Posts Tagged ‘antiretrovirals’

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.