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Andrew Sullivan Does Hit-and-Miss Public Health

May 17th, 2011 No comments

Yesterday, Andrew Sullivan reported on a recent, large-scale study that determined — pretty conclusively, for science — that HIV+ people on antiretroviral drugs were much less likely to transmit the disease to their sexual partners. His “duh” response was dead-on, and not just because it’s obvious. I wrote about this some nine years ago, reporting on a smaller-scale study in Uganda that showed even more impressive results (not one case of transmission among serodiscordant couples).1 So the information has been out there for awhile.

Sullivan may well be correct in his surmise that at least part of the reason that earlier studies weren’t touted by the CDC sooner was fear of more unprotected sex (and therefore a higher incidence of transmission), but it’s also true that large-scale studies of the sort just reported do take years. When the issue is the sexual transmission of HIV, which occurs only rarely (as a percentage matter) even under the riskiest circumstances, and where neither evidence of transmission nor symptoms are immediate, it’s not surprising that it took this long.

After that, though, he makes a series of statements that make my public health sense tingle (not in a good way, but in a Spiderman, danger-sensing way).

First, he calls for sero-sorting, in which HIV-positive men “do their best” to have sex only with other HIV-positive men. Let’s start with what’s good about that statement. One belated move by public health has been to get HIV+ men to own responsibility for their status, and the risk it entails to HIV- men, and (not by the way) to HIV- women. But there’s also a need for disclosure; once that happens, then sero-discordant couples (whether of the one-night variety or of the long-term kind) can negotiate the boundaries of their mutual risk/comfort levels.

But more seriously off-target is this last suggestion:

I wonder what the full effect would be if all men diagnosed with HIV were immediately put on retrovirals and all HIV-negative men were put on a basic anti-retroviral at the same time.

I bet you’d see a sizable decline in HIV transmission.

Some problems: You can’t simply put everyone on retrovirals. Some don’t have access to them  — yes, even here in the U.S., but even more so in most developing nations, where limited funding and daunting logistical problems mean that only those who are really sick have access. Even for those who do have access, though (and let’s assume that’s who he’s thinking about here), there’s the insurmountable issue of personal autonomy. Given the side effects of these drugs and the fact that HIV isn’t infectious in the way that, say, measles, is, there’s no sound justification in law or public health for putting “all men diagnosed with HIV” on these powerful drugs.

More problematic yet is the suggestion that all HIV-negative men be put on a basic anti-retroviral. Here the public health justifications and liberty-compromising justifications are even weaker. All HIV-negative men? Even sexually abstinent eighty-five year olds? Monogamous straight men? Even if he’s not suggesting that these men be compelled to go on the drugs, think of the costs and the side effects in administering these powerful pharmaceuticals to the public and the absurdity of this suggestion becomes manifest.

And why stop at men? Sullivan is writing from the perspective of a gay man (so am I!), and not thinking about other populations that are at serious risk of transmission — notably including poor women of color who are often infected by their male sex partners who, for cultural reasons, don’t know about or don’t disclose their HIV+ status. If we’re going to move in this direction at all (I don’t think we should, and in any case we couldn’t and shouldn’t force anyone to take these drugs), we need to carefully consider the populations really at risk. That’s hard to do, admittedly, but better than issuing a blunderbuss suggestion that “all men” be the targets.

  1. See John G. Culhane, Remarks, in AIDS in National and International Law,  Proceedings of the 96th Annual Meeting of the American Society of International Law, Mar. 13-16, 2002. Available only by subcription.

OK, OK (You Can Use a Condom, If and Only If…)

November 21st, 2010 No comments

The Pope has moved a teensy bit closer to sanity, recognizing that there are cases where condom use might be part of a strategy to reduce the incidence of STDS:

Pope Benedict XVI says that condom use is acceptable “in certain cases”, notably to reduce the risk of HIV infection, in a book due out Tuesday, apparently softening his once hardline stance.

In a series of interviews published in his native German, the 83-year-old Benedict is asked whether “the Catholic Church is not fundamentally against the use of condoms.”

“It of course does not see it as a real and moral solution,” the pope replies.

“In certain cases, where the intention is to reduce the risk of infection, it can nevertheless be a first step on the way to another, more humane sexuality,” said the head of the world’s 1.1 billion Catholics.

