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Great progress made in infectious disease during 2012
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Being asked to summarize the year in infectious diseases is, at the same time, totally enjoyable and totally impossible. Or at least impossible in any comprehensive or “evidence-based” manner. Events thought central might be seen as less important to others who may well have their own deeply held perspectives. The exercise reminds me of the Infectious Diseases Society of America sessions where John G. Bartlett, MD, director of the HIV Care Program at The Johns Hopkins Hospital, offers his favorite papers of the year — always an enjoyable and rewarding highlight of the meeting. I hardly wish to be compared with such an infectious disease luminary, but being brave, here are my thoughts.
HIV/AIDS
In HIV (how could I not start here?), the year saw even more startling proof of the impact of potent antiretroviral drug combinations in preventing HIV transmission. In several large and well-conducted trials, the tenofovir and emtricitabine combination prevented viral acquisition in those at ongoing infection risk with the degree of benefit directly linked to medication adherence rates. That pre-exposure prophylaxis (PrEP) works is no longer in doubt — as long as the drug is actually taken. The benefit was highest in a study of infection discordant heterosexual couples, intermediate in high-risk men who have sex with men and lowest in young women commercial sex workers and in each trial correlated directly with pharmacologic markers of medication use. These results leave open many practical policy questions of the right populations in which to use PrEP and of the cost and concerns of resistance and possible increases in risk taking, but there is little doubt that the PrEP strategy will be a vital one for some individuals, allowing them for the first time to control their own HIV risk.
Paul A. Volberding
The past year also saw the realization that treating HIV-infected persons can come close to eliminating transmission to sexual partners — a finding with dramatic worldwide repercussions on public health strategy. Guidelines now increasingly recommend that all HIV-infected persons be offered antiretroviral treatment for their own health, with the public health benefits on secondary prevention a tremendous additional gain. This breakthrough was a substantial reason for the upbeat tone of the AIDS 2012 conference in Washington, D.C., where science and optimism replaced much of the fear and anger so typically evident at these biannual international events.
HCV
As much as my own attention is usually on HIV, 2012 saw hepatitis C virus infection make a claim for even more progress. The huge international HCV epidemic — quietly but inexorably leading many to death from liver failure and hepatocellular cancer — may yet be conquered. While treatment has been progressing for years, oral direct-acting agents appear on the verge of completely replacing interferon and ribavirin, drugs known for modest potency combined with cumbersome administration methods and serious toxicities. At the recent liver disease meetings, reports from numerous drugs being developed at a fevered pitch by almost as many companies showed that even short treatment courses with two oral drugs could cure essentially 100% of cases regardless of genotype or prior interferon treatment failure. The race to get these new drugs to market is on, with the definite possibility that drugs may be combined in single tablet combinations so reminiscent of the trend in antiretroviral drugs but much earlier in the approval process.
Already, many are talking of “treatment as prevention” in HCV with the possibility that community-wide therapy may sufficiently reduce reinfection risk that the epidemic can be eliminated. A key issue in all this is the role of the ID community in this battle. ID practitioners know how to use oral antiviral drug combinations and work in settings where this care is delivered by well-organized teams. These are clearly positioned to take a leading role in the HCV treatment response, collaborating with colleagues in gastrointestinal medicine for those unfortunate patients where treatment has come too late to prevent serious hepatic disease.
Fungal infections and TB
Two other infections with substantial policy implications have drawn our attention in the past year, fungal infection of the central nervous system and other sites and extensively drug-resistant tuberculosis. Fungal infections, particularly meningitis, apparently transmitted as a contaminant of corticosteroid solutions, number more than 500 cases with 36 deaths as of late November with thousands potentially exposed and still at risk. While still being actively investigated, early reports suggest that FDA regulation of the compounding pharmacy source was restricted by previous Supreme Court decisions of an industry that has gone from a local to a nationwide scale clearly requiring oversight. Delays in reporting cases may have further exacerbated the problem.
Many more cases of extensively drug-resistant TB, first seen in South Africa, are now reported in India — a country with a population more than 1.2 billion. While again the focus of investigation, some have linked this potentially explosive outbreak to policy decisions of WHO and other national and international organizations to focus admittedly limited resources on the control of nondrug-resistant TB. Now, with very limited ability to monitor drug resistance, new cases with resistance are being treated with ineffective drugs, furthering the selection of fully resistant varieties. As always, infectious disease control finds itself in the cross hairs of organisms “eager” to evolve and spread with regulatory and fiscal politics.
Health care
Speaking of politics, in the United States, we are in the midst of one of the fiercest dialogues in decades regarding health insurance access and the cost of health care. On one hand, expansion of insurance access under the Affordable Care Act (ACA) will clearly happen. For HIV, now a chronic illness requiring lifelong treatment and largely affecting an impoverished population, the ACA will allow many to gain Medicaid coverage. However, this will vary widely given the Supreme Court decision allowing states the option of expanding Medicaid eligibility or not. In states that do, many now receiving primary care through Ryan White programs may move from those providers to Medicaid-based care. This may not be an option in other states, making our “system” of care even more obviously a fragmented and torn safety net negotiable only by the most resourceful of patients and advocates. And all this even before the bigger shoe drops; the obvious need to face the realities of controlling the unsustainable and still increasing cost of our nation’s health care bill.
I’m sorry to end on somewhat of a downbeat. The year was an interesting one, as we used to say in Minnesota, where that wasn’t always a good thing. Still, for the infectious disease community, 2012 saw great gains. And 2013 — especially in HCV infection — promises to be an exciting one. And we’ll do all we can to keep up with all the developments here at Infectious Disease News. Have a great New Year!