
Alarming surge in drug-resistant HIV uncovered - Guereric
https://www.nature.com/articles/d41586-019-02316-x
======
t34543
I had a scare and took PeP this year. I had to ER shop. First one denied me
coverage and made assumptions. I ended up getting care at a cost of ~$6000 to
my insurance. I paid $270. I have great healthcare but this is obscene. I
don’t want to get sick and die. I was being careful but accidents happen.

~~~
rdl
Are you sure it actually cost your insurance $6k? Usually they have a high
rack rate and negotiate down.

~~~
DanBC
PrEP was pretty expensive. It cost the NHS about £5000 per year in 2017.

~~~
dahfizz
I assume you meant per person?

~~~
martinald
No per year per person. The NHS prescribes it long term for various high risk
groups.

$6000 for a 'one off' course of treatment sounds very expensive.

~~~
chimeracoder
> No per year per person. The NHS prescribes it long term for various high
> risk groups.

The NHS does not prescribe PEP long-term for anyone.

For HIV+ people, it prescribes HAART, which everyone who has HIV should be on.

HIV- people can take PrEP, which is different from PEP and does not include
any NNRTIs.

------
jimbob45
Well, PrEP is a miracle drug that has gone criminally underutilized in the
fight to eradicate HIV. It would be nice to see governments really push it
hard for a change.

~~~
Aloha
PrEP is hard to get, my doctor outright refused to prescribe it to me, they
said they were not comfortable doing so

~~~
jlangenauer
The get a new doctor, one who values your health more than their antiquated
morals.

~~~
swebs
That's a big assumption that the doctor's decision was based on personal
morality rather than the damage caused by side effects, etc

------
jxramos
I always felt like the only way you can eliminate the spread of a highly
adaptive std is to develop a low barrier on-the-spot test administered just
before intercourse at the latest or some point reasonably earlier in a date or
whatever. This would still fail under the dormancy period viruses assume but
it should improve the odds I'd imagine for those connected in one way or
another to promiscuous sexual networks.

~~~
Fomite
That assumes a degree of agency in your ability to refuse sex that is not
necessarily the case in many high prevalence countries.

~~~
londons_explore
It's better to protect one party than neither party...

------
tuxxy
This is why PrEP is so important and everyone at risk should be on it. We need
to spread PrEP use as far and wide as possible.

~~~
roel_v
I know nothing about this topic and I'll admit that I even had to google what
'PrEP' is, and I have a vague feeling I'm stepping into a minefield asking
this question, but who is "everyone at risk" in this context?

~~~
Geimfari
That would be men-who-have-sex-with-men, those with infected partners, sex
workers, and intravenous drug users.

That is a fairly large number of the population that would be placed on an
expensive drug with several side effects.

~~~
nerdjon
I would honestly just say anyone that is not in a monogamous relationship.

Straight men/women can easily have it and one fuckup and you can be infected

~~~
luckylion
> Straight men/women can easily have it and one fuckup and you can be infected

The probability is low though, and apparently there are side effects. We also
don't preemptively dish out antibiotics for similar reasons: they won't do you
any good unless under very specific circumstances and you will likely
experience side-effects. Do no harm.

~~~
nerdjon
yes there are side effects.

But the plan for prep also specifically includes you going into the doctor
every 3 months to not only test for those side effects but also for a full STD
panel. (Source: my husband and me are both on prep)

Just saying that "at risk" people should be trying to prevent this ignores a
large portion of the population to try to stop its spread.

Thankfully a vaccine is in testing now, but if this was a vaccine most people
would probably not question taking it. So why is a pill to protect against
something like HIV so much different?

~~~
luckylion
My point was that "at risk" means "seriously at risk", not "well, you are
theoretically at risk, so better safe than sorry". If you're statistically not
very likely to be infected, the side effects may outweigh the good.

> if this was a vaccine most people would probably not question taking it

Doctors would, or so I hope, not recommend taking a vaccine with serious side-
effects without a reason. You typically don't get vaccinated for Dengue fever
when traveling to Helsinki.

~~~
nerdjon
I can agree with that.

Maybe I should rephrase that, anyone in not in a monogamous relationship (and
having sex) should at least discuss it with their Doctor and see if it would
be worth them being on.

I find it shocking when I am talking to someone and find out they have no idea
that prep even exists.

~~~
armitron
You should further rephrase that to be:

Anyone not in a monogamous relationship that has (unprotected) anal sex with
different men.

