Flu Vaccine 2011-2012 Season

Hi all-

It's that time of year again!

Flu season typically begins in October, peaks in January, and fizzles out by May. So, we haven't seen any cases in our office yet, but we're getting ready. We just got our batch of flu vaccine for the season, and I'm writing to urge you to get yours soon!

Because we are not expecting any big shortages worldwide, the CDC does recommend that everyone get a flu shot this year.

Here's a list of FAQ-type bullet points of issue that I typically get with patients:

• No, you can't get the flu from the flu shot. We are activating your immune system, however, and rarely sometimes people can feel like they're coming down with something for a brief period afterwards, but you won't get the flu from a flu shot
• Yes, you do need to get the flu shot every season. This year's flu vaccine is identical to last years (this is because they expect the same three strains to be the most dominant this season), and even if you got the flu shot last year, you need to get it again this year to boost your immunity. It's unlikely that you have enough antibodies from last year to protect you this season!
• Earlier is better. It takes about two weeks before your body generates protective levels of antibodies, so please consider getting your shot well before you start traveling this fall! It's particularly important for patients with chronic health conditions like diabetes or HIV, or those over 50 years old, to get their vaccination as early as possible before we start seeing the first cases of flu. Also, if you come into contact with kids or the elderly, or patients in general in your line of work, you should get yours early, too!

Make an appointment for your flu shot soon! Just got mine (it was a breeze) :D

Vy Chu, MD

The current syphilis outbreak is very real. Please read.

Hello patients and friends!

Here at Capitol Hill Medical we have noticed an uptick in the number of cases of syphilis cases, and we’ve just received an update from Dr. Joanne Stekler at the Public Health department confirming our fears that we are still in the midst of a worrisome, and worsening, outbreak. Yikes!

For the year, the county is double where it was in terms of new syphilis cases as compared to last year, and we have no indications that it’s going to slow down anytime soon.

So, let me recap some of the most important points about syphilis for all of you, so that you know what we’re up against:


What is syphilis?
Syphilis is a sexually transmitted disease caused by the spirochete Treponema Pallidum. There are various stages of syphilis that occur after someone is infected, mostly dependent on how long someone has been infected.

What are the various stages of syphilis?
Primary syphilis - the first stage, is characterized by a small, painless nodule or ulcer which typically occurs on the genitals but may appear anywhere on the body. This nodule or ulcer may appear anywhere from a week to a few months after someone is infected, but usually within a few weeks

Secondary - after the initial ulcer resolves, a patient enters the second stage, which can last up to several months. Patients with secondary syphilis may exhibit fevers, a generalized rash (it can look like small reddish or brown spots that appear all over your body and, in a telltale fashion, on the palms of your hands and soles of your feet), enlarged lymph nodes, weird patches on the skin of your oral cavity, generalized fatigue or general aches/pains, like from a flu.

Latent - the symptoms of a syphilis infection may seem to disappear, but unless someone is treated, the infection becomes more “hidden” in that the symptoms from the secondary stage disappear, but the infection is still active, and can be for up to decades! This smoldering infection can eventually cause severe damage to your vital organs and anatomy: your heart, your blood vessels, bones, liver, and especially your brain! (this is called “neurosyphilis” and may be characterized by odd numbness/tingling of the skin, or visual disturbances, and even confusion and dementia)

How is syphilis transmitted?
Syphilis is transmitted simply by contact with a syphilis ulcer or infected mucous membranes. Keep in mind that the ulcer is typically painless and can occur anywhere! So if it’s high up on the inside of your cheek, or hidden inside the anal cavity, you may never see it! Thus, syphilis can be transmitted through both oral or anal sex, or even kissing. We’ve even seen cases in the literature of primary syphilis ulcers on fingers. Condom use can reduce the risk of transmission, but you can see how even condoms may not prevent syphilis transmission completely.

How is syphilis diagnosed?
Syphilis is diagnosed with a simple blood test. However, because the blood test looks for antibodies that your body makes against syphilis, and it takes your body weeks to make antibodies, there are often many false negatives on screening tests in early syphilis infections. That’s why it’s so important to go to your provider or an STD clinic if you suspect an infection - someone needs to evaluate you!

