“Turning the Tide” on HIV/AIDS

In advance of the upcoming XIX International AIDS Conference, the International AIDS Society and the University of California, San Francisco, have issued the “Washington D.C. Declaration,” a nine-point action plan aimed at broadening global support for “Turning the Tide” of the AIDS epidemic.

Everyone is urged to sign the Declaration.

It calls for:

1) An increase in targeted new investments;
2) Evidence-based HIV prevention, treatment, and care in accord with the human rights of those at greatest risk and in greatest need;
3) An end to stigma, discrimination, legal sanctions, and human rights abuses against those living with and at risk for HIV;
4) Marked increases in HIV testing, counseling, and linkages to services;
5) Treatment for all pregnant and nursing women living with HIV and an end to perinatal transmission;
6) Expanded access to antiretroviral treatment for all in need;
7) Identification, diagnosis, and treatment of tuberculosis;
8) Accelerated research on new tools for HIV prevention, treatment, vaccines, and a cure;
9) Mobilization and meaningful involvement of affected communities.

Turning the Tide is the theme of this year’s biennial conference, which will take place July 22-27 in Washington.  It is expected to draw 25,000 attendees, including HIV professionals, activists, politicians, and celebrities. Sir Elton John will open the conference and Bill Clinton will close it. A large delegation of U.S. members of Congress will participate, and Bill Gates will moderate a session. An enormous “Global Village” outside the D.C. Convention Center will be open to the public. “If you haven’t been, it’s a conference like no other,” conference cochair Dr. Diane V. Havlir said at a press briefing.

The recent optimism regarding HIV/AIDS stems from major advances in knowledge regarding prevention of partner transmission with early patient treatment, pre-exposure prophylaxis, and male circumcision as HIV infection prevention (new data will be released at the meeting), all of which are viewed as breakthroughs  in the fight against HIV/AIDS. “So we have now in our hands the tools. The question is how do we combine those tools together, and how do we roll them out,” said Dr. Havlir, professor of medicine at the University of California, San Francisco, and chief of the HIV/AIDS division at San Francisco General Hospital.

Dr. Diane V. Havlir / Photo by Miriam E. Tucker

Monday’s plenary session will include an address from Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, on “Ending the HIV Epidemic: From Scientific Advances to Public Health Implementation.” Other plenary topics during the week will include viral eradication, vaccines, TB and HIV, and HIV/AIDS in specific populations including minorities, women, youth, and men who have sex with men. On Friday, there will be a plenary talk that may be of particular interest to the primary care community, “The Intersection of Noncommunicable Diseases and Aging in HIV.”

Plenaries and other conference sessions will be webcast at http://globalhealth.kff.org/aids2012.

-Miriam E. Tucker (@MiriamETucker on Twitter)

Are You Serving Your LGBT Diabetes Patients?

Are most health care providers attuned to the needs of their diabetes patients who are lesbian, gay, bisexual, and transgender (LGBT)? Does it matter? No and yes respectively, according to certified diabetes educator Theresa Garnero.

Rauchdickson photo via Flickr Creative Commons

More than half of medical school curricula include no information about LGBT people, and most multidisciplinary professionals have not received tools to care for LGBT individuals, Ms. Garnero said at the annual meeting of the American Association of Diabetes Educators.

A number of factors that increase the risk for developing diabetes are highly prevalent among people who are LGBT. For example, obesity and polycystic ovary syndrome (PCOS), both strong risk factors for type 2 diabetes, are more common among lesbians than among heterosexual women. Indeed, in one study, PCOS was identified in 38% of lesbians vs. just 14% of heterosexual women.

Antiretroviral drugs used to treat HIV/AIDS often lead to insulin resistance and type 2 diabetes. Men on HIV treatment have four times the risk of diabetes as do HIV-negative men. Moreover, cigarette smoking, alcohol abuse, and illicit drug use, all of which particularly endanger the health of those with diabetes, are frequent behaviors among LGBT individuals.

