4 ms·

Stem cell transplantation is usually performed by bone marrow transplant, which is a pretty risky procedure: it involves destroying the recipient's own bone mar

by vore 4y ago

Stem cell transplantation is usually performed by bone marrow transplant, which is a pretty risky procedure: it involves destroying the recipient's own bone marrow to introduce the donor bone marrow, which can leave the recipient without significant numbers of white blood cells for a while, making them extremely vulnerable to infection. In contrast, HAART for HIV is far less risky and far more safe, allowing people with HIV to live basically a normal life as long as their viral loads stay at undetectable limits.

torstenvl 4y ago
That's the received wisdom, but it really seems trite. HAART leaves people extremely vulnerable to infection as well, after all. The difference is that HAART means that point will come at some unpredictable point in the future, whereas a bone marrow transplant makes the window more predictable. And beyond that, it fails to consider the risks of decades of really toxic medication. Is a bone marrow transplant really worse than decades of liver damage followed by developing AIDS eventually anyway? Maybe, maybe not, but dismissing the heavy questions of a persons life with "basically normal" is not helpful.
- chimeracoder 4y ago
  > HAART leaves people extremely vulnerable to infection as well, after all. The difference is that HAART means that point will come at some unpredictable point in the future, > And beyond that, it fails to consider the risks of decades of really toxic medication. Is a bone marrow transplant really worse than decades of liver damage followed by developing AIDS eventually anyway? This is an outdated and objectively incorrect description of HAART. > but dismissing the heavy questions of a persons life with "basically normal" is not helpful. "Basically normal" is an approximately correct description of the life of most HIV+ people who have easy access to HAART. What's not helpful is responding to that with fearmongering based on incorrect and/or grossly outdated information.
  - torstenvl 4y ago
    Liver damage is a known adverse effect of both emtricitabine and tenofovir, which are extremely common antiretrovirals, an indisputable fact verifiable by anyone on the Internet. There's a difference between fearmongering and informed consent, and I would ask you to refrain both from spreading misinformation and from making personal attacks. Accusing someone of "fearmongering" for pointing out risks you falsely say do not exist is inappropriate.
    - chimeracoder 4y ago
      > Liver damage is a known adverse effect of both emtricitabine and tenofovir, which are extremely common antiretrovirals, an indisputable fact verifiable by anyone on the Internet. Your comment literally claims that long-term HAART carries a significant (or even certain) risk of long-term liver damage, a claim which is baseless and unsupported. You're also conflating acute adverse reactions - which are astronomically rare - with long-term side-effects, when there's no relationship between the two. Not only are tenofovir and emtricitabine safe for the liver, but they are literally commonly prescribed for people who have chronic liver problems because they are so well tolerated. People who can't take Tylenol are able to take them. It's a gross mischaracterization to suggest that they cause "decades of liver damage", a claim which is soundly contradicted by medical literature. > There's a difference between fearmongering and informed consent, and I would ask you to refrain both from spreading misinformation and from making personal attacks. I never made any personal attack at any point. I would, however, flip this request back at you and ask you to stop spreading misinformation, which is what you are clearly doing. > Your insistence on gaslighting does not lend credibility to your other claims. https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html
      - torstenvl 4y ago
        No. It "literally" does not. Read it again. Your comparison to Tylenol is misleading. People aren't required to receive regular liver enzyme tests before being allowed to use Tylenol. Read the guidelines yourself. Accusing people of fearmongering is a personal attack. If you think I'm wrong (and the FDA is wrong) about the risk of liver damage, feel free to present that evidence here (or better yet, to the FDA, so people can have better access to PrEP). Don't make false and ad hominem claims about my motivations.
- vore 4y ago
  It really is basically normal: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7296391/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7296391/ From 2011 to 2016, overall life expectancy at 21 years of age for individuals with HIV infection who initiated ART at a CD4 cell count of 500/μL or greater was 57.4 years (95% CI, 55.7-59.1 years) and for uninfected adults was 64.2 years (95% CI, 64.0-64.4 years), corresponding to a difference of 6.8 years (95% CI, 5.0-8.5 years) The risk profile for a full bone marrow transplant for treating HIV vs HAART for a difference of ~5-9 years is just not there.
  - torstenvl 4y ago
    > The risk profile for a full bone marrow transplant for treating HIV vs HAART for a difference of ~5-9 years is just not there. According to whom? Who gets to make the choice between 57 years of drugs and stigma versus 64 years of being cured?
    - vore 4y ago
      Of course the patient ultimately decides, but you are really really downplaying the risks of stem cell transplantation: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202970/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202970/ Based on their 2010 alloHCT volume, centers were categorized as low-volume (≤40 alloHCTs; N=42 centers, 1,900 recipients) or high-volume (>40 alloHCTs; N=41 centers, 9,637 recipients). 100-day survival was 86% (95% CI, 85–87%) in high-volume compared to 83% (95% CI, 81–85%) in low-volume centers (difference 3%; P<0.001). One-year survival was 62% (95% CI, 61–63%) and 56% (95% CI, 54–58%), respectively (difference 6%; P < 0.001). You are literally getting a coin flip of surviving past 2 years after an allogeneic hematopoietic stem cell transplant. If I was given the choice of HAART and living a mostly normal lifespan, or maybe die with a coin flip chance in 2 years, I would pick HAART, no contest.
      - chimeracoder 4y ago
        > You are literally getting a coin flip of surviving past 2 years after an allogeneic hematopoietic stem cell transplant. If I was given the choice of HAART and living a mostly normal lifespan, or maybe die with a coin flip chance in 2 years, I would pick HAART, no contest. Not to mention that the "64 years" comparison is not the correct reference point here, because it's talking about people who were never infected with HIV in the first place, not people who have received a stem cell transplant. The stem cell transplant almost certainly reduces both your lifespan and QALS in the long term, not just the first two years. Yes, it might be worth it if you have cancer, but it's not like it suddenly makes you clinically equivalent to a person who has never had HIV!

