In an era of one-pill regimens and natural life-span expectations, we HIV providers still work in a world with a huge, heart-breaking gap between those who are HIV+ and those who are in treatment. In our state, blessed with internationally renowned HIV institutions and determined to provide gold-standard treatment and resources for both providers and patients, there are still very big barriers between a prospective HIV patient and care. Finding a way to bridge the gap between being a person with HIV and a person being treated for HIV is arguably the number one job of everyone reading this e-mail. Whether you are a case manager or a doctor, whether you are looking at the HIV treatment cascade or simply contemplating the alarmingly fast growth of young black gay men becoming infected in our state, we’ve got a gap.

UNC and North Carolina’s Division of Public Health have launched a new program that should make that gap as small as the time it takes to call a toll free number. ONE CALL should become a key resource for providers and patients who are trying to get from “I’m ready for treatment” to “I’ve got the facts and I’ve got a clinic and I’m ready to go”. I wanted to take the time to explain how this resource will not only help those who are HIV+, but how it is designed to help you, the providers.

ONE CALL can benefit HIV providers or anyone working with HIV patients either newly diagnosed or out of care by providing immediate access to trained nurses who can counsel patients if you don’t have the time or comfort level. To our knowledge, ONE CALL has the only updated list of HIV providers across the state, with detailed information on hours of operation, availability of ADAP assistance, acceptance of Medicaid and language translation services, and more. In sum, ONE CALL provides the following:

• Free service
• Access to the only comprehensive and updated HIV provider directory in the state
• Contact information for your county’s State Bridge Counselor who can offer case management and connect a patient to additional support services
• The ability to speak to trained nurses who can provide basic HIV counseling for your patient
• Personal assessment of barriers to care for each caller
• Reassurance of a patient’s concerns related to care prior to their first appointment
• Individualized referrals and immediate transfers to HIV clinics to schedule appointments

Illustrating how this resource can serve you and your patient are provided by two recent calls:

A college student receiving HIV care at their current university clinic will be relocating to their hometown for the summer. Due to a lack of transportation, they will be unable to continue care at their current clinic and were looking for treatment and services close enough to their hometown to attend appointments, but at a discreet location as disclosure is a concern. They were connected to a clinic that both the caller and nursing staff felt would be a good fit.

A New York social worker called UNC’s Infectious Disease Clinic on behalf of their client who is relocating to eastern North Carolina. UNC provided the ONE CALL number and they were able to connect them with a clinic which has a financial counselor on staff and provides assistance with ADAP as these were two stated patient concerns. They were also given the number to their future State Bridge Counselor to aid in a smooth transition to HIV care in North Carolina.

ONE CALL holds considerable potential, for providers and our patients alike, to build a stronger network of care throughout North Carolina. We can now transition our patients from diagnosis to consistent care at the location of their choice without skipping a beat. All it takes is a single phone call.

I had been a medical student and resident during the early nineties and in the middle of that decade an Infectious Diseases fellow.  I know very well what the plague years were like.  However, the hollowed faces of my first patients and their quiet struggles to survive have become a gauzy memory, overlaid with a decade and a half of phoenix-like recoveries, a cornucopia of glitzy new meds, and the radical concept of geriatric HIV medicine.  The complacency that comes with worrying more about a patient’s blood pressure and LDL cholesterol levels than their CD4 cell count, only adds a layer of top soil on these buried memories.  But the film’s extensive footage of buyer’s clubs and KS speckled young men, protest marches and mimeographed treatment guides, reminds me of where this all began.

My first patient of the day was a large older man, recently incarcerated, who had been seen in the clinic only a couple of times before.  He slowly sauntered into the room, shuffling a bit from side to side and then wiggling a bit as he shimmied to sit on the exam table. Prison-issue eyeglasses magnified his life long disconjugate gaze making it difficult to know which eye to look at - I played it safe by talking to the bridge of his nose.  His lab report told a modern-day story of early diagnosis: a CD4 cell count over 700/mm³, a viral load in the 4-digits.  When he was first diagnosed on admission to the prison, he had been told he was too healthy for HIV medications.  But at the last visit, my colleague told him that thinking about therapy has changed and that we were treating HIV pretty much in everyone without long delays.  He was told to prepare to start HIV medications.  I too explained the evolving science, the change in the way we had come to regard uncontrolled viremia as, well, uncontrolled, and potentially harmful to the patient as well as others.