Depression is common in both LGBT individuals and people with diabetes. Withholding of insulin among closeted LGBT youth with type 1 diabetes could be a suicidal gesture rather than diabulimia.

How many LGB people have diabetes? It’s extremely difficult to obtain statistics – and there are virtually none for transgendered people – but based on self-reported health data, roughly 1.3 million LGB people have diabetes, a number approximately equal to that of type 1 or gestational diabetes, Ms. Garnero said.

So why does it matter? Lack of awareness and presumption of heterosexuality can lead to mistakes that alienate patients, such as lecturing a young lesbian with diabetes about the need for birth control or expressing negative attitudes toward patients who want to bring their same-sex partners to diabetes-education classes.

Importantly, patients who perceive that they can’t be open with their health care provider about sexual orientation may be reluctant to share other health-related information.

“Individuals who approach the health care system are already vulnerable from their illness … Intolerance is the last thing anyone wants when seeking health care. It is certainly not a part of the caring diabetes professional culture,” Ms. Garnero said.

What can the health care provider do? Placing a rainbow flag sticker or nondiscrimination statement that specifically mentions sexual orientation in the waiting room is a simple way providers can let patients know that they are LGBT-friendly. Other helpful information for providers can be found here.

Bottom line, she said: “All people with diabetes deserve the benefit of our expertise and access to ongoing support.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

Dr. Fauci Talks about AIDS with Stephen Colbert

Dr. Anthony Fauci (NIAID photo)

In case you missed it, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, was a guest on the March 29, 2011 episode of Comedy Central’s “The Colbert Report.”

Early in the interview host Stephen Colbert asked Dr. Fauci to forecast the next “hot, newest” infectious disease. “I want to get my graphics department working on the next thing that’s going to scare the poop out of these people,” Mr. Colbert said, as the studio audience chuckled in the background. “Turkey herpes? What’s it gonna be?”

Then the discussion turned serious, with Mr. Colbert suggesting that the public attention on AIDS treatment and prevention has waned in recent years. He asked Dr. Fauci: “Why aren’t we talking about it if it’s no big deal?”

Dr. Fauci said that AIDS remains a “serious problem” in the United States, with 56,000 newly diagnosed cases each year. “It’s been that way for the last 10 or 15 years,” he said.

“Why are so many people getting it? Because we have abstinence education…” Mr. Colbert asked.

“That rarely works,” Dr. Fauci said, noting that the majority of Americans practicing high risk behavior lack access to AIDS education campaigns and to good health care. In 2010, he added, about half of new AIDS infections in the United States were among African Americans.

To view the entire interview, click here.

— Doug Brunk (on Twitter@dougbrunk)

Video of the Week: New HIV Treatment Guidelines

The increased efficacy of antiretroviral therapy for HIV has changed the nature of HIV infection, according to Dr. Melanie A. Thompson. In response, treatment guidelines now call for treatment to begin earlier.  Our reporter, Mitchel Zoler, talked with Dr. Thompson about these changes at the 18th International AIDS Conference.

We now feel that the risks of untreated infection are tipping the scales toward earlier therapy.

Dr. Thompson is the principal investigator of the AIDS Research Consortium of Atlanta and chairwoman of the panel that wrote the new recommendations. You can read Mitch’s story at Internal Medicine News.

The Medicine Cabinet of Dr. Caligari

 

In the 1920 horror film “The Cabinet of Dr. Caligari,” the mysterious Dr. Caligari arrives at a carnival with a cabinet whose contents ultimately cause mayhem, madness, and murder.

In our modern-day editorial offices, a series of display cabinets has suddenly arrived in a side corridor—cases whose colorful contents once had much the same effects as the cinematic Dr. Caligari’s cabinet.