It’s a step, but an even smaller one than first appears. Male prostitutes don’t seem especially likely to listen to the Pope. Catholics who are married or in long-term relationships might be swayed, but the advice doesn’t apply to them — at least not clearly. It still seems as though the opposition to birth control trumps all, even a commitment to basic public health.

Of Brain Scans for Alzheimer’s, HIV Tests, and Unintended Consequences

July 14th, 2010 1 comment

Gina Kolata’s article in today’s NY Times discusses a proposed recommendation by medical experts to use brain scans to diagnose Alzheimer’s much sooner than is now possible. In practical terms, this “advance” would likely mean

“a two- to threefold increase in the number of people with Alzheimer’s disease. Many more people would be told they probably are on their way to getting it. The Alzheimer’s Association says 5.3 million Americans now have the disease.”

So, as many as 16 million Americans would have a diagnosis of this scariest of diseases, with untold millions more set off on a course of life-long worrying about an onrushing catastrophe that they can do nothing about. And at a staggering course for the new tests, to boot.

This is terrible public health policy. Aricept notwithstanding, at present there are no good drugs for battling this disease. While there would be research benefits to knowing who the at-risk population is, the article barely mentions the important, countervailing problem of unintended consequences. Dr. Doraiswamy at Duke put it well:

“We ought to be cautious that we don’t stimulate all this testing before we can give people something to manage their disease. There is no point in giving them just a label.”

Yet the guidelines for this testing are expected to be approved in the Fall.

This reminds me greatly of the early days of HIV testing — that decade-plus period when testing was available, but little besides AZT (the equivalent, very roughly speaking, of Aricept) was available to treat it. Elaborate state laws were crafted to manage the problem of delivering the bad news to those infected, including, in some states, a requirement that the grim tidings be accompanied by information about available counseling. (Not that anyone could hear what was being said right then, with all that blood rushing to their head and making a din that would drown out everything.) Many, quite understandably, avoided testing altogether. In the context of an infectious disease like HIV, of course, ignorance of one’s status presented a huge obstacle to reducing the incidence of transmission. So there was a good moral and public health reason to get tested anyway. But the fear of mortal knowledge was too great for some.

In this case, I can see only downside. Alzheimer’s isn’t infectious, so we don’t need to diagnose to protect third parties. There’s no good treatment right now, so the knowledge of early stage disease or, even worse, the likelihood of a future with Alzheimer’s will, for many, have only negative psychological (and resulting physical) consequences. Yes, there are some who think they’d like the information to be able to plan. But do those in, say, their fifties, really need or want to know what’s likely to happen to them in ten or fifteen years?

Do these guidelines need to be approved this quickly? Have these issues been sufficiently considered? And what counseling will be part of the package that accompanies these scary, high-tech tests?

Equality and Backlash in Malawi and Uganda

May 18th, 2010 3 comments

Consider this quote from a gay rights activist:

“Long before we built a movement…, no one bothered about us. We got away with so many things. When we decided to come out and claim our space, society came harshly against us.

“This implies that we are stepping on people’s toes. People hate to see us free and that’s why oppression of LGBT people is on the rise. One of the indicators of a progressive social movement is when its enemies start organising against it.”

While this might be a statement from, say, an advocate for the repeal of DADT or for marriage equality, in fact it’s from a spokesperson for a group in Uganda. This article from the Guardian discusses recent developments in several African countries, focusing on the backlash against the brave men and women who have begun to come out. Perhaps none is braver than Tiwonge Chimbalanga, one half of the Malawi couple about to be sentenced — for up to fourteen years —  for the “crime” of publicly declaring their marital commitment to each other. Said Chimbalanga:

“I love Steven so much. If people or the world cannot give me the chance and freedom to continue living with him as my lover, then I am better off to die here in prison. Freedom without him is useless and meaningless.”

This story (and others involving both governmental and citizen actions against their LGBT communities) would be bad enough, but then there’s this:

“This assertiveness is apparently being met by a ferocious backlash from religious fundamentalists and politicians determined to preserve the status quo. It has been described as a proxy war between US liberals and Christian evangelicals, both of which pour in funding and support to further their cause.”

