An ongoing dialogue on HIV/AIDS, infectious diseases,
June 2nd, 2008
Zoster Vaccine Guidelines — Official Answers, but Still Some Questions
The CDC’s Advisory Committee on Immunization Practices has just released the “official” guidelines for use of the zoster vaccine. And none too soon — if I had a dollar (or these days, make that a euro) for every curbside consult I’ve received about the zoster vaccine …
The vaccine’s indications are simple — age over 60, immunocompetent. Ah, but the devil is in the details, and that’s what make these guidelines so helpful.
Readers will find answers to many common questions about zoster vaccine, including:
- Should it be given to people younger than 60? Not at this point. It’s unlikely to be harmful, however, and I suspect some practitioners might stretch this age criterion downward, especially for patients who particularly fear getting shingles.
- Should it be given to people older than 80? Yes — although the vaccine appears not to work as well in this group. Still, not all 80-year-olds are created equal, and undoubtedly, some would respond and be protected.
- Should it be given to people who have already had zoster? Yes — but remember this group wasn’t in the licensing study. But it won’t be harmful and might help. And boy, do people who have had zoster want this vaccine.
- What about people who are taking antivirals with activity against VZV? Have them stop these antivirals for at least 14 days after getting vaccinated. (I love it when guidelines give precise information like this. And 14 days fits nicely into the “multiples of days of the week or fingers of the hand” rule that ID docs love.)
- Should we worry about secondary transmission of the vaccine’s virus? Generally not. Yet I guarantee we’ll still get calls on this one: “Hi Paul, my patient is visiting his baby grandson this weekend — is it safe to give him the zoster vaccine?” or “My patient’s husband is on chemo for CLL — should she get it?” or “He’s flying coach to Australia and will be on a jet for 15 hours — can he get the vaccine?” (Yes and yes and yes, by the way.)
- Can we give it to people who can’t remember whether they had chicken pox? So long as they were born before 1980, the answer is yes — in all likelihood, they did have chicken pox and hence are at risk for zoster. (All people older than 60 were indeed born before 1980 — hey, I knew that pre-med calculus would come in handy someday.)
- What immunocompromised patients should not get the vaccine? Basically, those with impaired cellular immunity shouldn’t get it, and the guidelines offer a nice summary of who these folks are.
May 14th, 2008
Certification in HIV Medicine — Another Try
In March, the American Board of Internal Medicine (ABIM) issued a proposal for a “Maintenance of Certification” (MOC) pathway in HIV medicine for general internists. This is the second such special pathway ABIM is considering (the first was hospitalist medicine). Regardless of whether you agree with the proposal, it’s a good read, providing an excellent snapshot of who’s providing care for HIV patients these days and how we got here.
Some of the interesting data:
- Out of the 100,000 general internists in the U.S., 95% do not practice HIV medicine at all.
- Only 4,000 U.S. MDs write prescriptions for antiretroviral agents.
- Approximately half the MDs practicing HIV medicine in the U.S. are ID specialists; of the remaining group, 80% are general internists.
Since only a small proportion of internists provide HIV care, ABIM would like to give formal recognition to this group, allowing them to allocate a significant proportion of their recertification activities in HIV-related topics.
May 5th, 2008
Brush with Greatness: Paul Farmer
Perhaps you caught this week’s 60 Minutes, featuring the work done by Partners in Health, the group founded and run by Paul Farmer.
(If he reads this, he’ll no doubt want to correct my description of him as playing these major roles, eager to give equal credit to his impressive colleague Jim Kim and his mentor Howard Hiatt. Ok, done.)
But if you missed the interview, no matter — in all likelihood you’ve heard of him. Maybe you’ve read the fine book about him or seen his smiling face in a variety of newspaper or magazine images. In the Infectious Diseases world, Paul Farmer is a true rock star — our equivalent of Paul McCartney, Mick Jagger, and Bono all rolled up into one guy.
He also was an Infectious Diseases fellow in our program and a clinical attending on our inpatient Infectious Diseases consultation service for several years.
And that’s what I’m going to write about — Paul Farmer here in the resource-rich USA.
April 30th, 2008
Young Doctors “Get a Life” — Whither ID/HIV?
