NEW YORK — Doctors report that a gay Canadian man contracted HIV even though he had been taking daily medication to ward off infection, HealthDay News reports.
Based on a genetic analysis of the virus, it was determined that the 43-year-old Toronto resident was infected with a strain of HIV that had become resistant to the anti-HIV drug Truvada, said report author Dr. David Knox. He is a doctor with the Maple Leaf Medical Clinic in Toronto, HealthDay reports in an article that ran in U.S. News & World Report.
However, HIV experts say this does not mean a completely drug-resistant strain of the virus is on its way.
“The number of highly resistant strains for Truvada is still very low,” said Greg Millett, vice president and director of public policy for amfAR, the Foundation for AIDS Research.
“Less than 1 percent of people living with HIV have a highly resistant strain. I do not have a concern that this is the beginning of a huge wave of multidrug-resistant HIV,” Millett said, according to HealthDay.
The Toronto man began taking oral Truvada in April 2013, according to the report published in the Feb. 2 issue of the New England Journal of Medicine. Pharmacy records show he had been taking the drug as prescribed, Knox and colleagues noted. But after two years of successful PrEP, a screening test revealed that the man had contracted HIV, Knox said.
“We looked at the genetics of this particular strain of HIV and proved there were mutations to counter both medications used in PrEP meant to stop the infection,” he said.
The man was not using condoms during sex, Knox said, which is recommended for complete protection against HIV, even for people taking PrEP.
As monkeypox spreads, Delaware looks to expand vaccine access
Those exposed to virus prioritized in limited distribution
The Delaware Division of Public Health on Aug. 4 confirmed the fourth, fifth, and sixth cases of monkeypox in the First State. Less than a month after the state announced its first case of the virus, the spread of monkeypox in Delaware mirrors trends across the country in what the U.S. Department of Health and Human Services has now declared a public health emergency.
Three Delawarean men ages 42, 24, and 19 were diagnosed with the most recent cases of the virus — none of whom reported close contact with an individual diagnosed with monkeypox, and all of whom are now self-isolating.
In an Aug. 4 press release, DPH noted that it intends to expand vaccine distribution, offering vaccines to high-risk groups with or without exposure to the virus.
Currently, the state only offers post-exposure prophylaxis, vaccines implemented after an individual comes into contact with a virus. Those who have had direct contact with individuals with confirmed cases of monkeypox are currently prioritized in the state’s limited post-exposure vaccination.
Groups that might be prioritized upon increased vaccine access include individuals who have had intimate contact with someone diagnosed with monkeypox within two weeks, individuals with multiple sexual partners within three weeks, individuals who have had intimate contact through dating apps, parties or clubs, and individuals who are HIV-positive or are currently receiving pre-exposure prophylaxis for HIV, according to the news release.
Some researchers suggest current monkeypox cases are underrepresented in public health statistics nationwide. Although monkeypox has been declared a national health emergency, Delaware has yet to make a similar declaration on the state level. DPH noted that health officials will continue to monitor public health conditions.
DPH encouraged Delaware residents and visitors to avoid close contact with those who have symptoms related to monkeypox, limiting their number of sexual partners, and cleaning their hands with soap and water or hand sanitizer regularly. DPH also urged those experiencing symptoms associated with monkeypox to contact their health care provider immediately, make a list of intimate contacts in the last three weeks and self-isolate until symptoms subside.
For more information, individuals can contact the DPH hotline for monkeypox-related questions and concerns on weekdays from 8:30 p.m. to 4:30 p.m. at 866-408-1899, or email [email protected]. Information concerning monkeypox prevention programs and resources can be found at de.gov/monkeypox.
Biden names White House National Monkeypox Response Coordinators
Governors of New York, Illinois, California declare ‘States of Emergency’
The White House announced Tuesday that President Biden has named FEMA’s Robert Fenton as the White House National Monkeypox Response Coordinator and Dr. Demetre Daskalakis as the White House National Monkeypox Response Deputy Coordinator.
