HIV and ID Observations

The folks over at the Journal of the American Medical Association have been doing a periodic HIV/AIDS themed issue for years, generally around the time of the International AIDS Conference.

The latest issue is out this week, and it’s terrific. Here are some highlights:

• In serodiscordant couples practicing “condomless sex”, there were zero transmissions if the infected partner was on suppressive HIV therapy. If you’re keeping score, the estimated number of sexual contacts in this ambitious cohort study was 58,000 (36,000 heterosexual, 22,000 MSM). Statistically-inclined nerds will point out that you can’t really say the risk is zero — there’s a 95% confidence interval around this zero estimate, you can read the upper limit in the full paper, both for the heterosexual and MSM groups. Plus, with a median f/u of only 1-2 years, of course further study is required for a more precise estimate of risk. Despite these limitations and others — well-described in the excellent accompanying editorial — we all must admit that ZERO transmissions to date is a very good start! And we should heartily thank the study investigators for introducing a nifty new word to the medical/ID lexicon — “condomless” is vastly preferable “acondomic” or “condomopenic”, though that last one might make more people smile.
• For our most challenging patients, providing “patient navigation” and financial incentives did not improve virologic suppression rates compared with standard-of-care. The inclusion criteria for participation in this study were just the things that usually exclude patients from other trials — they were hospitalized, with addiction, psychiatric disease, had poor compliance with ART, terrible outpatient follow-up — you get the idea, challenging. They were randomized to 1) usual care; 2) “patient navigation” (intensive case management); 3) patient navigation plus financial incentives. During the 6 month intervention, virologic outcomes were better in the patient navigation/financial incentives group, but 6 months after the interventions stopped the benefit wore off. I guess “pay for performance” works, but only while someone is paying! A fascinating and remarkable study.
• IAS-USA HIV Guidelines Updated. With the upfront disclosure that I was part of the panel that wrote these guidelines, this sparkling new version covers it all — just in time for beach reading. Who should be treated (pretty much everyone), what to start (one of the integrase inhibitors plus TAF/FTC or, if it’s DTG, TAF/FTC or ABC/3TC), who should be switched and how to do it, how to treat in the context of OIs, how to retain people in care, what lab monitoring to do, and how to prevent transmission. Plus, this version took care of a couple of my minor pet peeves:  MAC prophylaxis is not recommended to those with CD4 < 50 if they’re starting ART (hooray!), and, at the opposite extreme of the immunologic spectrum, CD4 cell count monitoring isn’t recommended if a patient is virologically suppressed and has CD4 consistently > 500 (hooray again!). I’ll now have to find something else to complain about (maybe the use of the term “HAART” — still trying to get rid of that one).
• A bunch of other interesting reads. An encouraging “demonstration project” on PrEP in community based clinics. Tony Fauci on the updated prospects of an HIV vaccine in the era of broadly neutralizing antibodies. (He could probably write a piece like this in his sleep — and I mean that in the most admiring way possible!) Gerry Friedland on the historic and symbolic importance of this year’s International AIDS Conference returning to Durban. An interview with transplant surgeon Dorry Segev on the challenges of organ transplantation among patients with HIV, in particular the use of HIV-infected donors for these individuals (which makes abundant sense on multiple levels, including the availability of organs for HIV-negative patients).

Hey, remember when JAMA had art on the cover? (And yes, I miss that.) The 1996 cover to the HIV/AIDS issue was famously blank (see image above), the absence of artwork making a strong statement about “the toll the virus has taken among artists and other creative persons who have died prematurely because of AIDS.”

Now, 20 years later, the current HIV/AIDS JAMA issue includes content that would have been unfathomable at that time. Little did we know that 1996 would be the pivotal year, the turning point when this rapidly fatal disease — then the leading cause of death among young Americans — would become both treatable and preventable.

Amazing progress.

Even “augmented reality” can’t compete.

[youtube https://www.youtube.com/watch?v=gEb4UFIuXLM&w=560&h=315]

(I predict 2-3 months for this Pokemon Go craze, but what do I know.)