An ongoing dialogue on HIV/AIDS, infectious diseases,
May 4th, 2011
How Much Do ID/HIV Doctors Get Paid?
A long time ago, I was very close to becoming a Cardiologist. Really.
Even though my fascination with ID and microbiology started in medical school — and believe me, not much fascinated me in medical school — the fact that all the top residents in my program were going into Cardiology made me feel that somehow I should be doing this too. Plus, the guy who was Chief of Medicine was very influential.
When I came to my senses, and realized that I wanted to go into ID, there was a small problem — I had already matched in a Cardiology program. Hence I faced the tricky task of telling the program director, “Thank you very much for your kind offer, but I’ve decided I want to be an Infectious Diseases specialist.”
I remember his look of annoyance (understandable). It was soon replaced by one of disbelief. And then came a line I will never forget:
At least your motivation isn’t financial — ID doctors get paid s–t.
All of this came back to me when I read this fascinating survey over on Medscape on what we doctors get paid.
Some of the interesting results:
- Yes, ID specialists (median of $174,750/year) are at the lower end of the specialist scale. Other bottom feeders? Pediatricians (it’s a family thing), Rheumatology, Endocrinology, Primary Care …
- And the program director at my cardiology-fellowship-that-never-happened was right: Cardiologists are the third-highest-paid physicians (after orthopedic surgeons and radiologists), with a median income of $325,000. 20% of Cardiologists report making more than $500,000, while almost this many ID/HIV docs get < 100,000.
- However, despite this disparity, a higher proportion of ID docs (55%) than Cardiologists (45%) report they were fairly compensated. Is that because ID is the most fascinating field in medicine? And that an endocarditis case is surely more interesting than the simple plumbing they generally care for? (That was a joke. Some of my best friends are cardiologists.)
- Weird disconnect between geographic cost of living and salaries, with the lowest pay coming in the most expensive places to live. This is of course the complete opposite of salaries in business, banking, and law. So if you want your doctor’s pay to go further, don’t live in California or Washington/NYC/Boston!
Of course, as we tell our kids, when choosing a career, it’s not about being rich — it’s about being happy.
But if you want to be both rich and happy, the specialty-of-choice is clearly Dermatology — median annual income is nearly $300,000, and a whopping 93% said they’d choose the same specialty again, the highest of all the fields surveyed.
Acne treatment never looked so good.
April 28th, 2011
Hepatitis C Week is Upon Us
After many — and I mean many — years of telling patients that new hepatitis C drugs were “coming soon,” that time has finally come.
An FDA Advisory Panel yesterday favorably reviewed the HCV protease inhibitor boceprevir; today telaprevir got the same unanimous report. The FDA will certainly follow with approval for both drugs, and hence they will be available for actual use soon.
While these are undoubtedly huge advances for patients with HCV genotype 1 — who faced a 30-40% chance of cure with IF/ribavirin now, compared with up to 80% by adding one of the new drugs — many questions remain about how they will be used, and in whom.
In no particular order, and without even trying to be comprehensive, here are some of the “known unknowns“:
- How will clinicians choose between them?
- Is a 4-week lead in with IF/RBV (as was done with the boceprevir studies) necessary? Additionally, is it useful, by identifying “null” responders who will have a higher rate of developing treatment failure and PI resistance? Could starting all three drugs simultaneously improve outcome?
- How long should treatment be? Will this vary depending on HCV RNA kinetics from person-to-person? Seems like this is a situation ripe for sophisticated modeling, and that more frequent HCV RNA monitoring (especially early) will inform this decision.
- How will patients in the chaotic real world tolerate these drugs? Interferon/ribavirin is already no picnic, and adding these additional meds will mean additional side effects.
- Related: Besides the signature toxicities (telaprevir — rash and anemia, boceprevir — anemia and dysgeusia), what other side effects will appear with more widespread use? Note that it’s not a question of if these side effects will occur, it’s when will occur, and what they will be.
- How will resistance be assayed? Will genotype testing become commercially available? If so, what new combination of letters and numbers (i.e. mutations) will need to be memorized?
- How do these advances influence treatment decisions about the patients who don’t have HCV genotype 1, especially those with genotype 4? I suspect not at all, at least for now.
