapy with dolutegravir/lamivudine provided similar results to a standard three-drug regimen of TDF/FTC plus dolutegravir, even in people with advanced HIV disease. I’ll have more to say about this important study in a later post, along with the fine editorial by Dr. Laura Waters — who also issued some wise career advice as she is about to leave her current position in Britain’s National Health Service.

6. China this summer battled an increase in chikungunya cases in Guangdong Province. We periodically see cases in the United States in returning travelers, especially coming from the Caribbean and South America. It is impressive how debilitating the post-infectious arthritis can be with this dengue- and zika-like virus.

7. I received a bunch of supportive comments and emails about my rant against learning objectives, thank you. A favorite was one from Andrea Demeter, who cleverly took to AI to find reasons to get rid of them — which she must have known would prove my point! But if they’re here to stay, maybe in the future AI can generate the learning objectives, generate the lecture and PowerPoint slides, and then generate the evaluation of whether the lecture met the learning objectives. Magic! And no learning required.

8. Federal, state, and professional societies now issue competing (and sometimes contradictory) vaccine recommendations. Examples: Florida plans to eliminate school requirements for vaccines, while California, Oregon, and Washington band together to ensure communication of “credible information” on vaccines, and Massachusetts makes COVID boosters available for all older than 5. You’d think we live in different countries or something. My Boston ID colleague, Dr. Shira Doron, said it best: “The chaos just doesn’t end.”

9. This group argues persuasively that we should designate Chagas disease endemic in the United States. There’s no doubt that this parasitic infection is far more common in our country than we realize, and that autochthonous transmission occurs here — especially in the Southwest. The labeling of the United States as nonendemic leads to inadequate surveillance and clinical knowledge about this potentially serious parasitic infection.

10. Some of the “friends” that dogs bring home are more welcome than others:

11. In this randomized clinical trial conducted in adults older than 65, high-dose influenza vaccine did not prevent pneumonia or hospitalization better than standard dose. The study was large and well-conducted, enrolling 332,438 participants. 332,438! Is this study the final word on this strategy as we await a better flu vaccine?

12. Switching people with HIV on second-line boosted-PI regimens to BIC/FTC/TAF was noninferior to continued PI therapy. Results reinforce the results from the 2SD and VISEND (Arm A) studies, but add baseline retrospective proviral DNA resistance testing in the bictegravir arm, which demonstrated a high prevalence of NRTI resistance. Hat-tip to Drs. Patrice Severe and Serena Koenig and the GHESKIO team for completing this clinical trial during a time of extraordinary civil unrest in Haiti. (I was a co-investigator.) Good accompanying editorial.

13. There have been six rabies deaths in the US in the past 12 months. This is more than the usual number — typically one to three, some years there are zero — for reasons that are unclear. Can anyone find reference to this on the CDC site? Because tracking rabies and the previously mentioned Chagas disease are exactly why we need a strong agency to do national surveillance for infectious threats. The states simply can’t do it all.

14. If you like documentaries about brilliant songwriters, put these two on your list. The first is about Billy Joel — you might have heard of him (you think?); he has a fascinating biography to back up his impressive song catalogue. I enjoyed it a ton even though I’m lukewarm about much of his music. The more obscure offering is about Charles Fox, a person unknown to me before watching this film. But let’s just say if there’s a soundtrack for us boomers who watched TV growing up, he’s written it.

15. HHS cancelled nearly half a billion dollars in research support for mRNA vaccines. This follows cancellation of a grant to Moderna of 800 million dollars. Vaccine experts consider this technology the most efficient way to respond to a pandemic threat; it also has promise for immune-based cancer therapeutics. Discouraging.

16. I liked this critical piece that highlights issues with excess screening requirements in primary care. Problems include misplaced incentives, strategies that are hardly evidenced-based, and fatigued or distracted providers who then miss the important aspects of patient care. We saw this recently as our electronic medical record flagged absence of hepatitis B immunity in all patient’s charts — for what reason, exactly? Drove multiple clinicians nuts with frustration.

17. What’s going on with pivmecillinam? With gepotidacin? With sulopenem? All three have FDA approval to treat UTIs, none is yet available in US pharmacies. The full name of the last one is “sulopenem etzadroxil with probenecid,” but I defy you to type that out every time you write it.

Seventeen Musings! That’s the age of Serena Williams when she won her first tennis Grand Slam title in 1999. And now, in all it’s glory, is a piece that explains why you should play tennis if you can:

18. We fanatics all read and cheered this tribute to the world’s greatest sport. So much here to love: the growing popularity (pickleball notwithstanding), the fitness advantages, the effects on brain health, the chance to play a sport for a whole lifetime. For the record, I think there’s room in the world for lots of racquet sports — tennis, pickleball, padel, squash, racquetball, badminton, ping pong… And not that she needs it, but I’d bet this is the first time that the writing of Alexandra Moe has been featured in an ID blog.

Ok, eighteen Musings — that’s a good number. It even has its own Wikipedia page!