Photo by Terry Rudd

The mysterious cabinets contain antique bottles of medicinal magic, including these pre-modern marvels:

• Who needed biologics when you had Yohn’s Rheumatic Elixir, “An Infallible Cure for Rheumatism, Lumbago and Gout”?
• The 18th Amendment probably went down easier with Dr. Fenner’s Golden Relief, containing “Alcohol 65%, Ether 22 minims, Chloroform 5 minims, Capsicum, Turpentine, Ammonia,” and several other Prohibition-relieving compounds.
• Chemoprevention was as simple as a spoonful of Dirigo Bitters and Blood Purifier: “A Preventive of Cancer.”
• And finally, Parke-Davis & Co. discovered what Ponce de Leon futilely scoured Florida to find: “Life-Everlasting,” featuring the apparently immortality-inducing agent Gnaphalium polycephalum.

These historical artifacts actually belong to our corporate cousins who cover the pharmaceutical industry. But on some level, they belong to us all, a bottled legacy of medicine’s sometimes perilous evolution.

The medicine cabinets offer a rare glimpse back into the Valley of the Shadow of Death and Snake Oil. They’re reminders that we haven’t been climbing the mountain of medicinal progress as long as we might think.

In a time when a routine case of acute otitis media practically autogenerates an amoxicillin script, it’s easy to forget that many of our parents lived their childhoods in the deep shadows of a pre-antibiotic Dark Age. It’s hard to remember that the politically disparaged words “government regulation” once weren’t even in the pharmaceutical vocabulary, with painful results for millions. It wasn’t so long ago that our well-meaning physician ancestors chipped away at disease with the pharmaceutical equivalent of stone tools.

At best, those cabinets’ antique contents did little for their users. At worst, they were products from the closing moments of a millennia-long medical era that spawned the phrase “The cure is worse than the disease.”

Medical practice and the drugs upon which it relies have escaped their Dark Ages. From the antibiotic I’m giving my AOM-afflicted 7-year-old to the antiretroviral revolution in HIV treatment, scientifically tested and government-approved pharmaceuticals have helped create a world of health and longevity inconceivable a century ago.

Certainly, its snake-oil ancestors’ mortal sins don’t excuse the shortcomings of today’s pharmaceutical industry. Or those of the industry’s sometimes fallible regulators. But while we work ourselves into a righteous dudgeon over the influence of pharmaceutical industry funding or clinical trial obfuscation, or point fingers over imperfections in federal government oversight, we might want to take a moment to look back down the medicinal trail.

And remember how far we’ve come from the madness of those Caligari-esque medicine cabinets.

—Terry Rudd

 

Medical Meeting as Performance

The medical meetings I cover are mostly academic exercises, with researchers reporting new data and other experts mulling the data over and trying to decide what it means. But there is another aspect to many meetings, especially the big ones with thousands or even tens of thousands of attendees, that has a decidedly theatrical element. I even know some people who insist on calling these meetings shows, although that’s mostly their exhibit-hall orientation.

No other medical meeting I’ve covered, easily more than 400 in my career, incorporates as much theater and performance as the International AIDS Conferences, which began in 1985 and have been held every other year since 1996. The AIDS Conferences are where conventional meeting science and discussion collides with demonstrations, passions, and flamboyant displays.

At the eighteenth International AIDS Conference, held this week and wrapped up today in Vienna, my vote for the most attention-grabbing and creative theatricality was the Condomize! display that maintained an expansive presence in the middle of the main traffic corridor all week. Volunteers from The Condom Project created condom mosaics on corridor columns, worked beneath billboard-sized condom murals along with a display of air-filled condoms (the better to see the variety of sizes), and had tables laden with thousands of condoms for distribution and for the creation of condom pins.

Other theatrical elements included the Haitian solidary demonstration that took over the podium and launched one morning’s plenary session.

Where else but at the AIDS Conference would you find Annie Lennox co-chairing a plenary session.

all images by Mitchel Zoler

And then there was the most electrifying and anticipated report at this year’s session, last Tuesday afternoon, when researchers from Caprisa reported results from their proof-of-principle clinical study that showed a tenofovir vaginal gel used by women before and after sex cut the rate of new HIV infections by a relative 39% (see my report here). During the course of the hour-long report, the large, packed audience greeted the exciting results with four separate outbursts of applause, ending with a standing ovation at the end of the talk.

