An ongoing dialogue on HIV/AIDS, infectious diseases,
November 14th, 2011
Here Are Two Things You Don’t Hear Together Very Often: Walmart and HIV
As the parent of teenagers (and having been one myself many years ago), I’m acutely aware that everyone wants to think that he or she is special in some way.
And while that is literally true (that is, no two people are exactly alike), as anyone will tell you who looks up a Sunday Times crossword puzzle clue on Google, there are a whole lot of people out there very much like us — no matter how special we think we are.
But here are four things about me that, cumulatively, probably put me into a very small percentage of Americans my age in 2011:
- I have seen every episode of “Seinfeld” (several multiple times), but never watched a single “Friends”.
- I have never eaten at an Olive Garden restaurant. (Would love to try — how is it?)
- Despite half of my family being huge fans, I have never read any of the Harry Potter series — not a chapter.
- I have never shopped at a Walmart — in fact, I’ve never even been inside one.
This last one (a Walmart-less life) is not a conscious move, not a politically/ethically driven avoidance. It just so happens that the places I spend most of my time are not conducive to shopping at Walmart, even though there are seven of them within 15 miles of where I live.
Which is why this news, from NPR, came as something of a surprise:
Wal-Mart wants to be your doctor… The nation’s largest retailer is planning to offer medical services ranging from the management of diabetes to HIV infections, NPR and Kaiser Health News have learned.
If you don’t believe me, it’s right here on page 7, “HIV management and monitoring”, along with more than a dozen other conditions that Walmart will manage as part of the proposal to become “the largest provider of primary healthcare services in the nation.”
Walmart later backed off this claim, but still — you have to imagine they’re planning something for 2014 when the federal health law kicks in. Could this be the “disruptive” idea that helps relieve an already bursting-at-the-seams primary care system?
And as the treatment for HIV gets better and better, and our patients live longer and longer, we should start expecting to see HIV along side of many other chronic medical diseases managed by all sorts of caregivers in all sorts of ways.
Will MinuteClinic — the rhyme that’s not a rhyme — be next?
November 9th, 2011
HCV Treatment Studies at AASLD: Wow … and I Mean WOW!
I didn’t attend “The Liver Meeting” (the nickname for the annual meeting of the American Association for the Study of Liver Diseases, AASLD), but the studies presented there this week on HCV treatment were absolutely mind-boggling.
“Breathtaking!” said one of my HCV-oriented colleagues. “Hopeful is an understatement,” said another.
An example:
Dual Oral Combination Therapy with the NS5A Inhibitor Daclatasvir (DCV; BMS-790052) and the NS3 Protease Inhibitor Asunaprevir (ASV; BMS-650032) Achieved 90% Sustained Virologic Response (SVR12) in Japanese HCV Genotype 1b-Infected Null Responders
Mind you, this was only 10 patients, but 9/10 is no fluke — especially when all the responders had HCV RNA below detection by week 8, and all 9 who completed 24 weeks were cured!
Want a larger study?
PROTON: PSI-7977 & Peg/RBV in Treatment-naïve Patients with HCV GT1: Sustained Virologic Response
Here, in nearly 100 patients, the addition of 12 weeks of the nucleotide analogue polymerase inhibitor PSI-7977 to Peg/RBV led to a cure rate of over 90%, regardless of baseline IL-28B status (13/13 cured with genotype TT). Works with other HCV genotypes, too.
I chose these two studies in particular because the companies developing these drugs — BMS and Pharmasset — are working together on a prospective study that features all-oral, interferon-less strategies lasting only 12 weeks.
But there’s plenty more. Don’t take my word for it — go over to NATAP, click on the “Hepatitis C” link on the left, and start reading.
And if you have limited time, and want a glimpse of the future of HCV therapy, limit your search to studies that say “interferon-free”.
November 7th, 2011
Can We All Agree That This Is Stupid? Thank You.
If this report isn’t an urban legend, then it’s pretty clear some people need a brain transplant:
The Facebook group is called “Find a Pox Party in Your Area.” According to the group’s page, it is geared toward “parents who want their children to obtain natural immunity for the chicken pox.” …On the page, parents post where they live and ask if anyone with a child who has the chicken pox would be willing to send saliva, infected lollipops or clothing through the mail.
One topic I’ve tended to steer clear from is whole vaccine controversy.
