HIV+ question

I think the latest evidence shows that HIV is mildly active continuously, replicating at a low level all the time. In other words, it doesn’t really become dormant. Though it’s true that people can be relatively symptom-free for years, so maybe that’s just getting picky.

Rob, Sorry if I’ve sounded exasperated or defensive. Of course there is scientific bias and we constantly evaluate our surveillance methods to try to find and address any bias we can find. No one would deny that is there. But I often deal with others’ political agendas around HIV issues, too. I may be unfairly lumping you into a group in which you do not belong. For example, I often hear people argue vociferously that there is a “hidden HIV epidemic” exploding in what are considered to be “low risk groups” such as teenage heterosexuals, elderly people or a certain ethnic group. None of our evidence: surveillance, seroprevalence studies, behavioral studies, etc. show this to be true (cases occur in those groups, but not at high rates), but certain people continue to misconstrue the data to make their point, or to spread mistrust about the data because the data do not support what they want to believe is happening. This is the kind of bias that drives me nuts. In some cases these are educators who are only interested in awfulizing sex for their students and want to use our data to scare them into delaying sexual activity (while denying that any of their students might be gay, too… most of these “sex education” curriculums I’ve seen are completely heterosexually based). Sometimes teacher sound downright disappointed that there are so few HIV/AIDS cases among teens in our area… I have to remind them that this is good news.

I suspect in some other cases the motives are to get more funding for organizations that cater to these low risk groups (taking funding away from groups who respond to the needs of populations that really are being heavily impacted by this epidemic). I’m not saying that such groups do not deserve attention and funding and that many of these people aren’t sincere, but I think their efforts are sometimes misguided and they are not looking at the big picture. It’s unfortunate that we end up in a funding situation in which different interest groups have to compete, but that’s what ends up happening, and it can be sickening to watch. We have been doing seroprevalence studies in STD clinics and youth detention centers for years and years. If there were a whole lotta heterosexual or teen cases, we’d have found them there, I think. We’ve found practically none (none at ALL in the youth detention facility). We’ve done other studies in other populations, too, as have most areas of the country.

Another thing we used to see - but not so often any more - is gay activists who want to focus on possible hidden epidemics in these other groups to draw attention away from what has been portrayed as a “gay disease” because they are tired of feeling blamed for the epidemic. This backfires, because HIV is still spreading like mad among men who have sex with men (about 75% of the cases in my state fall into this group - new cases, too), and they continue to need prevention programs and services.

As I said before, you seem pretty knowledgeable and I appreciate the discussion. I’m sorry if I’ve unfairly assumed motives that weren’t there.
Jill

Actually I did read it. It’s a consensus paper in which no one dares to say anything controversial. They point out the same arguments I did above for deferring treatment, and advise docs & patients to decide this jointly on a case-by-case basis. Right. In the complete absence of any data on the risks vs. benefits of immediate & deferred treatment… :rolleyes:

Jill, I nave never argued that when fullscale treatment is planned, that the multi-drug regimens are the way to go.

What I have been saying is that we have no idea if immediate treatment provides enough extra benefit over deferred treatment to offset the higher costs, higher side effects rates, and higher induced resistance rates caused by widespread use of these cocktails.

I absolutely grant you that multiple drugs are more effective than monotherapy at shutting down replication, and decreasing the opportunity for mutations and resistance to occur. BUT we have no studies that show if this benefit, especially if monotherapy is limited to the pre-CD4-suppression phase, outweighs the cardiotoxity, bone marrow suppression, hepatotoxicity, & financial costs that are more likely to occur with immediate multi-drug treatment.

It is perhaps true that no IRB would approve a study with a monotherapy arm in the US. But what about in Africa, where the available money to use per HIV infected person averages ~ $3.00/year in countries in which 25% of the 20-49 year old population is infected? Maybe there, the perceived risks & benefits would be vastly different IF an inexpensive monotherapy were available to partially suppress HIV replication and transmission in the early stages of disease.