Nothing else makes statistical sense. There is such a thing as a precautionary
principle for medicine and it goes against most of what you wish to be.

------
bhouston
Because we haven't eradicated HIV but just slowed it down, it is the perfect
situation for it to develop drug-resistance.

------
tim58
#What -- In several geographically distant third world countries HIV is
becoming antiretroviral resistant in ~10% of cases.

#Why -- No one is _really_ sure. The most popular hypothesis is that it
happens when people go on and off the medicine. Why would people do this?
Shame, access, and some mothers that went on only during pregnancy. WHO
recommended a pregnancy only treatment until ~2015.

#Impact -- These resistant breeds can spread, presumably just like the other
varieties. The people with it have a much worse prognosis than those without.

#PrEP -- All the other parent comments talk about it. Sure, it should be used
more frequently. It's a bit of a pipe dream to see it used in the 3rd world.

~~~
dtornabene
What purpose does the phrase "geographically distant" serve here? Seriously,
why include that? Because, for one thing, while this site was started by an
american, in america, its absolutely read all over the world, and two, HIV
rates are highest in these "geographically distant third world countries".
This is a really strange thing to post.

~~~
roel_v
It meant (to me) that there are several 'pockets' of this happening
simultaneously, it's not some local 'strain' or 'outbreak'. I thought it was a
crucial thing to add, for nuance. Not sure why you're so agitated over this.

~~~
feanaro
I think it's because the poster understood it as saying they were
geographically distant "from us", rather than that they are geographically
distant from _each other_.

~~~
tim58
root comment here. For the record I intended to use the term to imply that
they are geographically distant from each other and the mutation is probably
not from single parent.

------
DanBC
> But drug-resistant HIV might develop when people interrupt treatment, she
> suggests.

[...]

> People living with HIV might go on and off the drugs for several reasons.

They didn't mention the fact that in most countries for most medications
people just don't take meds as they should. We see this for meds that are
crucial to keep the person alive. Many organ transplants fail because the
person fails to take meds correctly afterwards. We see this where patients
need to pay for their meds and further treatment (the US) or where they get
free meds and further treatment (the UK).

This isn't a few percent of people who take meds. It's over a third of them,
maybe about half of them.

It's a big problem.

------
drchewbacca
Won't all drugs targeted at microbes fail eventually? Surely they create a
strong selective pressure which favours the resistant strains.