A front-page article in yesterday’s Wall Street Journal says that younger physicians (definition: younger than I am), “intent on balancing work and family,” are choosing specialties that allow them to control their hours. The content of the article will be familiar, including:
- The rise of the hospitalist movement
- A decline in those entering primary care fields
- The pros and cons of this change (a better-rested, more-balanced doctor vs. the inevitable lack of patient continuity — gone is the “hero model of the lone ranger who is there 24/7, 365”)
- Ways that specialties with unpredictable call (such as obstetrics) are adapting to this trend
April 17th, 2008
Required Reading: Bat-Related Human Rabies
A group of researchers in Canada have done infectious diseases experts a big favor — they’ve summarized a staggering amount of useful data on bat-related cases of human rabies in a paper just published in Clinical Infectious Diseases.
(Note to non-ID specialists: infectious diseases doctors spend a lot of time answering questions about rabies in general and the vaccine and bats in particular. I’m fairly certain that being a bat expert was not listed in my job description when I signed up for this field, but maybe that’s because there was no job description.)
This paper should be required reading for all ID docs. Whether the news is reassuring or terrifying will depend on whether you’re a glass half-full or half-empty type of person. Here are some of the key points:
April 10th, 2008
Needed: Something Better than “HAART”
I think we all have pet peeves, and so I’ll confess one of mine: I hate the term “HAART.”
(I work with someone, by the way, who hates the term “viral load,” preferring “virus load.” Go figure.)
Standing for “highly active antiretroviral therapy,” HAART first surfaced in the mid-1990s in order to distinguish potent anti-HIV treatment from the older, not-so-active form of antiretroviral therapy that preceded it. Writers often will use the phrases “era of HAART” or “advent of HAART,” both of which sound to me like essays on Dutch history.
But HAART has never been very precise — what exactly does it mean?
March 31st, 2008
FDA Investigating Safety of Abacavir and Didanosine — Old News or New?
The FDA has issued one of its new “early communications” indicating that it has opened an investigation into the safety of abacavir and didanosine based on analyses showing higher rates of myocardial infarction with these drugs than with other NRTIs in the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study.
The pace of our field is sometimes remarkably fast: Immersed in HIV care or research or policy, we think of this as old news — after all, it was presented over a month ago at the Retrovirus Conference. These D:A:D results linking abacavir and ddI to increased MI risk have already been the subject of extensive discussions in clinics, conference rooms, and meetings. But I have to remind myself that no, it’s not old news at all — the full paper has not yet been published, although it will be soon — and that we still need some time to process the data, and to consider the questions raised by the findings. Is this a causal relationship, or just an association? Why has it not been seen in other studies? What is the mechanism? Would it still be the case with HLA-B*5701 screening? Why is the risk not cumulative? When will we be seeing data on tenofovir? (I suspect soon, given when tenofovir was approved.) What do abacavir and ddI have in common that would cause this? What should we be doing with our patients on abacavir who are doing well? I confess my answer to all of these questions is the same: I just don’t know.
D:A:D is an extremely important study that has already provided enormous insight into HIV treatment. But as the D:A:D investigators no doubt would agree, there are limitations to ascribing toxicities to treatment based on observational data. So I guess I’m proposing that as of today (March 31, 2008) we view these results as suggestive, and hypothesis-generating, rather than defining standard of care right now.
The D:A:D data have now been published in the Lancet. There is also an accompanying editorial here (subscription required).
March 20th, 2008
How to Solve at Least One Part of the Healthcare Mess: ADAP for All
The presidential elections have once again made our Byzantine healthcare system a regular feature in the news. A recent film also made quite a splash, and though Michael Moore offered no plausible solutions (Cuba? c’mon!), he certainly made me wonder what I’d do if I had two severed fingers that needed to be reattached and only enough money to cover one procedure.
Everywhere, you hear the usual complaints: increasing numbers of uninsured, highly variable (but mostly mediocre) quality of care, “skyrocketing” (interesting how often that adjective is used) costs, misaligned incentives leading to overuse of expensive procedures and medications, greedy insurers denying coverage, and (always) unfavorable comparisons with outcomes in other industrialized countries. Reading the various candidates’ solutions to this quagmire, I get that same heavy-lidded feeling I had in medical school when lecturers tried to “explain” how the immune system works — yes, you have a theory and a lot of nice figures, but could anything so complicated really work? Many of those immunology theories have long since been discarded, and it would not surprise me a bit to see the same happen with the presidential hopefuls’ proposals.
It is with great magnanimity, therefore, that I offer the candidates — free of charge — a model of how to fix one aspect of our healthcare mess, the high cost of prescription drugs.
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
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