What is the treatment for syphilis?
Thankfully, the bacteria that causes syphilis is still exquisitely sensitive to penicillin, but you need a lot of it, so it needs to be given as an injection. Early infections require only one shot! Later infections (over a year, or unknown duration, or late stages) need more than one shot, and in some cases, IV therapy for several days in the worst cases. Our truly penicillin-allergic patients have oral medication options that may suffice. So you can see why we at Capitol Hill Medical insist that you get a syphilis screen AT LEAST once a year. It can save you a couple shots in the butt or more!

A special word to our pregnant, or planning-to-be pregnant patients:
Syphilis can be incredibly, catastrophically dangerous to an unborn child if untreated. Early perinatal care involves a syphilis screen, but please be aggressive about being safe and about screening if you are sexually active while pregnant.

SO, here’s the bottom-line, folks:
Syphilis is out there as we speak, infections seem to be accelerating, and only through education, safe sexual practices, aggressive screening, and appropriate treatment can we hope to stamp out this current outbreak.

Call any of us at Capitol Hill Medical to make an appointment for screening!
(206) 568-6320, or go to www.capitolhillmedical.com and click on “Make an appointment.”

More information is available from our friends at Public Health, who have created the "Syphilis Rising" campaign to spread awareness. Check it out HERE.

-- Vy Chu, MD

New Pre-exposure Prophylaxis (PrEP) study out yesterday, and what it might mean for you...

Dr. Vy Chu:

Hey everyone! By now you may have heard about the new study published yesterday in the New England Journal of Medicine about an HIV prevention strategy called "pre-exposure prophylaxis," or PrEP. Here's a link to the NYTimes article about it.

This post will be dedicated to explaining why this is an exciting development, how it might compliment or enhance the HIV prevention strategies we are using today, and who the study affects most directly. The conclusion might surprise you.

Hopefully, by now you already know about POST-exposure prophylaxis (PEP), whereby someone who is worried about a high-risk sexual encounter can start a triple-drug antiretroviral regimen within 72 hours of the exposure in order to decrease their risk of being infected with HIV. But what you may not know is that the guidelines on PEP were largely formulated based on a small 1997 study that looked at HIV prevention in a very different group (hospital workers who had a workplace exposure such as a needle stick) and who were given only one older medication (AZT). So a lot of leaps of faith had to be made in order to justify modern PEP guidelines.

Today's study was exciting for a couple reasons. For one, it was a pretty big study, and formulated specifically to study the effectiveness of using HIV treatment as a form of HIV prevention in gay men. Second, the researchers took the concept a step further by using PRE-exposure prophylaxis: having the medications already in the bloodstream when HIV exposure occurred. They followed two groups: one group took Truvada (a relatively safe and lower-side-effect HIV combination of two drugs) every day, and the other took a placebo. Both groups were tested regularly and received HIV prevention counseling as part of the study, and both groups were followed for up to two years. The final reason for excitement was the result:

The study found that the group taking Truvada had 44% less HIV infections compared to those who received a placebo. What's even more interesting is, when you examine the Truvada group closely - the people who had higher blood levels of Truvada during the study (and thus were likely taking it religiously every day) had even greater benefit - they were 92% less likely to be infected. So this is a big deal!

But, let's make sure we're excited for the right reasons. Remember that ALL participants in the study received pretty intensive (every four weeks) HIV prevention counseling, and were counseled and reminded to use condoms as the main form of HIV prevention. So these patients were practicing safe sex at rates higher than the general gay population.

My main point here: this study DID NOT compare the effectiveness of Truvada to condom use. In other words, this study by no means is saying that Truvada has any business being the primary HIV prevention strategy for anyone. And it shouldn't be, for a lot of reasons. Remember that there are a lot of STDs out there besides HIV, and only some are curable. Also, Truvada costs about $14,000 dollars a year to take - even people with very good insurance will pay really high copays monthly. And, as far as we know, you need to take this medication every day in order to get the maximum protective benefits. Add in the side effects and possible longterm health effects of taking this drug, and you really start to wonder: who exactly should be taking PrEP?

My thoughts are that this is a very useful and exciting study, but for a pretty limited group, at least in the short term, before more follow-up studies are done. I would say that the best candidates for daily Truvada PrEP are HIV negative gay men who are in relationships with an HIV positive partner. It would afford an enhancement of protection to those individuals, in addition to the safe sex and risk-navigation strategies they are already using.

