An ongoing dialogue on HIV/AIDS, infectious diseases,
June 1st, 2009
“Long-term Nonprogressors” and “HIV Controllers”: Rare Indeed
When giving an overview of HIV pathogenesis to a group of clinicians, Bruce Walker usually asks the assembled if they have any patients in their practice who have undetectable viral loads without antiretroviral therapy.
Generally about three-quarters of the audience has at least one such patient. They are then asked to refer them to his research cohort, which has a goal of trying to figure out why some patients can control HIV replication without needing antivirals.
But how common is this “controller” phenomenon really? And how about its immunologic correlate — people with long-term HIV infection but no significant decline in the CD4 cell count?
Nifty paper in AIDS this month trying to answer this question: Using the French Hospital Database, and starting with over 45,000 potentially eligible patients, the group found that only 69 were “elite controllers” — that is, had >10 years HIV infection, 90% of viral loads <500 cop/mL, and most recent viral load <50 cop/mL.
Stable CD4s were even less common. Only 25 patients were “elite long-term nonprogressors” — that is, had HIV for more than 8 years, CD4 cells > 600, and no CD4 cell decline. That’s an prevalence of 0.05%, or 5 for every 10,000 patients.
Medical students and residents sometimes ask me if a particular patient of mine, asymptomatic and not on antiretroviral therapy, is a “long-term nonprogressor.”
I always respond by asking them what specifically they mean by the term — because as this paper shows, when you look for a truly benign course of HIV infection, you need to look pretty darn hard.
May 28th, 2009
The Paul Farmer Watch
Our pal Paul Farmer keeps racking up the titles:
Dr. Paul Farmer, a pioneer in improving health services in the Third World, has been named chairman of Harvard Medical School’s Department of Global Health and Social Medicine …
(snip)
Peter Brown, spokesman for Brigham and Women’s Hospital, said Farmer also had been named to succeed Kim as head of the Division of Global Equity at the hospital, a Harvard teaching facility.
Of course what we we’re all wondering is whether he’ll stop with these, or go on also to accept a senior role in the Obama administration:
After weeks of feeling neglected and anxious that no new administrator has been named, USAID and international development community sources tell The Cable they are excited at reports that Paul Farmer, the legendary cofounder of an innovative group that has delivered healthcare to the poor in central Haiti and beyond, is under consideration to head the U.S. aid agency or serve in a top administration international assistance post that would encompass it.
Regardless of his decision, there is a huge irony here — which is that if ever there were a person in our field who couldn’t seem to care less about titles, it’s this guy.
Which is how it should be, of course.
May 24th, 2009
Another State Gets Ready to Make HIV Testing Easier
Don’t look now, Massachusetts, but Connecticut could be next:
AN ACT CONCERNING REVISIONS TO THE HIV TESTING CONSENT LAW. This bill revises the law on consent for HIV-related testing. Specifically, the bill:
1. eliminates the requirement for separate, written or oral consent for HIV testing and instead allows general consent for the performance of medical procedures or tests to suffice;
2. clarifies that HIV testing is voluntary and that the patient can choose not to be tested;
3. eliminates the current requirement for extensive pre-test counseling for all HIV tests;
4. adds a requirement that an HIV test subject, when he or she receives a test result, be informed about medical services and local or community-based HIV/AIDS support services agencies; and
5. provides that a medical practitioner cannot be held liable for ordering an HIV test under general consent provisions.
EFFECTIVE DATE: July 1, 2009
Not surprisingly, it passed unanimously by the Public Health Committee of the state; it was also adopted by the House on May 7, and is currently awaiting action by the Senate.
If it passes, it will be yet another state that is moving more in corcordance with the 2006 HIV testing guidelines. (FYI, nice table of the various states’ laws here.)
I’ve made no secret about how I feel on this issue — most clinicians seem to feel the same — and that I disagree with Massachusetts’ current HIV testing law, which may be the toughest in the nation. We not only require written informed consent before testing, but the process of getting this changed is hamstrung by the fact that testing and protection of HIV confidentiality are written into the same law.
But I’m an optimist — if California, Maryland, Illinois, several others, and soon Connecticut can make it easier for people to find out their HIV status, so can we. Stay tuned.
