Good news from DC
February 3rd, 2016
Over the past several years, the city government of Washington, DC, has dedicated itself to a comprehensive and concerted effort to reduce the number of new infections of the human immunodeficiency virus (HIV). It appears that the effort is working. (Blade)
A preliminary version of the city’s annual HIV/AIDS Surveillance Report shows that newly reported HIV cases in D.C. during 2014 declined for the seventh consecutive year.
The report, which the D.C. Department of Health released on Tuesday, shows there were 396 new HIV cases in 2014, a 29 percent decrease from the 553 new cases reported in 2013.
Whitman-Walker Executive Director Don Blanchon said the declining number of new HIV infections in D.C. reflects the value of community wide testing, treatment on demand and prevention efforts that include pre-exposure prophylaxis or PrEP, which involves providing a daily “prevention pill” to people who are HIV negative.
“Simply put, it is saving peoples’ lives and reducing new infections,” he said. “Today’s update reaffirms that we are on the right path to getting to zero new infections in a given year.”
We appear to now be in possession of the tools that we need to end the HIV/AIDS pandemic. Combining testing with TasP (Treatment as Prevention) and PrEP (pre-exposure prophylaxis) and treating the virus as a public health matter instead of a behavioral matter are the steps that are working in the nation’s capital. As the social acceptance of PrEP increases (as it has tremendously in Los Angeles over the past year), we should expect to see even more improvement in the upcoming year.
World AIDS Day
November 30th, 2015
Today is World AIDS Day, a time to reflect on lives lost and opportunities diminished. It is also a time to look forward to ways to eliminate this human immunodeficiency virus and reclaim the health of not only the LGBT community, but other communities ravaged by the HIV/AIDS pandemic.
Six AIDS Researchers, Advocates Confirmed Dead on MH17
July 19th, 2014
An earlier report from The Australian placed that toll at 108, but this morning Malaysian Airlines released its official manifest which confirms that six AIDS researchers and advocates were on board MH17 on their way to the International AIDS Conference in Melbourne when it was shot down over eastern Ukraine:
Malaysian Airlines has confirmed six HIV/AIDS researchers and advocates were among those who were on an airliner that pro-Russian separatists apparently shot down over eastern Ukraine on Thursday.
Joep Lange, a prominent Dutch HIV researcher who is a former president of the International AIDS Society, which organizes the biennial International AIDS Conference, and his partner, Jacqueline van Tongeren, were among the 283 passengers and 15 crew members who were on Malaysian Airlines Flight 17 from Amsterdam to Kuala Lumpur.
A passenger list that Malaysian Airlines released on Saturday also confirms Pim de Kuijer, another Dutch national who worked for Stop AIDS Now, and Glenn Thomas, a former BBC journalist who was a press officer for the World Health Organization, were also on Flight 17.
The airlines has also confirmed Lucie van Mens, another Dutch HIV/AIDS researcher, and Martine de Schutter, a program manager for Bridging the Gaps, were on the flight.
Report: More Than 100 AIDS Activists Were On Board Aircraft Shot Down Over Ukraine
July 17th, 2014
The Australian is reporting that among the passengers of Malaysian Flight 17 that was shot down over Eastern Ukraine were as many as 108 AIDS activists who were flying to Melbourne in Australia to attend the 20th International AIDS conference. That conference is set to begin on Sunday.
Among those thought to have been killed was prominent Dutch researcher Joep Lange, a former president of the International Aids Society. Glenn Thomas, a World Health Organisation media relations coordinator, also died in the crash, according to Dr Haileyesus Getahun, coordinator of the WHO’s Global TB program. Delegates Lucie van Mens, Martine de Schutter, Pim de Kuijer and Jacqueline van Tongeren were also reportedly on the flight. Dr Van Mens, director of program development and support at the Female Health Company, has been involved in public health, focusing on prevention of STIs and HIV/AIDS, since 1995.
The Australian Broadcasting Corporation tweeted that MH17 was due to change its flight number after landing in Kuala Lumpur to MH129 before proceeding to Melbourne.
— ABC News (@abcnews) July 17, 2014
Malaysian flight in Ukraine included many AIDS researchers/activists
July 17th, 2014
Buzzfeed is reporting that the Malaysian flight which may have been shot down by Russian forces in Ukraine included a number of prominent AIDS researchers and activists traveling to the AIDS 2014 Conference in Australia. Confirmed so far include Joep Lange, prominent HIV researcher from Netherlands and Glenn Raymond Thomas, a Geneva-based spokesman for World Health Organization.
Vancouver Hospital Shuts AIDS Ward
May 29th, 2014
Vancouver, with San Francisco, Los Angeles and New York, was an early epicenter of the AIDS crisis in North America. At its height in 1997, about one person was dying per day in Vancouver, and ward 10C of St. Paul’s Hospital saw the lions share of those deaths. But no more:
St. Paul’s Hospital has shut down its dedicated AIDS ward, saying they no longer have enough patients — and the end of AIDS is in sight. …
“It was not that long ago that HIV/AIDS was a death sentence and those who came to this ward at St. Paul’s were here to die,” said Dr. Julio Montaner, director for the BC Centre for Excellence in HIV/AIDS. “Today, ward 10C will provide treatment, support and care for those living with HIV-related issues. We have worked hard to make this day happen and I commend everyone who has supported our efforts.”
