Two new studies show better immune recovery if therapy was initiated early. One gave antivirals within 4 months of the infection. Many times the early infection is passed off as a mild viral problem or the patient has no symptoms. So in an area without many of these primary infections (unlike San Francisco, Palm Springs), this information isn’t that helpful.
Another study gave antivirals right after the primary infection for up to 48 weeks and again showed better CD4 recovery. These studies show improved numbers but no studies show that length or quality of life is improved with very early treatment.
The main US committee that reviews vaccines felt there was now enough data to recommend another pneumonia vaccine against Streptococcus pneumoniae. This is a common cause of pneumonia in addition to ear and sinus infections. The vaccine we have been using protects against 23 types. We usually give it to the elderly and those with chronic, serious diseases. Now there is another vaccine, Prevnar13™ which protects against some new strains of Strep and a few older ones. It is recommended for HIV patients. It may cost over a hundred dollars so the impact on a clinic may be severe when they have not planned for it. I am not seeing many pneumonias of this type. We are working out how to implement this recommendation.
Mild dementia can cause many problems such as poor job performance, disorganization, missing medication doses, and may strain relationships. It can be hard to detect. If you are noticing problems, please suggest to your provider to check you for dementia. It can happen even if you have high CD4s and low viral load.
GENERIC PREZISTA™ IN AFRICA
Johnson and Johnson said they will not bother generic companies about patent laws if they produce high quality Prezista™ for Africans. This is wonderful news. Medication costs are a big problem in poorer countries. By the way, Prezista™ comes in 800mg pills now, so if you are taking two 400mg pills, ask your pharmacy for the double strength pill.
Kaletra™ HELPS PREVENT MALARIA
In a region of Uganda, Africa children on Kaletra™ had less malaria than others on a non-nucleoside reverse transcriptase inhibitor (e.g. Sustiva™ –in Atripla™– or Viramune™). So remember that if you move to a high malaria area.
SCREENING FOR A FUNGUS
Cryptococcal meningitis (CM) is quite common in Africa in HIV patients. I’ve seen many cases here and in Malawi, Africa in patients who have CD4s less than 100. It is much better to prevent before the patient suffers. Ordering the blood test in areas where CM is common is a good idea according to the literature. If, before starting new antivirals, a patient has a positive test then the study showed that 25% of them would come down with CM and if the test was negative, none would come down with CM. Of course if the test is positive, a spinal tap may needed to see if they need intravenous therapy. If the hospital doesn’t have the resources to perform so many spinal taps or treat so many with intravenous Amphotericin, then treating with high dose fluconazole is an option. Waiting 2 weeks on CM treatment before starting antivirals is a good idea since treating with antivirals too early in the CM can cause an overreaction of the immune system (IRIS).
UNDETECTABLE IS BEST
With a small amount of virus, one Spanish study showed that there is still inflammation and we know that inflammation (e.g. gum disease–gingivitis) causes acceleration of the hardening of the arteries to the heart and brain, risking heart attacks and strokes. So it is best to keep that virus undetectable.
HEPATITIS C AND TATOOS
We know that Hepatitis C is transmitted by sharing needles and and most recently by sex, especially male to male sex. A New York study showed that the group without any needle exposure except tattoos had a higher risk for Hepatitis C than a similar group without tattoos. Always use new inkpots, needles, clean guns and equipment. Prison tattoos or tattoos from unlicensed friends may put you at risk for Hepatitis C.
Complera has become quite popular. It must be taken with a meal such as a sandwich, (more than a snack) at the same time each day, and medications to treat stomach acid may decrease its blood levels. It is now known that the viral load must be less than 100,000 before taking it since more patients with high viral loads failed Complera™. Also more failed if the CD4 was
Also, there were more liver problems than initially seen with Complera™ so that if a patient starts it with a liver problem, or has Hepatitis B or C, the provider should be cautious and monitor the liver closely.
Keep those questions coming. Be Safe!
Daniel Pearce, D.O., FACOI, AAHIVS
Associate Clinical Professor of Internal Medicine, Loma Linda University
HIV Specialist, Riverside County Public Health Department
Hepatitis C Specialist and Researcher, Southern California Liver Centers, Riverside
HIV Researcher, Desert AIDS Project