The president’s actions come as the governors of New York, Illinois and California have declared ‘States of Emergency’ as the case numbers of global cases of infection also caused World Health Organization’s Director-General Dr. Tedros Adhanom Ghebreyesus to declare the escalating global monkeypox outbreak a Public Health Emergency of International Concern.
The White House notes that Fenton and Daskalakis will lead the Administration’s strategy and operations to combat the current monkeypox outbreak, including equitably increasing the availability of tests, vaccinations and treatments.
Both men have extensive experience in infection disease outbreaks and response. The White House statement laid out their qualifications:
Fenton and Daskalakis combined have over four decades of experience in Federal emergency response and public health leadership, including overseeing the operations and implementation of key components of the Biden Administration’s response to the COVID-19 pandemic, and leading local and Federal public health emergency efforts such as infectious disease control and HIV prevention.
Both played critical roles in making COVID vaccines more accessible for underserved communities and closing the equity gap in adult vaccination rates, through the implementation and execution of FEMA mass vaccination sites in some of the country’s most underserved communities, and working with trusted members of local communities to build vaccine confidence.
Robert Fenton currently serves as Regional Administrator for FEMA Region 9 in the American West, with nearly 50 million people in his area of responsibility. One of the Nation’s most experienced and effective emergency management leaders, Robert Fenton has twice served as Acting Administrator of FEMA and led multiple challenging prevention, response and recovery operations throughout his long and distinguished career, including for natural disasters, disease outbreaks, and complex humanitarian operations.
Demetre Daskalakis, a leading public health expert, is currently Director of the CDC Division of HIV Prevention. Widely known as a national expert on health issues affecting the LGBGQIA+ communities, his clinical practice has focused on providing care for the underserved LGBTQIA+ communities. He previously oversaw management of infectious diseases for the New York City Department of Health and Mental Hygiene, one of the largest departments in the nation – including in serving as incident commander for the City’s COVID-19 response.
Both the U.S. Secretary of Health and Human Services and the President’s chief medical advisor issued statements applauding Biden’s actions.
“We look forward to partnering with Bob Fenton and Demetre Dasklalakis as we work to end the monkeypox outbreak in America,” said HHS Secretary Xavier Becerra. “Bob’s experience in federal and regional response coordination, and Demetre’s vast knowledge of our public health systems’ strengths and limits will be instrumental as we work to stay ahead of the virus and advance a whole-of-government response.”
“Bob Fenton and Dr. Daskalakis are proven, effective leaders that will lead a whole of government effort to implement President Biden’s comprehensive monkeypox response strategy with the urgency that this outbreak warrants,” said Dr. Anthony Fauci, Chief Medical Advisor to the President. “From Bob’s work at FEMA leading COVID-19 mass vaccination efforts and getting vaccines to underserved communities to Demetre’s extensive experience and leadership on health equity and STD and HIV prevention, this team will allow the Biden Administration to further accelerate and strengthen its monkeypox response.”
The Centers for Disease Control and Prevention as of Monday reported that there were 5,811 confirmed cases of the monkeypox virus in the United States.
Statement from GLAAD President and CEO Sarah Kate Ellis:
“The White House appointments today reflect the seriousness of the monkeypox (MPV) outbreak and should be a call for all appropriate federal and state officials to urgently commit necessary resources to educate the public and counter MPV. We must get more vaccines to vulnerable people, especially sexually active gay and bi men, and accelerate all efforts to inform the public to track, test, treat and contain this virus as quickly as possible. Bob Fenton’s experience shows this can be done. Dr. Demetre Daskalakis is a longtime LGBTQ and HIV health advocate whose work will be critical to ensure the federal government responds to the needs of the medical community and the LGBTQ community in equitable ways.”
With time, the Monkeypox vaccine provides good protection
In clinical trials, recipients who were HIV negative had an 83 percent immune response 28 days after one dose compared to 98 percent with two doses at 42 days.