If this indeed a proxy war, there’s only one side to be on: the one that supports people in their efforts to live authentic and fearless lives. Yes, it’s probably true that some well-meaning assistance has blundered in without sufficient awareness of local cultural and religious norms and mores, but their central argument can’t be countered. And consider the other side’s willingness to simply lie in order to rile people up about the evils of homosexuality. Here’s a comment about evangelical Scott Lively, who visited Uganda last year shortly before the introduction of the “gays must die” bill that has become an international lightning rod:

Gay activists have placed on the web a video of Lively telling a Ugandan audience that he “knows more than almost anyone else in the world” about homosexuality. He says that the genocide in Rwanda was carried out by gays, that AIDS is a just punishment for homosexuality and that foreigners are trying to promote homosexuality in Uganda.

It’s all true. Box Turtle Bulletin has posted three videos from Lively here.

Watch this one for the comments summarized above, and so much more.

Lively tells you that he “enjoys gender normalcy.” (Lucky guy.) He also expresses dismay that the Southern Policy Law Center considers him and his message to be “hate.” Oh, and gays were the spark for Nazism. One correction to the story quoted above: He says only that the “Rwandan stuff probably involved these guys.”

The “Rwandan stuff” was something called “genocide.” And where’s his evidence about the “probable” involvement of gays? He doesn’t have it, but this is about scape-goating and incitement based on pseudo-science (to dignify it). And he ends it with the AIDS comment, which is particularly stupid in a country where most of the infections occur from heterosexual sex.

Lively and his fellows have spilled the blood of gay men, lesbians, and transgendered people — ostensibly in the name of religion. But their lies can’t stand against the simple truth of men like Tiwonge Chimbalanga.

Catching up to Reality on Blood Donations by Gay Men

March 7th, 2010 No comments

When Obama was seeking the Presidency, the GLBT community had a well-defined punch list of action items, and he promised big things on all of them: repeal of DADT; repeal of DOMA (although he doesn’t support marriage equality); passing ENDA; passing inclusive hate crimes law (the only hole punched so far). A few others, notably the administrative implementation of the-then recent repeal of the insane prohibition against HIV-positive immigrants, were perhaps further down on the list, but also up for discussion. Conspicuously absent from the mainstream agenda has been an item of interest to the public health community: lifting of the ban on gay blood donors.

So I was buoyed to see that just a few days ago, a group of sixteen U.S. Senators sent a letter to FDA Commissioner Margaret Hamburg, urging the agency to reconsider its twenty-seven-year-old lifetime ban (“deferral” is the quaint term used, but it’s politely Orwellian in this case) on blood donations for men who have had even one sexual encounter with another man.

The policy is long overdue for an overhaul. As the letter notes, the policy is inconsistent with various other exclusions, and is an artifact of a time when all that was really known of HIV infection — and we weren’t even calling it that, in 1983 — is that it disproportionately struck gay men. Even today, MSM (“men who have sex with men,” which is the term used by the CDC because it focuses on sexual behavior, rather than on orientation) are prohibited, forever, from donating blood if they have had sex, even once, with another man, at any time since 1977. The Senators’ letter points out the many inconsistencies in the policy, including the fact that there’s no exclusion of those who have had high-risk, unprotected heterosexual sex, no matter how recently. Even more absurdly, those who have had heterosexual sex with those known to have HIV are only deferred for one year; not for 33! And “sex” isn’t defined when it comes to MSM: the safest kind of protected sexual acts are, in theory, treated the same as the riskiest.

It should go without saying that none of this can be justified from a public health perspective.

These inconsistencies should be enough to sink the policy which, as the letter notes, has lately been repudiated by the major blood banking organizations, most significantly including the Red Cross. But the problems are much deeper and more serious than even the letter recognizes. A few years ago, I discussed the issue in detail in this law review article. Here, I’ll summarize the arguments I made there that weren’t explicitly raised in the letter.

First, while the CDC is careful to distinguish behavior — men having sex with men — from identity, the FDA policy undermines this sound epidemiological distinction by effectively collapsing the two. By excluding any man who’s had any kind of “sex” (not defined!) with even one other man during the past thirty-plus years, the FDA has created a policy that isn’t about relevant behavior, but about some weirdly expansive view of (gay) sexual orientation. Because if it were about behavior, the line would have been drawn in an entirely different place; say, for a year after specifically identified, high-risk behavior.

Second, the policy undermines trust in public health in a few related ways. Obviously, as a practical matter the policy isn’t enforceable, and the sheer breadth of it has doubtless caused many to ignore it. People aren’t stupid: Gay men who know they have an HIV-negative serostatus might give blood, understanding that they pose no threat. (According to this very unscientific poll over at 365gay.com, almost 200 of 800 respondents admitted to having lied about their sexual practices on the questionnaire.) But by attempting to fence them out, the FDA has sent gay men an unwelcome message that could undermine the community’s trust in other ways. One important public health principle is that it recognizes the long-term value of respecting the dignity of all populations.