Nothing gets more theatrical than a performance received like that.

—Mitchel Zoler (on Twitter @mitchelzoler)

HAART Rules

Liberal use of highly active antiretroviral therapy for HIV infections, the kind of regimen that makes the virus undetectable in an infected patient, has been the mantra of the International AIDS Conference in Vienna this week. It’s been promoted as a strategy to both help HIV-infected patients as well as to help those who are not yet infected and wanting to stay that way.

image by Mitchel Zoler

The revised HIV treatment recommendations from the International AIDS Society-USA, released July 18, reset the threshold for starting HAART in asymptomatic patients from 350/mcL CD 4 cells to 500/mcL, as well as provided a list of eight special situations that also warranted treatment in asymptomatic patients. Even more aggressively, it said starting treatment could be considered for any asymptomatic patient, regardless of CD 4 cell count, saying that no contraindication existed for treating HIV infection at any CD 4 cell level.

But it was hard to see treatment of these patients as merely a consideration when the chairwoman of the recommendations panel, Dr. Melanie A. Thompson, said that “at any CD 4 count the body takes a hit from uncontrolled HIV infection,”  that’s believed to show up later as cardiovascular, renal, and hepatic complications, as well as cancer. She also said that one of the major, prior reasons to wait on starting treating–to avoid possibly wasting one or more of a limited panel of drug treatment options–has become much less of a concern because now more drug options exit, and the new options have good tolerability and potency. Here is my full report on the treatment recommendations.

But there is more to like about widespread, and early HAART: It also helps the community as a whole avoid HIV infections, Dr. Julio S.G. Montaner said in a talk on July 21 and in a paper that appeared last week in The Lancet. He assessed the impact of HAART on HIV transmission rates in British Columbia, Canada, and found a strong link between an increased number of HIV-infected patients on effective HAART and a substantial drop in new HIV infections. The way this works is if HIV-infected patients are on HAART and have an undetectable viral load they are much less likely to pass the infection on to someone else.

In his analysis, Dr. Montaner found that for every 100 additional HIV-infected patients on HAART the number of new HIV infections in British Columbia dropped by 3%, and that for each 10-fold drop in the “community viral load” of HIV the number of new infections fell by 14%.

Of course, many challenges remain, such as identifying people infected with HIV when they’re asymptomatic and still have high CD 4 cell levels, and paying for all this HAART.

—Mitchel Zoler (on Twitter @mitchelzoler)

Are virtual medical meetings the wave of the future?

It’s now possible to go to a medical meeting without actually going to the meeting.

I was assigned to cover the annual Conference on Retroviruses and Opportunistic Infections (CROI), one of the year’s most important HIV/AIDS meetings, currently underway in San Francisco. But through a series of snafus too boring to mention I was not able to register for the conference.

No problem, said the organizers, more than 90% of the conference will be webcast.

I’ve heard this song before, and usually it means that at some distant future date some low-quality audio may be available for purchase at the rate of $40/session or thereabouts.

But I was pleasantly surprised to learn that CROI is offering much, much more. The webcasts are free, they include high quality audio, video, and PowerPoint slides, and the day’s sessions are all available the same evening. Oh, and the audio files, with slides, are also available for download in mp3 and iTunes format. For free.

Virtual attendance via webcast has both advantages and disadvantages compared to physical attendance in “meatspace.”

Advantages

• No need to pay for travel, hotel, or even meeting registration.
• Smaller environmental impact.
• Can attend all sessions, even ones occurring simultaneously.
• Can clearly hear and see the speaker, the slides, and participants in the Q&A session.
• Can pause and rewind audio, study PowerPoint slides closely, and actually read those slides that speakers introduce by saying, “Now this slide is a little busy, but . . .”
• Can attend in pajamas.