by vore 4y ago

torstenvl 4y ago

That's the received wisdom, but it really seems trite. HAART leaves people extremely vulnerable to infection as well, after all. The difference is that HAART means that point will come at some unpredictable point in the future, whereas a bone marrow transplant makes the window more predictable. And beyond that, it fails to consider the risks of decades of really toxic medication. Is a bone marrow transplant really worse than decades of liver damage followed by developing AIDS eventually anyway? Maybe, maybe not, but dismissing the heavy questions of a persons life with "basically normal" is not helpful.

chimeracoder 4y ago
> HAART leaves people extremely vulnerable to infection as well, after all. The difference is that HAART means that point will come at some unpredictable point in the future, > And beyond that, it fails to consider the risks of decades of really toxic medication. Is a bone marrow transplant really worse than decades of liver damage followed by developing AIDS eventually anyway? This is an outdated and objectively incorrect description of HAART. > but dismissing the heavy questions of a persons life with "basically normal" is not helpful. "Basically normal" is an approximately correct description of the life of most HIV+ people who have easy access to HAART. What's not helpful is responding to that with fearmongering based on incorrect and/or grossly outdated information.
- torstenvl 4y ago
  Liver damage is a known adverse effect of both emtricitabine and tenofovir, which are extremely common antiretrovirals, an indisputable fact verifiable by anyone on the Internet. There's a difference between fearmongering and informed consent, and I would ask you to refrain both from spreading misinformation and from making personal attacks. Accusing someone of "fearmongering" for pointing out risks you falsely say do not exist is inappropriate.
  - chimeracoder 4y ago
    > Liver damage is a known adverse effect of both emtricitabine and tenofovir, which are extremely common antiretrovirals, an indisputable fact verifiable by anyone on the Internet. Your comment literally claims that long-term HAART carries a significant (or even certain) risk of long-term liver damage, a claim which is baseless and unsupported. You're also conflating acute adverse reactions - which are astronomically rare - with long-term side-effects, when there's no relationship between the two. Not only are tenofovir and emtricitabine safe for the liver, but they are literally commonly prescribed for people who have chronic liver problems because they are so well tolerated. People who can't take Tylenol are able to take them. It's a gross mischaracterization to suggest that they cause "decades of liver damage", a claim which is soundly contradicted by medical literature. > There's a difference between fearmongering and informed consent, and I would ask you to refrain both from spreading misinformation and from making personal attacks. I never made any personal attack at any point. I would, however, flip this request back at you and ask you to stop spreading misinformation, which is what you are clearly doing. > Your insistence on gaslighting does not lend credibility to your other claims. https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html
    - torstenvl 4y ago
      No. It "literally" does not. Read it again. Your comparison to Tylenol is misleading. People aren't required to receive regular liver enzyme tests before being allowed to use Tylenol. Read the guidelines yourself. Accusing people of fearmongering is a personal attack. If you think I'm wrong (and the FDA is wrong) about the risk of liver damage, feel free to present that evidence here (or better yet, to the FDA, so people can have better access to PrEP). Don't make false and ad hominem claims about my motivations.
vore 4y ago
It really is basically normal: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7296391/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7296391/ From 2011 to 2016, overall life expectancy at 21 years of age for individuals with HIV infection who initiated ART at a CD4 cell count of 500/μL or greater was 57.4 years (95% CI, 55.7-59.1 years) and for uninfected adults was 64.2 years (95% CI, 64.0-64.4 years), corresponding to a difference of 6.8 years (95% CI, 5.0-8.5 years) The risk profile for a full bone marrow transplant for treating HIV vs HAART for a difference of ~5-9 years is just not there.
- torstenvl 4y ago
  > The risk profile for a full bone marrow transplant for treating HIV vs HAART for a difference of ~5-9 years is just not there. According to whom? Who gets to make the choice between 57 years of drugs and stigma versus 64 years of being cured?
  - vore 4y ago
    Of course the patient ultimately decides, but you are really really downplaying the risks of stem cell transplantation: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202970/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202970/ Based on their 2010 alloHCT volume, centers were categorized as low-volume (≤40 alloHCTs; N=42 centers, 1,900 recipients) or high-volume (>40 alloHCTs; N=41 centers, 9,637 recipients). 100-day survival was 86% (95% CI, 85–87%) in high-volume compared to 83% (95% CI, 81–85%) in low-volume centers (difference 3%; P<0.001). One-year survival was 62% (95% CI, 61–63%) and 56% (95% CI, 54–58%), respectively (difference 6%; P < 0.001). You are literally getting a coin flip of surviving past 2 years after an allogeneic hematopoietic stem cell transplant. If I was given the choice of HAART and living a mostly normal lifespan, or maybe die with a coin flip chance in 2 years, I would pick HAART, no contest.
    - chimeracoder 4y ago
      > You are literally getting a coin flip of surviving past 2 years after an allogeneic hematopoietic stem cell transplant. If I was given the choice of HAART and living a mostly normal lifespan, or maybe die with a coin flip chance in 2 years, I would pick HAART, no contest. Not to mention that the "64 years" comparison is not the correct reference point here, because it's talking about people who were never infected with HIV in the first place, not people who have received a stem cell transplant. The stem cell transplant almost certainly reduces both your lifespan and QALS in the long term, not just the first two years. Yes, it might be worth it if you have cancer, but it's not like it suddenly makes you clinically equivalent to a person who has never had HIV!