Why has the policy persisted for so  long? One argument seems sensible, at first blush: If the exclusion were changed to, say, one year, there would be some infinitesimal increase in the number of HIV-positive blood transfusions (well less than one in a million, it’s estimated), so why do anything to increase the risk? But the “let’s not do anything if there’s a tiny risk of harm” canard — which, by the way, is also prevalent in arguments against marriage equality — wouldn’t be, and hasn’t been, applied to any other category of people, or of conduct. Of course there will be some tiny uptick, not  because of the three-week window period between infection and ability to identify it, which any contemplated new rule would  easily accommodate, but because of the irreducible human error associated with the process: If you add more people, some will get through who should not. But this could be said of any proposal to add donors; it’s just that “MSM” have had such a draconian policy applied to them for so long that the donor baseline is essentially zero for this group.

It seems that uprooting this policy is fairly far down on the priority list for the LGBT community. Indeed, this story seems to have attracted but little attention. But messages matter. The radical, embarrassingly outdated FDA policy sends a terrible signal that ought to concern us. It’s good to see that someone is finally suggesting action. Will Obama back them up?

The Public Health Peril in Oklahoma’s Anti-Abortion Obsession

October 18th, 2009 1 comment

Nan Hunter has just run a good summary of recent legislation in Oklahoma that, taken as a whole, is designed to prevent women from having abortions altogether. The state’s determination shows that, Roe v. Wade not to the contrary, there’s plenty that states can do to restrict what the Court has declared to be part of a fundamental right to self-governance, privacy, and autonomy.

The state’s zeal, though, shows that ideologues on a mission can wreak havoc with settled public health principles, thereby jeopardizing the public’s trust in health care — just in case there’s any such trust left. There are at least two recent examples of this misguided approach.

First, a recent piece of legislation — later declared unconstitutional — required women to undergo an ultrasound (vaginally in the case of early pregnancies) before an abortion could be performed. Such coerced invasion of the body has typically been required only in cases of epidemic; even there, often the resisting party can usually forego vaccination and pay a fine, or suffer the less objectionable deprivation of liberty. This would have been the first case I’m aware of where an unwanted, invasive procedure would have been made a prerequisite for a procedure that someone has a legal right to have, and where that first procedure isn’t needed for some other medical reason. In other words, this is quite different from requiring a biopsy before surgery to remove a tumor.

Laws educating women about fetal development (although also typically a smoke-screen for restricting access to abortions) are OK with me, at least in principle. This weird law, on the other hand, is creepy and offensive, and it’s lucky that the legislators blew it through a technicality (shoving too many subjects into a single piece of legislation).

The second, and more recent example, is a law currently under challenge. This one  would set up publicly available, web-based reports on anyone who obtains an abortion. The information would have to be reported to doctors, who would then be required to pass it on to public health officials. This is a very, very bad idea. I don’t even need to talk about abortion (thankfully!) to explain why.

This law will drive a wedge between physicians and their patients. Many people have distrust of the medical and public health professions, and won’t be warmly encouraged to make that next visit to their provider — or to any other — when they’re met with a battery of identifying questions that can then be used to pick them out of a probably hostile community. As a flimsy subterfuge for the laws’ true intent, names aren’t required — but, as a lawyer from the Center for Reproductive Rights has pointed out, names won’t be needed to identify someone from sufficiently small communities, especially when so much other identifying information is exposed. According to this article, quoted extensively by Hunter, there will be “answers to 34 questions including…age, marital status and education levels, as well as the number of previous pregnancies and abortions. Women are required to reveal their relationship with the father, the reason for the abortion and the area where the abortion was performed.”

It’s clear that the legislators are trying to slap a different kind of scarlet “A” on these women, hoping that the shame and ostracism of expected discovery will keep them from carrying out their intended abortions. It might have this effect, but the more sweeping result will be a lack of trust that will penetrate relationships between patients, doctors, and public health practitioners. Patients will learn how to lie their way around the obviously unenforceable law (some of the facts sought depend on patients’ willingness to disclose, such as “reason for seeking the abortion” and, often, the number of previous pregnancies), and doctors may be less than forthcoming with public health officials if they see them as interfering with the MD/patient relationship. And any public health official with good training will despise and, one thinks, try to circumvent the law.