People in prison, it will come as no surprise, are not generally the trusting type. They lie and are lied to.  It’s a means of surviving both inside and out in the ‘world’.  I could tell he was considering carefully whether I was a quack or worse.  He grilled me about alternatives to the meds, food requirements, interactions between these and his blood pressure and diabetes medicines.  “What was the name of that three in one pill again? No, the other one,” he asked more than once.

Like most everyone starting medications, he wanted to hear all about side effects and what horrible things the pills I was pushing could do. It was then that the images from the previous night ran through my head.  With my mind’s eye I saw the crowd of activists that demanded a new wonder drug called ddI, the bags of ganciclovir and foscarnet that people pushed on poles to fend off blindness from CMV retinitis, the desperation to take anything, even dextran sulfate, to slow the consumptive fires of AIDS.  I replayed the most dramatic scene of the documentary when the perpetually gray and grizzled ur-activist Larry Kramer quieted a room of squabbling members of a disintegrating ACT-UP by screaming “Plague! Plague!” as one would announce an approaching tsunami; snapping the bickers to stunned realization of what they had lost.

I looked my patient straight in the bridge of his nose, and with a steely reserve in my voice channeled Larry. Had you cancer, I told him slowly, I would pour chemotherapy into your veins, make your hair fall out, and have you puking into your steel toilet after each dose.  And, you would thank me for it.  You have an infection that left untreated, kills, and that has no cure.  But, it does have a very effective treatment - and one pill a day, at that.  So, if this pill makes your elbow itch or your hair glow in the dark, so be it, as it will let you live a long time.

Just like that old craggy Larry Kramer, I made my point and my audience of one was quiet.  Until, he said, eyebrows raised, “It will make my elbow itch?”

We talked a few minutes more and we finally settled on an antiretroviral regimen that I thought would work well for him.  He reluctantly walked out and looking at his back I thought about how he could not realize all that it took to get him that one pill: the small group meetings in Greenwich Village and San Francisco, the bull horns, the shouting, the die-ins, and the eventual response of the treatment community including regulators, pharmaceutical companies, and clinicians.  Perhaps all persons living with HIV should see this film.  Certainly, their providers should.   But, warning, may cause self-righteousness and intolerance for whining.

A version of this article has been posted on the Clinical Care Options (CCO) website along with additional clinical thought posts by Dr. Wohl and other HIV care experts.  Go to: http://www.clinicaloptions.com/HIV/Treatment%20Updates/ClinicalThought.aspx

As we move towards the end of 2012 and the mid-point of our second year of training work, we want to look back – and look forward. Although guilty of employing a cliché, I can say we have run with it. Out of the blocks (to really embrace the metaphor), we got busy listening to what you, the providers of care to North Carolinians living with HIV, say you want from your ATEC. One of the first things we heard was a desire for one-on-one educational opportunities. In response, we launched a clinical preceptorship program (sign up online here), in which trainees can spend a day or more with HIV experts from across the state. People told us they liked hearing the perspectives of folks from outside North Carolina, so we helped bring nationally recognized thought-leaders to come here to speak. We also learned that many providers recognized gaps in their expertise in particular areas, including STI management and treatment of HCV. Therefore, we linked with our friends at the AL-NC STI Prevention Training Center to develop workshops to increase expertise in STI diagnosis and treatment for major HIV providers in our state, a model we are using for HCV training.

With our first-year milestone reached, we are stretching further in year two. Geographically we have reached out to Charlotte and Asheville with preceptorships and group trainings; to Elizabeth City to talk with health professionals who work with a key audience: college-age populations; and to Scotland County and points south where more and more HIV clinic work is being done. And to accomplish some of this work we are very pleased to welcome two new faculty members to NCATEC family: Robin Peace, MD and Yvonne Carter, MD.

On December 1st, we will officially launch a new resource, the NCATEC Clinician Line. Providers can call the toll free line at 855-UNC-ATEC (855-862-2832) M-F 9am to 5pm to pose clinical questions regarding the management of HIV. In addition, we are developing our first web-based educational opportunities - from podcasts to to virtual case seminars – so that providers from across NC can access trainings at their convenience. Lastly, with the Affordable Care Act due to become fully operationalized in 2014, we will be working to help make sure that established and new HIV care providers are prepared.

We will never be done listening so continue to shout out to us about what you like and what you don’t; what works and what’s just “meh”. Before you do though, let me do some shouting about the people who keep the NCATEC moving. Michele Bailey is not only the center’s coordinator but also its most enthusiastic cheerleader and advocate. She has made it her life mission to have our ATEC reach each and every NC HIV provider. Megan (still waters run deep) Katsaounis keeps us organized and manages our website. I thank them for making this year (mostly) bump-free. My colleagues, Heidi Swygard, Becky White and Lynda Bell here at UNC, and Laura Bachmann at Wake Forest have been incredibly generous with their time and knowledge and for that I am tremendously grateful. Lastly, thanks to all of you for being in this fight. Keep it up and please let us know how we can help.

