An ongoing dialogue on HIV/AIDS, infectious diseases,
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.
March 19th, 2008
How long have I got, Doc?
Some aspects of seeing a patient newly-diagnosed with HIV haven’t changed much over the years — for example, the emotions in the room remain a mix of fear, shame (note to world: this is still a highly stigmatized disease), incredulity, and ultimately relief in finding a clinician who is comfortable with the condition.
But a lot has changed, of course, due to the availability of effective antiretroviral therapy. To illustrate, here’s a commonly-asked question, especially from newly-diagnosed patients and their loved ones — in fact, I heard it just last week:
How long can a person live with HIV these days?
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
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