The first week of March I attended CROI in Boston with about 4,000 others from around the world. Here is second article of my annual AIDS update from the Conference on Retroviruses and Opportunistic Infections.
METH AND HIV MAKE YOU AGE FASTER
There are ways a researcher can determine what age your cells look like and if you will die sooner. Meth and HIV speed up the clock to the final tick but together it goes much faster.
ANTIVIRALS WORK EVEN IF USING AND METH?
A new study showed that this can be successful. My only warning is if the patient misses meds then the virus won’t be controlled and may develop resistance. I have seen this in my practice; many meth users take their antivirals and have a well-controlled virus. Does the meth cause them to miss pills? That is the all-important question. We were told that meth is highly addictive, and that is true for some; they won’t stop unless injured or ill enough, in jail, or dead. Others use it very rarely. There are others in between these extremes. This, like many issues is not a two-sided question: all or none. There is a range of responses to a chemical. Where to you lie in this range? I lie in the “I don’t want to find out!” group. Who knows how I may respond; the risks are greater than the benefits for meth, tobacco, the lottery….. I’m happy not taking some chances or a dare.
ALCOHOL USE DID NOT HURT HEPATITIS C CURE CHANCES
At the risk of being labeled a pro-substance physician, I report another study: They looked carefully at Hepatitis C patients receiving the great new medications that seem to cure (we call it Sustained Viral Response [SVR] since we don’t know if it will pop up in 10 years) and found that even those who didn’t tell the truth about continuing to drink alcohol still got to SVR as well as the others. I will wait for the guidelines to tell me not to caution about alcohol since they are made up of very experienced, knowledgeable, wise mentors who look at more than one study. This is encouraging. I do have a patient who promised not to drink during treatment and in a couple of weeks we’ll find out if he got to SVR.
MARIJUANA SMOKING AND HIV PUT THE LUNGS AT RISK
Another study showed that smoking marijuana (they did not evaluate vaping, ingesting, or topical marijuana) was associated with infectious lung disease (influenza, bacterial and other pneumonia, tuberculosis) and non-infectious lung disease (chronic bronchitis, COPD, emphysema, lung cancer, pulmonary hypertension). We have all known that smoke is to be avoided since our first experience with smoke from a fire as children.
ORAL MEDICATION FOR SYPHILIS IN HIV?
Syphilis in HIV goes wild so we are on extra alert for this in our HIV clinics. If we can’t tell that your syphilis is less than a year old, you should get 3 painful penicillin shots spaced weekly, in your rear end. For those allergic to penicillin we have been giving doxycycline pills and this new study confirms this is a successful treatment, even for those with HIV.
MORE SYPHILIS IS BETTER?
This study found that second and third cases of syphilis were lighter/less severe compared to the first time. This effect was seen less in HIV patients. It was harder for the syphilis to get into the brains if they had syphilis before. Do you want to take that chance? Protection is available!
WHAT IS UNDETECTABLE? DO WE NEED CONDOMs OR PrEP?
U=U (Undetectable = Untranmissable) uses 200 as the highest viral load to be considered undetectable. A Spanish study showed that those with viral loads above 200 did poorly if they weren’t on treatment compared to those less than 200. So minor blips of virus below 200 are not of concern.
If you are below 200, you can accidentally bleed on someone, share needles, and have sex without transmitting HIV. There is no need to take or use a condom or take PrEP to prevent HIV transmission if you are lower than 200 when having sex for fun or making a baby. But beware: if there are other sexually transmitted diseases involved then we don’t have that assurance; this rule only applies to monogamous couples (no sex outside the two of you). Make sure your partner has a viral load less than 200; the only way to do that is to be taking antivirals faithfully.
DON’T TREAT CMV WITH AN ANTIVIRAL?
This study found, as I do, that there are a few newly positive HIV patients with Cytomegalovirus (CMV) DNA in the blood without an obvious site of disease, e.g. intestines, eyes, esophagus. The rule is to treat this with another antiviral on top of the HIV antivirals until the CD4 cells rise enough. CMV can attack when the CD4 is below 50. They found that putting patients on just the HIV medications did the trick without the CMV medication. I’ll wait for the guidelines to address this. Chalk this up to yet another reason to treat HIV as early as possible to avoid low CD4s and if they are low, the medication can take care of a lot of things by removing the HIV from the immune system to let it repair and fight other infections efficiently.
Daniel Pearce, D.O., FACOI, AAHIVMS
Clinical Associate Professor of Medicine, Loma Linda University School of Medicine
Adjunct Professor of Internal Medicine and HIV, Touro University California College of Osteopathic Medicine and Midwestern University Arizona College of Osteopathic Medicine HIV Specialist, Borrego Health (Riverside, San Bernardino, San Jacinto)
Member, Coachella Valley Clinical Research Initiative