D

This year, at a conference symbolic in its return to the US, we were directed to contemplate the end of AIDS. Hillary asked us to envision an “AIDS-free generation”. NIAID Director Tony Fauci gave a run down of the tools we have at hand to halt the spread of HIV and extinguish the epidemic and Phil Wilson of the Black AIDS Institute challenged us to use them. In the audience, there were hallelujahs among the believers. But, others (dare we say, skeptics?) could not be faulted for wondering where did all this end of AIDS talk come from and why was this not on our radars before coming to DC?

Serious consideration of an HIV epidemic endgame started with a thought experiment. In 2008, Rueben Granich and colleagues from the World Health Organization (WHO) published the results from simulations they did modeling the dynamics of the HIV epidemic after pushing variables such as HIV testing and antiretroviral coverage to extremes. According to their math, elimination of HIV transmission was achievable. It would take 50 years and an effort to scale up testing and immediate treatment that could only be achieved if Mao Tse Tung were put in charge, but it was possible. Simplistic by necessity, the model nonetheless propped open the end-of-the-epidemic door – an opening widened with the results from HPTN 052 (showing nicely that successful treatment of an infected individual renders them nearly un-infectious) and other studies of treatment as prevention.

At IAC/IAS/WAC we saw the idea of epidemic extinction transmute into agenda gold. With antiretrovirals cleansing body fluids of circulating virus and cure approaches trying to mop up the latently infected pool, it seemed like we could be at a tipping point. In enumerating the arrows in our quiver, Dr. Fauci was painting a target and egging us on to aim high.

But, this was not Vancouver and while it was exciting to think about the beginning of an end to the epidemic, for some this was overreaching. One activist I spoke to told me that such talk is premature and minimizes the substantial challenges we face in diagnosing and treating those who are currently infected. With almost 50,000 new cases of HIV annually just in the US and less than a third of those with HIV in the nation treated successfully, talk of eradication of HIV can ring hollow. Furthermore, where does ending the epidemic leave those who are now living with the virus or those who become infected today, this month or this year?

As a provider who tends to see the glass half full when it comes to HIV care, I don’t feel compelled to choose sides in the ‘yes, we can’ versus ‘no, we can’t’ debate and I see how hype can be useful for advancing noble causes. Plus, our collective attention is not quite zero-sum, and I believe we can focus on prevention of new infections and the care for those living with the virus at the same time. For me, the raising of the prospect of an AIDS-free generation in our lifetime is akin to JFK’s declaration that the US would blast a man to the moon and back. Fantastic, expensive, complicated? Yes. Thrilling? Yes.

Without the dream, there would be no reality. In Berlin, a few years ago some hematologists figured they could possibly (not probably) cure a man with cancer of his HIV infection. Cleverly, they found a bone marrow match that was also homozygous for the CCR5-delta deletion. It worked and in DC he walked into an elevator smiled at me and announced unsolicited that he was the first man cured of HIV (and, would I mind pressing the 7 button for him). I shook his hand – touching for myself the realized dream.

Meanwhile, for those of you whose heads are not spent in clouds of possibility but rather in the medical records of the newly HIV-diagnosed young man, the treatment-experienced woman about to start her fifth antiretroviral regimen, and the suppressed patient with a Framingham Risk Score that made you cringe, the end of the HIV epidemic can seem about as likely as your best ever fantasy football team coming over to your house to convince you to become their team doctor and director of all social activities during all away-games. Front line providers, these few practical IAC/IAS/WAC highlights are for you:

