Sunday, January 27, 2019

Protection against HIV in a pill

Here’s something really simple you can do to improve your child’s chance of future health and success: make sure he spends plenty of time playing outside.

There are many ways in which this generation’s childhood is different from that of the last generation, but one of the most abrupt contrasts is the degree to which it is being spent indoors. There are lots of reasons, including the marked increase in time spent interacting with electronic devices, the emphasis on scheduled activities and achievements, concerns about sun exposure — and, for many families, the lack of safe outdoor places to play. It’s not just children; adults are spending less time outdoors as well.

Here are six crucial ways playing outside helps children:

1.   Sunshine. Yes, sun exposure — especially sunburns — can increase the risk of skin cancer. But it turns out that our bodies need sun. We need sun exposure to make vitamin D, a vitamin that plays a crucial role in many body processes, from bone development to our immune system. Sun exposure also plays a role our immune system in other ways, as well as in healthy sleep — and in our mood. Our bodies work best when they get some sunshine every day.

2.  Exercise. Children should be active for an hour every day, and getting outside to play is one way to be sure that happens. They can certainly exercise indoors, but sending them outdoors — especially with something like a ball or a bike — encourages active play, which is really the best exercise for children.

3.  Executive function. These are the skills that help us plan, prioritize, troubleshoot, negotiate, and multitask; they are crucial for our success. Creativity falls in here, too, and using our imagination to problem-solve and entertain ourselves. These are skills that must be learned and practiced — and to do this, children need unstructured time. They need time alone and with other children, and to be allowed (perhaps forced) to make up their own games, figure things out, and amuse themselves. Being outside gives them opportunities to practice these important life skills.

4.  Taking risks. Children need to take some risks. As parents, this makes us anxious; we want our children to be safe. But if we keep them in bubbles and never let them take any risks, they won’t know what they can do — and they may not have the confidence and bravery to face life’s inevitable risks. Yes, you can break an arm from climbing a tree — and yes, you can be humiliated when you try to make a friend and get rejected. But that doesn’t mean you shouldn’t try; the lessons we learn from failure are just as important as those we learn from success.

5.  Socialization. Children need to learn how to work together. They need to learn to make friends, how to share and cooperate, how to treat other people. If they only interact in very structured settings, such as school or sports teams, they won’t — they can’t — learn everything they need to know.

6.  Appreciation of nature. So much of our world is changing, and not for the better. If a child grows up never walking in the woods, digging in soil, seeing animals in their habitat, climbing a mountain, playing in a stream, or staring at the endless horizon of an ocean, they may never really understand what there is to be lost. The future of our planet depends on our children; they need to learn to appreciate it.

So try it. Do what our parents did: send your children outside. Even better, go with them. And do everything you can to be sure that every child can do the same. Rain splattered, blurring my view of the Massachusetts state highway. The rental car’s wipers squeaked as they dragged across the windshield. Though I was briefly tempted to turn back, I kept driving. The man with the battery-operated heart had invited me to his home, and I didn’t want to be late.

I am a critical care doctor. Throughout the course of my training, I have learned how to manage a ventilator, how to treat sepsis, how to sort out the causes of renal failure. But what I didn’t learn is what comes after for those who do not die, whose lives are extended by days, months, or even years as a result of our cutting-edge treatments and invasive technologies, which is what led me to Van Chauvin — the man with the battery-operated heart — and his family that rainy Sunday afternoon.

I had met Van a few weeks before as he trundled through heart failure clinic, a sight in a camouflage vest to carry his battery packs, controller unit along his waist. His doctors had directed me to him. When I told Van that I wanted to learn more about life with a partial artificial heart (called a ventricular assist device, or VAD), he smiled incredulously and, with a chuckle, invited me to his home to see what living with a VAD was really like.

Later that day, I had talked with Van’s doctors. They explained to me that Van had initially undergone the surgery to place the VAD with the hope that the device would just be a step on the way to a heart transplant. But Van’s lungs, weakened by years of smoking, got sicker as he waited on the transplant list — and shortly before we met, Van had learned that he was no longer a candidate for a heart. This device, with all its cords and tradeoffs and the possibility of complications, would be the way Van would live until he died.

As I drove, I wondered what Van would tell me about what it had been like to learn that he wouldn’t get a new heart. Maybe he regretted the decision he had made to get the VAD, knowing now that he would never again be able to shower the way he liked, or to go fishing lest the machinery get wet. I wondered if he would be angry, resentful of his current reality.

So I was surprised when I walked into Van’s home (I finally made it, despite the rain and a few wrong turns) and found myself in the midst of what felt like a family gathering in the living room. Van’s sisters had stopped by, as had a niece, one of his daughters with her chubby-cheeked son, even his mother. They wanted to tell me about Van. I didn’t even recognize him at first, as he stepped out from the kitchen with a smile and a steaming tray of potatoes, chives, and sour cream he’d whipped up for the company. “Grab a plate!” he said, beckoning me in. First we would eat, and then we would talk.