Arkansas school bans kids suspected of being HIV positive
September 15th, 2013
Turns out that some idiot school superintendent in some podunk town in Arkansas seems to think it’s mid-80’s all over again and has banned three siblings from attending the local school until that take an HIV test and give him the results.
The Disability Rights Center of Arkansas, Inc. (DRC) claims the Pea Ridge Public School District has removed three siblings from school, two of whom have disabilities.
The group claims the students have been denied the right to attend school until documentation is provided that they are not HIV positive.
“The actions taken by the Superintendent of Pea Ridge School District are appalling and is reminiscent of times past and the case of Ryan White,” says Tom Masseau, Executive Director of DRC. “The fact that the foster families have to provide documentation that the children are HIV negative before entering the school is unlawful and immoral. Further, the fact the school’s attorney authorized this unlawful act is at best appalling. It stigmatizes individuals with disabilities or their “perceived” disabilities as there is no indication these individuals have HIV. There is only an unlawful fear that they do.
Other than that being likely illegal, it’s colossally stupid.
Not only is HIV a fragile virus that cannot exist outside the body and cannot be transmitted through casual contact, today’s medications make most infections so low in viral count as to be theoretically non-transmittable through high-risk sex*. There’s a greater danger of school children of being trampled by a buffalo stampede than there is from these children.
But stupidity and petty authority will always give us gems like this decision by Superintendent Rick Neal.
* – NOTE: The notion of non-transmissible viral loads is controversial and the science is not fully conclusive. There are documented cases in which HIV was transmitted even with a low plasma viral count and the CDC recommends condom use even when both the plasma and genital fluid viral loads are low.
Home HIV Test now available
September 26th, 2012
Tomorrow is National Gay Men’s HIV/AIDS Awareness Day. So it’s appropriate to announce that the OraQuick home HIV test is now available at CVS, Rite-Aid, Walgreens drugstores, along with Kroger and Walmart. And if it hasn’t been distributed to your local store, you can get it online directly form OraQuick.
Although it’s priced a little higher than I was hoping, at $39.99 it is still affordable to many who should get tested but who are either afraid of the intrusive and highly personal questioning that some testing centers employ or who never find a ‘convenient time’ to get to a center.
And for those who don’t have an extra $40 (and unknown HIV infection disproportionately impacts those who are less economically advantaged), in a week I’ll revisit my suggestion for a new October tradition.
The Republican Convention, circa 1992
August 29th, 2012
20 years ago, at another Republican National Convention, Mary Fisher stood up to say that “the AIDS virus is not a political creature” and challenged her party to see her as “one with the lonely gay man sheltering a flickering candle from the cold wind of his family’s rejection.”
It’s not far-fetched to believe that George W. Bush’s record on worldwide HIV/AIDS (called PEPFAR, the “President’s Emergency Plan For AIDS Relief”) was partly inspired by this amazing speech given when his father was up for re-election. In 2012, however, “HIV” and “AIDS” do not exist in the party platform in terms of US-based efforts (PEPFAR’s focus is Africa); instead, where the platform mentions publicly-funded research it says that “research must consider the special needs of formerly neglected groups” and lists things like “breast and prostate cancer, diabetes and other killers.” If HIV/AIDS were implied here, it is at the very least unclear and, by any reckoning, an obvious repudiation of Mary Fisher’s call to action.
This year, the Log Cabin Republicans in their most recent National Update in July had this to say:
As Republicans it is time to recommit to the defense of life and liberty and renew the fight against the HIV/AIDS epidemic. This month the International AIDS Conference was held in Washington, DC, focusing on the need to fight complacency, particularly among gay and bisexual men. Despite medical advances, LGBT minorities continue to be devastated by the crisis. While GOP leaders work to rein in government spending, funding for HIV/AIDS programs should remain the priority they were to the Bush administration.
Strong words and yet, thus far in Tampa, not a word has been breathed about HIV/AIDS. The focus for LCR in addition to a full page ad in Tampa has instead been on marriage equality.
Dr Semugoma (a.k.a. GayUganda) on LGBT Invisibility in the Fight Against HIV/AIDS
August 9th, 2012
Yesterday, I posted a video interview of Dr. Paul Semugoma (many of you know him as GayUganda) talking about the challenges of confronting HIV/AIDS in a country with such rampant homophobia that it is dangerous for LGBT people to disclose themselves to their doctors. Dr. Semugoma also spoke at a plenary session at the International AIDS Conference in Washington D.C. on July 27, discussing “The Dynamics of the Epidemic in Context,” the particular context being that in many governments around the world are unwilling to address the reality that gay men exist in their countries.
