Last week the Centers for Disease Control and Prevention released new recommendations for all physicians for HIV testing.  The new recommendations were generated in response to the fact that of the approximately 1 million Americans infected with HIV, about one quarter have not been tested and are unaware of their infection.  These patients can not take advantage of the many therapies available for HIV infection, and may unknowingly transmit HIV to others.  The CDC hopes that if all patients with HIV can be diagnosed, they can receive appropriate treatment and counseling, potentially slowing the spread of infection.  They also hope that routine testing will remove any stigma associated with testing, so that those who are infected can be tested whether or not they report high-risk behaviors to their physician.  You can read the CDC’s questions and answers about the new recommendations for the general public here.

The recommendations include testing all patients aged 13 to 64 once during any health encounter, whether it be in an emergency department, at their private physician, or at a public clinic.  After that initial screening, patients at high risk of HIV should be tested at least annually.

Persons likely to be at high risk include injection-drug users and their sex partners, persons who exchange sex for money or drugs, sex partners of HIV-infected persons, and MSM [men who have had sex with men] or heterosexual persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test.

Everyone else can be tested as frequently or as rarely as clinical judgment dictates.

So even if it’s entirely inconceivable that you have HIV, the next time I draw your blood for any other reason I’ll ask you if I can add an HIV test.  (Obviously, you can decline.)  I’ll be happy to answer your questions about the test and what a negative or positive result means.

I’ll be very curious to see what impact these new guidelines have on the rate of new HIV infections in the next few years.

Zostavax, a vaccine to prevent shingles, has recently been approved by the FDA and reviewed by The Medical Letter.

Shingles (also called herpes zoster) is a very painful illness involving blisters that occur in a stripe-like pattern on one side of the body.  Shingles can only happen in people who have had chicken pox.  The virus that causes chicken pox, varicella zoster virus (VZV), stays in the in sensory nerve cells of the infected person forever.  As decades pass after the initial illness, our natural immunity slowly fades, and enables VZV to reactivate, causing shingles.  Typically the blisters in shingles resolve after a couple of weeks.  In some people, however, the pain persists for months or even years.  This persistent pain is called postherpetic neuralgia (PHN).  PHN can be debilitating and happens most frequently in older patients.  It occurs to about a third of patients with shingles over 60.  Usually the immune response to an episode of shingles is quite strong, and it is unusual for patients with normal immune systems to have shingles again.

The Singles Prevention Study randomized over 38 thousand adults 60 years of age and older who have had chicken pox to receive either Zostavax or placebo.  They were followed for about three years.  Shingles occurred in 315 vaccine recipients and 642 placebo recipients.  PHN developed in 27 vaccine recipients and in 80 placebo recipients.  That means that 59 people have to be vaccinated to prevent one case of shingles over three years, and 364 people have to be vaccinated to prevent one case of PHN.

The vaccine is indicated for adults 60 or older who have had chicken pox and are not immunocompromised.  I would not recommend it to anyone who has already had shingles.  The biggest unknown factor is the duration of effectiveness, which would determine how frequently it would need to be readministered.

The CDC has not yet made a formal recommendation about Zostavax, but they are expected to do so in the next few months, so I’ll be keeping an eye on their vaccine-preventable diseases page.  In the meantime, shingles is treatable with antiviral medication, and the treatment works best if started within three days of onset of the rash.  So if you get a painful rash, don’t delay seeing your doctor.

The Associate Press reports in this article that 50 people have become ill this week and one has died because of food contaminated with a dangerous strain of E. coli.  The FDA suspects fresh bagged spinach as a possible cause and is advising all Americans not to eat any.

The death occurred in Wisconsin, where 20 people were reported ill, 11 of them in Milwaukee. The outbreak has sickened others – eight of them seriously – in Connecticut, Idaho, Indiana, Michigan, New Mexico, Oregon and Utah. In California, state health officials said they were investigating a possible case there.

The full text of the FDA warning contains the typical symptoms of illness due to this strain of E. coli:

E. coli O157:H7 causes diarrhea, often with bloody stools. Although most healthy adults can recover completely within a week, some people can develop a form of kidney failure called Hemolytic Uremic Syndrome (HUS). HUS is most likely to occur in young children and the elderly. The condition can lead to serious kidney damage and even death. To date, 50 cases of illness have been reported to the Centers for Disease Control and Prevention, including 8 cases of HUS and one death.

So throw away your bagged spinach, and if you feel ill after eating some, please see your doctor.

Last week’s New England Journal of Medicine features an important article by Dr. Thomas Bodenheimer, Primary Care – Will it Survive?  I encourage all of you to read it.

Dr. Bodenheimer starkly presents the looming crisis in primary care.  Patients are waiting increasingly long for shorter appointments, frequently do not understand their doctor’s instructions, and are increasingly dissatisfied.  Primary care doctors are seeing more patients then ever before, for flat or declining reimbursement.  Ironically, this is happening at a time that the number of preventive tests and services that primary care doctors are expected to deliver is increasing.  Not surprisingly, primary care physicians are increasingly dissatisfied, and fewer medical students are choosing primary care.  Just as the baby boomer generation ages and requires more care, there will be even fewer trained primary care doctors.  This is clearly a recipe for a national disaster.

While Dr. Bodenheimer perfectly details the symptoms and the severity of the impending disaster, he never attempts to diagnose the cause, and therefore recommends therapy that is sure to fail.

Why is it that for all other services, from transportation, to housing, to even leisure, Americans are generally satisfied?  Why is it that even those below the median income can typically afford the basics in other services, while the middle class increasingly can not access quality medical care?  The reason is that other services are generally purchased directly while healthcare is usually purchased through a third party.  When we shop for a service ourselves, we find providers who give us great quality at reasonable prices; when we allow middlemen to shop for us we pay them to tell us what services we need and to set the price we’re willing to pay.  Price inflation and decreasing quality is an inevitable consequence of delivering care through third-party payers.  That is why for all other services, insurance is purchased only to cover catastrophes.  You want home-owners insurance in case your house burns down.  You would never want home-owners insurance to cover mowing your lawn.  That would immediately lead to lawn mowers becoming unaffordable, and lawns being neglected.

In any other marketplace customer dissatisfaction would create an irresistible opportunity for a provider to give the customers what they want.  So when Dr. Bodenheimer prescribes

A covenant is needed between those who pay for health care and those who deliver primary care: primary care must promise to improve itself, and in return, payers must invest in primary care.

he misses the point entirely.  Payers investing in healthcare is what brought us to this calamity.  It is patients who must invest.

Like in every other marketplace, informed patients who demand quality and bear the cost of their care will lead us to affordable care for everyone, not just the rich.  You will bear the burden of the coming crisis, and you, not government, not insurance companies, will deliver the solution.