But the study is worth a conversation with your doctor if you feel this study would apply to you. I've already fielded a few calls and emails from patients wondering if they should be considering Truvada. In general, my answer is: probably not. But having a conversation about HIV risk and prevention is always a good thing to have. Have a visit with your doctor if you have questions. If you don't have a doctor, we here at Capitol Hill Medical are ready to serve - just give us a ring!

-VY CHU, MD


Dr. Rob Killian adds:

Wow - way to go, Dr. Chu, for making the science understandable and for sharing with our community a truly gay physician's perspective. This is such great news and gives us hope that we can work together as patients and doctors to prevent even more HIV transmission in many of our couples and others who are at increased risk. I would second his advice, make this a topic of discussion with your doctor. Understand the risks, the costs and the potential benefits if you feel you would consider yourself a candidate of this prevention approach.

Rob

Hepatitis B vaccination: some things to consider...

Hello patients, friends, and interested readers!

It's been a while since I've posted. Dr. Killian has been so prolific! It's been hard to match - but look for most posts from me from here on out...

Here's an interesting one on Hepatitis B vaccination and immunity:

"My boyfriend and I are both Poz and excellent health. Tcells normal, viral loads undetectable and liver/pancreatic enzymes are great. One thing, he has Hep B and I’ve been immunized for both A and B over two years ago. Should there be a concern about me for both of us? It’s my understanding that once you are immunized then you are good."

This a great question that I get from my patients a lot. Let me start the answer generally and get more specific as I try to answer the poster's question.

Hepatitis B vaccination:

Hepatitis B vaccination has been in place as a universal childhood vaccination since about 1991, so anyone born after that should consider catch-up vaccination if they're not sure of their immunization status. The vaccination consists of three shots given over about six months. There's the first one, then the second one a month later, and then the third one given 5-6 months after that. The Hep B vaccine isn't "ouchy" like tetanus - you may feel a little something as it's going in, but most people will not experience the same shoulder soreness after a hepatitis vaccination as you would with tetanus. If you go through all three vaccinations on the correct schedule, you have about a 90-95% chance of mounting enough antibodies against Hepatitis B to be considered "immune," which brings me to the next section...

Hepatitis B "vaccination" vs. "immunization":

Not everyone who gets vaccinated will be immunized. The vaccination is 90-95% effective, so for the general US population, from a public health point of view, this is good enough. But because patients of Capitol Hill Medical are primarily members of the GLBT community, they are considered a high-risk group when it comes to potential Hep B infection. Other high-risk groups include healthcare workers, IV drug users, patients born in areas where Hep B is moderately or highly endemic (Southeast Asia for example), and spouses of patients chronically infected with Hepatitis B. These high-risk groups should have prevaccination screening done.

Prevaccination screening:

Because there's a chance that these high-risk groups have already been exposed, it has been shown to be cost-effective to do a prevaccination lab test to see if they even need vaccination.

The providers of Capitol Hill Medical will often do prevaccination screening during your first physical exam, which can tell us a few things. In patients who haven't yet been vaccinated, it can tell us if they've been exposed to Hep B and are now immune or not. Or in patients who have been vaccinated, it can tell us if those vaccinations worked, or if those patients need another round of vaccinations.

More vaccinations for Hep B??

The good news is, if the 5-10% of patients who aren't immune after the first round start a second three-shot Hep B series, 60-70% will become immune after the second round. After that, we may have to conclude that your body just doesn't mount an antibody response to Hep B, and are thus at a higher risk of getting a chronic Hep B infection if you are exposed. So, practice safe sex!

Postvaccination testing:

I will often offer post-vaccination screening at least two months after I administer the Hep B vaccination (your body needs that long to generate the long-term antibodies). If you are found to be immune, I will note this in your medical record so that you don't have to have that test run again if you have to move and switch providers. Postvaccination testing is recommended mostly for patients "at high risk for recurrent Hep B exposure" including healthcare workers and spouses of those with chronic Hep B infection. However, I consider anyone in the GLBT population at risk for recurrent exposure, and so my patients get postvaccination screening :)

A quick aside on Hepatitis A vaccination:

I've pretty much ignored Hepatitis A so far, and here's the reason why: the vaccination for Hep A is as much as 99.9% effective, so if you've gotten vaccinated, you're pretty much good to go. Our prevaccination panel at CHM does include a check for this anyways,

Finally, a word on Hep B vaccination in those patients with HIV:

Immunocompromised patients (including chronic dialysis patients and HIV patients with low CD4 counts) might not always mount a robust antibody response to the Hep B vaccination.