The wider and more frequently the drug is used the faster this process occurs?

~~~
bluGill
That is a real worry in all areas where chemicals are used to selectively kill
something undesired. It isn't just microbes, weed killers have the same
problems. There is a real worry that in "a few years" (how long is not
defined) antibiotics will cease to be useful and deaths will skyrocket from
things we currently considered minor infections.

There is some hope though: having a resistant trait is only useful if it helps
you survive. Most resistant traits are "costly" to keep around. Thus if we
stop using some treatment - completely stop - in 100 years it will likely
become useful again as those "microbs" without resistance out compete those
with it.

------
dilippkumar
This article in Scientific American’s April 2019 [0] is an excellent article
that introduced me some of the details of HIV treatment.

While it isn’t related to the primary focus of the parent article, it gives
some useful context.

>> At the end of this first stage, the viral load stabilizes at a level that
can, puzzlingly, last for many years. Doctors refer to this level as the set
point. A patient who is untreated may survive for a decade with no HIV-related
symptoms and no lab findings other than a persistent viral load and a low and
slowly declining T cell count.

>> Eventually, however, the asymptomatic stage ends and AIDS sets in, marked
by a further decrease in the T cell count and a sharp rise in the viral load.
Once an untreated patient has full-blown AIDS, opportunistic infections,
cancers and other complications usually cause the patient's death within two
to three years.

>> The key to the mystery was in the decade-long asymptomatic stage. What was
going on then? Was HIV lying dormant in the body? Other viruses were known to
hibernate like that. The genital herpesvirus, for example, hunkers down in
nerve ganglia to evade the immune system. The chicken pox virus also does
this, hiding out in nerve cells for years and sometimes awakening to cause
shingles. For HIV, the reason for the latency was unknown.

...

>> When the researchers reran the experiment, fit the data to the model's
predictions and estimated its parameters again, they obtained results even
more staggering than before: 10 billion virus particles were being produced
and then cleared from the bloodstream each day. Moreover, they found that
infected T cells lived only about two days. The surprisingly short life span
added another piece to the puzzle, given that T cell depletion is the hallmark
of HIV infection and AIDS.

>> The discovery that HIV replication was so astonishingly rapid changed the
way that doctors treated their HIV-positive patients. Previously physicians
waited until HIV emerged from its supposed hibernation before they prescribed
antiviral drugs. The idea was to conserve forces until the patient's immune
system really needed help because the virus would often become resistant to
the drugs. So it was generally thought wiser to wait until patients were far
along in their illness.

>> Ho and Perelson turned this picture upside down. There was no hibernation.
HIV and the body were locked in a pitched struggle every second of every day,
and the immune system needed all the help it could get and as soon as possible
after the critical early period of infection. And now it was obvious why no
single medication worked for very long. The virus replicated so rapidly and
mutated so quickly, it could find a way to escape almost any therapeutic drug.

>> Perelson's mathematics gave a quantitative estimate of how many drugs had
to be used in combination to beat HIV down and keep it down. By taking into
account the measured mutation rate of HIV, the size of its genome and the
newly estimated number of virus particles that were produced daily, he
demonstrated mathematically that HIV was generating every possible mutation at
every base in its genome many times a day. Because even a single mutation
could confer drug resistance, there was little hope of success with single-
drug therapy. Two drugs given at the same time would stand a better chance of
working, but Perelson's calculations showed that a sizable fraction of all
possible double mutations also occurred each day. Three drugs in combination,
however, would be hard for the HIV virus to overcome. The math suggested that
the odds were something like 10 million to one against HIV being able to
undergo the necessary three simultaneous mutations to escape triple-
combination therapy.

>> When Ho and his colleagues tested a three-drug cocktail on HIV-infected
patients in clinical studies in 1996, the results were remarkable. The level
of virus in the blood dropped about 100-fold in two weeks. Over the next month
it became undetectable.

[0]
[https://scientificamerican.express.pugpig.com/2019/03/13/how...](https://scientificamerican.express.pugpig.com/2019/03/13/how-
calculus-was-the-unsung-hero-in-the-fight-against-hiv/)

------
krisalty
I think the scare of the HIV epidemic in the 90s is gone. Just from looking at
how we have progressed thus far, just looking at HIV medication alone, gives
me hope against news like this. Resistance will happen, but we will always
outsmart it.

------
himlion
Probably because homosexuality doesn't fit their 19th century worldview

~~~
bsagdiyev
Or some people take it and engage in risky sexual behavior because they're now
on it. I know more than a few people like that. Not everyone is a backwards
hick, you're just virtue signalling.

~~~
gleb
UpToDate.com:

STI incidence among MSM using PrEP Men who have sex with men (MSM),
particularly those who have indications for pre-exposure prophylaxis against
HIV (PrEP), are at high risk for sexually transmitted infections (STI). In a
study of nearly 3000 MSM in Australia who were initiating PrEP, the incidence
of new chlamydia, gonorrhea, or syphilis over the subsequent year was 92 cases
per 100 person-years [2]. Nearly half of the participants were diagnosed with
an STI during the study period, with 25 percent of participants accounting for
75 percent of all STIs diagnosed; the risk of STI was proportional to the
number of sexual partners and frequency of group sex. These data highlight the
importance of frequent STI screening for MSM using PrEP.

2\. Traeger MW, Cornelisse VJ, Asselin J, et al. Association of HIV
Preexposure Prophylaxis With Incidence of Sexually Transmitted Infections
Among Individuals at High Risk of HIV Infection. JAMA 2019; 321:1380.

~~~
matthewmacleod
We should remember though that what this demonstrates is a high correlation
between PrEP use and risky sexual behaviour. It does not suggest that PrEP use
encourages that behaviour - I don’t doubt that in some cases it does, but it’s
difficult to think it does so generally.

~~~
tallanvor
Honestly, if you ask just about anyone in the community you'll find the
general agreement is that PrEP does result in the decreased use of condoms, so
it's not surprising that there is a general increase of other STDs.

But as more people start using PrEP and get tested regularly due to the
general requirements, it is possible that STD rates will decline, but we're
probably a few years away from seeing that in the statistics.

------
wtdata
PrEP has negative side effects (besides being quite expensive for the state),
condoms on the other side, don't have side effects, and are cheap.

It's a matter of having some sense of personal responsibility really.

~~~
agentdrtran
> It's a matter of having some sense of personal responsibility really.

This exact phrase was used to spin the deaths of thousands of gay men as a
personal failing not many years ago. Stop doing it.

~~~
MaupitiBlue
It is a matter of personal responsibility. Just like obesity, smoking, and
often type 2 diabetes.

