Posts Tagged ‘HIV’

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.

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?

Public Health Gone Mad! (Manipulations on Abortion and Marriage Equality)

March 15th, 2010 1 comment

Public health has a lot to answer for. Aside from its many justly celebrated triumphs from the mundane (clean water and improved sanitation) to the dramatic (the polio vaccine, the development of antibiotics), it has also been guilty of using people, especially African Americans, as a means to an end. The best-known example of public health gone wrong is of course the Tuskegee Study of Untreated Syphilis in the Negro Male conducted by the Public Health Service (predecessor to the CDC) in conjunction with the Tuskegee Institute. The CDC has a good timeline and explanation of the study here, but the essential point is that the researchers allowed the study subjects’ syphilis to go untreated even after the development of penicillin. The study began in 1932 and wasn’t discontinued until forty years later. Since then, compensation and a national apology have followed, but the damage has been done. Many African Americans harbor a deep, and to an extent justified, distrust of public health authorities.

At its more extreme form, this kind of sour taste spins off theories of vast conspiracies to wipe out the population. During the early stages of the HIV/AIDS epidemic, a rumor that the virus was a plot to cause genocide against blacks had some currency. Even more recently, about half of African-Americans surveyed either believed that HIV was a man-made virus created for black genocide or were “unsure” whether that was the case.1

It should be obvious that such distrust, and such theories, can impede prevention efforts. Nowhere is this more depressingly apparent than in a recent effort by the Georgia legislature to pass what must be the stupidest — just stupidest — bill ever considered in the effort to prevent abortions. Under the proposed law, aborting a fetus because of its race or gender would be a serious crime by a health care provider (not the woman who has the abortion). This piece of cosmic idiocy is being supported by an unlikely coalition of conspiracy-theorists and “traditional” anti-abortionists. A horrifying stew of toxic conspiracy theories can be found at this site, which seems to be a clearing house for several groups claiming, variously, that abortions are being performed on black women because doing so is profitable for abortionists, that abortion is some kind of plot to eliminate African-Americans, and that abortion is a way of controlling the birth rates of blacks (and the poor).

As with many conspiracy theories, this one has some basis in historical fact: This page does offer some useful information and links on the eugenics movement, which not surprisingly targeted African-Americans to a greater degree than the majority population. But the idea that those who are willing to perform abortions — in the face of protests, threats, and often for little financial reward — are part of some whispered effort to control or limit the African-American population is…well, nuts. But it’s this theory that accounts for the idea of punishing doctors for performing abortions: “They’re aborting to get rid of African-Americans! These genocidal maniacs must go to prison!”

How many cases do you expect would be brought, or would be successful? Very few, obviously. But the radical edge of the pro-life wing is willing to abandon principle or reason in service of any law that might possibly cause a drop in abortion rates. The hope is that by adding another threat to abortion providers, the increased in terrorem effect will be enough to drive more of them away from helping women to realize the full range of their options.

Now it’s true that black women abort their fetuses at a much higher rate than do white women. The Radiance Foundation brought forth the numbers on Georgia here, but their effort to dismiss this report by the Guttmacher Institute doesn’t work. The plain fact is that a higher incidence of unintended pregnancies, which is itself caused by deep and systemic inequalities plaguing the African-American population, is a sufficient and much more plausible explanation for the disparity. The author of the analysis had this to say:

Antiabortion activists in minority communities who are trying to protect African American women and Latinas from themselves by restricting access to safe and legal abortion have it backward. They should instead focus their efforts on reducing the disparities in access to quality health care and in health outcomes more broadly. And if they are most concerned about the disproportionately high abortion rates, they should begin by advocating for improved access to high-quality contraceptive services to reduce the disproportionately high rates of unintended pregnancy in these communities.

But the Operation Rescue crowd will take whatever allies, and whatever arguments, they can get.

Distrust of public health shouldn’t lead to an abandonment of the scientific and population-based tools that public health uses; principally, epidemiology. But the inability or unwillingness to use public health where convenient is common. Let me finish this long post with a quick note on another disturbing case, this one from Iowa. Here is a statement from the President of The Iowa Family Policy Center:

“The Iowa Legislature outlawed smoking in an effort to improve health and reduce the medical costs that are often passed on to the state,” said Chuck Hurley, president of the group. “The secondhand impacts of certain homosexual acts are arguably more destructive, and potentially more costly to society than smoking.”

He continued: “Homosexual activity is certainly more dangerous for the individuals who engage in it than is smoking.”

Hurley was relying on a recent CDC report on the disturbing incidence of HIV and syphilis on MSM (men who have sex with men). And these statistics are disturbing. But will his solution — rolling back marriage equality in Iowa — do anything to fix the problem? And is he right on the smoking comparison? No and no. And this shows that talking-head ideologues should try public health only at home, to twist a well-worn phrase.

Gay men in stable relationships are less likely to have multiple partners than those who aren’t in such relationships. The more partners, the higher the likelihood of STDs. Marriage improves stability, as its proponents tirelessly remind everyone. (And by the way, he makes no case against lesbians.)

As for the smoking comparison? He has no evidence — none — for the assertion that homosexual activity is certainly more dangerous to the individual than smoking. But who needs evidence when demonization will do?

  1. As the survey shows, they’re not the only ones with this belief, but the percentages are highest among African-Americans, and, according to some studies, Latinos.

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.