In addition to the video above, you can find an error-laden transcript of his talk here(PDF: 160KB/55 pages). While Dr. Semoguma had come out in Facebook and other social media, this was his coming-out moment, quite literally, on the world stage (at about the 3:15 mark):
Men who have sex exist with men, everywhere. You know, it’s kind of interesting to start like that. When we talk about men who have sex with men, actually I am also a man who has sex with men. [applause.] It’s a major and important point to point out that men who have sex with men exist everywhere. If we say that they don’t exist then we don’t know how to deal with them, we don’t know how to get to the challenges that we have in HIV prevention with them.
He then described a pivotal moment in his life which showed him that the epidemic would never be dealt with successfully unless gay and bisexual men are included in HIV-prevention messages (at about the 4:35 mark):
I want to tell you a story about the patient who changed my life. This was in 2004. I was by then a medical doctor. I had studied in two medical schools, that is at Muhimbili Medical Center in the University of Dar es Salaam and I had also studied at Makerere University. I had a bit of work up country, and then I’d gone back to Kampala, which is the capital city of Uganda, to start work in private practice.
As I said, I’m a gay man. I had been dealing with HIV amongst Ugandans and I knew it was a disease that is spread by sex, but I had not been confronted by then by the fact that HIV is also spread by gay sex. I didn’t have that link. So I was faced by this guy. He was gay. I knew him. He had bisexual practices meaning he used to sleep with men and at some point in time he had slept with women. And He had been recently diagnosed with HIV.
One of the things that he told me was, “One of my lovers must have slept with a woman.” I was like, “You didn’t sleep with a woman at this particular point, you must have got it from your lover.” But his point was since I’ve been seeing all these nice photos of men and women and the government telling us, “Be careful, love carefully.” These are the ones who spread HIV; it is the women who give it to us. But he also asked me a question: how do I protect my lovers? And that was the question that changed my life. I knew at that particular moment that I didn’t know how to protect him, how to give him the information, how to tell him to protect his lovers, and that was the changing point because I then discovered that because I didn’t know, I was ignorant. I was in sort of denial because I was a gay man and I am still a gay man. I just needed to know.
I had access to the internet and I quickly educated myself, something which we all have to do. It is important that we leave from being just friendly to MSM, to men who have sex with men, to being competent in care. [applause]
This ignorance and denial it didn’t happen just with me. It is also with everybody. Just a few months ago, about three months ago in Uganda the first LGBT clinic was opened by one of the groups, one of the LGBT groups. They were saying that, well, we do not have a clinic, the doctors don’t really know the problems that we have and we need a clinic. They got funding (very good) put the clinic in Kampala (very good) and then made sure that the government
Then, what touched me was that three doctors were asked in Uganda. “What do you think about this?” They were saying, “We do not discriminate because we are doctors,” which is fantastic. Then, they said, “We do not discriminate because we do not ask about sexual orientation.” Now, if you do not ask about sexual orientation then that means that you are not aware that men who
have sex with men actually come and sit with you in the consultation room, and that men who have sex with men actually have a higher risk of HIV. [ applause]
This ignorance is part of what is there. We have to ask ourselves the question. Are we going to an AIDS-free generation without including MSM? Actually the answer from the science that we have is that no, we are not going to do that.
Dr. Semugoma then gave an overview of the populations most at risk, including not only gay men, but also within the gay community, black gay men. And he also discussed the general problems of reaching “pariah” communities in different countries, including here in the U.S., Canada, and Britain. He then returned his attention back to Africa and the structural barrier that those of us who have been following events in Uganda are all too aware of: criminalization (at about the 15:00 mark):
Criminalization. I have heard this over and over again. You are dealing with a criminal population and the criminal population somehow seems to not be citizens, somehow seem not to fit to have intervention, somehow they just don’t seem to deserve the attention that others get even in HIV prevention.
This is the relationship between criminalization and sex practices. Untargeted expenditure. This is for HIV programming. We saw that HIV burden is actually higher amongst MSM but what actually happens when the monies for HIV
prevention go to the countries there’s attenuation. Less and less gets to the MSM because of the stigma, because they are criminals.
…This case study is of Senegal. Senegal is a country in West Africa has an epidemic which is concentrated amongst MSM. They actually were one of the first African countries to do an MSM-targeted HIV prevention effort. They did a study, which I was very happy to come across in 2004. They saw that they have a concentrated epidemic with HIV 20 times higher amongst the MSM than in the general population. They did comprehensive outreach in place for MSM.
In 2008, we had this ICASA, ICASA is the equivalent of AIDS meeting for Africa. During that ICASA, they actually came to tell the rest of the country about what was happening that they are doing some HIV prevention amongst the highest risk population in Senegal. After ICASA, nine outreach workers were arrested and prosecuted. They were released April 2009. They had been convicted of spreading homosexuality most likely. The issue was that happening actually almost destroyed the HIV outreach amongst the highest risk population in Senegal.
