An ongoing dialogue on HIV/AIDS, infectious diseases,
September 16th, 2009
News Flash: The Internet Cannot Replace an Actual Human
Interested in researching the cause of AIDS? Well go ahead and give NetBase Solutions’ healthBase a try, but don’t expect much in the way of filtering:
One of the most unfortunate examples is when you type in a search for “AIDS,” one of the listed causes of the disease is “Jew.” Really. The ridiculousness continues. When you click on Jew, you can see proper “Treatments” for Jews, “Drugs And Medications” for Jews and “Complications” for Jews. Apparently, “alcohol” and “coarse salt” are treatments to get rid of Jews, as is Dr. Pepper!
To be fair, the site seems to have cleaned up its act quite a bit since this report — here’s an example of a search I just did. Most of the results are now much more plausible, but there’s still some wacky stuff there. HIV is the number two cause of AIDS (number two?), and number five is “Abbott” — and I don’t they’re referring to the guy up there in the baseball uniform.
Look, I’m all for using the internet for medical information, and acknowledge I can barely function without it these days. But this kind of advanced search engine takes lots and lots of human oversight, and for now the swarm of medical data out there in web-land can be as misleading as it is vast.
(Hat tip to Graeme M for the link.)
September 12th, 2009
49th ICAAC Starts Today
Browsing through the program book, I see these topics extensively covered:
- H1N1 and seasonal flu, in all their glory — transmission, pathogenesis, treatment, predictions
- Highly resistant GNR — acinetobacter, carbapenemases, ESBL, etc.
- MRSA — my personal favorite
- C diff — though perhaps a little less this year?
While no one expects ICAAC to be an HIV-focused meeting, usually there are a few important papers presented — last year, for example, NA-ACCORD and raltegravir in treatment-naives debuted at ICAAC.
But unless I’m missing something, I don’t see anything this year on the HIV front of comparable importance. One year blip or a sign of the times?
(FYI, the CDA — that’s the California Dental Association — is also having a meeting here. Their meeting-goers have much better teeth than ID doctors/microbiologists.)
September 4th, 2009
For Suspected H1N1, Get Out the N95 Masks?
So says the Institute of Medicine’s recommendations for protection of health care workers:
Healthcare workers (including those in non-hospital settings) who are in close contact with individuals with nH1N1 influenza or influenza-like illnesses should use fit-tested N95 respirators … Employers should ensure that the use and fit testing of N95 respirators be conducted in accordance with OSHA regulations.
Every so often — well, more like constantly — my wife (the primary care pediatrician in full-time practice) reminds me what life is like seeing patients outside of a tertiary care, academic medical setting.
Her response to this recommendation to use N95 respirators for evaluation of all “influenza-like illness”?
Amazement, incredulity, bafflement, dismay. Seeing as waiting rooms of pediatricians’ offices in the winter are filled with kids with cough, runny nose, and fever, I can certainly understand her response. If these guidelines were followed literally, everyone in these offices would have to wear such a mask virtually all day — never mind the high cost and short supply of N95s, the logistics of fit-testing everyone, the effect on provider morale, etc.
In short, since following this recommendation is currently impossible, one possible response would be to refer all such patients to hospitals. Bad for everyone.
Let’s hope when the CDC reviews these guidelines, they can provide some more practical (i.e., actually do-able) advice for people in practice.
September 2nd, 2009
Etravirine Warning
From the FDA Advisory:
There have been postmarketing reports of cases of Stevens-Johnson syndrome, toxic epidermal necrolysis and erythema multiforme, as well as hypersensitivity reactions characterized by rash, constitutional findings, and sometimes organ dysfunction, including hepatic failure. Intelence therapy should be immediately discontinued when signs and symptoms of severe skin or hypersensitivity reactions develop.
These rare — but potentially life-threatening — reactions have been reported with all the NNRTIs. From my extremely unsophisticated perspective (the less said about my biochemistry performance in med school the better), the molecular structure of these drugs look quite different.
So what is it with this drug class?
August 26th, 2009
Late Summer Odds and Ends: Circumcision, H1N1 Vaccine, Lyme Movie, etc.
A few ID/HIV items to cover before summer “unofficially” ends (Sept 1? Kids back at school? Labor Day?):
- Will US Public Health officials recommend infant male circumcision to prevent HIV? They might be considering such a move, but I suspect it will not be strongly promoted. After all, none of the studies demonstrating its efficacy have been done in developed countries, and the pattern of the US epidemic — predominantly gay men and women of infected male partners — excludes the very group circumcision has been shown to protect: circumcised heterosexual men. Look for lots of CDC-ese in these guidelines, with terms such as “consider” and “might choose” and “be offered.”
