HIV and ID Observations

An ongoing dialogue on HIV/AIDS, infectious diseases,
all matters medical, and some not so medical.

November 25th, 2019

Vaccine Defenders, U=U Holds Up, Zika Is Gone, and Other ID Things to Be Grateful For, 2019 Edition

A High Wind in the Park, London, 1819.

An excellent episode of the Freakonomics podcast introduced me to the headwinds vs tailwinds asymmetry, and how we humans perceive life.

It goes like this: We go for a walk, a run, or a bike ride, and the wind faces us dead-on, making the exercise a struggle.

(In windy Boston, the wind is always in my face. Always always always.)

When the route changes, there’s a brief moment of relief, but it’s short-lived. What we remember about the experience is the headwind, certainly not the boost the tailwind might have given us on the way home.

The researchers on that podcast argue that this same blindness to various good things, privileges, and benefits is how we perceive all of our life. We’re intrinsically wired to complain about the barriers and struggles.

In short:

Barriers and hindrances command attention because they have to be overcome; benefits and resources can often be simply enjoyed and largely ignored.

While evolution might have hard-wired this attitude in us for survival purposes, it can also make us into a bunch of unappreciative whiners.

Which is why the flip-side — expressing gratitude — is so important. Research consistently shows it makes us happier. And it definitely makes us better company, an important consideration as we approach the holiday season.

In that spirit, in what’s become a Thanksgiving Holiday tradition, I list below a series of ID/HIV things to be grateful for in late 2019. And hey, there’s so much to be grateful for!

  • Brave, authoritative, and respected voices continue to speak out against the anti-vaccine movement. There are many such voices out there, and IDSA has done a terrific job as an organization, but I want to highlight especially Dr. Peter Hotez. He appears regularly in public and in print to defend vaccines, risking his own safety; he has also written a moving and personal book entitled Vaccines Did Not Cause Rachel’s Autism: My Journey as a Vaccine Scientist, Pediatrician, and Autism Dad. Check out the ratings for this book on Amazon, and you’ll find a painful dichotomy — either 5 stars or 1 star — with the negative comments demonstrating how vicious the anti-vaccine movement can be.

  • An Ebola vaccine works! In perhaps no other disease will a vaccine play such a critical role in getting control of an outbreak. This is wonderful, very welcome progress!
  • U = U (undetectable equals untransmittable) continues to hold up. Perhaps the most transformative finding in the history of HIV medicine — that people on successful HIV treatment don’t pass the virus on to others sexually — remains a rock-solid fact. I’ve included U = U here before several times, but why not continue to celebrate it?
  • HIV incidence in many urban regions in the USA drops. In New York City, for example, 1,917 people were diagnosed in 2018, a 67 percent decline from 2001. Treatment as prevention and PrEP are yielding these impressive results.
  • Zika is all but gone. Remember how crazy things were in 2016? Especially for couples who wanted to have children? And for us ID doctors (and primary care and OBs) trying to advise them? Yes, Zika could come back (and likely one day will), but let’s be grateful for our current situation compared to that insane period.
  • New antibiotics, some with new mechanisms of action, expand our treatment options. No, they’re not perfect, and some are only incremental advances, or targeted at rare clinical situations — but great anyway to have lefamulin, pretomanid, omadacycline, eravacycline, meropenem-vaborbactam, imipenem-relebactam, cefiderocol (with some confusing data on this last one, still to be sorted out). Now let’s try to fix the economics of antibiotic drug development!
  • Additional studies continue to demonstrate the clinical benefit of ID consultation on outcomes. Just a few recent examples — candidemia, sepsis, and long-term outcomes in Staph aureus bacteremia. The parade goes on and on!
  • A “Shorter is Better” philosophy about duration of antibiotic therapy moves into clinical practice. And with this updated super list from Dr. Shorter-is-Better himself, Brad Spellberg, why not?

