HIV and ID Observations

Two patient-related anecdotes, then a news item.

Anecdote #1:

A little email exchange I had with one of my patients recently:

Hi Paul,
Wondering if you got the refill request for my meds from my mail-order pharmacy — their customer service is lousy, and I can’t tell if it’s been approved. I’d like to get this settled before the weekend as I’m going away for a few weeks to celebrate my birthday.
Roger

My response:

Hi Roger,
Yes, I got the message and efaxed them the approval. They should have it to you by the end of the week. And happy birthday!
Paul

So why is this notable? He got his HIV diagnosis in 1989, and was told by more than one person (some of them famous doctors) that he’d be dead in a few years.

After some clinical trials with AZT and other early treatments that didn’t work out so well, for the last 15 years or so he has been totally stable from the HIV perspective, virologically suppressed, with a normal CD4 cell count, and no significant side effects from his treatment.

For the record, it’s his 80th birthday he’s celebrating. Guess those early predictions about his survival were wrong.

And that some older people really can do email.

Anecdote #2:

It’s 1992, my first year as an ID attending — early on in my first “real” job.

(I put it in quotes because what are internship, residency, and fellowship if not “real” jobs? Never really understood that distinction. But you get the point.)

A primary care doctor asks me about one of her patients, an HIV positive woman in her late 30s. The patient has a low CD4 cell count, but is asymptomatic. Since there is no email then, the doctor and I have an actual conversation.

It goes something like this:

PCP: Hi Paul, do you remember Tara, whom you saw once and started on AZT and Bactrim?
Me:  Sure, how’s she doing?
PCP:  She’s doing OK — CD4 cell count is down to 120, but she’s feeling fine. I’m wondering what to do about her cholesterol, which is over 300! Plus her mother died of a heart attack, and she’s really worried about it. Should I start her on lovastatin?
Me (skeptically):  You could … but given the prognosis of someone with a CD4 of 100, and that she’s only in her 30s… is it really going to help her? How about we switch her to ddI? I can see her to discuss this.
PCP:  Sounds good. But I’ll start her on lovastatin [You kids might not remember, that was the first statin drug.] It will make both of us feel better.
Me (thinking this but not saying it): There is no way she will live long enough to benefit from cholesterol-lowering therapy.

Fast-forward to today. Tara indeed continues to feel “fine”, at least from the HIV perspective — zero HIV complications, ever. Cardiovascular disease is by far her biggest threat, as she clearly has familial hypercholesterolemia.

Not the first time I’ve been wrong. And certainly not the last, as I thought the touch screen keyboard on the iPhone was a stupid idea that would never catch on.

Now the news item, from this week’s Boston Globe:

Good news — but importantly, the company is not selling life insurance policies to people with HIV for altruistic reasons. It’s no more an act of charity than when viatical companies purchased life insurance policies from people with AIDS in the bad old days (see the ad above from a 1994 magazine).

As illustrated by the above anecdotes — and no doubt thousands of others in practices around the world — survival for patients with HIV who are on treatment is every bit as good as for people with other chronic illnesses, in many cases better.

Here’s why Hancock is making this policy change, and why other insurance companies will likely soon follow:

“It’s based almost entirely on data, such as survival rates for people who have been on certain types of medication,” said Steven Weisbart, senior vice president and chief economist for the Insurance Information Institute, a New York-based trade group … “This is a very competitive business,” he said, “and companies like the Hancock and the Pru are looking for new policyholders who will buy life insurance that’s hopefully been priced appropriately.”

“What a drag it is getting old,” said the Rolling Stones, famously, in this song.

But as our long term survivors will tell us, it sure beats the alternative.

Happy Passover!

[youtube https://www.youtube.com/watch?v=baQfqoZrEvI]