May 19th, 2009
Time for a Switch? Room for Debate
With first-line therapy for HIV being so astonishingly successful, much of what we do in practice is tweak regimens that are by virologic and immunologic standards, working just fine: Viral load undetectable, CD4 stable.
But not so fast — while one of my colleagues said that if he didn’t change his patients’ regimens, then he’d have nothing to do, the other said he NEVER changed a regimen that was working unless he absolutely had to.
Who’s right? Both of them, of course. The regimen might improve in convenience, tolerability, safety, etc, but new side effects could also occur, as well as virologic failure.
So consider these virologically suppressed, clinically stable patients (all recently seen) — would you switch?
- 50 year old man on ABC/3TC, EFV since 2000. No renal disease. Hyperlipidemia, on atorvastatin 80 mg a day. Father died of an MI age 48.
- 63 year old man, on EFV + LPV/r for years; past history of neuropathy on d4T and 3TC. Needs to go on inhaled steroids (preferably fluticasone) to help manage increasingly refractory asthma.
- 35 year old woman, on TDF/FTC, FPV/r BID — doing ok but missing some PM doses.
Keep in mind, all are doing fine — would you switch? If so, to what? Thanks in advance* for the consult.
(*ahem.)
May 13th, 2009
Working While Contagious: Why Do We Do This?
File this under, “physicians behaving badly”: The nearly universal MD practice of going to work while sick.
The ironic thing is we think we’re being selfless — after all, if we don’t show up, our patients will need to be rescheduled, or someone will need to cover, or some administrative/teaching task will not get done — but let’s imagine for a second that we actually asked our patients what we should do.
Answer: Go home. Get better. Don’t infect me.
Or, to quote the signs that have appeared in our hospital since H1N1 hit, “If you have a cough, sore throat, and fever, please do not enter the hospital unless you are here for care.”
(Patients with these symptoms who are here for care are instructed where to obtain a surgical mask.)
One primary care internist, writing in the New York Times, seems to have kicked the habit:
As a resident, my greatest pride was in never having missed a day for illness. I’d drag myself in and sniffle and cough through the day. Once, I’m embarrassed to admit, I trudged up York Avenue to the hospital making use of my own personal motion sickness bag every few blocks while horrified pedestrians looked on. Now, though, I see the foolishness of this bravura.
Sadly, I think she’s in the minority.
May 7th, 2009
Human Rabies from Bats: Another Look at the Numbers
The gang from Canada is at it again, reviewing human rabies cases from bats and trying to make some sense of the data.
(For a summary of their outstanding prior paper in CID, read this.)
But before we get to their latest masterwork, here are some questions to ponder. While doing so, keep in mind the practice of giving the rabies vaccine to a person with “bedroom exposure to a bat while sleeping, without evidence of direct physical contact”:
- Are you more motivated by avoiding an “error of omission” (a mistake from not doing anything) than an “error of commission” (a mistake from doing something)?
- Do you ever envision yourself being named in a lawsuit for failure to provide preventive therapy?
- Do you sometimes imagine yourself cited in a newspaper as the doctor who said, “that isn’t necessary”, only then to have the patient in question be the one in a zillion who gets rabies? (“We called Dr. Freepner, and he said not to do it. Later, she was dead.”)
- Do you feel you have a moral imperative to provide preventive therapy for a condition that will likely be fatal, no matter how unlikely it is that a patient will develop it?
- Do you think cost, limited supply, and personnel issues should always be secondary considerations when making decisions about an individual?
- When you read official guidelines that state that preventive vaccination “can be considered” in low but not zero risk circumstances, do you interpret that to mean it should be given?
- Did you ever find yourself doing something clinically that you just knew made no sense, yet you did it anyway?
I suspect we all could answer “yes” to some, if not all, of the above questions. These are not rational decisions, they are emotional ones.
Hence this latest paper is such a joy to read. It provides yet more evidence that a policy of giving the rabies vaccine to patients with a “bedroom bat exposure” but no contact is, to be blunt, pretty ridiculous. Some of the key numbers:
- Based on a telephone survey done in Quebec, fewer than 5% of people with such bat exposure get vaccinated.
- The estimated incidence of rabies due to this exposure is 1 case per 2.7 billion person-years.
