She's back. Tina, that is. Crystal, crank, meth, ice, amp -- all slang for the same drug: methamphetamine. In the early part of the millennium, meth was pervasive both in rural America and in urban gay communities. Its use peaked around 2005 when, following a federal law limiting access to its primary precursor, pseudoephedrine, usage seemed to drop. In gay communities, men became aware of its hazards as they watched friends lose lovers, jobs, health, freedom and even their lives. Pursued by law enforcement, hardcore users went underground but never really went away. Now, because of the cycles of recreational drugs, a new generation, short memories, and the seductive power of this dopamine-releasing supermolecule, the drug appears to be making a comeback, at least in the gay community.
In a previous post, we reviewed the various flavors of medication non-adherence, and concluded with this tantalizing line:
Next up: "An Adherence Intervention that Actually Works -- But There's a Catch"Well here it is, just published on-line in JAMA Internal Medicine.
Treatment of HIV has become so amazingly effective that when it fails, it's no overstatement to say that it's usually because the patient is not taking the medications. There are all kinds of provider-related reasons for this -- inadequate patient education, prescribing and dispensing errors, failure to address language or education deficits -- but here I want to focus on the patient-related causes.
In other words, on non-adherence.
In the modern world it can be remarkably easy to discover where you are. A simple tap on the screen of a smart phone or consultation with a car's GPS device instantly reports our location on the planet with almost absurd precision. Such effortless ability to locate ourselves in time and space can shroud the complications of maintaining emotional bearings in the more ambiguous, upside-down world of living with HIV. Those who are newly diagnosed, as well as long-term survivors, are buffeted by the powerful forces unleashed by living with or around HIV, and frequently find it challenging to maneuver this emotional realm.
Calimmune, a small biotechnology company, has been given the go-ahead by the U.S. Food and Drug Administration to start enrolling HIV-infected people in a first-of-its-kind gene therapy study that will modify two HIV attachment sites in CD4+ cells.
Management of recently acquired HIV infection -- especially acute HIV, pre-seroconversion -- has long been controversial, with the risks and benefits of treatment versus observation debated now for nearly two decades.
(Yes, it's been that long since the publication of this controlled trial of zidovudine monotherapy. Amazing.)
As part of my work as an HIV cure and salvage treatment activist, I am constantly searching for treatment options that could serve two purposes: help patients with multidrug resistance, and at the same time be used as an approach to cure HIV. Since my nonprofit, Program for Wellness Restoration (PoWeR), has a very small budget for me to attend conferences, I rely on the summaries that Jules Levin and his group at National AIDS Treatment Advocacy Project (NATAP) publish after he attends conferences. I am glad Jules can serve as eyes and ears for those of us who are unable to attend so many important scientific meetings.
Email exchange with a colleague who works at one of our community health clinics:
Guy: Hi Paul, your patient 17432862 [that's a made-up medical record number] came to our walk-in clinic with a rash on her hand. OK that I gave her a week of topical steroids? I know how inhaled steroids interact with some meds -- wasn't sure about the creams.
Me: Could be, good thought. Regardless, a short course should be fine. Tell me, who is the patient? What meds is she on?
Guy: I didn't want to put her name or meds in the email, what with her disease state, HIPAA, etc.
As Physician's First Watch noted, we sure know what the folks at the FDA were doing this holiday season -- and most emphatically they weren't visiting Aunt Selma in Boca Raton.
The CDC has recently issued the latest report on HIV incidence (i.e., new infections) in the United States, and as always it's fascinating to review the numbers.