HIV and ID Observations

Should be plenty of leftovers for the dogs this year — they’ll be grateful!

“Grateful?” some might wonder. “He must be out of his mind.”

But even in the cursed year that began shortly after the first report of the disease now known as COVID-19 on (almost) New Year’s Eve, we can still find some things to praise, and to offer our gratitude. Or at the very least, acknowledge that without them, things would be so much worse.

Plus, it’s become an annual tradition on this site.

So here’s a list to get us started, just in time for Thanksgiving.

The remarkably high efficacy of experimental COVID-19 vaccines. These vaccines could have been a complete bust. Or like the flu vaccine, 40-50% effective in a good year, less than 20% in a bad one, usually worse than a coin-flip. Or accompanied by terrible side effects.

Instead, not only are the first two vaccines roughly 95% effective, but they prevent severe disease, including (by report) in the most vulnerable populations. No major side effects reported (yet). And they were developed with record-breaking speed, using a novel messenger RNA technology that is quite brilliant — even if it is totally obvious, ha ha.

love this

Nation Can’t Believe They Spent So Long Overlooking Obvious Solution Of mRNA Instructions For Spike Protein Encapsulated In Lipid Nanoparticle https://t.co/hi8kYHxhgb via @theonion h/t @_j_sax

— Paul Sax (@PaulSaxMD) November 20, 2020

Now reports show a third vaccine is effective even without this (so obvious) mRNA approach.

To the scientists who started working on these vaccines, to the labs and factories that put them together, to the companies that bet big on them, to the NIH for supporting the research, to the clinical research teams who enrolled tens of thousands of people working tirelessly for months, to the participants who volunteered — we owe our most heartfelt thank you.

The endurable scientific acumen and utter professionalism of Dr. Anthony Fauci. One of my patients, a no-nonsense guy in his late 40s who manages a car dealership, brought him up the other day out of the blue. “I love the guy,” he said. “He gives the medical information, doesn’t sugarcoat it, and doesn’t care about the political stuff.”

Exactly. We’ve all seen Tony (which is what everyone calls him) rise to the occasion during previous infectious threats, speaking about the science without reverting to hyperbole or pandering to his audience, but what he’s done with COVID-19 continues to amaze — he’s living what he describes as his “worst nightmare,” yet hardly misses a beat.

Even after retirement, people often referred to Joe DiMaggio as “The Greatest Living Ballplayer.” So do we have in Tony Fauci our Greatest Living ID Doctor? I think we do — though while he’s in great shape, he should work on improving his pitching.

The people who keep the hospitals running, but never get enough credit. I’m referring to the hard-working folks in food services, housekeeping, transport, engineering, security, phlebotomy, IT, laundry, admissions, and a whole slew of other jobs that make hospitals function — they are all coming to work each day, just like us clinicians, but (I’ll say it again):

They never get enough credit.

So here’s some credit — thank you so much!

The arrival of telemedicine (finally). In the Before Times, several barriers stopped telemedicine’s full adoption. But there was one big fat elephant in the room blocking the doorway, which was that most doctors would only get paid for face-to-face visits. It didn’t seem to matter that telemedicine could make patient care better and more convenient by improving access and limiting wasteful travel time.

And there were technological hurdles, too. While everyone else used fancy video calls and web conferencing that would make George Jetson jealous — Zoom existed before COVID-19, you know — most of us clinicians had to put up with systems that were buggy at best and didn’t work at all at their worst. And just try and coach a technophobe on how to download a proprietary secure app onto their cell phone, create a username and password, and log on.

Since COVID-19? Presto-Chango, telemedicine has very much arrived — so much so that for certain specialties (psychiatry, endocrinology, some primary care), virtual visits now can outnumber in-person appointments. One of my friends does all her routine surgical post-op checks virtually, only bringing patients in if there are problems or if her patients request to come in (most don’t). And most payers get it, and pay for it, at least for now.

Plus, the technology is much better. Zoom has come to patient care, and I’m also a huge fan of Doximity dialer.

Regulatory and payment issues remain (in particular providing virtual care across state lines), but telemedicine is too good and too important to allow it to go away, even after the pandemic is over. It’s here to stay.

Our remarkable hospital microbiology laboratories. These magnificent places have always held wonder for us ID doctors, providing both fascinating information about our cases and, in turn, making us look smart. Thank you for that!

But what they’ve done since early 2020 is nothing short of extraordinary. As everyone knows, test shortages for SARS-CoV-2 consistently hamper our country’s COVID-19 response. Even with this pressure, the microbiology labs have nonetheless pulled together enormous resources to make testing continually available in hospitals, and they have employed multiple redundant platforms to ensure that the system doesn’t break down

Oh yeah — they continue to do all that other stuff (stains, cultures, sensitivities, PCRs, MALDI, antigens, antibodies) we need for patient care. Amazing.

The meticulous and hard-working infection control practitioners. For non-ID readers, it may surprise you to hear that within the field of Infectious Diseases there is a group dedicated specifically to the field of infection control. They are key players in keeping us safe while working in the hospital; their reach extends to outpatient activities as well.

Not surprisingly, they are by nature drawn from a certain type of detail-oriented person. Here’s what I wrote a few years ago when discussing the “raging” controversy over whether doctors should wear white coats:

People who specialize in Infection Control are some of the most measured, data-driven, and methodical individuals in all of medicine. You know the stereotype of the brash, volatile, and cowboy surgeon, the person that everyone tiptoes around? These Infection Control folks are the polar opposite.

They also have a drive to get things right. During the pandemic, when many of us are working harder than ever, the specialists in infection control (mostly doctors and nurses) have simply not rested for months. I’m enormously grateful for all that they do.

Long-acting cabotegravir for HIV prevention. Had to get one non-COVID thing in here, and this was the easy choice. Daily TDF/FTC and TAF/FTC work great for pre-exposure prophylaxis, yes — but only if you take it. Plus, the data in women didn’t quite reach the high efficacy in men.

Which is why the results of HPTN 083 (men who have sex with men, transgender women) and HPTN 084 (at-risk women) are so exciting. In these studies, while TDF/FTC was effective, an injection of cabotegravir every 8 weeks was even better — so much so that both studies could be stopped early. Hooray! We are all looking forward to seeing more when these studies are published.

Honorable mention. There are bunch more things I could have mentioned, but this post has already gone on too long. Sorry!

So just briefly, here are a few, rapid-fire style — the ancillary bonus of how social distancing decreases influenza and other respiratory viral illnesses; the highly qualified people on the president-elect’s COVID-19 task force; the way the pandemic reinforced ID’s commitment to support health equity; the insightful voices of Zeynep Tufekci, Julia Marcus, Ed Yong, and certain other non-MDs in making us all think a bit deeper about what this all means; that more people can attend conferences since they went virtual; that most of us haven’t had to suffer an interminable airport delay since forever; that my favorite sports (tennis and baseball) are naturally socially distanced; that people rediscovered the great outdoors as the safest place to socialize; the Olive and Mabel competitions (“a bit of showboating, needs to be careful”); the poems America and Good Bones; and that this guy does the best The Crown impressions you’ll ever see.

https://youtu.be/-LQTBOBfA18

You get the idea. So what are you grateful for in late 2020? Don’t be shy.