Wednesday, December 7, 2011

First Week at the AIDS clinic

This week I started shadowing an HIV physician at the AIDS Clinic in the city - the first day I tried driving and quickly discovered it would be a nightmare and is impossible to do for a decent price on a regular basis.  I figured out the BART schedule and the next day I came in that way - I have about a 15-20 minute brisk walk to the hospital, so that gives me a little exercise - I may start packing a change of shoes though in my backpack, don't exactly want to be walking several blocks in semi-heels or boots that are more fashionable than functional.  

As for the actual rotation - again pretty chill.  Most days I don't need to get there until pretty late in the day - 10-ish.  Some days even later - this Thursday I don't need to be there til 1:45pm.  We also get off relatively early.  And I get one day a week completely free, and Fridays he doesn't have patients in the afternoon.  The patients are mostly homosexual men with HIV - they are surprisingly compliant with their regimens - I haven't yet heard him give a lecture about how they need to be better about taking their medicines.

Yesterday I got to accompany him to a nearby hospital pharmacy where we met with a drug rep and my preceptor spoke about a new single dose multi-drug pharmaceutical that was FDA approved recently.  He says he looks at his main role as a health educator, and doesn't try to push one drug over others, that he doesn't speak for companies that wish him to be more heavy-handed in his talks.  At any rate, I got to learn a lot about Complera, and it's predecessor Atripla.  

Here's some of the medico-pharmacologic stuff that you may not be interested in but I will talk about nonetheless.  One of the major challenges with HIV treatment is that there are a ton of drugs, a lot of them have weird side effects, and a lot of the drugs have to be taken at various times of the day, making for a complicated regimen for patients.  Before Complera, there was only one single-dose multiple drug combination pill that could be used in patients with HIV.  Single day dosing is pretty rare in a lot of medications, and combination pills can be extremely useful.  The disadvantage with combination pills is that the dosages are fixed, so you cannot increase the level of drug A in combination ABC, you have to stick with the set dosages of A, B, and C.

Anyhow, a standard regimen for an HIV patient is two nucleoside reverse transcriptase inhibitor (NRTI)  class drugs, plus either a non-nucleoside reverse transcriptase inhibitor (NNRTI) class drug or a protease inhibitor (PI) class drug.  Atripla contained two NRTIs and one NNRTI (Efavirenz).  Efavirenz has a fair amount of side effects.  Anyhow, they came up with a new combination drug Complera, which is the same two NRTIs as in Atripla, but has Rilpivrine in place of Efavirenz - they are both NNRTIs.  Physicians also often add a protease inhibitor (plus a booster drug to increase it's effectiveness).  It was neat hearing about the differences between them, the restrictions.  We also got a free lunch, though apparently there's a new policy that pharmaceutical reps cannot provide catering to their events - another attempt to prevent there from being any "buttering up" to encourage use of the drugs.  I understand but if you are presenting during lunch time, it would be advantageous to provide a lunch...  

We also had a patient who decided he wanted to stop all his antibiotics that were treating him for Mycobacterium avium complex (a different species from Mycobacterium tuberculosis, which causes tuberculosis, and all species of Mycobacteria are notoriously hard to treat).  His reasoning: He has been getting magnetic therapy.  I immediately thought of the Penn and Teller episode about magnetic and other kind of hand-waving snake oil type new age medical treatments that masquerade as medical treatments but really just are, like the title of their show, bullshit.  I don't particularly object to gullible or desperate people trying alternative treatments, but I do object when these unproven, possibly dangerous, treatments are used in place of evidence-based medicine that WILL work!  Hopefully that guy won't have a recurrence of his infection, which may by this time be resistant to the antibiotics he was being treated with before...  

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