So, in response to the original person who asked the question: Because your CD4 counts are in a healthy range (at least now - was it in a good range when you got vaccinated?), your vaccination against Hep B was likely successful, and you needn't worry about getting Hep B from your partner, but if you haven't had your immunity verified, I would do so.

We're still accepting new patients at Capitol Hill Medical for anyone who needs help with vaccination or testing!

Vy Chu, MD

Blow jobs and HIV

I've recently recieved a blow job from a guy who shortly thereafter found out he was HIV positive. I've read that oral is lower risk, but are there differences in risk between giving and recieving for oral?

Rob Kililan, MD responds:

Every public health study among sex who have sex with other men show that the third most common way to get HIV is by being the receptive oral participant.

there is no myth that one cannot get HIV from Oral Sex.


If this just happened you need to page your doctor on call and begin the HIV medications tonight or go to an emergency room. If more than 72 hours have passed since the incident, please contact your physician and plan on being tested in two to three weeks from exposure.

Rob

Warts and transmission...

A lot of HPV questions lately... here's (possibly) another:

"I recently got in bed with a former lover who may've had HPV. He gave no inclination that he may be carrying it, but of course, it was obvious once our clothes were off.

On his testicles there were raised bumps, varying in size, lighter in appearance than his skin tone. Maybe 6-10 of them. At that point I should've really asked him what was going on, but just avoided it. We did some frotting and oral. I'm afraid that I may develop these bumps, though. I had little direct contact with them, with my hand only brushing over them and quickly moving on to other areas.

Is it likely that I've contacted this and is there anything I can do to prevent it/clear it up if it does occur?"

Dr. Vy Chu responds:

Before I answer your questions, let me first point out that the prevalence of HPV in the gay community is upwards of 60-70%, so it's actually likely you've already been exposed before this incident.

But, your description of those bumps sounds suspicious for HPV for sure. The warts caused by HPV are most commonly found on the penis or around the anus, but they can and do appear anywhere, like on the scrotum. They are usually raised bumps and can sometimes have a papilliform appearance (like the bumps are collections of "fingers" of tissue clumped together.

If those were genital warts, you may have been exposed, as HPV is very easily transmitted by contact. Your body may clear the infection on its own, but if it doesn't, it's very hard to predict when you will develop warts, if ever, and thus prevention of outbreaks once infected is difficult.

The Gardasil vaccine can prevent someone from contracting the strains of HPV that tend to cause anal cancer as well as the kind that tend to cause warts, and we're hoping this will be covered by insurance for men in the near future.

Now, as I said before, those bumps sounded like warts, but they may also have been other kinds of STDs: molluscum contagiosum (caused by a virus as well), as well as condyloma lata (caused by syphilis). If you develop any new bumps, please have them checked out. We'd be happy to take a look.

So your questions raise two points that I'd like to end with:
1) Please undergo STD testing regularly, ideally every 6-12 months, and
2) Please please please be an advocate for your own health - ask your partner what those bumps are, ask him his HIV status, try to be as open as you can and encourage your partner to be as well.

Communication is fundamental to good Risk Navigation.

Vy Chu, MD

Anal Dysplasia Clinic in Seattle

Here is a recent question:

"I've noticed in your postings you mention a new Anal Dysplasis Clinic in Seattle, however I can not find a contact for them. I had surgery for removal of warts in January and need a clinic to follow up with since I moved from where I was
I've noticed in your postings you mention a new Anal Dysplasis Clinic in Seattle, however I can not find a contact for them. I had surgery for removal of warts in January and need a clinic to follow up with since I moved from where I was"

Rob Killian, MD Responds:


There are actually two: One at The Polyclinic on Broadway and one at Virginia Mason Hospital.

But, first you must discuss this with your primary care provider and have an anal pap smear and then referral if necessary. If you do not have a provider that does anal pap smears you can sign up with one of our providers. We do them daily.

Rob