- How will compliance be with these three-times a day regimens? Will it improve over the course of therapy, or will patients get “pill fatigue.” We know they will get regular fatigue — I have yet to see a patient receiving interferon who didn’t mention this as a side effect.
- View from 20,000 feet: If someone is currently very stable — with low risk of HCV disease progression — should they “act now” or wait for even better, less toxic options? Given the huge effort in HCV drug development, how long before we have treatments for HCV that are comparably simple to HIV therapy? Is a single-pill combination tablet too much to ask? Remember, for HIV, such a treatment would have been unimaginable in 1996; less than 10 years later it was the mostly widely-used HIV combination in the country, and remains so today.
- Who will be the HCV Providers? Will the legacy of gastroenterologists’ leading the way in hepatitis therapy continue, or will this Infectious Disease finally be embraced by Infectious Disease Doctors? (Italics represent my view.)
- How much will the new drugs cost? Will they be covered for all patients? How about for those who have a favorable IL-28B genotype — and would be likely responders to IF/RBV alone?
- How will our HIV co-infected patients respond? Data are extremely limited — and the drug-drug interactions promise to be unbelievably complex. As of April 28 2011, we only have data on use of telaprevir with either EFV or ATV/r.
- How do you design an HCV clinical trial once these drugs are approved? Will all “control” arms now need to be IF/RBV + something-previr?
Answers to some of these questions will come with formal FDA approval, which will necessarily include some “package insert” indications for therapy.
But stay on your toes, because it seems highly likely that this is one therapeutic area in ID that truly lends itself to the cliche, “moving target.”
April 25th, 2011
FEM-PrEP: A Set Back in HIV Prevention Research
HIV prevention has been on such a roll recently that the recent negative news from the FEM-PrEP study came as something of a surprise. Bottom line:
Following a scheduled interim review of the FEM-PrEP study data, the Independent Data Monitoring Committee (IDMC) advised that the FEM-PrEP study will be highly unlikely to be able to demonstrate the effectiveness of Truvada [emtricitabine (FTC) and tenofovir disoproxil fumarate (TDF)] in preventing HIV infection in the study population, even if it continued to its originally planned conclusion. FHI subsequently concurred and has therefore decided to initiate an orderly closure of the study over the next few months.
When studies are stopped early by a data and safety monitoring board, the investigators are of course as taken by surprise as the rest of us, and hence lots of details from this study are still not available.
As a result, we can only speculate why TDF/FTC (Truvada) worked for prevention of HIV among gay men, but not among heterosexual women. Some (unofficial) thoughts thoughts from my friend/colleague Raphy Landovitz, who does research in HIV prevention:
I’m willing to bet it all comes down to adherence, with the proof to come in the drug-level analyses. As iPrEx showed, self report of 95% in both arms is meaningless. One also wonders if there was more condom non-adherence as part of fertility goals.
Regardless of the cause, these negative results underscore one of the most important specific items in the CDC “Guidance” on use of PrEP: that for now, if it’s prescribed, the only appropriate recipients are high-risk MSM.
[Edit: Nice summary of the FEM-PrEP study findings and implications over here in Journal Watch HIV/AIDS Clinical Care.]
April 18th, 2011
When to Start Antiretroviral Therapy, Take 3
A third observational study on “When to Start ART” has just appeared in the Annals of Internal Medicine, “The HIV-CAUSAL Collaboration.”
As with ART-CC and NA-ACCORD, it’s a large study, starting with over 20,000 people with HIV with baseline CD4s >500 receiving care in Europe and the United States. Out of this group, 8392 experienced CD4 declines into the 200-500 range and are included in this analysis. Outcomes of interest are mortality and new AIDS-related events, depending on when combination ART (“cART”) was started.
The results?
Initiation of cART at a threshold CD4 count of 500 increases AIDS-free survival. However, mortality did not vary substantially with the use of CD4 thresholds between 300 and 500.
The authors also cite a “number needed to treat” of 48 for starting at 500 rather than 350 for prevention of AIDS or death, a fairly low number when compared to some interventions widely adopted in cardiovascular disease.
