For the first 25 years of the AIDS epidemic, HIV testing was treated differently from all other types of medical diagnostic testing. Formal pretest and posttest counseling was required, and patients had to give written informed consent before being tested. The need for testing was focused primarily on assessment of risk, which required the taking of a detailed sexual and drug use history for which few clinicians had the time, training, or inclination. The rationale for this particular form of “HIV exceptionalism” was mostly historical, dating back to times when concerns about stigma; discrimination; and loss of insurance, jobs, or housing outweighed any modest benefit that might have been derived from early medical care.

Digestive diseases are costly to manage, with annual costs totaling $141.8 billion in 2004 (Figure 1), according to an NIH report. Direct costs associated with digestive diseases jumped from $85 billion in 1998 to nearly $98 billion in 2004. Prescription drug costs alone were $12.3 billion. Indirect costs for digestive diseases more than doubled, from $20 billion in 1998 to $44 billion in 2004, of which $32.8 billion was associated with lost productivity caused by increased mortality.

Genetic studies are slowly leading to a better understanding of certain diseases as well as progress toward individualized drug therapy. Developments in DNA sequencing make it relatively simple to look for allelic (ie, alternative) versions of a gene by examining samples of a specific gene taken from different members of a population (or from a heterozygous individual). Genetic variants that appear in at least 1% of a population are called polymorphisms. With the cutoff at 1%, one does not get sidetracked by spontaneous mutations that may have occurred in-and spread by the descendants of-a single family.

Researchers at Northwestern University, Evanston, Ill, report that insulin, by shielding memory-forming synapses from injury, may slow or prevent the damage and memory loss caused by amyloid b–derived diffusible ligands (ADDLs)-toxic neuroproteins associated with Alzheimer disease (AD). Findings of the study, which provides additional evidence that AD may be caused by a new, third form of diabetes, were published in the February 10 issue of the Proceedings of the National Academy of Sciences of the United States of America.

Financial incentives offered by employers significantly increased rates of smoking cessation, according to results of a study published in the February 12 issue of the New England Journal of Medicine. The study, one of the largest of its kind, was funded by the CDC and the Pennsylvania Department of Health. The CDC reports that smoking costs employers about $3400 per employee annually, or about $7.18 per pack of cigarettes smoked, in health care costs, presenteeism (lost productivity), and absenteeism.

A 37-year-old white woman, previously in excellent health, presented to a local emergency department for evaluation of evolving left-sided weakness and a slight left facial droop.

New guidelines from the Centers for Medicare & Medicaid Services (CMS) that increase the number of compendia health insurers rely on to determine whether a drug use is appropriate will greatly expand the number of off-label uses of chemotherapy agents for which the agency will reimburse.

Levothyroxine is one of the most commonly prescribed medications for the treatment of persons with hypothyroidism and the suppression of thyroid neoplasms.1 Most persons with hypothyroidism require lifelong therapy with levothyroxine.

New data from UNAIDS show that several African countries with a high HIV prevalence have made significant gains in preventing new infections.

Employers and their employees are facing tough times in today’s economy. To stay competitive, employers must scrutinize all areas of business for cost-cutting opportunities, including health care benefits. Consumers, too, face challenges. In October, a Kaiser Family Foundation poll reported that the percentage of consumers who skipped dosages or split pills in the past year to save on medication costs had increased to 22%, up from 19% in April. The percentage of consumers who reported not filling their prescriptions rose from 23% to 27% over the same 6-month period.1

Much of health care today consists of treatment of disease. Few resources are allocated to prevent disease. Many treatments are not delivered optimally because of a lack of patient discipline and insufficient follow-up by physicians and other health care providers.

In August 2008, as part of its Critical Path Initiative, the FDA released a table listing genomic biomarkers that have established roles in determining drug response.1 This initiative, started in 2004, is aimed at identifying “patients likely to benefit from a treatment and patients more likely to respond adversely to a product,” according to the FDA’s Office of Management, Budget Formulation and Presentation.

Clinicians often override electronic medication safety alerts, according to study findings published in the February issue of the Archives of Internal Medicine, indicating that such systems need to be more selective to be truly useful.

Adults in the United States spent more on medications for diabetes and high cholesterol and other metabolic disorders than on any other class of medications in 2006. Expenditures for metabolic agents totaled $38.1 billion, or 18.3% of total outpatient drug expenditures for noninstitutionalized adults 18 years and older. In all, outpatient drug spending totaled $208.1 billion in 2006. Expenditures for the top 5 therapeutic classes accounted for $130.8 billion, or 62.9% of total expenditures. Findings are from the ongoing Medical Expenditure Panel Survey conducted by the Agency for Healthcare Research and Quality.

A health care reform strategy proposed by the Commonwealth Fund Commission on a High Performance Health System relies on insurance, payment, and system reforms that would purportedly improve access, enhance quality, and save $3 trillion in costs by 2020 (if undertaken by 2010). The 122-page report, titled “The Path to a High Performance US Health System,” was released last month and is available at www.commonwealthfund.org.

Although highly effective with a high benefit-to-risk ratio, highly active antiretroviral therapy has a variety of adverse effects, including metabolic, lipid, and bone toxicities. Importantly, renal toxicity has been associated with some of the more widely used agents, specifically from the NRTI and protease inhibitor classes.

The availability of highly active antiretroviral therapy has improved the survival and quality of life of patients infected with HIV. Clinicians are now focusing on the management of metabolic complications and previously unrecognized drug toxicities. The incidence and prevalence of kidney disease are increasing in older HIV-infected patients because of the widespread use of antiretroviral therapy.

In 1998, President Clinton declared HIV/AIDS to be a "severe and ongoing crisis" in the African American community and launched the

THE CASE: A 7-year-old boy has had left ankle pain for 2 days. Neither he nor his mother can recall any recent trauma to the joint. He is usually very active, but he has been unable to bear weight on the left foot and has been resting in bed. His mother reports that he had some tactile fevers, which were transiently relieved with ibuprofen, and that he has been eating and drinking normally. Despite the application of ice and elevation, the ankle has become red and swollen.

This rash erupted on the upper body of a 58-year-old woman in late August. It was mildly pruritic and nontender. The patient had not started any new medications and was not taking photosensitizing drugs. She had Sjögren syndrome; the rest of her history was noncontributory. Subacute cutaneous lupus erythematosus (SCLE) was diagnosed. SCLE typically affects white women aged 30 to 40 years.1 It presents as nonindurated, nonscarring, erythematous plaques with or without a fine scale that may progress into a diffuse, widespread, papulosquamous or annular lesion with central hypopigmentation or telangiectasia.