Lancet 7 July 2007 Vol 370

This week’s Lancet is devoted to HIV-1 and in particular to the effect of new anti-retroviral drugs in treatment-experienced patients. If you have such a patient, you might want to dip into the original papers on pp. 29, 39 and 49. But if you have resigned yourself to never being able to remember the difference between lopinavir, ritonavir, efavirenz, duranavir and etravirine, to name but a few, you might just want to skim-read the commentary piece on p.3 – especially for its cheeky criticism of The Lancet’s publication strategy. It ends with the welcome prediction that “The day will come when suppression of the viral load to undetectable levels can be attained by all. We look forward to reading about it in The Lancet – three times over if need be.”

Immunosuppression leads to an increased risk of cancer, and is a common factor in patients with HIV infection and transplant recipients. A team from Sydney looked at the similarities, and found them to be quite striking – both groups have a raised incidence of 20 out of 28 cancer types, including the three AIDS-related cancers, the HPV-related cancers, cancers of the stomach and liver, plus Hodgkin’s lymphoma.

HIV infection continues to be associated with behaviours condemned by religious traditionalists, both Christian and Muslim – sex between men, multiple sexual partners, and intravenous drug use. The idea of pre-exposure prophylaxis is regarded in such circles as the encouragement of sinful behaviour; and like the Spanish Inquisition, they would rather the body were condemned to death than the soul go to Hell – though in most cases, both will do fine. From a rational perspective, stopping the virus entering cells is the ideal way of tackling the HIV problem (see p.81 for a review of HIV entry-blocking drugs) and so people likely to be exposed might do well to have antiretrovirals circulating inside them. There remain, however, difficult issues of cost, potential resistance and so forth which are touched on in this discussion piece.