• Dolutegravir vs. Raltegravir: One is a lonely number and the integrase class is about to get a bit less roomy. In the SPRING-2 trial comparing dolutegravir to its classmate raltegravir in treatment naïve patients also receiving TDF/FTC or ABC/3TC, the newcomer performed well with 88% achieving an HIV RNA level below 50 copies/mL at week 48 compared to 85% in the raltegravir arm – a statistical dead heat. Toxicity was rare and similar across the arms. Among the small number of patients in each arm experiencing virologic failure who had genotypes able to be performed, none of those failing doultegravir had detected resistance mutations in the integrase or reverse transcriptase regions. In contrast, 1 of 18 participants on raltegravir who were failing and had resistance testing performed had integrase resistance and 4 of 19 had nucleoside resistance. With plans to be formulated in a fixed dose with the comeback combo, ABC/3TC, this is not a me-too drug.
• Simplification with TDF/FTC/Rilpivirine: A common use for this newer fixed dose single tablet regimen is as a switch from more complicated combinations in suppressed patients. In the SPIRIT study, this strategy was compared in patients on a ritonavir-boosted protease inhibitor and two NRTIs with undetectable viremia and no history of drug resistance. At 24 weeks, 94% switching to TDF/FTC/Rilpivirine had a viral load <50 copies/mL compared to 90% of those staying on their entry regimen (non-inferiority achieved). Historic baseline viral load (i.e., before entry regimen) above or below 100,000 copies/mL did not influence the efficacy results - indicating that pre-treatment viral load (a prickly problem in the ECHO Trial) is not an issue when switching stably suppressed patients to this regimen. As expected, gastrointestinal symptoms and lipids improved with the switch from PI therapy.
• NRTI-Sparing with Maraviroc+Boosted Atazanavir: You say you want a nuke-sparing regimen, well, you know, we all want to change the world. You tell me that its evolution, but you just can’t change the fact that despite numerous attempts over many years, no such revolution to free us from NRTI domination has succeeded. The latest attempt looked at a combination of maraviroc plus ritonavir-boosted atazanavir, compared to the same PI with TDF/FTC in 121 treatment-naïve patients harboring R5 tropic virus. In a presentation that I think may have used Jedi mind tricks, the 96-week performance of the NRTI-sparing regimen (68% with viral load < 50 copies/mL) compared to the TDF/FTC arm (82%!) was considered to be, you know, sort of, close enough. No statistics were applied, as the study was “small”. Also, no mention how the NRTI-sparing performance looked much like the underwhelming results seen with darunavir/ritonavir+raltegravir in ACTG study A5262, a study which helped put the kibosh on the PI+integrase strategy. This trial again shows that, for reasons yet to be fully explained, it does seem that a drug that works at the reverse transcriptase is key to optimal success of PI-based therapy.
• And there was a bunch of stuff on pre-exposure prophylaxis.

Looking ahead to AIDS 2014, to be held in Melbourne, Australia (!), I do not know what the theme will be, but it will be hard to top ending the epidemic. I am sure we will think of something.

This month we have a guest poster to our site, Dr. Christopher Hurt. Here at UNC, Dr. Hurt is considered a thoughtful and careful thinker about many of the most pressing contemporary issues in communicable diseases. His expertise ranges from transmission of drug-resistant HIV, analysis of sexual networks of HIV transmission, use of pre-exposure prophylaxis to prevent HIV, HCV treatment and novel approaches to influenza therapeutics. Here he shares his thoughts on home-based HIV testing. - DW

Many of you probably heard the buzz in the media last month about at-home HIV testing. On May 15 2012, the FDA’s Blood Products Advisory Committee (BPAC) voted unanimously to recommend approval of an in-home HIV testing kit manufactured by OraSure Technologies. The kit is essentially the same as the OraQuick ADVANCE Rapid HIV-1/2 Antibody Test, with which many of us are familiar from rapid testing in our clinics or at outreach testing events. Oral fluid wicks into an absorbent pad placed between the cheek and gum for several minutes, and then the whole device is set upright in a vial of liquid developer. Within 20 minutes, the user gets their result: one bar, negative; two, you’re HIV-positive. Many people don’t realize that a self-collection HIV test kit using dried blood spots has been commercially available in pharmacies since the FDA approved the method in the mid-1990s. Users prick their finger with a sterile lancet (like those used by diabetics), soak up the small droplet of blood onto a special card, and then mail the card in to a lab for antibody testing. Results are available within several days, by phone or online. Proponents of home OraQuick feel that it offers a distinct advantage over the existing lab-based method: you don’t have to wait for your results.

