Hope for HIV Prevention and Treatment

HIV is a disease that has evolved during our lifetime. As a clinician, during my years of training I saw men and women present to the Jackson Memorial Hospital emergency room with a strange overwhelming lung infection and a shutdown of the body’s immune response to infection. Even with aggressive treatment they failed and succumbed to the disease quickly. We had no idea what the process was back in the early 1970’s and were privileged to be around to see pioneers like Margaret Fischl, MD at the University of Miami Miller School of Medicine, begin to take on this dreaded disease in a population no one else would care for.

Hard work and millions of dollars in expense for research coupled with courageous patients has led to announcements like the one released by Michael Martin , MD of the Center for Disease Control that a drug called tenofovir, administered to high risk intravenous narcotic users, significantly reduced the risk of catching the disease. One pill a day In the 2400 volunteers, from 17 drug treatment centers in Thailand, taking one dose of tenofovir per day reduced the risk by almost half. The results were so striking amongst IV drug users that the author recommended beginning a once a day tenofovir program as a pre-exposure prophylaxis in all the high risk groups. He defined the high risk groups as men who have sex with men, heterosexual individuals and heterosexual couples where one person is HIV positive and the other HIV negative.  The drug was surprisingly well tolerated with only 8% of the patients experiencing episodes of nausea.

The purpose of discussing this article is to fan the hope among all individuals, providers and citizens, who have seen the ravages of this disease and did not believe a treatment, prevention or cure would occur in our lifetime. The presence of newer medications for prevention should not allow any of us to let our guard down and eliminate using the tried and true methods that prevent transmission of the disease.  Practicing safe sex by using condoms, avoiding sharing needles when injecting medication and being aware that when you are sexually active you are exposing yourself to your partner’s entire sexual past history will still need to be the cornerstone of prevention.

 

Electrical Stimulation May Improve Sleep Apnea

Sleep Apnea v2Patrick Strollo Jr., MD of the University of Pittsburgh Medical Center presented preliminary data on the use of a surgically implanted neurostimulator to improve sleep apnea symptoms. The device was implanted to stimulate the hypoglossal nerve. The participants in the study were 124 patients who could not tolerate the CPAP mask treatment or who were never before treated. After implantation they were treated and followed for one year. The participants were mostly men (83%) in their mid-fifties (mean age 54.5 years old), Caucasian and overweight (mean BMI 28.4 kg/m2). Thirty eight percent of the participants had hypertension, 9% were diabetic, and 5% had COPD. Interestingly, 18% had undergone previous surgery on the uvula called uvulopalatopharyngoplasty which was felt to be an effective alternative to wearing a CPAP mask for sleep.

At 12 months all the parameters to assess the effects of sleep apnea had improved dramatically. Interestingly enough, some of the study participants were allowed to continue treatment while others were randomized to stop the neurostimulation. Those who stopped the treatment were followed and their scores regressed.

Like all treatments there were some adverse effects such as tongue pain and mild to moderate infection in 1%.

This is very preliminary data. The study must be presented to a peer review journal, evaluated and published before this treatment becomes acceptable. We recognize sleep apnea as a dangerous disease that leads to pulmonary hypertension and right heart failure if not treated. CPAP masks work well but are cumbersome, awkward and difficult to travel with. The epidemic of sleep apnea is being fueled by a worldwide epidemic of obesity. The current preliminary work at the University of Pittsburgh holds out hope for a future solution that may be easier to live with.