::shaking head:: I’m not really sure why I’m arguing this vociferously for a treatment arm I threw out without a lot of thought for a study I introduced as one that will never be feasible, and will never be done… But while multi-drug treatment makes a great deal of theoretical sense, and certainly appears to afford seamingly indefinite delay of opportunistic infections in a great many patients taking them here in the US, the US “epidemic” is a drop in the bucket of worldwide catastrophe from this virus. What is best here (long-term multi-drug treatment allowing people to live their full life expectancy) may not be achieveable in Africa - maybe we have to settle for allowing couples to have kids with a low risk of perinatal transmission & keeping infected adults alive long enough to finish raising their kids into adulthood. And I do maintain that monotherapy may just have a role in achieving that.


Sue from El Paso

Does being married to another poster make me part of a clique?

Experience is what you get when you didn’t get what you wanted.

[[It is perhaps true that no IRB would approve a study with a monotherapy arm in the US. But what about in Africa, where the available money to use per HIV infected person averages ~ $3.00/year in countries in which 25% of the 20-49 year old population is infected? Maybe there, the perceived risks & benefits would be vastly different IF an inexpensive monotherapy were available to partially suppress HIV replication and transmission in the early stages of disease.]]

Can’t you just go back and look at the AZT days in the U.S. to find out that it doesn’t work and resistance quickly occurs? Or were you thinking of drug, like a protease inhibitor or non-nucleoside reverse transcriptase inhibitor?

Not to keep dragging this out when we’re probably the only ones reading it at this point.

Interesting that you should bring this up. I seem to recall that the AZT trials were stopped prematurely BECAUSE AZT worked so much better than nothing. And that is all I am talking about here. Using one drug in a situation where no drug is being considered…

Once CD4 counts fall, or HIV viral load is increasing, or a person is showing any signs of immunocompromise, there is no uncertainty that multi-drug regimens are the treatment of choice. But, there IS real uncertainty about whether immediate multidrug treatment is superior to, or at least offers a better benefit/risk ratio, than no treatment until the HIV infection begins showing some adverse effects on the immune system. Which, I would think, leaves open the question of whether any single drug therapy might a) prolong that infection-to-signs-of- infection period compared with no therapy, and b) cost less/have less SE’s than cocktail therapy.

I believe I’ve mentioned that when I originally made the suggestion, I did so off the top of my head. So, no, I didn’t really think about which specific single drug might be the best candidate. Important qualities would include:

  • Low cost
  • Good Side Effect profile and
  • resistance to this agent would not make virus resistant to planned cocktail agents. This is the most important characteristic.

Why not - looks like we’re in a close race for post count & this is at least semi-productive… :stuck_out_tongue:

I’ll draw one analogy here, Jill, that might illustrate why I think the idea of initial monotherapy followed by multi-drug therapy if the HIV load increases might just be workable.

TB is another chronic infection with a long latent period before it becomes active, highly contagious, and potentially fatal. It develops resistance quickly to antibiotics.

When treating someone with active disease, standard of care in the US is to begin therapy with 4 drugs.

When treating someone with a positive skin reaction, however, the standard of care is to treat with no drugs (if the reaction is not known to be new, there is no known exposure, and the person is >35) OR with one drug (usually INH/isoniazid) if the reaction is new (within 2 years), the person has been exposed to persons with active TB, or the person is < 35. (Disclaimer: This is accurate as of 2-3 years ago; I don’t do a lot of TB care since specializing in Endocrinology, so if you know that it has changed, I’ll accept that).

So while multiple drugs are always needed for advanced disease, the loss of efficacy from treating early disease with one drug is considered acceptable in the face of decreased costs, decreased side effects, & increased compliance.

This is not a perfect analogy; TB does not inevitably progress to active disease and death if left untreated. Still, prophylactic treatment with the one-drug regimen is the single most effective public health tool we have for preventing wide(r) spread epidemics of TB from occurring.


