The Daily Agenda for Sunday, December 6

Jim Burroway

December 6th, 2015

TODAY’S AGENDA is brought to you by:

From The Calendar (San Antonio, TX), December 3, 1982, page 15. (Source.)

From The Calendar (San Antonio, TX), December 3, 1982, page 15. (Source.)

Lollie JohnsonLollie Johnson, a divorced mother of three, owned a number of gay bars and nightclubs in San Antonio, including the Hypothesis Club (1972-1976), The Zoo Club (1974-1979), Faces (1979-1983), and the Noo Zoo Company (1983-1993). She was also active in numerous San Antonio charities, including the Alamo Human Rights Committee, the San Antonio AIDS Foundation, and the San Antonio Tavern Guild. She sold her businesses in 1994, and passed away in 2001 at only 62. Her papers were donated to the University of Texas at San Antonio, which digitized them and made them available online.

An overcrowded ward at Wisconsin’s Mendota State Hospital, 1947.

Wisconsin Sheriffs Call For Indeterminate Sentences for Gay People: 1944. The annual convention of the Wisconsin Sheriffs Association, meeting at Milwaukee’s Schroeder Hotel, passed several resolutions, including one endorsing a bill proposed by the Wisconsin Police Chiefs Association which would mandate medical treatment and indeterminate sentences for gay people, among other sexual offenders, who were charged with disorderly conduct. The problem, apparently, was that the current law only carried light fines and minimal jail sentences.

What the Wisconsin Sheriffs Association was asking for was what would become known as a “sexual psychopath law.” Through much of the 1930s and 1940s, American newspapers found sensational stories in gruesome murders, often of young children, which reporters and authorities attributed to “deviates,” whether there was any evidence linking gay people to the crimes or not. Those newspaper headlines feed the belief that sexual lawlessness was growing across the country. Michigan was the first state to pass a sexual psychopath law in 1935 which required a judge to determine anyone convicted of a sex crime to determine whether that person was “psychopathic, or a sex degenerate, or a sex pervert.” If so found, the judge was to order the defendant to a state mental hospital until the defendant “ceased to be a menace to the public safety because of said mental condition.” How mental health officials were supposed to make that kind of a judgment, the law didn’t say.

By 1967, twenty-six states and the District of Columbia had passed similar laws. Wisconsin’s sexual psychopath law, enacted in 1947, gave broad powers to the local sheriff to place a suspect in detention without a hearing and without a conviction. That law was replaced in 1951 with the Sexual Deviate Act, which required the individual to be convicted of a crime first. In 1954, it was noted that of 22 individuals who were being indefinitely committed under the law, thirteen had been convicted of sodomy. Wisconsin’s Sexual Deviate Act was finally repealed in 1980.

American Medical Association Opposes Gay Cures: 1994. The AMA’s governing House of Delegates adopted a revised policy paper calling for an end to efforts to change sexual orientation. The old position paper titled, “Health Care Needs of the Homosexual Population,” had been adopted in 1981. It read, that “some homosexual groups maintain, contrary to the bulk of scientific evidence, that preferential or exclusive homosexuality can never be changed, these people may be discouraged form seeking adequate psychiatric consultation. What is more important is that this myth may also be accepted by homosexuals.”

But by 1994, the AMA became convinced that the growing evidence showed that whatever disturbance gay people may have felt about their sexual orientation “is due more to a sense of alienation in an unaccepting environment” and called for “nonjudgmental recognition of sexual orientation by physicians.” The AMA also said that “aversion therapy” — which involved showing a gay man, for example, nude pictures of men and shocking them with a jolt of electricity — “is no longer recommended for gay men and lesbians.” It went on: “Through psychotherapy, gay men and lesbians can become comfortable with their sexual orientation and understand the social responses to it.” The new policy paper was adopted without dissent.

20 YEARAS AGO: FDA Approves First Protease Inhibitor for Treating AIDS: 1995. The Food and Drug Administration gave its approval for Saquinavir(marketed as Invirase), the first protease inhibitor for treating AIDS. This approval was notable for two reasons. First, the FDA gave its approval only 97 days after receiving the application for approval, which was in marked contrast to the years that it would have taken under the normal drug approval process. But after several high profile protests (see, for example, Oct 11), the FDA changed its process for approving drugs for treating HIV/AIDS to allow for a significantly accelerated schedule. But the most important aspect of this approval was that Invirase would prove to be the third part of what would soon become a three-drug cocktail which, for the first time since 1981, gave people with AIDS hope for a reprieve from what had been assumed to be a death sentence.