However, in studies conducted by the company leading up to the BPAC hearing, the sensitivity of the test in the hands of untrained users from a high prevalence (2%) population was only 92.9%, a substantial drop from the performance among trained personnel, where sensitivity was 99.3%. Let’s put it another way, hopefully to make it clearer: consider 1000 people who actually have established, antibody-positive HIV infection and are members of a population with a heavy burden of HIV already – like young, Black men who have sex with men (MSM), for example. If you gave the OraQuick at-home test kit to those 1000 people, only 929 would be correctly diagnosed (“true positives”) – leaving 71 incorrectly thinking they’re HIV-uninfected (“false negatives”). The exact same test, when used by trained personnel, would correctly identify 993 of those 1000, leaving only 7 false negatives. When the FDA modeled the data, they found that the number of false negatives we can expect per year with the at-home OraQuick test could be as high as 7,000. Additionally, the number of false positives – people who will be incorrectly diagnosed as having HIV when they really don’t – could reach as high as 3,600 per year. In their briefing document, the FDA summed up the conundrum: “[t]here is considerable personal and public health value in informing infected, but otherwise untested, persons of their true positive HIV status. However, this benefit is offset in some measure by HIV-positive individuals who receive an incorrect message that they are not infected (false negatives).” The pros outweighed the cons, and the committee voted 17-0 to recommend approval of the kit.

I agree in principle with the BPAC’s stance on approving in-home rapid tests, but I also have qualms about their use. First, we’ve been rightfully focused over the past several years on a “test, link, and treat” model of HIV prevention, given the potential impact of getting HIV-infected people onto therapy – both for individual and public health benefits. Yet, in-home rapid testing fulfills only the first part of this model, leaving the linkage part entirely up to the user. My worry is that it’s already difficult enough for newly diagnosed patients to get appointments set up with the assistance of counselors at testing centers or bridging case managers. How can we expect people who choose to test outside of the existing system to then seamlessly enter and navigate that system on their own? I do think there’s a happy medium between rapid tests and the current system of presenting to a testing center: testing of self-collected dried blood spot or oral fluid specimens in professional labs, with reporting and post-test counseling in person, online, or by phone. Such centralized testing has certain advantages, perhaps the most important of which is quality control. If conducted by public health agencies, this approach could also yield more accurate epidemiological data to estimate HIV incidence and enhance our ability to facilitate linkage to care. There are precedents in Europe and the U.S. for specimen self-collection with STI and HIV testing in public health laboratories, but they have not been scaled up on a widespread basis.

Second, from a public health perspective, I feel that false negatives are worse than false positives. Prior to the approval of the first dried blood spot test kit over 15 years ago, concern was expressed that people would become psychologically unstable (maybe even suicidal) if they received a positive result without a counselor present. Since such a kit is still on the market, I can only assume the risk of suicide must be pretty low – otherwise, FDA would have surely pulled it. Times have definitely changed since 1995, as well; HIV is no longer the inevitable “death sentence” it was before combination antiretroviral therapy became the standard of care, and the public has at least some consciousness of that fact. No, it’s the false negatives that are of greater concern, and the potential for people to use rapid tests as “point-of-sex” testing, or as permission to forgo condoms. The earliest that rapid tests can diagnose a new infection is around 20-30 days after infection, since they rely on antibodies to HIV that need time to crank up to detectable levels. If you hook up with a high-risk new partner who has seronegative acute HIV infection and is in that 20-30 day window before antibodies develop, his or her rapid test is going to be a false negative. We also know that during the window period, people tend to have very high viral loads and are therefore highly infectious to others. We’re going to have a tough time getting the message out that a negative result isn’t necessarily reassuring.

Finally, there’s the issue of cost and what restrictions that will place on who’s using in-home rapid testing. Currently, to obtain a home specimen collection kit, you have to go to a pharmacy or order it online, at a cost of between $50 and $80. No price has been set yet for OraQuick, but it’s likely to be more than $20 and less than $60. Who’s going to be able to afford that kind of money in this economy? I feel like those using rapid tests at home are more likely going to be people with disposable income – often White, insured, and male – and may not be representative of those at greatest risk. Over the past six years I’ve been at UNC, most of my new patients have been young, Black MSM, generally working paycheck-to-paycheck. Given the CDC’s statistics showing this population experienced a 48% increase in incident HIV between 2006-2009, I doubt that those in greatest need of expanded testing are going to be able to avail themselves of this new option.

What do you think? Will in-home HIV testing make a difference? Will that difference be good or bad? Talk with others about it, get additional perspectives, and decide for yourself. As members of the HIV treatment and advocacy communities, it’s up to us to start that dialogue and help our friends and loved ones make the best possible decisions about how to implement this new strategy in HIV testing.

Christopher Hurt, MD is a Clinical Assistant Professor in the Division of Infectious Diseases at the University of North Carolina at Chapel Hill School of Medicine. He graduated from the University of Florida College of Medicine in 2003, and went on to complete Brown University’s residency program in internal medicine at Rhode Island Hospital and The Miriam Hospital. He came to Chapel Hill in 2006 for his fellowship in infectious diseases at UNC and has been a faculty member since 2009.