Sue from El Paso

Experience is what you get when you didn’t get what you wanted.

I’m sorry I missed this last night.

Yes, some STD’s are thought to increase the probability of viral transmission, because the inflammation associated with the STD makes the mucosal surfaces of the vagina, rectum, & urethra more permeable to virus particles, and increases blood flow just below the mucosal surface.

But anyone saying that STDs are necessary for viral transmission to occur is overly optimistic.

[[Interesting that you should bring this up. I seem to recall that the AZT trials were stopped prematurely BECAUSE AZT worked so much better than nothing.]]

But AZT stopped working in almost all who took it when they quickly developed resistance. I remember the AZT days. I lost over 20 friends and co-workers to AIDS from 1989-1992. I agree with the rest of what you said.

The recent developments in this string bring up another issue. There are epidemiological models, and there is reality. That is a gross simplification of the arguments I made in the middle of this thread.

When it comes to treatment, because this field is rife with extrapolations about “long-term” when in certain cases a long term does not exist: average progression in the beginning of the epidemic, and noted immediately above, efficacy and “long-term” drug strategies with the recent and not so recent treatment options.

I have no question Jill that transmission is through certain behaviors (we might dispute specifics, ie oral, etc) but the main risk is unprotected passive anal sex, sharing needles, and infected blood (the last one depends more on the medical establishment of the place where you are treated - less a behavoir issue).

As far as the unprotected sex and drug use, the problem is that THE INDIVIDUALS who are doing these things are not easy to identify. The show up as a demographic, but not as individuals, for treatment, intervention or prevention, in many cases.

The poor survival rate of African Americans may be die as much to poor treatment, as no treatment and poorly targeted information.

People in general (all colors) can be a lot dumber than you think. In response to the standard, “I you are a practicing homosexual (gay) you need to do the following: blah blah” poster tacked up in a gay bar or in a bath-house, or in a magazine, has helped, but falls short in many ways.

The GMHC poster mentioned by me previously, which ommitted the word “gay” and got an in credible response. Brothers who percieve themselves as masculine and fit in to mainstream Black society, may have unsafe sex, they are not however “gay”. In some communities that word has connotations that have nothing to do with the bedroom, but with a wardrobe, hand gestures and other sterotypes.

Infection rates of American teenagers are too high, due to our societal attitudes about condoms etc.

Infection rates of gey men are not declining fast enough due to the “good news” of new drugs (hardly good, but better - they are not a panacea or reason to throw out the condoms).

A prevention model that admits what we don’t know, go far to investigate those “holes” in the model. Relying on gay health clinics, ads targeted at the gay community etc. neglect those who will only enter the demographics shortly before death. The current numbers for African Americans are grim testimony to this.

I think I know about this better than some epidemiologist do, I admit. Not the actual figures (my hypothesis is of an uninvestigated question - not the answers) but some of the stumbling blocks to a totally rigorous model that addresses real numbers, not those that show up from the standard methods of data collection.

Question, Jill - if you want to know how many self-identified heterosexual men are actually bi-sexual and possibly at risk, where do you look? Gay health programs? - no. Figures on infection rates of those tested? - no .Even bi men who ARE tested while being honest about being bi will lie about having a wife - so as to avoid embarrasment. There may be no provision at the facility for informing the wife, but constant political wrangling over creating such provisions scares these men, as well as the real possibility of prosecution for reckless endangerment in Illinois - if you are positive, technically you have to tell your partner, even if you do nothing to put them at risk , like being passive and requiring them to use a condom - or avoiding anal altogether.

Previous models were woefully inadequate in their sociological rigor. The term “bi-sexual sex” was actually used in some. Sex is either het- or homo-, unless it is a manage au trois, for crying outloud. Current models are better but still neglect groups that are not perceived as being high risk.

There are not vast numbers out there lurking. But the role of those outside the demographic is important in bringing infection numbers under control.