Now, let’s talk about my country, Uganda. Uganda had a study done in 2008, a study done in Kampala. The HIV rate was almost 14 percent, but it’s 13.7 percent amongst MSM in Kampala, compared to a rate of 4.4-percent amongst other men in Kampala, which actually means that this was a high-risk population. During the time of the study the Director General of Uganda AIDS, the national program, said that for the first time he actually admitted that MSM exists in Uganda — which was a positive — but he said we are not going to deal with them.
Now, what happened is that some of us decided that no, this was a bit too much and we had the Implementers’ Meeting happening in Uganda, and we decided to come and storm the meeting and held a five minute protest. What happened after that was that some of us were arrested and they continued to be prosecuted for demanding for HIV prevention program amongst MSM in Uganda. For demanding for an HIV prevention program amongst a vulnerable population in Uganda. That’s why there were prosecuted.
Now, this had an effect on the study which was happening in Kampala at that time. Those people were studying the respondents, that MSM were not coming to the study, the respondents who are not coming. The recruitment dipped, it recovered sometime later, but then dipped again, because Uganda unfortunately is a very highly homophobic country. They got about 300 respondents, which in six months was very few homosexuals, compared to Kenya, compared to Tanzania, compared to Zanzibar. In two months they’ll get 500 people. In the first study in Kenya they actually had to stop the study, because in Nairobi they were getting more than 500 gay people.
Now, Uganda has definitely been one of the worst offenders in HIV prevention for MSM. They want to ban the agencies which work for gay rights. That was about last month I think. And the LGBT clinic, it needs to be shut. All this homophobia is actually happening when we have a study done with folks that we have a vulnerable population, which actually is responding to the homophobia in the country. Okay, HIV prevalence amongst the MSM was related to external homophobia.
Dr. Semugoma ended his talk with a stirring call to action, which hinged on increased visibility of gay men and the elimination of homophobia, anti-AIDS stigma, and ignorance about HIB/AIDS. He also remembered that the advocacy fights to achieve those aims are not without cost (at the 26:30 mark):
Now, I wanted to acknowledge the fact that a lot of people have helped me to prepare this speech, but I remembered that I can acknowledge also those people who have lost this fight, I mean who have been killed, the price of advocacy. Advocates are beaten, they are arrested, they are killed. I just wanted to remember these few, Alim Mongoche in Cameroon; Steve Harvey in Jamaica, David Kato in Uganda, Thapelo Makutle in South Africa [applause].
One of my most enduring memories of David Kato is of him when we went into the Implementers’ Meeting when he wanted to engage the speakers, and then running very fast on this big road with the police behind him. They wanted to arrest him because we had barnstormed the Implementers’ Meeting.
Many stories are untold and unreported. It is tough to achieve comprehensive HIV prevention and treatment in this context, but it has been done. It has been done before. It is being done now. It is going to be done again. We have tried and they continue to try.
At the end of his talk, he acknowledged his partner, whose name I did not catch. But it was very heartwarming to see him lean into the microphone and say, out loud, “I love you.”
Uganda’s Dr Semugoma: Optimistic and Living With Hope
August 8th, 2012
Longtime BTB readers will recall our good friend, the anonymous blogger GayUganda. To get you caught up to date, he’s no longer blogging and he’s no longer anonymous. Meet Dr. Paul Semugoma:
Dr. Semugoma was in Washington D.C. for the International AIDS Conference last month. In this video he talks about the barriers to AIDS prevention caused by homophobia and discrimination — a situation that he says is exacerbated by the influence of American anti-gay evangelicals in Uganda. He points out that Uganda’s anti-gay laws currently are virtually identical to those of Kenya and Tanzania, both of which border Uganda and are also, like Uganda, former British colonies. Yet Kenyan and Tanzanian HIV/AIDS prevention efforts include special programs for those nations’ LGBT communities, while Ugandan authorities claim, falsely, that similar efforts in Uganda are prohibited by law. Dr. Semugoma makes the case that this stance works against the interests of the entire country, not just LGBT people.
At about the 7:00 mark, Dr. Semugoma talks about his own process of coming out recently and the difficulties that poses in his country and in his practice. Before coming out, he had been using his standing as a medical doctor to provide medical-based arguements for a more inclusive approach to HIV prevention and treatment. But even doing that generated questions about his sexuality, questions that he has only recently been answering. He is also preparing to move to South Africa where he can live without the kinds of fears and stresses that he experiences in Uganda.
