HIV Care Today

If I hear or read another proclamation about the "HIV treatment cascade" and the need for more research to understand engagement in care, I am going to scream! There, I said it. It seems this cascade -- described initially by Laura Cheever at HRSA and most recently and formally by Gardner and colleagues -- has taken the HIV world by storm. It has captivated the field of HIV practitioners, advocates, researchers and scientists and peppers nearly every lecture at conferences and conversation at the watercooler. But why?

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Some very hard-working folks at the NIH, CDC and IDSA have updated the Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents, which are available for review here.

As with the previous versions (the prior iteration is from 2009), the OI Guidelines are comprehensive, exhaustively referenced (184 references for TB alone!), and authoritative. Note that the PDF version weighs in at 416 pages, so I doubt many people will be printing this out and carrying it around in their white coats. Fortunately, for the first time these Guidelines are also available in their entirety online in an HTML version, which is undoubtedly how most will access them, and certainly make them easier to update.

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Less than 20 years ago, when I started doing HIV/AIDS care, most of my patients died within a year or two of their diagnosis. Medications were only marginally effective and caused side effects (or even death), and the notion of long-term survival was only a hope. To discuss a normal life expectancy was wishful thinking, perhaps false hope.

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There it is, right in your daily paper, on your tablet or computer screen, or wherever you get your news today -- a headline about a great medical breakthrough everyone's been waiting for:

Scientists on Brink of HIV Cure
Researchers believe that there will be a breakthrough in finding a cure for HIV "within months."

Yes, I read this exact headline recently.

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Widespread publication of the treatment cascade has heightened the level of concern for engaging and retaining patients in HIV care. A significant percentage of persons living with HIV are unaware of their status, and an astonishingly low number of people have successfully suppressed their viral loads. Despite recent articles that have reported potential variation in these calculations, it is clear that a significant number of people remain out of care, marginally engaged or worse.

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On Friday, the NIH announced that HVTN 505, a clinical trial of an HIV vaccine using an adenovirus vector, would be stopped based on a finding of futility by an independent DSMB.

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From a colleague came this query:

We are being consulted by surgeons who are finding within blast victims tissues from other humans. We have been offering post-exposure prophylaxis. Have you folks developed any policies re PEP for explosion victims?
Welcome your thoughts,
P

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Over in Clinical Infectious Diseases, a recent study pretty much nails the fact that routine measurement of CD4 cell counts in clinically stable patients is an all but useless exercise. As summarized by Abbie Zuger in Journal Watch, here's the key finding:

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In a host of meetings on treatment access and HIV research, we have repeatedly heard the following statements about multidrug-resistant HIV (MDR-HIV) patients:

"These patients no longer exist -- they're either dead or have responded to the latest ARVs."

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As noted previously by Carlos del Rio in his nice summary, the Conference on Retroviruses and Opportunistic Infections (CROI) turned 20 this year. It also made it's first-ever stop in Atlanta, home of many things that begin with "C" -- CDC (note that insiders rarely say, "the CDC"), CNN, Coca Cola, and Carlos himself.

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