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Oversell

Fri, 17 May 2013 10:00:29 +0000

It's easy to get angry about reports like this one describing how a promising combination treatment for hepatitis C may never hit the market because one pharmaceutical company doesn't want to play nice with another one. However, it's important to remember that just because a combination therapy worked very well in a small clinical trial doesn't mean that it would work as well in the real world. That was one of the lessons learned at last month's International Liver Conference in Amsterdam. Several studies examining "real world" use of Direct Acting Antiviral combination therapies found that while the drugs still worked much better than their predecessors, they weren't nearly as effective in clinical populations as they were in research populations.

Why does this happen? Well, a number of things can keep a drug from working as well in the real world as it does in a research study. Patients may not follow the drug regimen as closely. However, they may also have a hepatitis C genotype that isn't affected as strongly by the drug combination, or they might have other health factors that impede its use. Therefore, although it's good to wonder if the two-company combination might be worth exploring further, it's premature to assume that not exploring it is a tragedy. We simply don't have enough data to know, and while it might be nice to get it, at least we can be comforted by the knowledge that there are other therapeutic regimens coming down the line.

Hepatitis C 101

Keeping Herpes in Check

Wed, 15 May 2013 09:29:54 +0000

Scientists recently discovered a new type of immune cell that helps keep herpes infections in check. It's long been known that most people with herpes have few (or no) breakouts and that breakouts usually get better with time. However, what hasn't been well understood is exactly how their immune systems keep the virus under control. That's unfortunate, since understanding what makes some people's bodies so effective at suppressing the virus could help unlock new options for treating those people who suffer frequent, severe outbreaks and currently have difficulty finding relief.

A letter recently published online in the journal Nature may help change that. Using a variety of techniques, they isolated a group of T-Cells that were involved in viral suppression and classified them as CD8αα+ cells. Large, diverse populations of these cells were associated with short, sub-clinical viral reactivation -- leading to asymptomatic shedding instead of visible, painful lesions. In contrast, people whose immune systems did not quickly produce or recruit such cells to the genital skin were more likely to have noticeable, and unpleasant, symptoms.

Although it's still early days, this type of research could potentially help scientists develop new therapies to enhance the immune response against HSV. In theory, this might assist in the creation of a therapeutic or preventative vaccine, but such practical applications are many years down the line.

Could I have genital herpes and not know it?

Emptying the Reservoir

Mon, 13 May 2013 22:13:04 +0000

The problem that doctors face when trying to cure people who are infected with HIV isn't eliminating the virus from the blood. Combined antiretroviral therapy(cART) is pretty good at doing just that. The problem is trying to get rid of the virus that still remains hidden in quiescent immune cells, virus that is invisible until those same cells undergo some sort of activation. This pool of hidden virus is known as the viral reservoir, and until recently it has been the bane of researcher's existence. It's hard to find, difficult to measure, and almost impossible to definitively eradicate.

That said, one of the things that many scientists were excited about at the AIDS 2012 meeting last summer was new research on drugs that looked as though they might be able to reactivate those latently infected immune cells, releasing the hidden virus into the bloodstream so that it could be eliminated. However, few people realized how quickly those studies would begin to move forward. Scientists in Denmark have recently started human trials of a drug that, in the lab, was effectively able to flush viral RNA out of human cells so that it could be detected and destroyed. A consortium of UK scientists who are looking at a related drug isn't far behind, and at least in theory, this is the sort of technique that could one day move doctors from a functional cure for HIV to a real one.

What is a functional cure for HIV?

Change The Talk

Fri, 10 May 2013 09:51:47 +0000

It won't be a surprise to anyone that I think the fact we advertise HPV vaccines as cervical cancer vaccines is short-sighted. Not only does it make the vaccine seem like it's only important for women, I have long felt like it's the advertisers' way of caving to the loud minority who don't think that teens are or should be having sex -- and therefore shouldn't be spoken to about STD risk. That said, the only good thing about advertising the "cervical cancer" vaccine, in my mind, has been that it's acceptable for parents to protect their teenagers from cancer. It isn't nearly as acceptable for them to protect their teens from STDs.

