HIV and ID Observations

Here’s a question for you ID and HIV and other clinicians out there as you start 2020 — what are the 10 biggest changes to ID/HIV clinical practice over the past 10 years?

Not necessarily what are the biggest stories or biggest advances (though they certainly are eligible) — but more specifically, when you are seeing patients, what are we doing or seeing or thinking now, in early 2020, that we never could have done in 2010?

You’ll see by reading this list that 10 years is plenty of time for progress — hooray for that. So with the up-front apology that my list inevitably reflects where I practice (USA, New England) and what I focus on academically (HIV), off we go with 10 big changes, one for each year — there obviously could be many more!

#10.
Then (2010): “Vancosyn” or “Vitamin L” (levofloxacin) for everyone? No problem …
Today (2020):  Certain antibiotics, once considered quite safe, now have well-recognized severe side effects.
On the inpatient side, there’s now broad agreement that giving vancomycin and piperacillin-tazobactam together increases the risk of nephrotoxicity. This awareness has led to dramatic reductions in the use of “Vancosyn,” which was all but ubiquitous on medical and surgical services a decade ago. And the toxicities of fluoroquinolones deserve their own brilliant graphic:

Comparing 2010 to 2020 in clinical ID, some very big changes. Here's one — fluoroquinolone toxicity was a known thing, but it wasn't a THING. Others? pic.twitter.com/9WSVvNEmXl

— Paul Sax (@PaulSaxMD) January 1, 2020

#9.
Then (2010):  Order an HIV test? What a pain.
Today (2020):  Written consent for HIV testing no longer required.
In 2010, labs required that formal written consent, signed by the patient, be on file before running an HIV test. This was an actual law in most states! While one might argue that such a policy made sense in the mid-1980s due to fears of discrimination and lack of effective HIV treatments, it was absolutely bonkers (that’s the medical term) in 2010, so many years after we had lifesaving HIV therapy, and were still facing a large proportion of those with HIV undiagnosed. And yes, Massachusetts was the last state to drop this outdated law — not proud about that fact! Fortunately today, a clinician who wants to order an HIV test now just needs to document that the patient verbally agreed to testing — easy peasy. Was that so hard?

#8.
Then (2010):  MRSA is taking over!
Today (2020):  MRSA is way less common.
If you’d asked me in 2010 to estimate what proportion of our hospital’s Staph aureus isolates would be MRSA in a decade, I’d probably have guessed 75%, or if I was feeling glum that day, 90% — the trend in the early 2000s was just up and up and up for this pesky and difficult-to-treat pathogen, and it was by far the most common microbiologically confirmed cause of skin infections. However, for reasons no one can quite understand, MRSA rates are down everywhere — both in inpatients and outpatients. (Our hospital’s antibiogram now lists MRSA as 27% of Staph aureus isolates.) Not only that, penicillin sensitivity locally among staph is making a comeback, too. No one predicted that.

#7.
Then (2010):  Otitis media — antibiotics needed now!
Today (2020):  Observation, rather than immediate antibiotics, is now an accepted strategy for certain cases of childhood otitis media.
I put this one in for the pediatricians, especially one particular pediatrician! Although treatment guidelines endorsed observation for otitis media in 2013, apparently only in the past few years have parents grown comfortable with this approach.

#6.
Then (2010):  CD4 700? You don’t need to start treatment, let’s monitor blood tests, see what happens.
Today (2020):  The “When to Start” debate in HIV therapy ended — everyone should be treated.
In 2010, we might have monitored someone with high CD4 cell counts for a while, allowing them to be viremic for months or even years if they remained asymptomatic. We would never do that today because the START study randomized people with HIV who had no symptoms and high CD4 cell counts to immediate versus deferred therapy, showing a clear clinical benefit for early treatment. Plus, there’s the #2 Big Change listed below as an additional factor favoring treatment.

#5.
Then (2010):  Recurrent C. diff? Let’s try another round of vancomycin, maybe with a long taper.
Today (2020):  Fecal transplants for relapsing C. difficile colitis are now standard of care.
After a period of initial (and quite understandable) disgust and reluctance from patients and clinicians alike, clinical data on the efficacy of fecal transplants for relapsing C. difficile colitis are now strong enough to give it a place in the most recent treatment guidelines. These clinical trials data have has been strengthened by largely favorable anecdotal experience. While not a panacea — some patients don’t respond, and there are ongoing safety and regulatory issues — the fact that fecal transplant has such a major role in treatment of any condition would have been unfathomable in 2010.

#4.
Then (2010):  Worried about acquiring HIV? Make sure you and your partner use condoms.
Today (2020):  Pre-exposure prophylaxis (PrEP) for HIV is an established HIV prevention strategy.
As I’ve mentioned before (and will continue mentioning forever, since it’s in hindsight so bizarre), the first time I  heard of this concept was in the 2002 CROI in Seattle, when keynote speaker Bill Gates was asked about people without HIV taking ART to prevent infection. (Why someone was asking the CEO of Microsoft this question is still not clear to me!) His response concisely summarized HIV prevention in that time: “Wouldn’t a condom be easier?” Fast-forward to the IpReX study, the FDA approval of TDF/FTC for PrEP in 2012, several follow-up studies — and today PrEP is broadly endorsed in national guidelines for HIV prevention.

#3.
Then (2010):  We have to bring tuberculosis diagnosis and treatment into the 21st century!
Today (2020):  TB diagnosis and treatment are both much better.
On the diagnostics side, the The GeneXpert MTB/RIF system has been absolutely transformative, both in high prevalence countries (where it establishes the diagnosis much faster and more reliably than smear), and here as well, where we can rapidly rule out the diagnosis and stop respiratory precautions in low risk cases. Treatment of latent TB now has several  shorter options than the old standard of care 9 months of INH. And for multi-drug resistant disease, Dr. Catherine Berry’s comparison says it all!

XDR-TB treatment

2010
“Cat IV” low priority, minimal access
6-7 drugs, daily IM aminoglycoside
2 yrs treatment
Daily vomiting, hearing loss
10 to 20% cure

2020
3 to 5 drugs
All oral
6 to 18 months
PN, ON, myelosuppression
?up to 90% cure

2022
Watch this space

#2.
Then (2010):  The most important thing you can do to protect your partner from acquiring HIV is to always use condoms, even if you’re on treatment.
Today (2020):  “Undetectable = Untransmittable” is now a mainstream part of HIV medicine.
Though the prescient Swiss Statement appeared in 2008, it was not until release of the HPTN 052 data in 2011 that this “treatment as prevention” idea gained mainstream acceptance — only to be further supported by the PARTNER and PARTNER2 studies. The bottom line is that we now routinely tell people with HIV that they are not contagious to others if they’re on suppressive HIV therapy. Few (if any) non-Swiss people would have been so bold to say that in 2010.

#1:
Then (2010):  Treatment of hepatitis C will be injectable interferon and multiple tablets of ribavirin. Not only that, you’ll need to take it for 12 months, endure many side effects, some of them quite severe — oh, and it will have a 20–30% chance of the treatment working.  Sorry about that.
Today (2020):  Hepatitis C is cured with 8–12 weeks of well-tolerated, oral treatment in around 99% of people.
I still don’t think we quite appreciate just how miraculous an advance this is, so I’m making it an emphatic #1 biggest change in ID clinical practice. (And Monica Mahoney, PharmD agrees, so it must be right.) As one of my patients said, after having relapsed during interferon treatment twice previously, and finally being cured with sofosbuvir/velpatasvir:  “Curing things is good. You doctors should work on more of that.” Agree!

What would be your Top 10? And of course my order won’t be your order, but that’s what the comments section is for!