Notes from Dr. Ken Greenberg’s HIV Overview

November 17, 2017

For a number of years, Dr. Ken Greenberg of Denver, Colorado, has been doing a medical update workshop at our annual Retreat. He is knowledgeable, articulate, straightforward, honest, and funny. He answers questions clearly and directly. I wish he were practicing in Vermont.

 

Here are some notes that I took while attending his HIV Update presentation last July. Those who were fortunate enough to have attended may want to be reminded about what he said; I hope that those who were not there will be able to make sense of my notes. There was a lot of information.

 

Dr. Greenberg started by telling us that he lost a patient last Saturday simply because the patient had stopped taking his meds. He is particularly frustrated by preventable losses.

 

I. Some Positive Accomplishments

  A. We’ve taken a fatal disease and made it into a chronic disease.

  B. Life Expectancy of HIV+ vs. HIV-

    1. Back at the beginning of the epidemic, there was a 45 year difference in life

 expectancy.

    2. Now there is around a 10 year difference.

    3. Right now, 50% of people with HIV are over the age of 50.

 

II. He worries about “co-morbidities”:

  A. Brain

    -Ability to think things out

    -Memory

  B. Heart disease

  C. Lung disease

  D. Kidney disease

  E. Liver disease

  F. Non-AIDS-defining cancers:

    -Skin cancer

      Get a skin biopsy if you have a skin lesion.

      KS is rare.

    -Lung cancer

    -Anal cancer

  G. HEP-C

    -There is a cure for HEP-C.

    -Patients who are co-infected with HIV and HEP-C are cured of HEP-C as easily as

    patients who are HIV-.

 

III. Epidemiology is starting to change.

  A. The number of new HIV patients is declining.

    1. This may be due to pre-exposure prophylaxis.

      a. PrEP is recommended for high-risk people (e.g., sexually active) on a daily basis –

      NOT as needed.

      b. Taken daily it is 92% effective.

  B. However, we are seeing a rampant increase in other sexually-transmitted diseases.

    1. Syphilis

    2. Chlamydia

    3. Hepatitis A, B, and C

  C. His colleagues monitor for these things on a regular basis.

  [BTW, there is increasing resistance to gonorrhea meds.]

 

IV. Prevention of these “co-morbidity” diseases:

  A. Immunizations:

    1. Immunizations are second only to clean water in disease prevention.

    2. Flu vaccine:

      a. There are no more “live” flu vaccines.

      b. 30,000 people die per year in the U.S. from flu.

    3. Pneumonia vaccine:

      a. The newest is Prevnar 13.

      b. Everyone should get it.

    4. Meningococcal vaccine:

      a. Meningococcus is a bacterial infection that leads to meningitis (and death).

      b. The CDC recommends that HIV+ people should get the vaccine.

      c. Dr. Greenberg recommends the vaccine for sexually active people - not for people

      in monogamous relationships.

    5. HEP-A and HEP-B:

      a. He recommends vaccine for people who are not already immune.

      b. BTW, about 10% of the U.S. population will not respond to the HEP-B vaccine.

    6. Human papilloma virus:

      a. Most people have already been exposed to HPV.

      b. Vaccine is recommended for people younger than age 26.

    7. Tetanus:

      -Get a tetanus shot every ten years.

    8. Pertussis (whooping cough):

      -Get a pertussis shot every ten years.

    9. Shingles (Herpes zoster):

      a. The current zoster vaccine, a “live” virus, is not very good.

      b. There is an excellent vaccine in Europe.

        -It has not been approved by the FDA.

  B. Colonoscopy:

    1. This is valuable, especially if there is a family history of colon cancer.

    2. Get a colonoscopy at age 50.

      a. If there are polyps, repeat every 3 to 5 years.

      b. Getting a base-line at 50 is a good idea.

    3. There is also an expensive stool test to see if there is a predisposition to colon

    cancer.

  C. Anal Paps:

    1. HPV causes anal cancer.

    2. HIV speeds the release of HPV.

    3. Rectal intercourse is not an issue here.

  D. Stop smoking!

    1. Not smoking prevents 40% of heart attacks.

    2. Controlling blood pressure prevents 30%.

    3. Controlling cholesterol prevents 25%.

    4. Controlling HIV prevents 10%.

    5. Dr. Greenberg is leery about chemicals in e-cigarettes.

 

V. Meds Coming Down the Line

  A. This year: New formulation: Isentress - 600mg. - 2 tabs - 1 per day

    -He is not changing the regimen of his patients who are rock steady.

  B. Early next year:

    1. A new Integrase Inhibitor - 1 tab - 1 per day

      -These drugs are very well tolerated.

    2. A new NRTI

      a. This will probably replace Truvada.

      b. It sends fewer toxins to kidney and bones.

      c. Truvada is still used for Pre-Exposure Prophylaxis.

  C. Next year: A new non-nucleoside med: [Daramery?] - 1 tab - 1 per day

  D. Odefsey - 1 tab - 1 per day - needs to be taken with food:

    1. Dr. Greenberg has not used Atripla for 7 years.

    2. He thinks we have better agents now that have better brain-related side-effects.

      a. Cognitive abilities decreased with Atripla.

      b. Increased suicide may be related to Atripla,

    3. He would change to Odefsey.

  E. “If it ain’t broke don’t fix it” is bullshit.

    1. If he can improve your cognition, he will.

    2. Some meds are more conducive to depression.

      -Take another class of drugs.

  F. A new integrase inhibitor is being developed that will be injected - once a month.

    1. This is still being looked at.

    2. They’re also thinking of an injection every 8 weeks as a prophylaxis.

  G. Another new drug - puts a condom on CD4 cells.

    1. An infusion every two weeks

    2. Only for patients who are out of options.

 

VI. A Functional Cure

  A. HIV spreads to parts of the body where meds can’t reach.

    1. Hiding places include brain, lymph nodes.

    2. The virus sometimes mutates in these sanctuary sites.

    3. The mutations came as a surprise to researchers.

  B. But they are working on drugs that can penetrate into the safe spaces and drive the

  HIV out into the bloodstream - and then block entry to the safe spaces, so that the HIV

  can’t go back in.

    -Then the immune response is stimulated to fight the released virus.

  C. We are at Stage 1 in developing this technique.

    1. Maybe it will be ready in 10+ years.

    2. There are many sites in the world that are studying this.

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