A recent paper in Health Communication may be shifting my opinion a bit, at least about the relative acceptability of the two messages. The study compared mothers' and daughters' responses to HPV vaccine information pamphlets with the headlines "Stop genital warts" and "Stop cervical cancer." What they found was somewhat surprising. Mothers were equally likely to say they would recommend HPV vaccination to their daughters with either pamphlet. However, daughters were more likely to say they would ask for the vaccine if they received the pamphlet with the heading about genital warts. The investigators suggest that this may because STDs are a more immediate concern for young people then cancer. In retrospect, that makes a lot of sense. However, I'm still a bit surprised that moms weren't put off by the genital warts messaging. That may have had something to do with the fact that the study population involved college students, rather than the younger teens who would ideally be targeted by vaccination campaigns.

Comparing HPV Vaccines

Covering our Assets

Wed, 08 May 2013 09:09:20 +0000

A few years ago, I reported on a weird new chlamydia variant that had popped up in Sweden - and couldn't be detected through standard urine testing. I haven't thought about it a lot since then, but I was still relieved to read a new report in the journal Sexually Transmitted Diseases. The study looked at over 400 chlamydia samples from 15 laboratories around the United States and, fortunately, found that the ninja bugs weren't in any of them. This suggests that the Swedish chlamydia variant probably hasn't taken hold in the United States. In fact, it has only rarely been seen outside of Sweden and Norway, and all of the other cases have been linked back to contacts with individuals from those countries.

It's reassuring to know that scientists are keeping an eye out for sneaky chlamydia variants that might otherwise sneak under the testing radar. However, it's also comforting to learn that a growing number of tests are being developed that will be able to detect not only ninja-chlamydia (technically known as nvCT -- where nv stands for "new variant") but other mutated forms of the pathogen. Given my ongoing concerns about problematic, antibiotic-resistant gonorrhea mutations, it's nice to feel relatively confident that the stealth-chlamydia issue is one that seems relatively easy to control.

The Problem of Antibiotic-Resistant Gonorrhea

PreP School

Mon, 06 May 2013 09:34:47 +0000

I've had my concerns about the potential downsides of widespread use of pre-exposure prophylaxis(PreP). In particular, I've been worried that it might encourage sexual risk taking among users, who might decide that taking a pill is preferable to using a condom or engaging in other forms of prevention. Furthermore, I know I'm not the only one to harbor such worries. That's why it was somewhat refreshing to read a recent paper in the Journal of the Acquired Immune Deficiency Syndrome, which researched just that question in a population of men who have sex with men (MSM).

The study found that, in a group of 400 men participating in a PreP trial, there were no increases in problematic risk taking behaviors among men. If anything, unprotected anal sex with HIV-positive or unknown status partners may have actually declined over time. However, it is important to know that the behavior shift wasn't the result of men using PreP - it was the result of participating in the study. There were similar improvements in risk behavior between men who were assigned to PreP initially and those who were randomized to wait 9 months before receiving the medication.

On the face of things, these results seem positive, but they should be taken with caution. Why? Because although risky behaviors with partners known to be HIV positive declined over the course of the study, risky behaviors with those assumed to be HIV negative actually went up. This type of behavior, known as sero-sorting can be quite dangerous, as what people assume about their partners' HIV status may or may not be correct.

Go Canada!

Fri, 03 May 2013 21:38:09 +0000

Once again, the Canadians are moving ahead of their southern neighbors in the world of sexual health, a fact which I always tend to find somewhat ironic given that the first thing I ever learned about Canada's relationship to sexuality was that border agents were known to be enthusiastic about stopping sex toys and pornographic material from entering the country. This admittedly gave me an entirely inaccurate impression of Canadians, but it has had one advantage. Sexual health news coming out of the country always feels like a delightful gift.

Last week's present was a recommendation from the Society of Obstetricians and Gynecologists of Canada that HPV vaccination programs throughout the country should expand to cover boys. Although Gardasil has been licensed for young men in the country for a number of years, relatively few are vaccinated. In part, this is because of cost, which is also likely behind local governments' reluctance to expand their programs. HPV vaccination isn't cheap, but expanding it further into the male population can not only help protect young men from the direct effects of the virus - such as certain cancers and genital warts - it can also reduce the risk of them transmitting the virus to their sexual partners.