While not the blockbuster results of the NA-ACCORD study — whose nearly two-fold reduction in mortality for starting at >500 remains both unreproduced and, let’s face it, unexplained — these results still point to a substantial clinical benefit of starting ART before CD4s fall too low.
In addition, none of these large observational studies even hints at a negative effect of starting early on clinical outcomes, and other potential benefits of treating HIV (reduced risk of HIV transmission, reduced long-term incidence of non-AIDS events) can’t be included.
As nicely summarized in the accompanying editorial, the quantitative benefits of early ART can’t come close to the benefits of late ART, which are nothing short of miraculous.
It’s up to us — patients, providers, society — to determine whether early ART is worth it.
April 15th, 2011
A “New” Antiretroviral Option Quietly Enters the Market
There’s a new antiretroviral option out there, a 400-mg extended-release tablet formulation of nevirapine that can be dosed once daily.
However, you might not have noticed, since it’s not really that new, and it’s not clear that this formulation offers any significant advantages over the nevirapine we already have. Writes Keith Henry over in Journal Watch:
Issues that will temper enthusiasm for the new formulation include continued concern about serious adverse effects with nevirapine (namely, Stevens-Johnson syndrome in the general patient population, and liver toxicity in women with CD4 counts >250 cells/mm3 and men with CD4 counts >400 cells/mm3), the availability of safe and effective non–nevirapine-containing regimens, the likely approval of additional one-pill once-daily regimens (e.g., tenofovir/FTC/rilpivirine, abacavir/3TC/dolutegravir, and tenofovir/FTC/elvitegravir/cobicistat), and the possibility of nevirapine coming off patent in 2012 (which creates potential for a lower-priced generic).
Add to these issues the need to still take* the 200 mg once-daily lead in for 14 days, and one wonders how much use this “new and improved” nevirapine is going to get.
(*I know, split infinitive — it just sounds better that way!)
April 11th, 2011
Organ Transplants from HIV-Infected Donors
On the heels of last month’s report of HIV transmission from an organ donor — covered here in Journal Watch — comes this remarkable article in the New York Times about lifting the ban on organ donation from donors known to be HIV positive.
Naturally, the first group of patients slated to receive these HIV positive organs would have HIV themselves.
But the article goes further:
But some experts, including Dr. Segev and Dr. Kuehnert, say they can foresee such transplants even for H.I.V.-negative patients because contracting H.I.V. would be preferable to kidney or liver failure.
“I don’t want to minimize living with H.I.V, but it is a medically treatable disease now,” said Charlie Alexander, president of the United Network for Organ Sharing, which manages the country’s organ transplant system. “In certain cases, I think it would be medically appropriate.”
If ever there were proof that HIV is now a highly-treatable condition, I’d say this could be Exhibit One.
April 9th, 2011
And Now, for a More Comprehensive CROI Report …
Although I’ve already provided a Really Rapid Review™ of the 18th Conference on Retroviruses and Opportunistic Infections (CROI), the editors of Journal Watch/AIDS Clinical Care have put together a more comprehensive summary here.
I sometimes wonder what research from these conferences will not only stand the test of time, but will grow in importance and be viewed one day as a landmark event.
Past notable examples include the first triple-therapy study with indinavir — which showed that virologic suppression could be durable — presented way back in 1996 at the 3rd CROI, and the phase III study of raltegravir in patients with highly drug-resistant virus, presented 11 years later at CROI 14.
My bet this time? While it’s notoriously tough to make predictions, especially about the future, my vote goes to these zinc finger nuclease studies — which are part of a very concerted and growing effort to cure HIV.
April 5th, 2011
Scamming Academic Journals
Academic scams are not just limited to meetings.
Every so often, I receive an e-mail that goes something like this:
Dear Dr. Sax,
The journal Contemporary Organic Biosynthesis [journal name made up] covers all the latest and outstanding developments in organic biosynthesis studies. It is one of the leading journals for expert reviews in the field. Please visit the journal’s Web site at www.organicbiosynthesisreviews.com to see our Mission and Scope.
