Wednesday, November 23, 2011

Boosting Adherence to Antiretrovirals / UN AIDS reports AIDS epidemic may be reaching plateau

I already had HIV on the mind yesterday when I saw this news brief from the AMA (below). I had the privilege to hear a professor from Tufts speak about strategies to monitor and encourage adherence to antiretroviral therapy. There was an old thought that perhaps we shouldn't offer antiretrovirals to Africa because folks in resource limited settings wouldn't be able to adequately adhere to the regimen and would breed resistance. That's a scary proposition!

Well, the data flips that perspective upside down. Turns out, adherence studies in a half dozen or so cities in the US (think NYC, San Francisco, Hartford, and others) show Americans only reach 50-70% adherence rates while our counterparts in Africa frequently surpass 95%. Turns out they harness their social capital much more effectively and it boosts adherence. Imagine asking a friend or neighbor for money so you can get lifesaving drugs (or even so you could get the transportation needed to pick them up). To maintain the relationship, you're going to make darn sure you take those medications.

What about the issue of taking meds at the same time when you don't have a clock? You'd be amazed how creative folks can be - one gentleman had nearly perfect compliance over the course of a month (he timed his meds to a radio news broadcast at 7am and 7pm daily). He struggled a bit the next month, but that was because he fell in love and donated some pills to his HIV positive girlfriend who was running short on medications. So what turned out to be the best estimate of adherence? It was data from the pharmacy regarding prescription refills, this estimates the maximum possible adherence (and would miss the case of a patient sharing meds with others), but lined up very nicely with actual viral suppression rates.

In other news, this article below was published as part of the AMA Morning Rounds.

UN AIDS report suggests AIDS epidemic has plateaued. The New York Times (11/22, D5, McNeil, Subscription Publication) reports, "The world's AIDS epidemic has hit a plateau, with 2.7 million people becoming newly infected each year for the last five years, according to the annual report (pdf) released Monday by UNAIDS, the United Nations agency fighting the disease." The report also notes that "last year, 1.35 million got on treatment for the first time, meaning 200 people were newly infected for each 100 newly treated," compared with "two years ago, when 250 were infected for each 100 treated." However, "donor funds dropped about 10 percent last year as the worldwide economic crisis made some countries cut their donations." The report also compares a number of countries, pointing out that a large number of new cases are driven by "drug addicts, who are notoriously hard to reach, and also by groups like gay men and prostitutes who in conservative societies...have furtive, rapid sex -- a high-risk behavior."   

      The Washington Post (11/22, Brown) reports, "The biggest advances have occurred in sub-Saharan Africa, where a massive rollout of antiretroviral drugs, increasing acceptance of circumcision and changes in sexual behavior are driving new cases of infection to the lowest number in years." In contrast, "the big exception to the global trend is in the countries of the former Soviet Union and Central Asia, where there has been a 250 percent increase in people with HIV from 2001 to 2010.     

    Bloomberg News (11/22, Bennett) details, "A failure in Russia to implement harm-reduction programs such as offering drug users clean needles, or switching them to methadone tablets from heroin injections, is fueling the spread of the virus, said Paul De Lay, the deputy executive director of the Geneva-based agency." De Lay added that "five years ago they were really starting to see a turnaround," but now the progress has "pretty much fallen apart" and UNAIDS is pushing "for the surrounding countries not to follow the Russian Federation model."    

     The AP (11/22) reports that while "UNAIDS says it is working toward zero new HIV infections, zero discrimination and zero AIDS-related deaths," critics contend "that the body's aim of wiping out the disease is overly optimistic...considering there is no vaccine, millions remain untreated and donations have slumped amid the economic crisis."     