Personally, I think it's a good move. I'd suggest that it's one that the U.S might want to emulate, but that would be getting ahead of myself. At this point, the U.S. still doesn't even have great HPV vaccine coverage for girls.

Another one bites the dust

Wed, 01 May 2013 09:26:04 +0000

Late last week, news came down the pipeline that the National Institutes of Health had just called a halt to HVTN 505. That means that yet another HIV vaccine study has failed to bear fruit. The trial was initially designed to see whether vaccination could reduce viral load in individuals who eventually became infected with HIV. However in 2011, after primate studies of the vaccine showed promise for preventing SIV, the study analysis was expanded to see if the tested regimen could work as a preventative vaccine as well.

Unfortunately, neither outcome was meant to be. When last Monday rolled around, and it was time for an interim review of the study data, the word wasn't good. The experimental vaccine regimen neither prevented HIV nor reduced viral load in people who became infected after taking it. In fact, as had been seen in previous HIV vaccine trials, there was actually some suggestion that vaccinated individuals might have ended up with a slightly increased risk of becoming infected with the virus -- although the numbers were not quite large enough to make that clear. It's possible that the difference was just a fluke, but the scientists will keep following the trial participants in order to make sure.

The Trials of Developing an HIV Vaccine

Medicine in the Real World

Mon, 29 Apr 2013 09:06:29 +0000

Listening to the coverage of the first generation of hepatitis C(HCV) direct acting antivirals (DAAs) that is coming out of the International Liver Conference (ILC2013), I am reminded of a very important fact. Clinical trials aren't the real world. When boceprevir and telaprevir were approved two years ago in May, it seemed like they would revolutionize hepatitis C treatment. In some ways that was true. Triple therapy with a DAA, interferon, and ribavirin is far more effective for some HCV patients than the former standard of care. However, the patients that triple therapy is most effective for are the types of patients who were recruited for the clinical trials... not necessarily the patients who need therapy most in the real world.

Information presented at ILC2013 suggests that, when looking at real-world data, the first generation DAAs aren't nearly as effective in the neediest patients - those who have previously failed treatment and who have advanced liver disease - as scientists might like. As revolutionary as these therapies have been, they still have a long way to go. That's why it was so exciting to hear the other news coming out of ILC2013. There has been a great deal of progress made on second generation DAAs, and some of them are getting close to market readiness. The clinical trial data certainly looks good. We'll just have to wait to see how they do in the real world.

Oh, just suit up already....

Fri, 26 Apr 2013 09:37:12 +0000

Word is that the condom law recently passed in Los Angeles county had the expected, rather than the intended, effect. It's driving adult film producers to seek out new communities in which they can film throughout the state -- communities where they won't have to subject their male performers to the horrible indignity of protecting themselves and their partners by wearing condoms. Unfortunately, this also has the legislatively unanticipated side effect of also driving producers out of an area in which testing rules for performers have been relatively consistently enforced, which is a good thing... even if they are far from perfect at preventing STDs. According to news sites, the adult film industry is now shopping around for a new home where they can make bareback films in peace.

I don't honestly have much to say about this that I haven't said before. Unfortunately, many filmmakers value the potential profit advantage of unprotected sex over the safety of their stars -- who are easily enough replaced in a world where many people voluntarily put videos of their sex life online for free. If they can find a way to lower their costs even further by not just avoiding condom requirements but also potentially reducing testing, it takes a company with a strong sense of morality and public health to do anything else. Although I don't buy the free speech argument, I also think there's a limit to how much you can practically legislate personal responsibility. We may have just found where that limit is for the porn industry.

Don't get me wrong. If we could find a reasonable way to make sure every sexually active person in the country reliably got tested and appropriately practiced safe sex, that would be lovely. I just don't see that being possible without unacceptably trampling on people's right to privacy, not to mention their need for autonomy in the bedroom. And really? If we can't get people who are having sex for fun to see the merits of spending a little time and energy on doing it safely, how are we going to convince the people who are doing it for money*?

*Okay. That last bit was total hyperbole. Many people who have sex for money are actually a lot smarter about it than people who have sex for free. They recognize that both their lives and their livelihoods could be on the line if they don't take care of their sexual health.