The first component of that three-drug cocktail, azidothymidine (AZT, marketed as Retrovir), was first approved in 1987. AZT was a nucleoside analog reverse transcriptase inhibitor (or “nuke”), which blocked a particular enzyme associated with HIV. It was virtually the only means for fighting the disease for almost a decade, but it’s effectiveness was sorely limited. In November of 1995, the FDA approved another “nuke”, Lamivudine (3TC, or Epivir) which gave doctors a second option for when patients became unresponsive to AZT. But when taken together, AZT and 3TC seemed to offer an additional “punch” for many people than they experienced when taking the drugs individually. When protease inhibitors became available and were used in combination with AZT and 3TC, doctors soon discovered that this combination therapy reduced the amount of HIV swimming around in patients’ blood by about 99 percent. In early 1996, two more protease  inhibitors, Ritonavir (marketed as Norvir) and Indinavir (marketed as Crixivan), joined Invirase on the market, giving doctors more options to choose from for what would be known as the “AIDS cocktail,” or Highly Active Anti-Retroviral Therapy (HAART).

AIDS Diagnoses, Deaths (in thousands).

AIDS Diagnoses, Deaths (in thousands).

Researchers had previously seen too many supposedly promising treatments quickly proved to be ineffective before to get their hopes up too high now. Early reports of a possible breakthrough in 1996 were tentative, but the results soon proved unmistakable. When 3TC joined AZT in 1995 as a viable treatment, there was a noticeable plateau in the number of deaths due to AIDS. But in 1996 when the three-drug cocktail became available, the number of deaths due to AIDS would see its first drop since the epidemic began. And it wasn’t a slight drop either. It was a 20% improvement from the year before. People at death’s door began coming back from the abyss. For some who had prepared to die, finding that they were living again presented an entirely new set of challenges. The emotional whipsaw, dubbed “the Lazarus Syndrome” made restarting a life (including an education, careers, or simply a place to live) that had been systematically dismantled through disease, disability and stigma just one more challenge to surmount while still dealing with the anxiety of wondering whether this combination would soon fail as all of the other treatments had done before.

The three-drug cocktail wasn’t a cure, but the breakthrough was undeniable. Further improvements in HAART resulted in more effective combinations and dosages which made adherence much simpler, reduced some of the more harmful side effects, and more effectively manage viral load. HAART would eventually transform AIDS from a terminal disease to a chronic disease, albeit still a very serious one. More recent research shows that, thanks to HAART, people with AIDS can now expect a nearnormal lifespan, and when their viral load is undetectable, the likelihood that they can pass the virus on to others is reduced significantly. The probability isn’t zero, but it is quite low. “In fact,” says the CDC, “the rate of HIV infection for the HIV negative partners was 96% lower if the positive partner was on ARVs (Antiretrovirals). While we don’t know for sure whether HIV medications will have this huge benefit in preventing HIV transmission between men who have sex with men, or between other types of partners, we think it will. Having said that, it will never be 100% protective for all couples.”

If you know of something that belongs on the Agenda, please send it here. Don’t forget to include the basics: who, what, when, where, and URL (if available).

As always, please consider this your open thread for the day.

David Nelson

December 6th, 2015

Sanquinavir was very poorly absorbed leading to a suboptimal blood level. This resulted ina viral protease inhibitor resistance. Shutting off treatment options for many. Boosting with Retonavir made it a effective drug but too late for many. So the push for early release of sanquinavir was of dubious value for many.

Jim Burroway

December 6th, 2015

Thanks for the details.


December 7th, 2015

One point of clarification, the 96% reduction in risk was not for HIV-positive people who were undetectable, it was (as the quote actually says) for HIV-positive people who were on ARVs. The figure comes from an early report from HPTN 052 (the final figure was actually 93%), a study that was looking at the effect of starting treatment on the risk of transmission. That’s a similar but different question than the effect of having an undetectable viral load on transmission.

The instances where transmission occurred in the study were either before or at the earliest stage of starting treatment, before the virus was effectively suppressed, or when the positive partner was experiencing treatment failure (such as from poor adherence). As this more recent source notes: “Researchers did not observe any HIV transmission during this study when the HIV-infected partner’s virus was stably suppressed by ART.”

There are at least two studies currently underway to evaluate the risk of transmission when HIV is effectively suppressed by treatment. The PARTNER study includes both opposite-sex and male same-sex couples and in preliminary findings announced last year observed no instances of transmission. The Opposites Attract study includes only gay male couples and announced similar preliminary results with no observed transmissions from an undetectable partner.

All of that is just to note that while we love to be able to put a solid, scientific-seeming number to things—and the 96% figure from HPTN 052 seems like such a figure—we don’t yet have a firm number for how low the risk of transmission from an undetectable partner is. It’s quite likely to be on par with the risk of acquiring HIV when using PrEP properly: impossible to rule out but so unlikely and infrequent that we can only estimate the risk.

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