I could tell by his crestfallen look that John was disappointed. It was the second time I had seen this expression – eyes a bit narrowed and the corners of his mouth pointing definitely down. About a year prior, he found out that, unlike him, I was not a Christian. Now, he knew, unlike him, I was not gay. Not a Christian, not gay. To John, this was not good.

Maybe John felt duped. My skinny jeans, passion for Kenneth Cole shoes, and knowledge of the lyrics to most every Lady Gaga song, may, in retrospect, have been misleading. I did indeed fly at a moment’s notice to NYC to stand in line at the Met for two hours to see the exhibit of the work of the late fashion designer Alexander McQueen, but I was sure I spotted some other MSW there too- and it was my daughter’s idea we go. I do wear a wedding band on my finger, but then so do half of the Gay Men’s Choir.

I suspect that what really led John and most of my other gay patients to think me also to be gay, was not what I wore or my interests, but that I am a man who decided to be an HIV care provider. They assumed my response to the AIDS crisis was motivated by my sexuality – a call to arms among the rainbow brotherhood - rather than by my medical curiosity or sense of social responsibility. Certainly, there is a historical precedent. In the early days of AIDS, many at the forefront of HIV medical care and research were gay men and women. Often these providers had practices that included gay men and many did answer their own calls to action from their communities. I came along just after that first wave of that clinician response, long after that first MMWR report of a mysterious illness felling young men in the Castro and the Village. As a medical trainee, for me, HIV was less a disease of the gay than an affliction of the young – people my age who were succumbing not to the built-in obsolescence that accompanies old age, but an infection that sucked the once over-flowing vitality out of them.

Of course, to my patient John and many other men, being treated by a gay doctor can be a comfort, just as some women prefer female clinicians. When you share experiences there is not as much to explain. I have been a health care provider to gay men for almost two decades and still I don’t always understand what my patients may be talking about when they describe their dating, social lives, and sex. I rely on gay providers and a few patients willing to share to help clue me in. So, I understand and acknowledge John’s disappointment.

Additionally, gay patients, previously stung by prejudice and discrimination within the health care system may not be willing to give a straight doctor the benefit of the doubt. Some have been scorned overtly by local medical providers and even by providers in our ivory tower academic centers. And, with a ballot scheduled this May to allow North Carolina voters to add an amendment to the state constitution to ban same-sex marriage, potentially threatening some domestic partnership benefits and domestic violence law protections, it is easy to see how many gay men and women may feel under siege.

Straight doctors may also be clueless in other ways. A study published last September in JAMA that examined medical school curricula for instruction in health topics related to lesbian, gay, bisexual and transgender (LGBT) health found that the median time dedicated to such issues was only 5 hours across the entire 4 years of medical education. The authors highlight in their article that LGBT individuals experience significant barriers to health care, despite a number of health disparities including higher rates of diabetes and hypertension. Another study conducted with over 700 physicians in California (of all places) found almost 1 in 5 was sometimes or often uncomfortable providing care to gay patients. As many health care providers are not well versed in how to best apply their skills to LGBT patients, such patients may then naturally gravitate toward those who are, including gay providers.

Soon after my appointment with John, a few other patients came in to clinic and after the pleasantries, told me they heard I was straight. Clearly, John knows more of my patients than I realized. “I always assumed you were gay, doc”, one long time patient told me. Trying to be careful not to offend any sense of my masculinity, he assured me he did not think me particularly effeminate. “Just thought you were because you’re an AIDS doctor”, he confirmed. I am an AIDS doctor and I am proud that my patients thought me a kindred spirit. I am even happier that none, including John, have dropped me for being straight.

Close to home, Gretchen Durham, the beloved matriarch of our local HIV service community, died at age 71. There were few degrees of separation, if any, between Gretchen and most any of you reading this tribute. Gretchen was the small but radiant jewel of a person who made things happen when all seemed hopeless. She contributed to progress in HIV work in countless big and small ways -- establishing an HIV teen hotline where many newbies to HIV service cut their teeth, organizing workshops on condoms, creating a safe haven for persons with HIV to live -- she advocated for those living in poverty selflessly and persistently.

There is a big hole left where Gretchen stood and we can only hope to continue to do the good work she dedicated herself to. For those who can, contributions to her beloved AIDS Community Residence Association (ACRA) can be sent to P. O. Box 25265, Durham, NC 27702. This would be a small thank you to a tough woman who made life so much easier for so many.

