Map of life expectancy at birth from Global Education Project.

Wednesday, May 26, 2010

Back to civilization

from the wasteland of Miami Beach. I couldn't post yesterday because a) I actually wanted to participate in the conference instead of writing blog posts about it and b) various women kept plying me with alcohol in the evenings so I was a little bit out of it. Unfortunately, they were only trying to get me to talk.

Anyway, as I reported last time, the HIV pandemic is running away from us, particularly in Africa but probably in some parts of Asia and perhaps Eastern Europe as well. In the U.S., new infections continue at a steady state of around 65,000/year. Up until now, we have been treating most people who engage in care, although that may be about to change -- right now 10 states have waiting lists for their HIV Drug Assistance Programs that purchase drugs for people who have no other way of affording them. About 1,000 people are on waiting lists and that number will likely grow sharply in coming months as states struggle with budget deficits and curtail or eliminate their contribution to the program, which is required to obtain the federal match. For example, Florida is about to start a waiting list, and North Carolina's program is closed to new enrollment with the list expected to grow sharply.

However, even many people who are in treatment fail to achieve suppressed viral loads because they don't take the pills consistently. I haven't been able to find any reliable national estimates (let me know if I've missed something) but from the various studies I've read of clinical populations, somewhere around 30% tend to have detectable viral loads. Since some people are not in treatment, the proportion of people with HIV who have unsuppressed viral loads is obviously a bit higher than that.

Everybody knows that HIV is a life threatening disease, unless they've been listening to psychopaths, but guess what? So is hypertension. The consequences can be just as unpleasant -- renal failure, stroke, heart disease. It turns out that only about 50% of Americans with hypertension have it under control. That actually represents major progress since 1990 and that's how this number is being spun, but really, there's no excuse for it. 72.5% of people with hypertension are no in treatment for it, which I suspect is not that different from the percentage of people with HIV who are in treatment; and about 70% of people in treatment have controlled blood pressure, also not that different.

A few people have really intractable hypertension, mostly because they are very obese; but for most people, two pills a day, maybe three, will do the trick. Full disclosure: I take two, lisonpril and nifedipine, and that totally works. I am absolutely committed to taking them every day; it's just part of getting up in the morning and taking a shower and getting dressed. But lots of people get the scrips and never fill them, or stop taking them. Side effects of these meds are minimal. A few people have side effects from lisonopril and similar drugs, called angiotensin converting enzyme (ACE) inhibitors, but if they just tell their doctors, they can get an alternative prescription. But lots of people don't do it, they just stop.

It's wise to question the conventional wisdom and educate yourself about your own health, but let me tell you something -- if you have hypertension, most of the time, very inexpensive and very safe pills will fix it, if you take them every day. Just do it.


roger said...

lisinopril and hctz. i do it. works for me. i recorded a message telling myself to "take your meds. now!" and my computer plays it every morning at 8 am.

Cervantes said...

Those technical aids can work, but only if you actually want to do it in the first place. That's actually the bottom line for a lot of people.

robin andrea said...

Makes me wonder if 30% non-compliance is a rough constant in the population for drugs that are daily, lifetime treatments. (I am assuming that HIV is an ongoing treatment, and not like a two-week course of antibiotics.)

Cervantes said...

Yes, HIV treatment is lifelong.

In the past, typical rates of adherence to long term treatment have tended to be found around 50%. We actually seem to be doing a bit better recently, perhaps in part because doctors have learned to pay more attention to it. But they still aren't very good at talking with their patients about it. That's what my program of research is all about.