Over the course of that afternoon and the many phone calls that followed, I came to understand that I had been wrong about Van. I met him because I wanted to learn what it was to live a life that I perceived as a state of limbo. I thought that the very obvious reminders of living with a battery-operated device — carrying battery packs and sleeping plugged into a wall socket — might have been untenable. But Van told me that he wasn’t angry at all. Once he learned that he was no longer a transplant candidate, he was able to come to terms with his life for what it was. And a big piece of that process of adaptation meant finding ways to do the things he enjoyed, even if he needed to bend the rules.

The summer after we met, which would be the last summer of Van’s life, he even fixed up a boat to take out on the lake near his home. His voice lifted when he told me about the afternoons he spent on the water, catching fish and enjoying the sunshine. In one of our last conversations, he’d invited me to come out with him. I had smiled and thanked him, thinking maybe next summer, assuming there would be time. Though I will never fish with Van, I will remember the lessons he taught me. Van had priorities other than survival, other than living as long as possible. And contrary to what I had assumed, as long as Van could find ways to regain the independent life that his heart failure had taken from him, he could tolerate the cord that connected him to the wall each night. Rather than feeling tethered, as I had assumed, Van found a way to be free. HIV (the human immunodeficiency virus) weakens the human immune system and destroys the important cells that fight disease and infection. A person can get HIV when bodily fluids — including blood, semen, pre-seminal fluid, rectal fluids, or vaginal fluids of a person with the virus — come in contact with a mucous membrane or damaged tissue. HIV can be transmitted through breast milk, or when a contaminated needle or syringe comes into direct contact with the bloodstream.

There is no cure for HIV, but with proper medical care the virus and its effects can be controlled. HIV transmission can be reduced by consistent use of condoms and clean needles. However, another way to protect against getting HIV is pre-exposure prophylaxis, or PrEP.
PrEP is a pill that can help prevent HIV

PrEP is a combination of two antiretroviral medications, tenofovir and emtricitabine, that, if taken every day, can now prevent HIV. The pill (Truvada) is FDA approved. Truvada works by blocking an enzyme so that HIV cannot reproduce and establish infection in the body.

The pill is taken by mouth with or without food. It is best if taken at the same time every day, as this helps establish a routine. Skipping days isn’t recommended. If you forget a dose, take it as soon as you remember. If it is almost time to take the next dose, skip the missed dose and continue the regular dosing schedule. Truvada takes full effect seven to 20 days after starting the medication. It can be discontinued whenever the protection it offers is not necessary (for example, if your risk for HIV or preferences change). Do talk to your doctor when stopping or starting any medication.
Who should consider PrEP?

The following circumstances mean that PrEP may be a good choice and worth a conversation with your doctor:

    if you have had anal or vaginal sex with more than one partner and prefer to use condoms only sometimes or not at all
    if you are a sexually active adult male who prefers male partners, whose HIV status may not be known
    if you are in a relationship with an HIV-positive partner
    if you have recently had a sexually transmitted infection in your anus or vagina
    if you have had sex with people who inject drugs, or if you inject drugs yourself
    if you are trying to conceive with a known HIV-positive partner
    if you have used stimulants, poppers, cocaine, meth, ecstasy, or speed in the last six months.

What about condoms?

Condoms do provide protection against HIV. Unlike PrEP, they also protect against other sexually transmitted infections, and prevent pregnancy when used correctly and consistently.
Does PrEP have side effects?

Overall PrEP is very well tolerated. As with starting any medication, some people will experience side effects such as nausea, gas, or headache. In general, these side effects are mild and tend to improve with time if the medication is stopped. Kidney problems can occur infrequently, and so your doctor will monitor your kidney function with regular blood tests. Some people may experience a mild reduction in bone mineral density. The significance of this is not known, but it tends to stabilize or go back to normal over time.

PrEP does not interfere with most medications including suboxone, methadone, or oral contraceptives, and does not affect sexual performance. While this medication has been used extensively in pregnant and breastfeeding women who have HIV infection, the risk/benefit of using it for HIV prevention during pregnancy or breastfeeding needs to be individualized. Talk to your doctor if you are taking NSAIDs like ibuprofen or naproxen, or antivirals like valacyclovir or acyclovir.
What are the next steps if you think PrEP is right for you?

Make an appointment with your doctor and talk about why you think you would like to take this medication. Your doctor will run tests to check for HIV and other sexually transmitted infections as well as hepatitis A, B, and C, and check your kidney function before starting PrEP. Usually your provider will need to get prior authorization for the medication. Most insurances cover the cost. If your provider is uncomfortable prescribing this medication, ask to be referred to an HIV specialist in your area.

You will need to see your doctor initially after one month and then every three months, when HIV and sexually transmitted infection testing will be repeated. Your kidney health will be monitored via a blood test once within six months, and PrEP must be stopped if the kidneys are adversely affected.

No comments:

Leave a comment