Probably not as well know to you was my friend Bonnie Goldman. If you have ever gone to TheBody.com or TheBodyPro.com to look for a post-conference report or a review of a research article, you know Bonnie, if not personally then through these sites, which she conceived and molded as its Executive Editor. One of the most interesting persons I have met, she was utterly indefatigable in her commitment to get HIV-related information to those living with the virus and the professionals who cared for them. But, this was no sixties era radical or HIV+ activist. She was raised in an orthodox Jewish community in New York and looked more the part of a slightly unintentionally Goth writer than one of the leaders of the HIV information media. The death of her younger brother from AIDS set her on a crusade, which she pursued from conference to conference and story to story, in a constant battle against ignorance.

Like most heroes, Bonnie could be tough. I would write an article for her about some new discovery or clinical trial and she would reply back that it did not tell the reader why this mattered or she would complain that I did not share enough of my own thoughts about the finding. For her, everything had to matter and everything had to be personal. Bonnie made me a better writer. She made me a better doctor.

Bonnie died at age 55, right after New Year’s Day, of breast cancer, a diagnosis she hid from almost everyone for over five years. Who can even begin to count the number of people she helped, even saved, by literally making knowledge into power. One day, I hope her young daughter, Hillary, whom she loved so dearly, searches her mother’s name and reads just how special Bonnie was to so many.

Four years later we have seen a renaissance in HIV prevention research with creative approaches being tested in the US and abroad. The fruits of these labors, most notably, include studies that have combined the understanding of human behavior with an appreciation that antiretrovirals work really well at shutting down the replication of HIV. Antiretrovirals are being used in novel and imaginative ways: compounded into vaginal microbicides, administered to high risk uninfected people as a pre-exposure prophylaxis (PrEP), and given to HIV+ patients to lower their HIV viral load, and therefore, their infectiousness.

But, what will it take to really end HIV/AIDS? Modeling exercises show that only with major reductions in transmission can the HIV epidemic be expected to dry up. Such simulations are guilty of simplicity and have a hard time accounting for the complex interaction of biological and social forces.

That said, there is certainly a sense that stopping HIV is not fantasy and that we are on a path that will lead to just that. For me, the finding (by NC’s own Dr. Myron Cohen) that HIV therapy administered to HIV+ individuals greatly reduces their ability to infect partners is major and means that the seeds of the stemming of the HIV epidemic may have already been sowed with each prescription of ART given to a person with HIV infection. The problem is too few have been treated.

A few weeks ago, the CDC released another important and sobering important analysis this time estimating that of the 1.2 million people living with HIV infection in the US, 36% are receiving HIV therapy and while most achieve viral suppression, this is only 26% of all those infected. Therefore, three quarters of HIV+ people in the country are not being treated and have a much higher potential to infect others when engaging in risky behaviors. Details of this report can be found here.

Clearly, there is more to ending HIV than using more ART. Yet, broader use and adherence to HIV therapy is essential and within our capabilities to accomplish. Foremost, for the majority of infected persons aware of their HIVseropositive status need to treated and maintained on therapy. Next, we must reach the 1 in 5 people with HIV do not know they are HIV+. Testing more people at risk for infection, starting HIV therapy early, and supporting ART adherence can make a sizable dent in the incidence of HIV. Throw in some PrEP for some very high-risk men, microbicides for women (and eventually guys too), seeking and destroying other STIs that increase risk of getting and giving HIV, along with good old behavioral interventions and you got a Highly Active Prevention PartY. Yep, that is HAPPY.

Next, who caught HIV today.

Check out my top 10 HIV clinical developments of 2011 at The Body.

I have just completed a brief two weeks attending on the inpatient medicine service here at UNC. What started as an HIV ward is now a general medicine service with an Infectious diseases flavor. Most of those with HIV admitted to the hospital come to us. Of a typical census of, say, 15 patients, about two to three would be HIV+. But, these few patients speak volumes about where HIV has found a safe haven. Here is the story of one:

The Case:

The other day we admitted a middle-aged woman with severe pain in her left jaw radiating down her neck. She was seen at an outside hospital a month earlier for chest pain and was found to have had a myocardial infarction requiring coronary artery stenting. She was diagnosed with HIV infection 5 years ago. At that time her CD4 was 250/uL and she was prescribed Atripla. She took this medication for only a month and never returned to clinic. Why? She was terrified that her family and community would learn of her HIV. She said she felt she would be judged harshly by these people and would be an outcast. "You know how people are about HIV", she told me during the initial history and physical.

