An ongoing dialogue on HIV/AIDS, infectious diseases,
June 24th, 2008
HIV Occupational Post-exposure Prophylaxis: Do the Right Thing
From one of our local HIV providers:
There were two occasions recently when our local infectious disease doctor was consulted by the emergency room to decide what type of post exposure prophylaxis regimen to recommend for individuals who had sustained an occupational exposure (needlesticks) to two of our HIV positive patients. It had been known to the emergency room physicians that the patients had been HIV-infected and that they were receiving their care here. The ID physician contacted our clinic for information about the patients to come up with the most appropriate preventive regimen.
Some here have felt that we could not give information out to the physician to preserve patient confidentiality.
But others (including myself) felt strongly that given the CDC recommendations that information should be obtained regarding the source patient’s antiretroviral therapy, the resistance pattern, and the viral load in order to recommend the best regimen for PEP to avoid HIV transmission, it was completely appropriate for the ID physician to try to get more information.
I would be curious to know your thoughts on this issue ….
One of the (many) things that has always bugged me about “HIV exceptionalism” — where HIV is treated differently from other infectious diseases — is the way it burdens healthcare providers who sustain occupational exposures to blood-borne pathogens.
June 15th, 2008
Curbside Consults: What are They Worth?
Below is a friendly email exchange I had last week with with one of our hospital’s primary care providers:
Dear Paul, do you know anything about whether pts should be given prophylactic antibiotics prior to dental procedures etc. if they have an indwelling IV catheter? I have a pt. who has a BardPort porta cath in her subclavian that was placed surgically for her chemo treatment about 2 years ago and she is doing well but asked me this question and I could not find an answer.
Thanks
Cathy
Hi Cathy,
It is not formally recommended; and in this virulent C diff era, I wouldn’t do it. But some oncologists still recommend prophylaxis (and/or some patients really want it), so if they insist, I suggest you use the endocarditis prevention guidelines.Regards, Paul
Thanks much, very helpful. Cathy
According to the Allied Physicians Salary Survey, the average salary of an Infectious Diseases Specialist with at least 3 years experience is $178,000/year. If we assume a fifty-hour work-week (ha), with 4 weeks for vacation, that comes to an hourly rate of $74/hour, or $1.24/minute.
The time it took me to read the email, type a response, then open her gracious note of thanks (note to curbsiders — we like being thanked) was all of around 5 minutes. Applying the above hourly rate, we find the email curbside consultation was worth approximately … 6 dollars.
In other words, for what a curbside consult “costs”, you could get a gallon of gas and a cup of coffee at your nearby Quik Mart. But not much more.
But is that really all a curbside consult is worth? Didn’t my response also save the primary care provider some time? The patient a potentially severe (and costly) adverse effect (C difficile colitis — very scary these days)? What about the training and experience required to to answer the question authoritatively? Or the time it took away from other critically important activities?
Sure, I’ve been asked this question before (so it was kind of a slam dunk, to invoke the currently appropriate Boston sports metaphor), but isn’t that why we pay the experienced neurosurgeon his/her $500K+ a year? Because they’ve done brain surgery before?
The sad fact (for us ID doctors, at least) is that curbside consultations don’t fit into any reimbursement model for health care. And by the way, the “price” for a curbside consult isn’t even $6 — it’s $0.
June 9th, 2008
When (and Where) in the World is the 2009 Retrovirus Conference?
The Conference on Retroviruses and Opportunistic Infections — “CROI” — is the premiere scientific and clinical conference in the HIV world. Every February, thousands of serious scientists and clinicians huddle in some frozen northern city, spending three and a half days intensely reviewing the latest and greatest in the field.
So it’s time for an annual gripe about the mystery surrounding the date (especially) and location of the conference. Perversely, this is the only major scientific conference in the universe that waits so long before announcing its date and location. By contrast, if you want to know when ICAAC in 2009 will take place, here you go: Sept 12-15, San Francisco.
For the current when-is-next-year’s-CROI issue, there’s a new twist: We sort of know the date. I’ve heard from several people — very important people who should know — that the conference will be February 8-11, location to-be-determined. So I’ve taken this Feb 8-11 information as gospel, placing it on my work and home calendars, telling my practice manager I won’t be seeing patients that week, and setting up the academic schedule accordingly.
Yet the CROI web site still says, “CROI 2009 dates and venue will be posted in June” — which replaces last month’s “CROI 2009 dates and venue will be posted in May”, which replaced the earlier “CROI 2009 dates and venue to be announced soon.” And when our AIDS Clinical Care Executive Editor tried to get confirmation of the Feb 8-11 date — which reportedly even was mentioned briefly at this year’s conference (though I didn’t hear it) — no one would confirm it.
So am I confused? Worried that the date will not be Feb 8-11? (One year, it was smack in the middle of school vacation week in Boston — grrrrrr.) Annoyed?
An emphatic yes to all of the above.
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
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
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