March 8, 2010
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Myles Helfand: I also imagine there's a certain amount of realism that needs to play into that discussion that you have with a patient who may have been recently diagnosed. Because I think, as probably many of the clinicians who are listening to this could attest, a pretty large number of people aren't diagnosed until they already have CD4 counts that are low enough to have brought them into a clinic or hospital to get tested for something.
Joel Gallant: Yeah. That's the thing we've got to fix. There's all this talk about "test and treat." Let's test everybody and treat everybody. But it was, what, four years ago that the CDC [U.S. Centers for Disease Control and Prevention] recommended routine testing for the whole population. And we have not come very close to doing that in most parts of the country. In fact, in some states, it's still illegal to follow those recommendations.
We have got to do something about this. It's got to be more on the radar screen of people doing primary care, people doing urgent care, emergency room care. We've got to start testing people before they become immunosuppressed. Because so many of these benefits of early therapy are really not even available to such a large percentage of people who are positive, just because they don't get tested soon enough.
Far more important than the question of when to start is: How do we get people diagnosed? And then, if we do that, then how do we get them into care? How are we going to expand HIV care and expand payment for HIV care, to be able to accommodate the patients that will be coming in as a result of testing?
Myles Helfand: Are there answers to those questions? There were a couple of presentations at CROI that talked about antiretroviral therapy as prevention. And I know that here in the U.S., federally funded research is examining a test-and-treat style program in both Washington, D.C., and in part of New York City. But as you said: It's been four years since the CDC recommended routine testing for all adults and many teens, but it's still not happening on a very broad scale. How much of that is related to funding? How much of that is related to inertia -- the tendency for things at rest to stay at rest? How much of it is that stigma about HIV is still pretty bad in the United States, not to mention the rest of the world?
It's a lovely idea, and it's great that it's being investigated. But people are still debating whether global warming exists.
Joel Gallant: And evolution, and landing on the moon, yeah.
Myles Helfand: So how realistic is it?
Joel Gallant: I think that routine testing is realistic. But when I talk to doctors who are friends of mine who aren't in the HIV field; they will be telling me about a case, and I'll say, "What's the HIV status?" "Well, I don't know." I say, "Well, don't you know about the CDC recommendation in 2006? You're supposed to know all your patients' HIV status." "I am?"
It isn't out. They don't know. Unfortunately, maybe we need to have some teeth in this. We need to have some kind of -- you know, link it to state funding. Or some really highly, well-publicized case of a huge lawsuit against a physician for failing to diagnose HIV would get this into the attention of clinicians.
It's partly patient awareness, but I think it's mostly in the hands of clinicians to be implementing this in their practices. In emergency rooms, it's tricky, because obviously they have got a lot of other stuff going on. There is [also] some funding, some financial, aspect to the testing in emergency rooms.
But certainly, in a clinician's office, where you're drawing blood anyway, and you're just checking off a bunch of boxes for blood tests, and all you have to do is just tell the patient, "I do this kind of testing, and I include HIV," and you check off the boxes; that's not really a funding issue. It's just an issue of having it, being aware of it.
You brought up the issue of antiretroviral therapy as prevention. There was this incredible study at CROI looking at discordant couples in Africa. They found that only one transmission occurred among couples where the positive partner was treated, versus 102 transmissions in the couples where partners weren't treated. And that one transmission that occurred, it occurred in somebody who had just started therapy a few weeks ago.
It's an incredibly valuable form of prevention, probably better than anything else we have, including condoms and circumcision and abstinence and everything. It's yet another reason why we have to be finding these patients and getting them into care.
Myles Helfand: We've talked about the testing part of it. But what you've just gotten into is the treatment part of it. And globally, obviously, there are still issues with treatment access, which would limit this. But even in the United States, I would imagine that, for a clinician -- I mean, you probably have a lot of patients who are maybe not thrilled with the idea of starting treatment. So what do you tell them if they maybe aren't psychologically ready to start treatment? What do you tell them to try to convince them that it's a good time to do it?
Joel Gallant: Well, I talk to them about the guidelines. I talk to them about the evidence that we've been discussing. I talk to them about the issue of prevention. If somebody's got a CD4 above 500, I talk to them about these things. I don't push it too hard. But as a CD4 gets lower, I get a little more pushy about it.
But I think getting people into care is the biggest, first step. At least they know they are positive. Hopefully they are not transmitting HIV, and hopefully the fact that they've even come to see me means that they believe in medical care enough to consider therapy when it's really necessary.
I think that, for so many years, people have had this idea that HIV is a disease that you don't treat right away. So that's in everybody's mind. They know that. And I think it's going to take a while to change the mindset of people towards an idea that HIV is a disease you treat unless you have a really good reason not to. That's going to take some education, on the part of clinicians, on the part of patients, so that they won't be so surprised when they come in and they're diagnosed, and you say, "Let's talk about treatment."
But we'll get there. If you have TB [tuberculosis], you don't go to a doctor and say, "What do you mean, I need treatment?" You know that you're going to have to be treated. And I hope HIV will eventually be seen in the same light.
No comments have been made.
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