CD4 Or Viral Load Monitoring?

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HIV and HEPATITIS C NEWS

There is a trend to only check the viral load since that is what the medicine affects. The immune system recovers to a certain level, or doesn’t worsen if the viral load is down. Checking CD4 is useful for staging purposes, e.g. stopping propyhylactic therapy if it rises enough, filling out paperwork. But this may be difficult in countries where there isn’t enough funding for viral loads which must, so far, be done on a frozen blood sample.

I am at a hospital in Malawi, Africa and we discussed this very issue with medical staff this morning. How do we get the blood to the lab quickly which is far away, to keep the blood fresh? In the US we freeze it and put it in special cold containers, sometimes dry ice is used, or the patient drives to the central lab. All of these are difficult in Malawi, the poorest country in Africa.

There was a study in Thailand where the providers changed medications, thinking there was resistance, when the CD4 went more than 30% lower than the highest CD4 recorded vs. changing when the viral load was more than 400 after a recheck to confirm it. They found no major difference in who had their medications changed and the success of these strategies. So if it is difficult to perform viral loads, maybe relying on CD4s with this new strategy is a good idea. I am looking for confirmation before recommending this, but maybe for those patients here in Malawi who can’t get a viral load, we can try this strategy rather than keep taking the same medication when there is already resistance.

PEP
Post exposure prophylaxis recommendations are now updated for workers but this applies to sex or needle exposure that is not part of a legal occupation. If you are exposed to HIV through a needle stick or sex, you may contact your clinician or emergency department for advice. Treatment should be started as soon as possible up to 72 hours later. The US Public Health Service also recommends that emergency departments have a few days of medications on hand for the patient to take immediately so they can get a new prescription from their clinician or an HIV specialist during office hours. The specialist may change the medication based on information from the person exposed and about the person who had the HIV. When someone’s health is in danger, physicians are allowed to share information quickly via fax or phone to another physician in California and we do not need a release of information (permission, consent) from either person. I have used this good law many times. I am proud of our Riverside County Public Health HIV division where we will drive the medicine across our huge county to get medicine to such a patient if there is no other way to get it to them quickly. We have used donated medicines and Prescription Assistance Programs (where Drug Companies will supply medications for free if the patient meets certain financial requirements).

NEW HIV SELF-TEST APPROVED
The FDA has approved another self-test for home use. This test will determine if you have HIV-1 (the regular HIV we talk about) and HIV-2 (a much less common virus that is weaker and has been found mainly in East Africa). This new approval will continue to get the word out that the estimated 20% of HIV positive people who don’t know they are positive, should be tested and linked to specialty HIV care and that those who are negative, keep up the safe sex and needle behaviors or start them now since they have been lucky so far, but their luck may run out.

IS YOUR DOCTOR GETTING GIFTS?
There have been studies showing that even giving a physician a pen with a drug name on it will influence their behavior to prescribe that medication. I don’t think I was influenced, but the pen study shows I may have been fooling myself. Many universities, hospitals, and clinics have restricted these activities. Hundreds of dollars in lunches for staff have been paid to get a message to 1 or 2 physicians. They can receive speaker fees or consultant fees for advising the company about how the medication is accepted by patients.

I have done some of this, but when the tide started turning in 2009, I thought long and hard about this. I have friends who speak and consult and make much money after hour. Those mentors whom I hold high up in the HIV arena do not accept these gifts. I may have a meal with a pharmaceutical manager to discuss research issues, and that will go on the list, but my conscience is clear on that. You may see our reports for the past at: http://projects.propublica.org/docdollars/ . The law started on 8/1/13 requires that all gifts/meals/speaking fees, consultant fees must be reported, not just the ones some of the companies reported. My report has some, but not all of my payments listed prior to that date.

GUT BUGS
UC San Francisco researchers found that the types of bacteria in the bowels of HIV patients had more disease causing bacteria than HIV negative patients. They feel that this immune deficiency (HIV) allows the worse bacteria to live there and this may be one mechanism to explain why HIV patients are not as healthy.

GAY MARRIAGE MAY DECREASE HIV TRANSMISSION
There was a recent article in the Atlantic. The author feels that making gay marriage legal now will cut down on HIV risk-taking behavior. “Studies have consistently shown that low self-esteem, being closeted, family rejection and internalized homophobia all contribute to increased risk for contracting HIV.”

Keep those questions coming. Be Safe!

Daniel Pearce, D.O., FACOI, AAHIVS
Associate Clinical Professor of Internal Medicine, Loma Linda University
Researcher, Veterans Administration Hospital, Loma Linda
HIV Specialist, Riverside County Public Health Department
Hepatitis C Specialist and Researcher, Southern California Liver Centers, Riverside

References: Medscape.com
The Atlantic Monthly

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