How could I be rational? I’m an Infectious Diseases specialist married to a pediatrician! I believe that the benefits of vaccines — especially for childhood diseases — so overwhelmingly outweigh the risks that I can’t really engage in a polite debate about it.
So each time I’m about to write something about the vaccine issue, I hear Dana Carvey’s voice saying, “Not gonna do it … Wouldn’t be prudent.”
And I write nothing.
But sending infected lollipops in the mail? Some things just deserve open ridicule, and this is one of them.
November 5th, 2011
A Mysteriosis about Listeriosis
For obvious reasons, listeriosis has been much in the news recently. The latest information from CDC on the Colorado cantaloupe outbreak cites 139 cases and 29 deaths.
The recent outbreak aside, however, actual cases of listeriosis are pretty rare. We easily could go months in our hospital without seeing a single case, and we have the largest obstetrical service in New England.
Which brings me to the mystery part: Why is medical student knowledge about listeria so high?
I meet with the medical students to review basics of antibiotics at the beginning of every rotation. Depending on the time of year and the number of prior clinical rotations they’ve done, they have variable amounts of ID knowledge before they get here.
But all of them know about listeria. And they know a lot about it.
- Causative organism? (Listeria monocytogenes — check)
- Dietary risk factors? (deli meats, soft cheeses, now cantaloupes — check)
- Population at risk? (pregnant women, transplant patients, and the elderly — check)
- Clinical manifestations? (meningitis, sepsis, gastroenteritis — check)
- Antibiotic of choice? (ampicillin — check)
They seem to know way more about listeria than they do about far more common infections, such as Strep pneumoniae or Epstein-Barr virus.
It’s the oddest thing. Any proposed explanations for this remarkable expertise would be most welcome.
October 29th, 2011
Will An Antiretroviral Patch Help Adherence? Doubtful …
This little nugget came up recently, found by our Journal Watch Executive Editor:
Preliminary research suggests that a patch could deliver an AIDS drug to patients … The researchers successfully used transdermal patches to administer 96 percent of an AIDS drug to simulated skin over a week. “Still, the important limitation of pills, regardless of how few there are or even how minimal the side effects, is adherence,” Johnston [the investigator] noted. Research has shown that many patients, if not most, don’t take their pills all the time.
Setting aside for a moment the fact that most patients actually do take their medications just fine, thank you — and that this particular transdermal HIV drug delivery system hasn’t even been tested on animals, let alone humans — I have always wondered about the assumption that novel drug delivery systems would improve adherence.
Seems to me that the major problem with non-adherent patients isn’t that they can’t take pills.
It’s that they won’t take them.
And I strongly suspect that most would make the same choice when it comes to putting on a patch every day (or even every week).
October 26th, 2011
Xigris is Gone — Not That Many ID Docs Will Notice
From the FDA comes this news:
FDA notified healthcare professionals and the public that on October 25, 2011, Eli Lilly and Company announced a worldwide voluntary market withdrawal of Xigris [drotrecogin alfa (activated)]. In a recently completed clinical trial (PROWESS-SHOCK trial), Xigris failed to show a survival benefit for patients with severe sepsis and septic shock.
Some quick (and non-scientific) thoughts on these perhaps no-so-surprising turn of events:
The use of various adjunctive therapies in acute sepsis has a long and mostly checkered history. ACTH-directed glucocorticoids, mineralocorticoids, intensive insulin therapy, disparate antibody treatments (most famously anti-endotoxin antibodies) — none has really worked very well. Now we can add recombinant human activated protein C — Xigris — to the list of disappointing (and sometimes dangerous) therapies. In failure there may be opportunity, but treatment of sepsis is one tough nut to crack.- I know trade names are frowned upon in academic medicine, but is there anyone who actually said, “drotrecogin alpha (activated)”? What kind of word is “drotrecogin”? Is there a “Drotrecogin Beta (Activated),” and is it a space ship? The use of the parenthetical post-name word — “(activated)” — is particularly cumbersome.
- Finally, how many ID doctors ever literally prescribed this drug? In our institution, the use of drotecogin alpha … oh you know, Xigris … was overwhelmingly in the hands of the intensivists. They would consult us sometimes after giving it to their critically-ill patients for advice on the usual ID issues (choice of antibiotics, source of fever, whether to change the lines). I only remember being specifically asked, “should we give it” a few times, and am certain I never ordered it.
Meanwhile, “Xigris” happens to be a terrific name. Kudos to whatever advertising brainiac thought of that one.