Even in states that require doctors to report HIV infection to public health, the goal is partner notification and contact tracing to eliminate an established risk. These laws are controversial, but they at least have arguments to recommend them — and the results aren’t published on public websites.

With this level of identifying information, the Oklahoma statute looks more like the sex-offender laws (which have their own problems, btw) than anything else. What more do you need to know?

Promise and Caution: Assessing the New HIV Vaccine

September 24th, 2009 1 comment

It’s all over the news this morning: The U.S. Army (partnered with the Thai Ministry of Public Health and the National Institute of Allergy and Infectious Diseases) has shown a modest, but statistically significant, protective effect from a vaccine against HIV.

Here are the details. The trial, which used a vaccine that is a combination of two others that had failed, involved some 16,000 Thai citizens, and was targeted at a strain of HIV that is common in that part of the world. The result was that those who received the actual vaccine were more than 30% less likely to be infected with HIV than those who’d received a placebo.

As this BBC report (click on 9/24 show) reminds us, there’s a small chance that the disparity is a statistical glitch. In the much likelier event that the result is real (and can be replicated), though, this constitutes a major breakthrough. Even quite recently, one could read only dismal prognoses for the development of a vaccine against HIV — most scientists believed it was far off, if not impossible. It’s fair to say that this latest trial was greeted with a great deal of skepticism, too.

What will this mean? What should we do, from a public health point of view, with a protective effect of about 30%, which is much lower than the 70-80% that researchers typically look for before licensing a vaccine? It depends. Right now, the mechanism by which the vaccine works isn’t understood: For one thing, it’s puzzling that those who became infected received no protective effect from the attempted immunization. Typically, where a vaccine confers incomplete protection, those who become infected have some response to the vaccine, even if it is too weak to prevent infection. So for now, it seems the best course is to work towards better understanding of this vaccine’s mode of operation, thereby to design a better candidate that will confer immunity on a much higher percentage of the population.

If that’s not possible — if this vaccine turns out to be a dead end, with scientists getting stuck at 30% protection — then it will be time to consider licensing it, thereby gaining a significant tool in the prevention arsenal. The vaccine, which requires more than one injection, will then best be seen as part of a comprehensive prevention strategy that continues to emphasize condom use, male circumcision,  education, and the social and economic empowerment of women.  Reducing the percentage of infection by 30% has enormous ripple effects, as those in the protected group are then incapable of passing infection along. Over time, the combination of strategies — with a modestly effective vaccine as a substantial component — can be expected to significantly lower the staggering global costs of HIV; costs that have been measured, for thirty years on, both financially and in terrible human suffering.

Categories: HIV/AIDS, public health, vaccination Tags:

Bubbling Under

July 3rd, 2009 No comments

For reasons probably too psychoanalytically complex to unravel, I was once obsessed with the Billboard HOT 100 chart. And I was almost as obsessed with another chart, known only to savants, called “Bubbling Under,” which listed the next ten or sometimes twenty songs that didn’t quite make the grade. These songs were Kathy Griffin, D-List material, unimportant to almost everyone except the has-beens and wanna-bes who’d recorded them. They must have attacked the mailman each week, ripping Billboard from his hands and tearing through to see if they’d been liberated from chart purgatory.

So it is with the low-wattage cases that arise, every day, because of various public and private actors’ inability or unwillingess to recognize the human beings in front of them. They’re vital to those involved, but generally ignored by even the LGBT community (never mind the general public). Two such cases, summarized in the Summer issue of Lambda Legal Impact, caught my attention this morning. In one, Dr. Robert Franke, a 75-year-old former university provost and Unitarian-Universalist minister, was turned out of his retirement home a day after he’d entered, when the paperwork from his physician arrived, revealing that Franke was HIV positive. Lambda Legal has taken the case, filing a complaint challenging this indefensible decision under a battery of state and federal discrimination and disability laws.

In another case, the Brainless-under-Bush Social Security Administration forever delayed, and then denied, child insurance benefits to one Gary Day, a disabled gay dad.  With the help of a high-octane private firm (McDermott Will & Emery), Lambda Legal eventually secured the benefits — some three years after the request for them had first been made. There was never a legal argument for withholding the benefits, but that didn’t prevent the bad faith delay.  