- Getting lots of questions from my patients about the H1N1 vaccine. Some decent interim answers here. When available? (Don’t know yet.) Who will get it? (The young, pregnant women, those at risk for severe flu) Will there be enough? (Maybe.) Will the regular flu vaccine still be needed? (Yes.) Will this season’s flu vaccination programs/clinics/sites be civilized affairs with minimal panic, anger, waiting lines, frustration? (I hope so, but the media will do their best to portray the situation otherwise.)
- Anyone see this movie on chronic Lyme? Would love to hear your impressions. I have not seen it — but this will definitely be a Netflix choice when it a appears on DVD. (Note that I did not link to Netflix; I’m a big fan, but they are the most egregious purveyors of annoying pop-up ads in the universe right now.)
- How’s this for a new definition of contagious? Be reassured: my little teaser photo has been thoroughly autoclaved.
Enjoy the sunshine …
August 20th, 2009
The V.A. Opts Out
Read all about it here:
As of August 17, 2009, written (signature) consent is no longer required for HIV testing in the VHA. Instead, patients will provide verbal informed consent prior to HIV testing. Furthermore, scripted pre-test and post-test counseling are no longer mandated.
Since the VA is the largest HIV provider in the nation — and has an exceptional electronic medical record/database — it will be fascinating to see how this policy influences new case detection, linkage to care, and whether there are any negative repurcussions.
Nice page of FAQs here. And though you’re sick of hearing from me on this issue, I totally agree with this move.
August 14th, 2009
Who Gets Toxoplasmosis in the United States?
This might seem bizarre, but one of the reasons I chose to go into Infectious Diseases as a field was the names of the diseases (and often the micro-organisms that caused them) sounded so darn cool.
For example, if you were a science fiction writer you could hardly come up with a better-sounding name for a mysterious disease than “toxoplasmosis.” Or its full name, “Toxoplasma gondii”.
Major Pribulon, I’d advise against taking your Colonial Defense Armada into Sector 18, Ambrilla Zone — I hear reports of a widespread outbreak of TOXOPLASMOSIS.
Wow, that sounds scary.
Anyway, from the only toxoplasma diagnostic reference lab in the United States — the one at Stanford, founded by Jack Remington, now headed by Jose Montoya — comes this fascinating paper on risk factors for acquiring toxoplasmosis in this country. It’s a case-control study using 148 newly-acquired cases from their serology lab, comparing them with 413 negative controls. Here are the significant risks:
- eating raw ground beef or rare lamb
- eating locally cured, dried, or smoked meat
- working with meat
- drinking unpasteurized goat’s milk
- having 3 or more (!) kittens
- eating raw oysters, clams, or mussels
Interesting that having 1 or 2 kittens was not a risk factor, and neither was gardening. Raw shellfish consumption is one I hadn’t heard before; there are several plausible explanations:
Oysters, clams, and mussels are filter feeders that concentrate T. gondii, as has been shown under experimental conditions. Sea otters in California have been found to be infected with T. gondii, and it is likely that they are often infected by eating mollusks, which filter T. gondii from seawater. The seawater in California is thought to be contaminated by T. gondii oocysts that originate from cat feces, survive or bypass sewage treatment, and travel to the coast through river systems.
And don’t forget: stay out of the Ambrilla Zone, Sector 18.
August 5th, 2009
Just Out: Primary Care HIV Guidelines
Over on the CID web site, they have the revised version of the “IDSA Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus”. It’s a great document, filled with useful references and a particularly strong table where to find other consensus guidelines (diabetes, hyperlipidemia, mental health, others).
My vote for what will be most commonly-cited part of the guidelines it Table 5 (Recommended Baseline Lab Tests) — though Table 9 (Vaccines) could be a close second.
Some potential areas of controversy:
- No recommendation for routine screening for osteoporosis
- No recommendation for routine anal pap smears in MSM
- LP for all patients with late-latent syphilis or syphilis of unknown duration
Regarding the bone density, I suspect this will will be recommended one day, though agree for now it’s premature.
However, I’m sure there are many who will be surprised that the anal paps are not routinely recommended. Solid quote:
Anal cytologic screening (ie, anal Pap smears) in HIV infected women and MSM is not considered to be the standard of care at this time but is being performed in some health care centers. Additional studies of screening and treatment protocols for anal dysplasia are in progress to clarify this issue.
Seems that it is done uniformly at clinics that have enthusiasts, or zealots — plus a high-resolution anoscopy plus biopsy protocol. (“If you’re at Disneyland, you go on the rides.”) We don’t really know yet whether this screening prevents cancer.
For the LP issue — I know it’s in the STD Guidelines, but do you really LP all such cases in your HIV patients?
July 25th, 2009
IAS Cape Town 2009: Some Greatest Hits
Below is a highly-subjective list of some of the highlights from the Cape Town IAS meeting. I’m sure I missed something — it’s impossible to see everything at these large conferences. Corrections/additions welcome!