Disadvantages

• No schmoozing, no networking, no catching up with old friends and colleagues.
• Requires a fairly fast Internet connection for non-jerky video. Even with a fast connection (in CROI’s implementation, at least) streaming tended to stop halfway through a 2-hour session, and the only way to resume was to exit and reload.
• Not possible to get a sense of how interested–or uninterested–the audience was in a particular talk.
• I’m a big fan of poster sessions, but the CROI did not make the posters available on its webcast.
• No way to earn CME credit for watching the webcasts, in this implementation at least.
• No opportunity to spend time in San Francisco, one of the most exciting and beautiful cities on Earth.

I’m interested in hearing from physicians who have attended a conference via webcast. What did you think about the experience? I’d also like to hear from physicians who think this is the worst idea since bloodletting went out of fashion. Please vote in the poll and leave comments!

— Bob Finn (on Twitter @bobfinn)

Hepatitis C: Drugs in the Pipeline

Photo by flickr user zieak (Creative Commons).

A rich pipeline of anticipated new drugs to treat hepatitis C is motivating one clinician to delay treatment in select patients who have chronic disease and can safely defer treatment.

According to Dr. Norah Terrault, director of the Viral Hepatitis Center at the University of California, San Francisco, two new protease inhibitors — boceprevir and telaprevir — are expected to be approved as add-on therapy for hepatitis C sometime in the first quarter of 2011, to be used in combination with pegylated interferon and ribavirin.

At a recent conference, Dr. Terrault discussed the pros and cons of treating vs. delaying treatment of hepatitis C in patients co-infected with HIV. The co-infected patients whose hepatitis C she generally treats without delay include any with genotypes 2 or 3  (because all the new drugs are being developed primarily for genotype 1), patients with low levels of hepatitis C RNA regardless of genotype (because they’re the most likely to achieve a sustained viral response to therapy), patients with advanced fibrosis (because “they can’t wait for new treatments”), and patients with acute (not chronic) hepatitis C who are on stable antiretroviral therapy with no opportunistic infections and CD4 counts above 200 cells per cubic millimeter.

For all other co-infected patients, “it’s a matter of weighing the risks and benefits of treating now versus later,” she said. For example, hepatitis C tends to progress faster in the presence of HIV, which could argue for earlier treatment, but the new regimens should offer a better chance of response, if the patient can wait. Toxicity with today’s hepatitis C drugs is a bigger burden for patients with HIV than those without HIV, but the new drug combinations will be even harder to tolerate.

It’s only in the past year that she’s begun deferring treatment for hepatitis C, she said, and the main reason is that better treatments are “just around the corner.”

Dr. Terrault has received research support from Schering-Plough Corporation (boceprevir)  and Vertex Pharmaceuticals Incorporated (telaprevir) as well as numerous other pharmaceutical manufacturers.

— Sherry Boschert (@sherryboschert on Twitter)

Celebrity Viruses

Transmission electron micrograph of HIV, courtesy of CDC.

Today the Institute of Medicine released its report on improving recognition of and care for chronic hepatitis B and C infections.  In the report the IOM highlighted the lack of knowledge about hepatitis B and C among the general public but also among physicians, other healthcare providers, and social service providers. (see story)

In particular, the IOM recommended mounting a public awareness campaign similar to the successful HIV/AIDS campaign.  That begs the question of why HIV/AIDS has engendered such attention while hepatitis B and C have not.  Why has HIV been a sort of celebrity virus?  It’s estimated that 3-5 times as many people live with chronic hepatitis B and C than with HIV/AIDS. Yet in general, even physicians are poorly educated about these diseases.

Why?  Is it because HIV/AIDS posed an imminent threat to the health of an individual (i.e. death) when it was initially identified and before effective treatment regimens were available, ?  Is it because those with hepatitis B and C are often asymptomatic?  Is it because there are no celebrities with hepatitis B and C?  Is it because HIV/AIDS organizations are better organized and less fragmented?

The pervasive lack of knowledge about hepatitis B is particularly troubling, given that there is a very effective vaccine to prevent infection.  However, you can’t really get the vaccine if your physician doesn’t know about it.

Let us know what you think.  What’s behind the disparity?

—Kerri Wachter ( @knwachter on Twitter)