Toward the end of the video, he describes further the obstacles that UGanda’s government places on prevention efforts. He describes the case of an HIV/AIDS clinic that recently opened in Kampala with the mission of providing care for LGBT citizens. The government moved to close the clinic because it “promoted homosexuality.” Doctors in the country joined the government in saying that the clinic was not needed because they don’t discriminate against LGBT people if they don’t ask about sexual orientation:
At the same time, doctors were asked, Ugandan doctors, that, “Do you think this clinic is necessary?” And to them it was not necessary, and their reason was, “We do not discriminate because we do not ask patients about their sexuality.” In actual fact that shows their ignorance because for a doctor to sit with their patient and to be able to counsel you about your HIV prevention needs, I need to know your sexual practices. So if you’re going to talk to a gay person like you’re going to talk to a heterosexual person, then you are missing the point. You’re going to advise him to use condoms, while he actually needs condoms and a water-based lubricant. You’re going to advise him to get married and stick to his partner when in actual fact he cannot get married in the country. You are going to advise him to be faithful and abstain, and he will think in his mind, “I abstain until when?” because he cannot get married. That is the kind of problems, structural issues, that are there.
He says that we have the medical knowhow and the tools to end the epidemic. The problem is not medical, but structural. He nevertheless closed on a note of optimism. Five years ago, the LGBT community was invisible. Now people know that it’s there. “I am optimistic. I mean, I am a human being and I think we live with hope.”
A proposal for rolling out universal testing
July 20th, 2012
Yesterday I told you about something that Phill Wilson, Executive Director of the Black AIDS Institute said that inspired me to start thinking of HIV transmission as being something we can bring to a stop. But Wilson said something else that made me less happy.
Neither Black America nor the LGBT community has made the fight against AIDS among Black gay men a priority.
Sadly, that too is true. For far too long the gay community has pretended that one size fits all and that what’s good for gays is good for black gays. And we have chosen not to notice that merely identifying a program as being targeted at gays well make it a program that alienates many black men who have sex with other men, regardless of how they identify.
So it is fitting that we take the first steps toward full knowledge about HIV infection in the community in America that is hardest hit, the African American community. But I don’t make this suggestion out of some altruistic notion or that it’s ‘their turn’; rather, I have very pragmatic reasons. For a roll-out of a universal testing program to be effective, the following two criteria must be met:
1. The first phase must have high, nearly universal, participation
2. The first phase must show dramatic results.
We live in a divided society in which support of a program – any program – by one segment of society virtually guarantees opposition by another. And, as the First Lady’s nutrition efforts show, including “everyone” only fractures your target population. Any roll-out that starts with a diverse demographic – say “all the residents of Memphis” – is designed to fail. Far too many people would immediately go to “oh that’s just the gays” and once that definition was established participation would not be much other than the usual gays and supporters.
I don’t want to support a program that is designed to fail. We have to think outside of the parameters of lines on a map. And we must be willing to think pragmatically.
Racial identity is a self-selection that allows for nearly complete inclusion. African American is an identity that includes Larry Elder and Al Sharpton, the richest businessman and the poorest indigent. It is an “us” that is stronger than economic or political boundaries. And HIV disproportionately impacts the black community – and by disproportionately, I mean HUGE disparity – a fact that is increasingly becoming known within all segments of African American society. It is much less “gays get that” and becoming understood that “this is a problem in our community”. I believe that African Americans are one of the few demographics that could coalesce around this project at its inception and make it work.
And the results of an effective testing program within the African American community would impressive. So impressive, I believe, that expanding the program would be a given. Where as in the nation as a whole, the rate of unknown infection is between a quarter and a third of those infected, about sixty percent of African Americans with HIV are unaware of their status.
If we could give some discrete population of black men and women the knowledge of their HIV status and access to the tools to address transmission, I believe that this knowledge would result in a precipitous drop in the spread of the virus. And I believe this drop would be the result needed to convince our population that HIV transmission can be stopped and that the effort to stop it is well worth the expense.
Yesterday I discussed the tools we have that could stop the transmission of HIV, all of which are based on knowledge about one’s serostatus. Today I offer the following for consideration, keeping in mind that our task is testing for HIV infection but our goal is stopping the transmission of the virus altogether.
Suppose that the target population selected were the black community in Washington DC. And suppose that a program was created in which every African American in the city who was sexually active – or had been in the past decade, or intended to be in the next – were to take an HIV test whether they were a girrrrrrl or the right reverend bishop at the First Church of Abstinence. And suppose that in subsequent years it were continued to those who were sexually active. And suppose that a firm commitment was made to find funding to provide care for the newly diagnosed who lacked financial ability.
Estimating 250,000 African American residents of sexual activity age, a three-year testing program would cost less than ten million dollars (cost of care is a separate concern – one which should be considered whether a testing program is established or not).
With one of the highest HIV rates in the nation, along with one of the most rapidly increasing HIV populations, this could be an ideal test location. If, as I believe, the rate of increase dropped precipitously over two or three years of testing – especially if compared to other major urban centers – it would take very little persuasion to convince politicians that this is a very cost effective long term solution.
Selling this idea would not be easy. It would require laying down political and religious mistrust and posturing. And it would require that heterosexist presumptions about “who gets it” be discounted.