A review of academic literature published in the Journal of Internet Medical Research last year determined, when it comes to information about health topics, social media is not the place to turn. (Unless you follow me, of course!) One study found 87 percent of health-related posts contain misinformation. More than 40 percent of posts about vaccines contain incorrect information.
These findings are, perhaps, not surprising. But they are important to keep in mind as we doom-scroll for information about monkeypox.
I’ve already seen a number of posts on Twitter claiming to have monkeypox breakthrough infections after vaccination. One author said they developed a monkeypox rash two weeks after vaccination. While this person’s experience was not likely a breakthrough case, the post brings up important questions. How much protection does a person have after being vaccinated and when? And, as some cities move to a one-dose regimen due to vaccine supply, what does research say about the number of doses needed to protect a person?
Monkeypox rashes and lesions can take up to three weeks to develop after exposure to the virus, which means it is possible the Twitter user mentioned above was exposed before vaccination or shortly after. The time following vaccination and when you are exposed to the virus matters in terms of the amount of protection you have.
Simply put: vaccines do not offer protection immediately after being administered. Remember what we learned when getting our COVID-19 vaccines: no matter which vaccine you received, you were not fully protected until two weeks after the final dose. For the monkeypox vaccine the time to protection is actually longer. Clinical trials indicated it takes up to four weeks for patients to develop strong protection. In fact, two weeks after the first dose, the immune response was just 29 percent! Take extra care during this period to prevent spread.
Now, what about one dose versus two? With limited monkeypox vaccine supply, cities and states should consider limiting doses to one per person to protect more people.
The U.S. Food and Drug Administration (FDA) approved a vaccine, Jynneos, developed by the U.S. government and Bavarian Nordic in 2019 to protect against both monkeypox and smallpox. The FDA recommended a two dose regimen, four weeks apart. This regimen outperformed an older smallpox vaccine (ACAM2000) for producing an immunological response. The Jynneos vaccine also has fewer side effects and is much safer.
Unfortunately, the Jynneos vaccine is in very short supply. Bavarian Nordic, the only manufacturer of the vaccine worldwide, says it can produce 30 million doses of Jynneos annually, meaning with a full regimen less than 15 million patients worldwide will have full protection. That’s why cities like Washington, D.C. and New York have chosen to move to a single-dose regimen. The United Kingdom and some countries in Europe have done the same.
This approach is the right one.
In clinical trials, recipients who were HIV negative had an 83 percent immune response 28 days after one dose compared to 98 percent with two doses at 42 days. HIV positive recipients had a 67 percent immune response 28 days after one dose. It was 96 percent 42 days after two doses.
While that data indicates a two-dose regimen is best, with supplies limited, a one-dose regimen for most people is a reasonable approach. That strategy allows double the group of individuals to be immunized — even though there is slightly lower efficacy. A recent article in Science highlighted this important point. Jynneos’ CEO, an immunologist, said one dose of the vaccine conferred a “robust immune response.”
There is one caveat, however. Based on the clinical trial data, we might need to stick with the original two-dose regimen for people who are immunocompromised or live with HIV (irrespective of immune status).
In the face of what appears to be a public health system in disarray, Americans need to be partners in fighting the virus’ spread. Get vaccinated when available. Individuals who are most at risk should sign up now to receive a vaccine. Second, understand it takes time after receiving the vaccine to develop immunity whether you are HIV positive or not. Understand monkeypox symptoms, the timing of symptoms and how to reduce your risk. And, of course, take care when it comes to social media. Spread truth.
Dr. N. Adam Brown is a practicing emergency medicine physician, founder of a healthcare strategy advisory group ABIG Health, and a professor of practice at the University of North Carolina’s Kenan-Flagler Business School. Previously he served as President of Emergency Medicine and Chief Impact Officer for a leading national medical group. Follow him on Twitter @ERDocBrown.
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