It is my pleasure to invite you to submit the title of your article, a one-page abstract and the submission deadline for the Editor-in-Chief’s approval to editorial@obsr.com. We also invite you to to consider to guest edit a thematic issue to the journal of 5 – 12 invited articles from colleagues of your choice.
Guest Editors of thematic issues and all main contributing authors will receive a free online subscription to the journal for one year.
Sincerely,
Griffila Zaporsky-Branson, PhD [I also made that name up]
Editor-in-Chief
As you probably know if you’re reading this site, I am barely more qualified to write a review on “organic biosynthesis” than Oprah Winfrey. So obviously this is a form letter sent to hundreds (if not thousands) of academic MDs.
But beyond that, how do “journals” like this make money? Is there a large author fee once the scholarly review is written and “approved” by Dr. Zaporsky-Branson? Do they sell advertisements? Do they require a valid credit card before the requested reprints are sent out, with money neatly diverted to someone’s bank account?
Regardless, as with the Nigerian e-mail scams, obviously someone is biting — otherwise these emails wouldn’t exist at all.
April 1st, 2011
Clindamycin or Cephalexin for (Mostly) MRSA?
Over on the Journal Watch Pediatrics site, there’s a summary of a study that compared clindamycin with cephalexin for purulent skin infections in kids age 6 months to 18 years. The results?
MRSA and methicillin-susceptible Staphylococcus aureus (MSSA) were isolated from 70% and 19% of children, respectively … The primary outcome — clinical improvement at 48 to 72 hours — was similar in the cephalexin and clindamycin groups (94% and 97%, respectively), as was the secondary outcome — resolution of infection at 7 days (97% and 94%).
Should we be surprised that cephalexin — an antibiotic with notoriously poor systemic absorption — did so well vs. infections that were 70% resistant to the antibiotic?
Not really — after all, if antibiotics were required for skin and soft tissue infections, we would have perished as a species in the many thousands of years before the discovery of penicillin. Most of the cure comes from the local care, which was done in 97% of patients.
Plus, this study of cephalexin vs placebo in adults found the same exact thing.
Finally, it proves something that Primary Care Providers, Emergency Room Doctors, Surgeons, and Pediatricians have known for some time: If you want to use a weak antibiotic (i.e., almost a placebo) “just in case,” hardly anything beats our old friend “Keflex.”
March 30th, 2011
Journal Club: Even When You Think You Should Wait, It’s Probably Time to Start
Two papers just published in AIDS with relevance to the “when to start” antiretroviral therapy question.
Both apply to certain patients in whom we might consider waiting to start treatment– but both these studies suggest we do otherwise.
The first applies to the patients with slooooow CD4 decline. Perhaps so slow that both you and your patient are very comfortable watching it drift down over the years, from initially normal — let’s say 900 — to 700, then 500 over a 10-year period. After all, with such a slow decline, what could the harm be in waiting?
Certainly I’ve shared this kind of mutual denial with patients of mine, most of whom also have very low HIV RNA levels.
But according to this paper, it’s just this sort of patient who has the worst immunologic response to ART. In reviewing 2,038 patients with pre- and post-ART CD4 trajectories, the study finds that the patients with the slowest CD4 decline have the worst immunologic response to ART. In other words, slope going down predicts slope going up.
As the authors note in their discussion, it’s ironically the other group — those with fast CD4 decline — who have been targeted in HIV treatment guidelines for early ART regardless of CD4 cell counts. But perhaps these data (which are displayed in some very cool figures, by the way) tell us that if one important goal of treatment is maintaining a normal or near normal CD4, then the rate of decline is immaterial — just be sure to start ART before the CD4 count becomes abnormal.
A second paper, from Cote d’Ivoire, looks at patients who recently acquired HIV, another group we might traditionally hold off on treating. Looking at 304 patients with recent seroconversion, the investigators track the time to relevant CD4 thresholds for starting treatment. The results: more than half (57%) have a CD4 cell count < 500 at diagnosis, and 72% are at this level just two years later.
In short, the great majority of patients with recently-acquired HIV meet CD4 criteria for starting treatment sooner rather than later. So while the “time to AIDS” in untreated HIV might average 10 years, in no way should we count this as “time to starting HIV therapy”, which will come much sooner.
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
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