    CQ (11/22, Bristol, Subscription Publication) notes, "New infections reduced by 21 percent since they topped out in 1997. Deaths, which peaked in 2005, had also fallen by 21 percent by the end of last year. ... The report attributed progress in reducing the disease to changes in sexual behavior, especially among younger people who are reducing their number of sexual partners and using condoms more."         The UK's Telegraph (11/22) reports, "A significant expansion in access to treatment helped slash the number of Aids-related deaths in 2010, bringing the number of people living with HIV to a record 34 million," according to the United Nations. Also covering the story are Reuters (11/22, Kelland) and BBC News (11/22)"

Saturday, November 19, 2011

All I need is a little help from my friends...

Although my roommate has thus far been unable to convince me to join her at bikram yoga, a couple of news items this week attest to the powers of peer pressure in changing one’s lifestyle.

The first is a study out of Stanford about the families of patients who underwent gastric bypass surgery. The investigators found that obese family members of bariatric patients lost an average of 3% of their total weight in the first year following the surgery – this is equivalent to the amount of weight loss achieved on the average diet plan such as the Atkins diet. So although the family member wasn’t officially on the post-op bariatric diet, it is as if they were.

The second is a program called the “Daniel Plan” created by Rick Warren (best known for “The Purpose Driven Life”) at his church in California. Warren has used what he calls “the healing power of the group” to motivate members of his church to lose weight; he effectively utilizes the existing foundation of church small groups not only for spiritual growth but also physical betterment. The first point of his six-point program is to “connect” or create partnerships that foster positive change. Fourteen thousand people signed up and 72% lost weight. A survey found that participants lost nearly 7 more pounds following the plan in a group than they following the plan on their own.

Both of the above examples involve groups – either natural or constructed. What is fascinating about the Stanford study is that the weight loss was unintentional – it was purely a product of environment. The other interesting thing is that there is really nothing inherently special about either diet plan. What is amazing is the difference the support of a group makes in adhering to that plan. Not surprisingly, this has great implications for global and public health. It is one of the reasons why Alcoholics Anonymous and Partners in Health have been so successful.

Message to my roommate: if exercise is anything like nutrition, the stats are on your side! Eventually, I may succumb to your good example.

(Arch. Surg. 2011;146:1185-90)

Wednesday, November 2, 2011

Practicing what we preach: Hospital Cafeterias

It's relatively common knowledge in the medical field and to many people that poor diet and physical inactivity is a leading "actual" cause of death. It is quickly catching up to tobacco and may soon overtake it to become the leading cause of death in America; no question, a leading public health threat.

So it may seem ironic when a cafeteria at a health care institution actively promotes a leading cause of death. While many institutions have taken the steps to a smoke free campus, saturated fat filled cheese pizza, fries, hamburgers, hot dogs, and macaroni and cheese still seems to be the rule, not the exception.

How would we feel if a hospital not only allowed tobacco on campus, but sold cigarrettes from vending machines? From a public health standpoint, these practices are equally harmful.

The cynical side of me recognizes that other than institutional philosophy, there has been little financial incentive for a hospital cafeteria to provide healthful food (and perhaps even has some incentive to keep their vascular surgeons and cardiac cath lab busy!). This may change if the new payment system under discussion, Accountable Care Organizations becomes the norm where the hospital or provider group stands to save money by promoting a healthy patient population.

So far, it is the rare hospital that has made health a priority. St Joseph Mercy Ann Arbor is one of those, employing a chef from Google and investing $1million to remodel their cafeteria in the name of health; reducing portion sizes, color coding options to help indicate nutritional value, and saying goodbye to their deep fryer.

By popular request, WooFood is actively working with the Cafeteria at UMass Memorial to promote change that will at least encourage healthful options. (Disclaimer; the author of this post is a founding member of WooFood). The need has been recognized by many people including the CEO of UMass Memorial who has stated that the healthcare community needs to practice what it preaches when it comes to healthful options.

What are your thoughts on hospital cafeteria food? How is the food at your school's or hospital's cafeteria? Does a hospital cafeteria have a responsibility to serve healthful foods because it is a healthcare institution?