But I believe that if every black senator and congressman, every local preacher or official, and the President himself took the lead it could be possible. And if neighbors and community provided encouragement (not taking “no” as an acceptable answer), it could be possible. And if (but only if) the churches got behind it, it could be possible. And if employers supported the effort with on-site participation, it could be possible. And if obviously not-at-risk church ladies set the example, and shamed the rest, it could be possible. And if service agency made testing part of their program for those not included through usual means, it could be possible. And finally, and most importantly, if this is not some outsider coming in to tell blacks what to do but instead if it could somehow be made part of a black identity – led by black people and directed to speak to black people about stepping up for the community – it could be possible.
And remember, our goal is not “test the blacks in DC”, this is just our initial demographic. It is just the first step in rolling out this project to the broader populace.
Perhaps the next step is to target the other half of of DC’s population and see if we could get close to 100% testing in the entire city. If the results are as I think they would be in our roll-out demographic, it would be an easier plan to sell. While I think that if we start with the entire population of DC we would get very little participation from most congressmen thus starting with an image of failure, the success we establish from the roll-out should result in a much higher degree of high-level participation thereafter. And after DC, on to a small state – perhaps Maryland. And so on.
This is just one proposal. Others may have better ideas. Perhaps there is a better demographic in which nearly universal participation could be achieved and in which the results would be dramatic.
But, for the first time since I first heard of this virus on the news as a scared college kid, it is now not only possible but feasible and practical to stop it in its tracks. If we have the resolve to do so.
We can stop the further transmission of HIV
July 19th, 2012
The Black AIDS Institute has released a new publication in which they detail the statistics relating to HIV infection within the black gay and bisexual community. But while the report is very grim (and I’ll discuss that separately), Executive Director Phill Wilson said something that surprised me in its forthrightness:
There is hope, however. New evidence indicates that antiretroviral treatment reduces the odds of HIV transmission by 96%, leading preeminent scientific experts to advise that the tools now exist to end the AIDS epidemic – for all populations, and in all settings.
As I thought about this, I realized that it’s true. We have the technical ability to ensure that the transmission of HIV from infected to uninfected persons stops. Entirely.
Currently, nearly all cases of seroconversion are due to sexual activity. And while moralists are correct that “if sex was limited to marriage” the virus would be halted, that is not a realistic plan (or one that is based in finding a way to reduce transmission). And while “everybody must use a condom every time” was for a time the only possible approach, it is evident that it is not and will not be the plan that eliminates transmission.
There are a number of reasons that “condoms every time” fails. Discomfort, inconvenience, the awkwardness of sexual negotiation. But the most significant reason, the single largest contributor to the spread of HIV, is personal ignorance about HIV status.
Sure there are some totally amoral bastards who hide behind “It’s your responsibility to protect yourself and I have no obligation to divulge my status” and a few on the opposite side who find a thrill in the risk of the unknown. But most people who are positive take steps not to pass on the virus and those who are negative do engage in some measures (though not always wise or effective) to minimize exposure, even if that step is limited to asking and placing too much reliance on the answer.
But one thing keeps transmission rates steady or increasing year after year. One thing we can halt: ignorance.
The key to stopping HIV is knowledge. The CDC estimates that between a quarter and a third of those who are HIV positive are not aware of their serostatus. And that is a reality that we could end – if we have the resolve to do so.
In British Columbia, officials have announced a new goal and allocated funding for it. (globeandmail)
Saying it is now possible to end HIV/AIDS, medical experts in British Columbia have launched a four-year, $48-million pilot program aimed at detecting and treating the disease faster.
The goal is to test everyone in the province who has ever been sexually active.
The sweeping approach is an attempt to catch the estimated 1 per cent of people who are unaware they are HIV-positive and aren’t taking advantage of an effective treatment program that is available provincially.
This is the right approach and we should find a way to implement it globally.
Of course, British Columbia only has 4.4 million people and universal health care so it’s not as easy as insisting that every state, province and nation follow suit. But testing is inexpensive and highly accurate. For less than $20 per person (BC is only spending $10) we could identify nearly every HIV positive person in our city, state, nation.
Even in states and countries in which there is insufficient postconversion medical care, even if this would place a burden of dread on those diagnosed, there would be knowledge. And knowledge would reduce future transmissions. (And surely we care as much about the physical health of the person who would be saved from seroconversion as we do about the mental health of the newly diagnosed.)
But knowledge is not the only key to complete elimination of future transmissions. We also have the tools to stop transmission when knowledge is ignored or when accidents occur.
Highly active antiretroviral therapy, or HAART, is a combination of three or four separate drugs that prohibit various steps of HIV replication (what we used to call a “drug cocktail”) and is highly effective. The vast majority of those who consistently use this process reduce replication of the virus within their system to the point where it is “undetectable”. And with the reduction in viral load comes a reduction in transmittablity – possibly to the point where the virus cannot be transmitted through sexual activity.
It is true that many HIV infected people do not have funds – or insurance – to pay for a medicine regimen. But there are programs established which are designed specifically to assist such people and when exact numbers can be provided it will be politically difficult for officials to intentionally deny funding for specific individuals who can be identified.