There is a strange dance that goes on behind closed doors in America. People percieve bi or “straight” men to be “safe” and both parties may get sloppy about safe sex. Any party that eschews the “gay” moniker may feel that messages do not apply to them. Teens have actually taken to anal sex, as one study reported, as you didn’t ever need a condom to prevent pregnency in this act, there must not be an AIDS risk either.

AIDS is a societal roplem, not one of just individuals. Rigorous studies must team epidemiologists, sociologists, and even anthropologists in developing real effective models for determining not risk groups, BUT INDIVIDUALS AT RISK. Things have gotten better in the last 15 years and a lot of hard work has been done, but i do feel strongly from anacdotal evidence that people are slipping through the cracks.

And yes, anecdotal evidence is what is used to first posit questions, and then develop rogorous studies to then verify these hypotheses.

I agree with most of what you say, Rob.

[[Question, Jill - if you want to know how many self-identified heterosexual men are actually bi-sexual and possibly at risk, where do you look? Gay health programs? - no. Figures on infection rates of those tested? - no .Even bi men who ARE tested while being honest about being bi will lie about having a wife - so as to avoid embarrasment.]]

I know about this, too, as I worked in the anonymous testing sites for several years. I saw married men test positive and faced that quandry. This is why we use the term “men who have sex with men” instead of “gay,” because there are, as you said, men who do not identify as gay who have sex with other men. These men are particularly at risk, too, because they are less likely to have a regular, intimate partner, but tend to have sex with strangers. Their wives often don’t have a clue. We have intervention programs in anonymous sex venues, some of the prevention programs advertise in the personals, etc. But you are right. The prevention interventions fall far short. Until the stigma about being gay is eliminated - the major problem here, in my opinion - we’re gonna have this problem.

And the guys who never test? They show up sick at some point, as you pointed out.

[[Rigorous studies must team epidemiologists, sociologists, and even anthropologists in developing real effective models for determining not risk groups, BUT INDIVIDUALS AT RISK.]]

Epidemiologists do not work in a vacuum. All studies I know of team the above groups as well as often including HIV/AIDS activists and those living with the disease to design the study protocol. We would not think of conducting a study or developing a program for injection drug users, for example, without eliciting the help of current or past injection drug users who know and have the trust of that community. Same with studies or prevention efforts in gay bars.

Use of the term “risk groups” is appropriate when discussing the epidemiology of a disease. It is less appropriate for prevention educators, because - as you alluded to - it can feel denial in those who don’t want to identify with certain “risk group” behaviors or demographic attributes, and it can sound blaming.

[[i do feel strongly from anacdotal evidence that people are slipping through the cracks.]]

So to speak.
Jill
(sorry about that, couldn’t help it)

I ran across this news story today. Since there seemed to be some difference of opinion about the risk of heterosexual transmission, I thought I’d share it. It would seem to contradict the widely held belief that female-to-male transmission is less likely than male-to-female…
http://www.msnbc.com/news/363534.asp?0m=N11N

Caveat: This was presented at a national AIDS meeting. It is not published yet (or peer-reviewed). There may be flaws in study design that make the conclusions debateable at best. Still… pretty interesting stuff.

Sue from El Paso

Experience is what you get when you didn’t get what you wanted.

Hey Jill, did you see this story?
http://www.msnbc.com/news/238328.asp

I am not saying that this supports monotherapy, but it certainly flies in the face of everything conventional wisdom would say to us about intermittant treatment of infections…

You have to question what you think you know every once in a while.

[[I am not saying that this supports monotherapy, but it certainly flies in the face of everything conventional wisdom would say to us about intermittant treatment of infections…]] No, it certainly doesn’t support monotherapy. It’s mostly about one single enigmatic case that has been fascinating for scientists to study. I don’t know how much it tells us about the thousands of others, but hopefully something will come out of it that is useful.

One? I don’t think so.

from the article:

Sounds like twenty to me. Not a basis for changing how patients are treated, but a basis for doing something non-conventional, something not standard-of-care, under study conditions.