Such cases underscore the importance of the work that organizations like Lambda Legal are doing, but even their own newsletter devoted just one paragraph to each of these stories, while giving over three full pages to the reaction to Varnum v. Brien, the Iowa Supreme Court’s unanimous decision in favor of marriage equality. Were I writing Impact, I’d likely do the same thing. State-wide victories on key issues (especially marriage, these days) have enormous political, legal, and social consequences, and they keep the money coming in.

And surely marriage equality will make more difficult the kinds of literally unexplained discrimination of the Gary Days of the country. Once all citizens enjoy the same basic civil rights1, it might not even occur to whoever it was in SSA that they could deny a lawful father benefits for his children. 

Marriage equality, though, wouldn’t be likely to do anything to have prevented the treatment Dr. Franke suffered. HIV discrimination, while often closely linked to anti-gay  animus, isn’t the same thing. (Is Franke gay? Who knows, and why does it matter?) His mistreatment is yet another reminder that the swirl of excitement over marriage equality is just one weave of a much larger tapestry that, like Penelope’s, will never be completed.

  1. Yes, we still have to speak in terms of the future, amazingly.

I’m Not Sick, Mr. President

June 12th, 2009 No comments

Here’s Obama’s response to Brian Williams’s question about whether proponents of gay marriage have a friend in the White House:

Translation: No.

Instead, we get the boilerplate about civil unions, benefits — and “the right to visit each other in hospitals”?? After the show, I half-expected an episode of “L.A. Law.” How very late 80’s of you, Mr. President.

Please, can we stop talking about hospitals? Yes, there have been (and even today, continue to be) horror stories of loved ones denied access to hospitals, but is this really a controversial issue today? Even some of the most right-wingnuts support our right to visit each other in the hospital.

And speaking of the late 1980’s, I can’t help noting that the whole issue of the right to hospital visits took on political currency during the darkest days of the AIDS epidemic. There’s always been an uneasy mix of compassion and fear to this discussion. The compassion part was the text; the fear of the diseased “other,” the subtext. I’ve seen more than one AIDS caregiver become lachrymose, years later, when recounting stories of how only they would change the sweat-and-blood soaked sheets of their spouse, son, or brother.  Often the nurses charged with that duty simply refused. So letting gay spouses visit each other in the hospital stemmed in part from a “better them than me” sensibility.

How about a “live” issue? Here’s one that reflects reality today for many gay people and their families: The lack of dignity, transmitted through law and rhetoric, that the children of gay parents have to deal with every day, in ways overt and subtle. If my twin daughters were to say to Maggie Gallagher: “My daddy and papa are married,”  she would respond: “Not in the United States.”1

What would President Obama say to them? It disturbs me that I can’t answer that question.

  1. Her statement was made in connection with her support of a constitutional amendment banning gay marriage, but  is to an extent true even in its absence, because DOMA commits the federal government to the position of non-recognition of gay  marriages, even if valid in the couples’ home states.

Marriage Bans and HIV

June 11th, 2009 No comments

This is interesting:

“In a new study conducted by economists at Emory University, it has been found that banning same-sex marriage raises the U.S. HIV infection rate by four cases per 100,000 people. Using data from the General Social Survey, a popular research tool that has gauged American public opinion for over four decades, Hugo Mialon and co-researcher Andrew Francis found that a widespread increase in tolerance for homosexuality between the 1970s and the 1990s resulted in a decrease of one HIV infection per 100,000 people. Recent controversy over the issue of same-sex marriage has led to a new culture of intolerance say the researchers, which, in turn, leads to riskier sexual behavior.

“’Intolerance is deadly,’ said Mialon, assistant professor of economics at Emory. ‘Bans on gay marriage codify intolerance, causing more gay people to shift to underground sexual behaviors that carry more risk.’ Mialon continues, ‘We found the effects of tolerance for gays on HIV to be statistically significant and robust – they hold up under a range of empirical models.’ Francis adds, ‘Laws on gay marriage are in flux and under debate. It’s a hot issue, and we are hoping that policymakers will take our findings into account.'”

The article also links to the study itself; those interested and with the capacity to do so can read the whole (40+ page) thing and draw their own conclusions about methodology, inference, and conclusion. But at least intuitively, this is a plausible connection. A society that shames behaviors and drives them underground can’t claim surprise when unhealthy outcomes result.