CHANGES IN HEALTHCARE
67-70% of of the money spent on HIV care is to buy medications. They are very effective and generally non-toxic. But with the high price of medications, e.g. Stribild’sTM cost from one source is $2700/month, might managed care organizations restrict access to some medications as do poorer countries. Where does the money come from as prices seem to skyrocket. More generics are available each year. If you put together two of the ingredients of AtriplaTM with a similar agent, lamivudine, then 2 out of three are generic (this is done in Africa as one pill) and the cost per year goes down by $6,000 per patient, or nearly 1 billion dollars a year for the US. The patient would take 3 instead of 1 pill a day. Is that worth it? Would you pay $6,000 a year to have the convenience of 1 tablet vs. 3?
CURES
- So far we have the Berlin patient who had lymphoma and had the dangerous bone marrow transplant from a donor who couldn’t get HIV.
- A baby in Mississippi who was treated right from birth for a period and now has undetectable viral load off medication.
- 2 Boston patients who had bone marrow transplants also, but not with the special donor and this did not work.
- Patients in France who were treated when they had the acute HIV infection and now have undetectable viral load off medication.
It is now obvious that we must treat those who have the acute HIV infection early to cure them. Curing people is prevention too since they can’t pass the virus on! The new 4th generation HIV test can detect this early stage well and many hospitals and labs are buying this machine. This test makes it also possible to cut down transmission by treating early when the viral load is the highest it will ever be, and patients can be routed to HIV specialty care much sooner in their disease. The current protocol is the rapid test which doesn’t detect HIV infection as early and one must wait about a week for the Western Blot confirmation before action is taken.
SHAKE THE BUSHES FOR CURE
A recent strategy for cure is to drive the virus in dormant (inactive, “sleeping”) cells to a place where they can be eliminated. This strategy is still being investigated but there are no new breakthroughs recently. The latest effort is focusing on where these cells are and how many. They found that the reservoir is 40-50 times larger than previously thought. The lining of the intestines seem to be a major reservoir.
They are trying to learn about the reservoirs of Long Term Non-Progressors (those who maintain a great CD4 for many years but have a viral load less than 10,000 without treatmnet) and Elite Controllers (those who have positive HIV test but undetectable viral load) to help with this effort. Note that the definitions of the two conditions above vary between experts.
Using medications that prevent entry such as Selzentry TM, Tivicay TM, Issentres TM can possibly keep the HIV from entering the reservoirs. This is being studied.
NEW CD4 DISCOVERED, KEY TO CURE?
CD4 T Memory Stem Cells may live for decades and this may be an important reservoir to treat to eradicate HIV from the body. Stem cells are the parents of other cells, so these stem cells are continually making more CD4 cells, and if the parent is infected with HIV, the offspring will be also. They showed that the virus dormant in these cells is competent—it can infect and multiply well
VERY LONG ACTING ARVs (NANO)
There are two antivirals modified by nano technology to last 1-3 months in the body after a single dose. This may be a game changer.
HOME VIRAL LOAD KITS HELPFUL?
New kits are becoming available to check the Viral Load at home. If the viral load is not perfect, then the clinic may be getting many calls. The patient still needs other labs to check for toxicity and see the provider to monitor treatment. This will be a help in less developed countries.
TRAVEL HELPS HIV HURT YOU
It is important to mention travel to your provider, since this is a frequent cause of missing care or medications, and therefore losing control of the HIV. Whatever the reason for the disruption in the routine, doses were missed and the risk of viral resistance was present. Examples of reasons are: family needs, vacation, war, and moving your home to another place. Medications are frequently misplaced or forgotten. Providers should anticipate this problem by mentioning it to patients.
OLDER HIV POSITIVES GET TESTED LATE
A recent study showed that older adults over 50 get tested later in their disease (they are in denial that they are at risk for HIV and don’t get tested regularly) and are more ill and have lower CD4s than younger patients. Their immune system is already weaker because of their age and letting HIV worsen it so much before seeking care can result in major complications, hospitalizations, disability, and death.
HEPATITIS C TREATMENT WITHOUT INJECTIONS
2 new studies show high cure rate with a combination of medication without the injections of interferon which usually cause flu-like symptoms. More and more studies are confirming this strategy. It is best to get on a clinical trial to get these medications since most are not approved. Success depends on your genotype. Certain drugs work better with certain genotypes.
The two newest medications are out and are very expensive. There is no information that the combination will work since it is not in the companies’ interest to combine them since one company will be coming out with a second medication soon and they want to use their combination only. Many Hepatitis C specialists are combining the two that are out in hopes that it will work well without the injectable interferon. They are hesitant since there is not much data to prove it will work other than stories shared among the specialists confirming it is working for some. Stories (anecdotes) are not as good information as a trial. Stories are usually what sell over-the-counter health food supplements.
Keep those questions coming. Be Safe!
Sorry if I repeat myself, but we do have new readers each month!
Daniel Pearce, D.O., FACOI, AAHIVS
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
Researcher, Veterans Administration Hospital, Loma Linda
HIV Specialist, Riverside County Public Health Department
Hepatitis C Specialist and Researcher, Southern California Liver Centers, Riverside
Source: Medscape, Answers.com, Wikipedia