On examination, she was very thin but lively. Her left jaw was swollen and there was a nasty looking lower molar on that side that was long over due for extraction. There was thrush in her mouth and she had decreased breath sounds at the bases of her lungs. Otherwise, the exam was pretty much unremarkable. She did not have a fever and her oxygen saturation was 98% on room air. ECG showed evidence of her prior MI. A chest X-ray, however, showed nodular densities at the bilateral lung fields, most dense at the lower lobes. A follow-up CT scan was done of her jaw, neck and chest as there was concern for Lemierre's Syndrome (a mixed anaerobic abscess of the mouth that tracks to the jugular vein, forming clot that can shower the lungs). No abscess or clot was found and the lung portion of the scans revealed multifocal small densities in the lower lobes that were described as tubular and branching. No mediastinal adenopathy was seen.

Her CD4 cell count came back the next day at 66/uL.

The patient was placed on clindamycin IV. Dental was consulted and an extraction of her tooth scheduled. Respiratory isolation was instituted and after sputum was unable to be obtained, a bronchoscopy was performed. Bronchial lavage was sent for bacterial, fungal and mycobacterial stains and culture. Viral culture and PCP direct florescent antibody (DFA) testing was also performed. The diagnosis?

PCP was found on the DFA and on cytology. Oral TMP/SMX twice a day was added. An HIV genotype was drawn and while results of this resistance test was pending, Atripla was re-started. She was discharged with a 2 week supply of her medication, including oral clindamycin, and a follow-up appointment with dental and me in the UNC Infectious Diseases Clinic in 1 week.

Discussion:

The case is instructive in many ways. Foremost, the patient was someone who had suffered considerably since over the past several years due to her fear of disclosure of her HIV infection. He weight plummeted, she developed rashes and thrush and now a painfully infected tooth and PCP. Her MI a month ago may well have also been facilitated by HIV via on going inflammation and low HDL cholesterol. I spent a considerable amount of time with her discussing her fears and ways we could protect her privacy and provide on going HIV care. I think she is committed to care.

Her diagnosis of PCP is also of interest. PCP can present in myriad ways and here we had a patient with minimal pulmonary symptoms and apparently good oxygenation. Her X-ray was concerning for a non-tuberculous mycobacterial infection or fungus to me, but it was plain old PCP. Her toothache may have saved her from a more catastrophic presentation a month from now.

Lastly, the decision whether to re-start HIV therapy and what to use is worth considering. A chorus of studies demonstrate a benefit of antiretroviral therapy (including a better survival) when started earlier rather than later in the course of most opportunistic infections, especially PCP. Her virus may well have developed drug resistance during her initial course of Atripla. But, a genoptype is cooking and there is little risk of re-starting Atripla and modifying in a week or so, if necessary, when the results come in.

I will let you know if she comes to her clinic appointment.

As you know, the Ryan White Care Act-funded North Carolina AIDS Training and Education Center (NCATEC) has been successfully educating the HIV treating community for well over a decade. Under the leadership of our colleagues at Duke University, the ATEC has made a deep and enduring mark on the care of HIV in our state that has benefited thousands of providers and the patients they care for.

As the NCATEC moves to its new home at the University of North Carolina, I am excited at the opportunity to continue this good work, but also humbled by the big shoes we at UNC now have to fill. Over the past few months we have thought hard about what the NCATEC can do to best support your work and, with the help of our friends at Duke and through discussions with many of you, have developed a set of core services we believe will further the NCATEC mission.

• Foremost, we will take advantage of the wealth of clinical expertise we have here in NC and offer intensive preceptorships to health professionals including physicians, physician assistants, nurse practitioners, dentists, and pharmacists. Providers who are new to HIV or those with more experience but looking to hone skills will have an opportunity to see patients alongside NCATEC mentors at one of our UNC clinical sites or, in some cases, their own clinics.
• In addition, the NCATEC will offer a phone consultation service. This ‘warm line’ will be a resource that providers caring for those with HIV infection can use to ask a clinical question of a NCATEC physician.
• Traditionally, the NCATEC has supported major educational forums and will continue to do so by sponsoring speakers and workshops at these events.
• We will also look to developing a recurring interactive case conference and hope to start this program in the first quarter of 2012.
• Lastly, our website will not only be a portal through which you can learn more about what we offer, but it will also continue to grow to include resources, data, links and other information we hope will make it useful to you.

As we move forward, my NCATEC colleagues, Drs. Becky White and Heidi Swygard and our program coordinator, Michele Bailey, encourage you to share your thoughts and suggestions. We look forward to working together to provide the best care for North Carolinians living with HIV.

David Alain Wohl, MD