HIV and ID Observations

I was speaking with a British colleague the other day, and she was remarking how jealous she was that we get a Thanksgiving holiday each year. Starting with a long whine (or moan, as they would say) about the pressures, commercialization, cost, and religious aspects of Christmas, she then went on about how perfect Thanksgiving seems from her outsider perspective.

“What’s not to like? A big pot-luck dinner. Family and friends get together. No presents. A four-day weekend. And the sentiment of gratitude is so lovely.”

(That’s another one of their words — “lovely.”)

Can’t say I disagree, so in that spirit, here’s a quick list of five things from our little ID/HIV worlds to be grateful for, in no particular order:

1. Vaccines. Did you see this paper in the New England Journal of Medicine? By conservative estimates, 75 million to 106 million cases of polio, measles, rubella, mumps, hepatitis A, diphtheria, and pertussis prevented by the vaccines in the United States alone. Add to this hepatitis B, H. flu, rotavirus, varicella, etc., along with the global effect of preventing all these infections, and the impact of vaccines on public and personal health cannot be overstated.
   
2. Antiretroviral therapy. For those of us who have been doing this HIV treatment thing for a while, the movie “Dallas Buyers Club” quickly takes us back to a time that is almost unimaginable today — before effective antiretroviral therapy, before opportunistic infection prophylaxis, to a time when the clinical and research medical establishment was often at odds with the very people we were supposed to help, the people with AIDS. Sure, some of the medical details in the film are screwy — ddC a better treatment than AZT? — but it’s highly recommended nonetheless, with an unbelievably great performance by Matthew McConaughey, as you can see in the trailer below. Good to be reminded, every so often, just how transformed HIV disease is by current therapy.
3. Doxycycline. How much do we ID doctors love you? Let me count the ways: Lyme disease, MRSA, anaplasmosis, ehrlichiosis, community-acquired pneumonia, urethritis, syphilis, Rocky Mountain Spotted Fever, malaria prevention, anthrax prophylaxis, pelvic inflammatory disease, brucellosis, wolbachia (that last one a trivia question for ID fellows)… And not only that, the drug is relatively safe (just don’t take it before lying down) and inexpensive (this year a bit less so, unfortunately). To continue the British theme, if you want to know every ID doctor’s “Desert Island Drug”, this is it — just be sure to bring the sunscreen. “Doxy,” thank you for being you — we are very, very grateful.
4. AIDS Drug Assistance Programs (ADAPs). Here’s a challenging problem for the healthcare “system” (ha): A disease that is fatal, transmissible, stigmatized, and disproportionately targets the poor. Oh, and treatment is extremely effective, but also quite expensive. Problem? What problem? For HIV, we have a national program, administered by the states, that virtually guarantees everyone (with few exceptions) lifesaving antiretroviral therapy, regardless of their ability to pay — yes, ADAPs are truly miraculous. Sure, we worry about waiting lists and strained budgets (especially in the Southeast), but the number of people denied HIV therapy in the United States today remains small indeed. Who knows what form ADAPs will be in over the next few years with institution of the Affordable Care Act, but let’s hope this remarkable state of affairs is preserved.
5. Microbiome and Resistance Awareness. Every healthcare provider has vast experience with the “green phlegm” patient encounter. It goes something like this: Patient is suffering from a prolonged cough, or runny nose, or some other respiratory symptom, and he/she keeps telling you that they have “green phlegm.” This term, you see, has long been a code for, “I need an antibiotic.” Never mind that the color of these secretions says little about whether the infection is bacterial or viral, somehow the public perception was that the only way to return to health, to eliminate the nasty green goo, was to start an antibiotic. Yet over the past few years, a Gladwellian Tipping Point has been passed: We still have the green phlegm conversations — isn’t being a doctor/nurse wonderful? — but for various reasons there are now lots of people out there who would prefer not to take an antibiotic if at all possible. Microbiome (all those good bacteria) awareness? Fear of antibiotic resistance? A friend/family member with C diff? Probably all of the above, and it couldn’t be more sensible, since of course all antibiotics can be harmful (even doxycycline).

What are you grateful for these days?