On the other side of the equation, the Food and Drug Administration has just approved the use of an AIDS drug for preventative measures. Pre-Exposure Prophylaxis (PrEP) is only currently advised for those who are at highest risk (and as yet with unidentified means of paying for such a drug) and we cannot know the extent to which this will diminish transmission, but it could play a significant role if prioritized and adequately funded. This drug can virtually eliminate the ability for HIV to infect the who take it consistently and properly.
Finally, it is now possible to eliminate transmission after “the condom broke”. Those who engage in sexual behavior that is risky have a second chance, an ability to reverse their bad decision (or, as actually does happen, when the condom breaks). Post-Exposure Prophylaxis (PEP), a drug regimen started within 72 hours and taken consistently for a month, has shown high effectivity in prohibiting seroconversion.
But all of this relies on knowledge. You won’t get treatment if you aren’t tested and the likelihood of PEP being utilized is greatly decreased if the insertive partner is unaware of his HIV status. And there will be those who refuse to care for themselves or who lack the structure to commit to a regimen and for whom PrEP, PEP, or retroviral regimen will not be a reality. But they are only one cog in the transmission cycle.
And this is not to suggest that everyone in a serodiscordant relationship or who enjoys frequent sexual diversity should adopt a PrEP regimen. Nor will those who select serosorting or seropositioning likely replace their choices with either drugs or condoms. But these are tools that can be employed.
And using all our tools together – a universal testing strategy combined with treatment for those who are positive, PrEP for those who are either in serodiscordant relationships or whose behavior is at high risk for conversion, and PEP readily and immediately available at every local drugstore (perhaps through 24/7 dial up prescription), all as a supplement to a message of consistent condom use – we could effectively end the transmission of HIV.
I know it sounds like a the final scene of Longtime Companion and a bit too hollywood to be real. After two decades, I’m not sure we believe in happy endings any longer. But it really can happen.
And I have a proposal for how we could roll out a program that could give us that day when HIV transmission is a sad history and not a present reality, and see it in this decade. My idea will not sit easily with some and will run into automatic objections. But I hope that when I present it tomorrow that you’ll give it a fair hearing.
A new tradition: give a gift in October
July 18th, 2012
This October I propose a new tradition: give a gift to someone. Not just any gift, but one very specific gift. And not to your mom or that lovely family across the street.
In October the OraQuick home HIV test will show up at your local drugstore. Instead of taking an afternoon off of work to go down to the local clinic and give your ever-professional local government representative your name, social security number, sexual orientation, and a count of everyone you’ve had sex with – along with what position you used, how you met them, how many times you had sex with them, and explicit details about the sexual encounter – you can test yourself at home. Privately. And you won’t even need to takes notes about yourself on a clipboard or enter data into a database that is “confidential” until a civil servant leaves it on the bus.
The test takes 20 minutes, is 99% accurate, and involves nothing more invasive than running a lightly swab over your gums. You can make an omelet, go for a jog, watch TV, or even say “please God no” over and over for 20 minutes – but when it’s over you will know whether or not you were infected with HIV as recent as three months ago (in some rare cases six months ago). If you want assurance about more recent events, you can get a nucleic acid test which looks for the virus itself and shortens the window of uncertainty to two or three weeks – but then you’re back to dealing with blood and people with a clipboard and a little lecture at the ready.
And the cost is not prohibitive. It has not yet been publicized, but is expected to be somewhere between $18 and $60 (And listen up, OraQuick, unless you want a whole pile of ill will, you’d best keep it closer to $18 than $60). But even at the upper end, you have three months to save up. So buy two.
Perhaps you believe that you already know that you are negative. Test anyway. It won’t kill you to have more information (and it might just save your life) and if you can’t think of another reason, it gives you bitching rights when you coerce your friend (you know the one) who you really think needs to be tested and is making up excuses.
I say buy two because the second one should be a gift. But a special gift, one you give to a total stranger that you will never meet. Because while you probably can afford to buy a home HIV test, many people cannot. In fact, those who most need to be tested are often those who have the least ability to buy a test. And, in many many cases, they are also those who are the most afraid to go to be seen going to the clinic.
The biggest contributor to the spread of HIV is ignorance about one’s own status. And while there are testing centers aplenty, clearly that isn’t working. Between a quarter and a third of all HIV positive people in this country are unaware that they are carrying the virus, a number that doubles once you get into less affluent communities. And while there are many outlets for testing that are funded by federal or state grants, there are plenty of people who need help – or want to give it – for whom institutional bureaucracies or a trip to the gay community center are not the solution.
So buy a test and give it to a the health science teacher at a high school located in an economically disadvantaged community. Give it to the storefront church that serves an immigrant population. Find a coach for an after-school program for troubled teens. Or a soup kitchen. Or get really brave and walk into the local Church of God in Christ and tell the pastor, “Reverend, I know and you know that someone in your congregation needs this. Pray about it.”
