Hepatitis C and the "Retooling" of HIV/ID Specialists

February 23, 2012

Paul E. Sax, M.D.

Paul E. Sax, M.D., is director of the HIV Program and Division of Infectious Diseases at Brigham and Women's Hospital in Boston.

The news that hepatitis C (HCV) has passed HIV as a cause of death in the United States got quite a bit of attention when it was first presented last year at ICAAC -- and no doubt the published paper, in this week's Annals of Internal Medicine, will also cause a stir.

In fact, I boldly predict that going forward, (approximately) 94.2% of HCV-related research grants, journal articles, and lay press articles will cite this paper, making it (for now) the "Palella NEJM 1998″ of HCV.

(For those of you who don't know Palella NEJM 1998, this was the first paper in a major medical journal to demonstrate the dramatic decline in HIV-related mortality due to effective HIV therapy. Figure 1 from that study is permanently emblazoned on HIV specialists' retinas.)

But the Annals paper also reminded me -- again -- that there's a significant retooling going on in the HIV/ID field to accommodate HCV. And for some docs and HIV organizations, it's more than a retooling -- it's practically a comprehensive overhaul. What do I mean exactly? Some citations, some anecdotes:

  • The International AIDS Society-USA is now officially known as the "International Antiviral Society-USA" and has HCV therapy as a major focus of its efforts.
  • Two large HIV annual educational meetings -- one led by Clinicial Care Options, the other called Opman -- both now prominently include hepatitis as a substantial component of their conference agenda. In fact, both have even changed their names: "2012 Annual CCO HIV and Hepatitis C Symposium" and "Optimal Management of HIV Disease & Hepatitis."
  • Several of the larger clinical trials sites for HIV therapy now devote a significant proportion of their research efforts to HCV. The leader of a well-known site told me that nearly half of their studies are now HCV-related.
  • Many clinical ID practices (including ours) now openly solicit patients with HCV (not just HIV/HCV co-infection).

Of course, it's easy to see why this is happening. These HCV cases call for all the skills we've sharpened over 16 years of combination antiretroviral therapy -- managing complex regimens, myriad side effects, virologic responses, resistance, and drug-drug interactions.


Then there's the dynamic pace of HCV therapeutic research. Seemingly every week, there's another major story, most of it happening too quickly for peer-reviewed medical journals. See here for an example.

Oh, and you get to cure people. Wow.

By contrast, HIV therapy is in a plateau phase, with few major recent advances in treatment. The top four recommended initial regimens haven't changed since 2009, and they are all remarkably effective. Clinical sessions of HIV follow-up have been likened to "well-baby checks," a startling turnaround from the drama of HIV practice just a few years ago.

Yawn. And I mean that in the best possible way. Patients are doing great!

So if HIV/ID specialists seem to be jumping on the HCV bandwagon, it's completely understandable. Though whether gastroenterologists mind sharing this bandwagon with us is highly debatable -- most would probably just as soon let us drive, given the current difference in compensation between endoscopy and office management of medically and socially complex patients.

Perhaps I should even rename this blog "HIV, HCV, and ID Observations"?

Nah, it still needs a complete name overhaul -- and I'm waiting for some good suggestions.

Paul Sax is Clinical Director of Infectious Diseases at Brigham and Women's Hospital. His blog HIV and ID Observations is part of Journal Watch, where he is Editor-in-Chief of Journal Watch AIDS Clinical Care.

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This article was provided by NEJM Journal Watch. NEJM Journal Watch is a publication of the Massachusetts Medical Society.

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