  • Pragmatic clinical trials in ID give us important new strategies for therapy. The most notable examples in the past year are the POET and OVIVA trials, demonstrating the noninferiority of oral to IV therapy for endocarditis and osteomyelitis. More of these, please!
  • The “Ask the Experts” section on the Immunization Action Coalition remains a gold mine of useful information.  I’ve mentioned it before, but that doesn’t mean I can’t still be grateful! Barely a week goes by without my consulting this site.
  • Shorter treatment courses for latent TB gain traction. Drug interactions aside, who doesn’t prefer 4 months of rifampin to 9 months of INH? Can 1 month of isoniazid/rifapentine be far behind?
  • New guidelines for diagnosis and treatment of Lyme Disease are imminent. The draft guidelines have already been released — final version expected soon.
  • Dolutegravir-based regimens are increasingly available globally. In many settings that previously had only efavirenz (first-line) and lopinavir/ritonavir (second line), dolutegravir represents major progress — for both treatment-naive and treatment-experienced patients. It will be important to see how this big change in strategy works out, which is the primary goal of this observational study.
  • ID fellows continue to amaze us. Smart, mission-driven, and hard working, they take on the most complicated cases in the hospital with aplomb. As my down-the-hall neighbor Dr. Sigal Yawetz says:

Happy Thanksgiving! What are you grateful for this year?

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4 Responses to “Vaccine Defenders, U=U Holds Up, Zika Is Gone, and Other ID Things to Be Grateful For, 2019 Edition”

  1. Shishir Gokhale says:
    November 26, 2019 at 1:36 am

    I am grateful for all the information packed in entertaining manner on this blog. Every issue is educative and thought provoking. I often use it in my discussions and teaching.

    Thanx

  2. Lisa Kaufmann, MD says:
    November 26, 2019 at 9:07 pm

    I enjoy your blog and it has a large readership, so I hope you are ok with an off topic email.
    I am very frustrated by the rising prevalence of Cdiff present on admission to our hospital. One approach to antibiotic stewardship that I have not seen recommended anywhere is to require truth in labeling on meat and poultry products “this animal was routinely fed antibiotics and is at higher risk to contain drug resistant bacteria”. Or something to that effect. In the US I can’t ever imagine prohibiting use of prophylactic antibiotics in large scale agriculture due to the pattern of political donations and the ability to say truthfully that raising animals in tight quarters is much more expensive when antibiotics are not used, but truth in labeling is much harder to credibly oppose since all it does is permit consumers to make a more informed choice. Are there any groups advocating for an approach like this?

  3. Mark Crislip says:
    November 27, 2019 at 11:54 pm

    I beg to differ. I spent decade blogging, reading about and immersed in the anti-vaccine movement over at sciencebasedmedicine.org. The striking thing about IDSA, outside of Paul Offit, and his work appears more independent than IDSA, has been its lack of engagement on the website and at meetings combatting the anti-vaccinators. In all reading and blogging I did, I never found anything from IDSA as a reference or helpful. The only reference I ever found/saw from the IDSA was Vaccine Rejection and Hesitancy: A Review and Call to Action in OFID. I assume, pathetically, given how the OFID works, the author had to pay for the only review/article of note from IDSA to counter the modern anti-vaccine movement. It wasn’t even published until 2017, 18 years after Wakefields Lancet article which led to thousands of measles cases. Sad. The organization was/is a major fail on one of the most important public health issues this century, esp when compared to the CDC or SBM or skeptical raptor or respectful insolence or the others who have worked in the trenches to counter the anti-vaccine movement. I only make it to 1 in 4 IDSA meetings, but there has never had an anti-vaccine symposium or lecture during my 34 years of attending until this year. That is sad. Even now there is virtually nothing of note on the website to counter the anti-vaccine arguments. The antivaccine movement lives and thrives on the web, in blogs and facebook and twitter, where IDSA is never seen or heard. IDSA is an almost complete embarrassment. IDSA: F grade at best.

  4. prof .dr. Michiel van Agtmael says:
    November 28, 2019 at 3:58 am

    Dear Paul, great blog again:very funny and informative. I am grateful everyday to be around inspiring colleagues and students !

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

Biography | Disclosures | Summaries

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