I’m sure he/she cashed the check for these services many years ago.
October 25th, 2011
Important Reminder: Don’t Eat Raw Garden Slugs
From the pages of the New York Times, courtesy of ProMED, comes this case report:
An Australian man has been hospitalized for more than a month in serious condition as a result of eating two garden slugs on a dare…The 21-year-old Sydney man apparently contracted a rat lungworm parasite from the slugs, which pick it up from rodent droppings. The parasite, a nematode called Angiostrongylus cantonensis, can cause fatal brain swelling.
From the perspective of an Infectious Diseases doctor, the surprising thing isn’t that a person would actually eat a raw garden slug — or even, as in this case, eat two raw garden slugs. After all, in our field one regularly hears of risk-taking behavior that, to quote a particular novel, “… runs to Z and beyond!”
Nope — my favorite part of the case report is this line:
“We hope this will help to remind others to avoid eating raw slugs,” the moderator, Eskild Petersen, said.
And with that, Public Health Crisis averted.
October 19th, 2011
Going, Going, Gone … HIV Treatment Failure Is Disappearing in People Who Take Their Meds
World Series time, hence the baseball reference in the title.
(Doesn’t take much.)
But over in Lancet Infectious Diseases — which has turned out to be a terrific journal, by the way — there’s a study reminding us that advances in HIV treatment in the late 2000s were truly spectacular.
The goal of the paper was to track the outcome of patients with “triple-class virologic failure” (TCVF) over the course of the last decade. Using data from 24 European cohorts, the investigators had access to over 90,000 patients, out of whom 2722 failed treatment with regimens that at some point contained the original three drug classes: NRTIs, PIs, and NNRTIs.
Rates of virologic suppression after TCVF steadily increased over the decade, from 19.5% in 2000 to 57.9% in 2009, and both AIDS complications and deaths declined. Significant predictors of virologic suppression by multivariable analysis included later calendar year, transmission category (MSM did the best), low viral load, and high CD4.
Those who had previously been able to achieve virologic suppression before TCVF were also more likely to be successfully treated — this clearly being a marker for good adherence. And although “past performance is no guarantee of future results,” it sure can be useful regardless. You have to assume that most of the 40% or so who did not achieve virologic suppression simply didn’t take their meds.
So what’s missing from their analysis?
Notably, because our objective was mainly descriptive, we did not attempt to further adjust for time-dependent variables such as access to new drugs …
In other words, the single most important factor for improved treatment outcomes in the 2000s — the introduction of darunavir, raltegravir, maraviroc, and etravirine — is left out.
(They also didn’t include data on resistance or adherence, but I suspect the former was tough to find, and the latter probably didn’t change all that much.)
So these results are either truly remarkable (if you follow HIV from a distance) or, if you are actively practicing HIV medicine day-to-day, are so obvious you can legitimately wonder why they did the study in the first place.
Both reactions are appropriate.
October 4th, 2011
Hormonal Contraception MAY Increase Risk of HIV
From the pages of Lancet Infectious Diseases, a study from Africa:
We aimed to assess the association between hormonal contraceptive use and risk of HIV-1 acquisition by women and HIV-1 transmission from HIV-1-infected women to their male partners … Among 1314 couples in which the HIV-1-seronegative partner was female, rates of HIV-1 acquisition were 6·61 per 100 person-years in women who used hormonal contraception and 3·78 per 100 person-years in those who did not (adjusted hazard ratio 1·98, 95% CI 1·06—3·68, p=0·03). Among 2476 couples in which the HIV-1-seronegative partner was male, rates of HIV-1 transmission from women to men were 2·61 per 100 person-years in couples in which women used hormonal contraception and 1·51 per 100 person-years in couples in which women did not use hormonal contraception (adjusted hazard ratio 1·97, 95% CI 1·12—3·45, p=0·02).
We’ve heard this story before, that hormonal contraception may increase the risk of HIV acquisition. The mechanism is unclear — vaginal thinning, increased HIV replication in genital secretions, something else — but undoubtedly part of it may be the simple fact that women receiving hormonal contraception must be less likely to use condoms.
In fact, that last factor is pretty darn likely, and why the results cannot be considered definitive — even though condom use was controlled for in the study.
Lack of concrete proof notwithstanding, women should be counseled that hormonal contraception could increase the risk of HIV acquisition and transmission — and hence it’s even more important that condom use be emphasized, especially in high HIV prevalence regions.
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
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