My miss-rate might be particularly high since the international AIDS meetings are appropriately focused on HIV treatment in resource-limited settings (especially Africa) whereas my perspective is as a US treater/researcher. That said, studies from these countries often have important take-home points for all of HIV medicine.
Apologies over, on to the content:
Immediate therapy increases survival for asymptomatic patients in Haiti (WESY201). This landmark study (CIPRAHT001) randomized asymptomatic patients with CD4 cell counts between 200 and 350 to start treatment immediately with ZDV/3TC + EFV or to wait until CD4 fell to 200. An independent DSMB stopped the study early after finding 23 deaths in the “standard” therapy arm vs only 6 in the early treatment group. The difference in the risk of infection-related deaths was particularly striking– 1 vs17 — and the standard therapy group also required greater intensity of lab follow-up and had higher treatment-related toxicity. The results are a strong challenge to the WHO treatment guidelines (essentially to start rx with cd4 at 200), and can be added to the growing list of studies that find early ART is better than waiting.
Incidentally, the presentation was kind of hidden since apparently the study was submitted after the late-breaker deadline. Too bad — I hope it gets a larger venue at CROI.
Treating pregnant women with ART for at least 6 months post-partum reduces breast-feeding transmission (WELBB101). Women in Botswana with higher CD4 cell counts were randomized to either ZDV/3TC/ABC or ZDV/3TC + LPV/r, and those with lower counts got standard ZDV/3TC/NVP. The individual regimens are less important than the fact that they continued treatment for 6 months post-partum, and were instructed to breast feed (switching to formula feeding in developing countries might avert some HIV infections, but the overall outcome for the infants is worse — even when clean water can be provided). The results showed a transmission rate of only 1%, which is the lowest ever reported for a transmission study that includes breastfeeding — and not dissimilar to what is observed in industrialized countries.
Implications? Seems to me that the myriad byzantine regimens being tested in this setting — including various single-dose NVP strategies, giving the babies prolonged “post-exposure” prophylaxis even though they are not infected, prescribing a “tail” of NRTIs to the moms to reduce resistance with the NVP — can all be replaced just treating the mom with standard antiretroviral therapy. Of course easier said than done, but since when shouldn’t we try to do what’s best for pregnant women, which in general is the same thing as for non-pregnant women? Let the controversies ensue, I know they are heated.
July 20th, 2009
Cape Town IAS Meeting — A Quick Look Back at Durban 2000
The international AIDS meeting finds its way today to South Africa, the country with arguably the greatest needs for HIV prevention and treatment.
This is not the first time the meeting was in this country, of course — in 2000, the World AIDS Conference took place in Durban, a truly landmark event in the history of the epidemic.
Aside from the obvious fact that HIV/AIDS was at that time largely ignored by the South African government, so that having the conference here was a major symbolic step forward, what else transpired?
- President Mbeki, in his opening speech, continued to focus on poverty — not HIV — as the cause of AIDS, with no concrete mention of antiretroviral therapy as either treatment of HIV nor as a way of preventing perinatal transmission.
- By contrast, Judge Edwin Cameron — openly HIV positive — stood up in front of thousands as the picture of health, describing how this was all due to his taking two pills twice a day. (His regimen: ZDV/3TC + NVP.) He pleaded to make treatment more widely available. It was riveting.
- Tony Fauci introduced us to the idea of “STI’s” — structured treatment interruptions — with several purported benefits, including decreased toxicity of treatment, “auto-immunization”, and lower cost. No, it didn’t work out so well, but it became a major research agenda for the next 5-plus years. The paradox of STI was perfectly encapsulated by my colleague Abie Zuger, who noted that while Aftricans were desperate for treatment, her patients in the US were almost as desperate to stop, so bad were the side effects of therapy at that time.
- There was yet another study comparing ZDV/3TC plus either ABC or indinavir; ATLANTIC compared d4T/ddI plus one of either IDV, 3TC, or NVP; lopinavr/r was still called “ABT-378”; and the “next frontier” in antiretroviral therapy was correctly identified as entry inhibitors, with enfuvirtide right around the corner, and CCR5 antagonists already in development.
- The whole issue of mitochondrial toxicity, and its link to lipoatrophy and lactic acidosis, was coming into clearer focus. Although many studies had begun to target d4T as a main culprit, there was still some debate.
- Nelson Mandella closed the conference with a beautiful speech — there was a general sense of hopefulness that contrasted markedly with the opening ceremony.
I also remember that the conference was superbly run from the technical perspective, and that the Durban beaches were gorgeous. I purchased a pair of plastic flip-flops that my son still wears, and a cute bowl for my wife that has a giraffe handle. The sun set very early in July way down here in the southern hemisphere.
Oh, and I learned then that South Africa is a long long way from Boston, and I was just reminded of that fact after a 24 hour trip here. I am in awe of the stamina of my colleagues who make this trip on a regular basis.
Updates on interesting stuff here to come.
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
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