Let’s make this a tradition. Let’s be creative. Let’s find a way to reach the people who are still outside the net, who still don’t have access, who still live in a paradigm of fear. If there is someone they trust – even if it is someone who doesn’t trust you – give that trusted person a testing kit. It will reach the right hands.
And then set yourself a reminder for next October.
Truvada and politics
July 16th, 2012
The Food and Drug Administration has now just approved the use of Truvada, an AIDS drug, as a preventative medication for some high-risk HIV-negative people. To my way of thinking, this is WONDERFUL, yet another tool in our arsenal for slowing and preventing the spread of the virus.
Not everyone agrees. (Wall Street Journal)
In a media call after the decision was announced, the AIDS Healthcare Foundation called the FDA decision “a catastrophe in the fight against HIV in America” and said it was likely to lead to more, not fewer, HIV infections.
The organization has opposed FDA approval for Truvada’s use in preventing HIV in healthy people. Gilead Sciences is the maker of Truvada, which was already approved to treat people who are infected with HIV.
Michael Weinstein, co-founder and president of the AIDS Healthcare Foundation, later told the Health Blog that healthy people should be required to show proof of a negative HIV test before getting Truvada as a prevention medicine.
[UPDATE: Sorry, I left out essential information] However, Weinstein is not just demanding testing, a condition that was announced a month ago. He and AHF have led a campaign against this step altogether.
Weinstein and AHF are a bit, well, peculiar. I don’t want to trash an organization that works hard to encourage testing, but sometimes I think that Weinstein’s brand of politics is based more in micromanaging the lives of others than in utilizing tools to prevent the spread of AIDS. (He has collected enough signatures to put a proposition on the city ballot to ban the production of all porn in the city of Los Angeles that does not feature condoms. He thinks this will reduce non-condom porn – gay or straight – from being produced and marketed; I know it will simply cause a multi-billion dollar industry to move somewhere else at a time in which our city is in financial panic mode. Porn producers will provide for demand.)
Here’s what I know: some people will behave irresponsibly for a time. Here’s what I believe: that irresponsibility does not deserve sero-conversion as some sort of punishment or moral judgment. If we can limit their transmission rate, that is a good thing EVEN IF they are bad bad boys who don’t have sex the way that Michael Weinstein thinks appropriate.
HIV is not an automatic presumption for unsafe sex. And I get the impression that Weinstein – who has for years sang the mantra that condoms must be worn every time – would prefer that we act out of fear rather than truth. And here is some truth that he surely will not appreciate.
- HIV is not an every-time transmission even if anal sex is unsafe and the top is positive.
- Oral sex has such a low transmission rate that it remains more in the realm of biological plausibility than of likelihood.
- Medications are very effective and many HIV positive people have so low a viral load that they are “undetectable”. It is theorized (and widely rumored) that undetectable people cannot pass on the virus.
And I firmly believe that too many young gay men have thought “yeah, well I screwed up so I’ve probably become infected by now so why should I even try to protect myself this time”. Truth is a tool that allows us to respond and it has always infuriated me that the AIDS prevention community has been less than forthright.
I am not suggesting, hinting, implying, or advocating for giving up rule number one which is “wear a condom”. And the inclusion of counseling and risk management as a requirement for prescription is, I believe, a wise move. And there are many unanswered questions including cost of the medication, availability, and the extent to which some will see it as a magic shield.
But I also am realistic enough to know that safer sex will not always happen. Sorry, that’s just the truth. And I also know that some serodiscordant couples negotiate the risks they are willing to take so as to allow some measure of spontaneity and enhanced intimacy and I’m not going to stand in their bedroom with a clipboard and a bureaucratic tone. If this gives them an additional tool to decrease the odds of infection, then by all means allow them the tool.
I agree with AHF that everyone really needs to be tested. I would love to see a massive governmental effort (yeah, I said it) to test every single person in the country above the age of 13, regardless of who they are (preferably using the nucleic acid test twice over a two month period). I believe that people are basically decent and that knowledge of one’s status would go a long way to avoiding infecting others.
And I want to praise that organization for being on Santa Monica Boulevard in a ‘testing bus’ during the evenings when the bars are packed while the institutional (and increasingly pointless) Gay and Lesbian Center offers testing in West Hollywood from noon to 7 PM four days a week for up to 20 people per day. I also appreciate Weinstein’s support of the newly approved at-home HIV simple swab test that requires only 20 minutes and no outside participation.
I also pledge that if Weinstein proves right and sero-conversions increase rather than decrease, I will apologize and join him in calling for a reversal of the FDA’s position. But for me, fewer transmittable and fewer infectible people means less virus transmission which makes me want to stand up and dance around the table.
I think that FRC and Weinstein need to let go of the nanny instinct and find ways to utilize new tools to maximize results rather than seek to mold behavior. Because you don’t want to find yourself wondering why you feel sad, angry, and in objection on the day that we finally find an effective vaccine for this vir