HIV and ID Observations

Amidst outbreak hysterias, anti-vaccine imbecility, electronic medical record whining, and slug-related eosinophilia, I bring you this year’s version of the good news — the 2014 edition of Five ID/HIV Things to be Grateful for this Holiday Season, just in time for your holiday turkeys.

(Needless to say, the bird will be properly cooked to ensure it’s salmonella-free, with all cooking surfaces and utensils kept scrupulously free of cross-contamination. Gosh we’re an interesting bunch, aren’t we.)

So a humble and very sincere THANK YOU for the following, in rough order of impact:

1. Interferon-free HCV treatment has finally arrived. With the December 2013 approval of sofosbuvir following closely after simeprevir, and the stellar results of the COSMOS study — limitations notwithstanding — we finally had an interferon-free regimen that worked (>90% cure!), and one which was blissfully free of significant side effects. Notably, the guidelines agreed, and this quickly became the most commonly used treatment for HCV genotype 1 in the United States. Then last month the news got even better with the approval of sofosbuvir/ledipasvir, along with a substantially greater body of data supporting its use and a a one-third lower price. Yes, the cost issues remain substantial, which is why I invited a colleague to join me at our Medical Grand Rounds recently to discuss it (you can watch here) — but the bottom line is that these advances in HCV treatment will transform the lives of literally millions world-wide.
2. Many brave doctors and nurses are volunteering to assist in the Ebola relief effort. The health care workers who have chosen to go to Western Africa to help treat patients with Ebola virus disease deserve our profound thanks. Think about it: they are volunteering to leave home, volunteering to live in relatively poor surroundings, and most importantly, volunteering to put themselves at the greatest risk of contracting Ebola by caring for the sickest patients, all in the regions without sufficient “staff, stuff, systems, and space”. (That 4-s phrase is Paul Farmer-ism. I might have gotten the order wrong.) Needless to say, lunk-headed quarantine measures, imposed for political reasons or to fan the flames of fear, are not popular among ID doctors. Here’s an interview with Paul describing the Partners in Health relief efforts; you can guess his view on the governor of New Jersey.
3. Treatment of HIV continues to look like the best way to prevent it from spreading. TAP might be best known as the abbreviation for Air Portugal, and the cardiologists might use it to describe transesophageal pacing, but to us ID/HIV specialists, it stands for “treatment as prevention”. The great news is that even 3-plus years after the publication of the 052 study, the data continue to show that effective HIV treatment all but eliminates transmission of the virus to others. An example: a study from CROI 2014 not only demonstrated that the rate of HIV transmission from on-treatment individuals to their uninfected partners was zero (caveat: there were confidence intervals), it also introduced many of us to the term “condomless sex.” And let’s face it, that kind of sex is here to stay, whether we like it or not!
4. Fecal microbiota transplantation (FMT) not only works for recurrent C diff, but it is becoming the treatment of choice. Once all of us got over the “eww” factor (probably overrated to begin with), practitioners have increasingly made FMT available for patients with recurrent C diff — which is a very good thing because the treatment actually works. That’s more than we can say for these cobbled-together antibiotic tapering regimens, for which the supporting evidence was scant at best. The logistics of how best to go about delivering the healthy bacteria to these imbalanced colons still need sorting out, but one could envision something like these frozen poop pills — “poopsicles”, anyone? — as a prescription item in the not-too-distant future.
5. Incentives for antibiotic development seem to be bearing fruit. In 2012, the Generating Antibiotic Incentives Now, or GAIN, provisions were signed into law with bipartisan (fancy that) support, extending by 5 years the exclusivity period for novel antimicrobials before generic competition. Whether this ultimately will be a good law or not remains to be seen, but it certainly is stimulating much-needed antibiotic development for drug-resistant bacteria. This year we saw three new agents active against gram positives, tedizolid, dalbavancin, and oritavancin; coming soon will be ceftazidime-avibactam and ceftolozane-tazobactam, both gram-negative cephalosporin-beta lactamase inhibitor combinations. Interesting overview of drugs in development here.

A few runners-up: The slow but certain end of the Western blot for HIV testing, conjugate pneumococcal immunization decreases childhood admissions for pneumonia, chikungunya cases might be declining in the Caribbean, and the CROI dates are now known well in advance (academic and vacation schedulers around the world thank you!).

What are you thankful for this late November 2014?