HIV and ID Observations

Not a fan.

The calendar says it’s nearly the fourth Thursday of November, so here in the United States, the Thanksgiving holiday is upon us. It’s a day when we gather with family and friends to express thanks, to eat plenty (usually too much), to watch a bunch of spectacular athletes bash themselves to smithereens in the name of sport, and to wonder why anyone would eat sweet potatoes with marshmallows.

(Must be the same people who eat candy corn during Halloween. Yuck on both accounts. And no, I cannot be convinced otherwise.)

It’s also time for me to take stock of our ID world, citing some things in our field that I’m grateful for — an annual tradition on this site. Off we go:

Twice-yearly lenacapavir was really effective for HIV prevention. How could this not garner first mention? While it awaits FDA approval for this indication, and making it broadly available will be a critically important challenge, this should a major advance in pre-exposure prophylaxis (PrEP) for HIV.

We’re about to get a bunch of new drugs for treatment of urinary tract infections. The FDA already approved sulopenem etzadroxil with probenecid and pivmecillinam, and they granted gepotidacin priority review (approval expected by March, 2025). Since UTIs are increasingly caused by resistant organisms, I count this as progress. Naysayers will say, “But what about resistance, side effects, cost, and access?”, so allow me to cite the ID doc’s consistent ambivalence about new antimicrobial agents.

But since this is a gratitude post, I’ll just go with the glass half full here — and hope I can figure out how to say sulopenem etzadroxil with probenecid without using the trade name (it might be impossible).

Three additional studies confirmed the remarkably high resistance barriers of dolutegravir and bictegravir. The results of D2EFT (pronounced “DEFT”), VISEND, and a study from the GHESKIO treatment center in Haiti all gave the same message — that these two integrase inhibitors could be used with tenofovir/3TC or FTC and still achieve or maintain viral suppression, regardless of the degree of baseline NRTI resistance. Amazing! Great to have confirmatory data in support of the prior NADIA and 2SD studies.

Seven days of antibiotics was noninferior to fourteen days in the treatment of bloodstream infections. What a great clinical trial — ask an important and common clinical question, set up the primary and secondary endpoints to be of substantial interest, and then power it appropriately to answer the question. The results provide some solid evidence for The Rules, at least if Staph aureus and endocarditis aren’t in the picture. Why can’t we have more clinical trials like this? Can’t wait to hear what they find in secondary analyses, and in their follow-up BALANCE+ studies.

Metagenomic sequencing and other advanced molecular techniques are slowly making their way into clinical practice. I’d bet good money that if I asked 100 practicing ID docs whether they’ve had at least one case where one of these tests provided a solid, practice-changing diagnosis — rapidly and without an invasive procedure — more than 90% would raise their hand. Maybe 99%.

Rwanda appears to have contained the Marburg virus outbreak. In doing so, the country provided a model for pathogen response, involving enhanced testing, rapid initiation of isolation policies, and scaling up supportive care. If there are no further cases by December 21, the outbreak will be declared over.

The DHHS HIV treatment guidelines removed abacavir from its list of recommended initial treatment regimens. If you combine abacavir’s deficiencies (hypersensitivity, cardiovascular risk, lack of hepatitis B activity, pill size) with the remarkably high effectiveness of dolutegravir/lamivudine and the renal and bone safety of tenofovir alafenamide, there’s hardly any reason to use abacavir anymore — you really have to do some mental acrobatics to come up with a compelling indication. Nonetheless, I suspect HLA-B*5701 will live rent-free in our brains forever.

Non-ID gratitude section:

eBikes are now widely available, in many different styles and at a broad range of price points*. If you haven’t tried one yet, what are you waiting for? They are miraculous machines, allowing you to ride unthinkable distances and zoom up steep hills, so therefore can replace cars on many routes. I already have over a thousand miles on mine and have had it only around a year. (*What’s the difference between a “price” and a “price point”. Gosh if I know.) 

Andrea Petkovic is a very fine writer. Two things I’m obsessed about are tennis and great writing. How exciting it’s been, therefore, to discover a professional tennis player (now retired) who provides both? Her writing alternates topics breezy and serious, the tone is deft, human, and humorous, and every week there’s a new selection — the most recent example a beautiful rumination on the retirement of Rafael Nadal. The strength of self-published newsletters comes to life in examples like this.

I discovered at least one thing that Microsoft Teams does better than Zoom. Perhaps unsurprisingly, it’s sharing a Powerpoint presentation. Here’s the brief summary:  if you share the file rather than sharing your screen, it gives you a great look at your upcoming slides and other features. It’s the “Presenter View” without having to do anything. Transformative!

Jim Gaffigan is skinny now, and even better, he has a new comedy special. He naturally starts out by explaining how he got his new sleeker physique (this will be no surprise), and the responses he’s received from others — all A+ comedy material from this brilliant and prolific comedian. But he quickly veers off into much broader territory, in particular parenting (he has 5 kids) and, in one particularly funny bit, technology.

Take it away, Jim!

Hey, I’ve been doing this post for years now and expect that I’ve missed one of your favorites. What are you grateful for this year?