- The number needed to treat to prevent a single case of human rabies from bedroom exposure (but no contact) is around 2.7 million.
- If all potential exposures were investigated and evaluated fully — after all, this is recommended in the guidelines, right? — this would require 49 physicians, 491 nurses, and 259 veterinarians working full-time for a full-year. And this estimate does not even include administration of the rabies vaccine!
In short, what we are doing is absurd — we are giving preventive therapy to a small proportion of the potentially exposed only because they show up, and because we can. It has very little to do with preventing actual cases of rabies, but it sure makes us and our patients feel better.
But if it’s indicated for those who show up, what about the 95% who don’t? Solid quote:
Failure to intensely pursue a greater proportion of eligible persons then becomes paradoxical public policy: a recommendation that is known to be sustainable only if ignored by most eligible persons is of doubtful usefulness and questionable ethics.
So what are we to do? The authors conclude that the recommendations for rabies vaccine for bedroom or other occult exposures “be reconsidered.” I read that to mean, “be scrapped.”
And someone please point me in the direction of why some irrational physician behavior is so hard to shake.
May 3rd, 2009
H1N1! Didn’t You Used to Be Swine Flu?
At the end of last week, “swine flu” became “H1N1”. The CDC web site explains why:
This virus was originally referred to as “swine flu” because laboratory testing showed that many of the genes in this new virus were very similar to influenza viruses that normally occur in pigs in North America. But further study has shown that this new virus is very different from what normally circulates in North American pigs. It has two genes from flu viruses that normally circulate in pigs in Europe and Asia and avian genes and human genes. Scientists call this a “quadruple reassortant” virus.
(Note the URL: http://cdc.gov/h1n1flu/swineflu_you.htm. Hmmm.)
Meanwhile, H1N1 (I’ll get used to it) is off the front page of the newspaper, at least the ones around these parts. A sign we’re in the clear, or just our short attention span?
I think you know the answer.
Still, for some very well-reasoned reassurance, I’ve been referring my non-medical friends and family to this excellent summary in the Wall Street Journal by Peter Palese from Mount Sinai. A key point:
Although the swine virus currently circulating in humans is different from the 1976 virus, it is most likely not more virulent than the other seasonal strains we have experienced over the past several years. It lacks an important molecular signature (the protein PB1-F2) which was present in the 1918 virus and in the highly lethal H5N1 chicken virus.
Of course no one really knows what is going to happen — other virulence properties might be present, next year’s seasonal outbreak could be worse, etc — but it’s welcome to hear some balanced views in the mainstream media along with all the hoopla.
April 29th, 2009
Swine Flu Treatment Guidelines — For Now
The swine flu situation is so dynamic that what I wrote earlier this week now seems hopelessly dated — except that from the perspective of a clinical ID doctor, it still feels eerily similar to the anthrax and SARS outbreaks.
But related to that post — specifically the use of antivirals — these interim guidelines for use of antivirals in suspected cases of swine flu were posted this afternoon on the CDC site. They make good sense.
Note the strategic use of the word “interim”. What are the odds they are unchanged during the next week? 1 in a 1000?
April 26th, 2009
Swine Flu Curbsides: Anthrax, SARS Redux?
In my email in-box yesterday AM from a primary care doc:
A patient of mine, 40 year old woman totally healthy, is going to Cancun on Tuesday for a conference. She’ll be there for 6 days.
I know there are no cases of swine flu in Cancun yet, and the situation is evolving, but here’s my question: what should she do (besides the obvious stuff like handwashing, etc)?? Bring tamiflu?? A mask?? Should she cancel her trip???? [N.B., actual punctuation retained for effect]
Ah, memories of the anthrax attacks and SARS, when an ID threat hits the headlines and people understandably want to know what they can do to protect themselves.
So they turn to their primary care providers, who then turn to us.
And in these situations, there’s the official response to such a question, which as we all know is sometimes different from the practical response — and I define the latter being what would you do for you or your family.
So not only did I say that it would be reasonable to bring some osteltamivir (Tamiflu), I even thought it wouldn’t be crazy to consider a prophylactic strategy — though the fact that she’s totally healthy made me favor the former approach.
And I wonder how many ID docs out there purchased some ciprofloxacin back in 2001, even though we were told not to.
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
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