HPV Vaccination-A Wasted Resource for African Americans?

The United States has no reporting system for Human Papillomavirus (HPV) infections. Infections and the development of warts appear to be common throughout life. In general, genital HPV infection is considered to have become dramatically more frequent over the past several decades. In the United States, young adults aged 15-24 years account for approximately one half of new HPV infections each year. The highest rate of infection is among young females aged 20-24 years. Using data from these sources, the US Centers for Disease Control and Prevention (CDC): there are an estimated incidence of more than 6 million new patients a year in the United States (in 2008) and an estimated prevalence of more than 20 million. HPV infections has been identified as a potential cofactors in a number of serious diseases including cervical vancer and even HIV infection. In the United States, African Americans have a rate of HPV infection that is 1.5 times higher than their white counterparts. One US survey reported that among women, the prevalence of HPV infection due to any HPV type was 39% for non-Hispanic blacks, and 24% for non-Hispanic whites and Mexican Americans. From 1987 to 1991, the age-adjusted cervical cancer death rate reported by the US National Cancer Institute was higher among black women than among white women, with a ratio of 6:1. HPV may also linger longer in African American women. Because most HPV infections are transient, it is usually cleared by ones immune system within one or two years. However, a recent study of college aged women by the University of South Carolina found a tendency for more persistent HPV infection. It also found black women to have a 70% greater chance of abnormal pap smears than white women. A vaccine for HPV was first licensed in 2006. The vaccine, distributed under the name Gardasil, was the first vaccine known to protect against approximately 70% of the strains of cervical cancer in girls as well as roughly 90% of the strains that cause genital and anal warts. It was not for another 3 years before the vaccine was considered for use in boys and 2010 until it received licensure from the United States Food and Drug Administration for the prevention of cancer in boys, especially anal cancer. However, despite its proven effectiveness, most African American young people are not accessing it. In 2010, only 1% of boys recommended to receive the vaccine did. Only 8% received one dose but did not complete the series. A recent survey of adolescent black girls and their caregivers conducted by the Pennsylvania Department of Public Health found that only one in four eligible black adolescent girls has received the vaccine. Many of the 71 young people surveyed, most of whom were black, expressed that they thought that the vaccine was "safe and effective." Moreover, the 45 caregivers who were surveyed agreed, but most of them said they didn't remember the HPV vaccine being mentioned by their health-care provider. Young people, particularly minorities, and their parents/guardians need to edcuate themselves about HPV infection and vaccination and become their own advocates. They cannot assume that health care providers will mention it. Many are still struggling with performing routine testing of HIV. Vaccine is paid for by most insurances, is available at sites such as Planned Parenthood and will be required under the Affordable Care Act (Obamacare).

Compulsory Sexual Education

The Centers for Disease Control (CDC) recently released its report on Sexually Transmitted Diseases for 2011. Sadly, there are few surprises. With a total of 1,412,791 cases Chlamydia trachomatis infection remains the STD leader. This figure is the largest number of cases ever reported to CDC for any condition and represents an increase of 8.0% compared with the rate in 2010. The national Gonorrhea rate increased as well after over a decade of fluctuation and/or decline. However, the greatest concern about the "clap" as we used to call it is its increasing resistance to the medications commonly used to treat it, cephalosporins and azithromycin. Syphilis, which we once actually believed could be eliminated, continues to thwart those efforts. Although the 2011 rate remained unchanged from 2010, it continues to grow in MSM and now, women. With other STDs such as HPV, Trichomoniasis and Herpes also showing consistent increases, the overriding conclusion that one must draw is that we continue to experience this epidemic of preventable diseases. The most troubling aspect remains the disparities in race and age. Younger minorities continue to be disproportionately affected by STD'S. Which brings me to my main point: the need for compulsory sex education in schools. A recent report by the Guttmacher Institute highlights the information gap: * One in four adolescents ages 15-19 received abstinence education without any instruction on birth control or disease prevention. * 46% of teen males and 33% of teen females receive no formal instruction about contraception before the having sex. * Of older teens, ages 18-19, 41% said that they knew little or nothing about condoms and 75% say the same thing about the birth control pill. * Only 21 states and the District of Columbia mandate sex education. See the disconnect here? With STD rates rising in children especially minority children, over half the states don't require education to prevent STDs, as well as unwanted pregnancies. I understand that discussions about sex education in school are like the proverbial "third rail," because parents feel that they should be the ones providing the information. The problem is that many don't do it and others are poorly informed. While the Guttmacher report states that parents are considered an important source of information on sexual health for teens, it adds that their knowledge may often be inaccurate or incomplete. The report also fails to mention the number of children who are not living with their parents, such as those living with other relatives, in foster care or in group homes. The bottom line here is that this belief system that sex education should remain at home isn't working. As there is no evidence to support that sex education promotes more sexually activity (most parents greatest fear), then it is time that we have a substantive dialogue with parents to allay their fears and gain their support. Legislators too, should be more assertive is passing legislation to mandate it. Its time that we address this issue before more young lives are ruined.

World AIDS Day 2012

Saturday was the 25th commemoration of World AIDS Day. The theme this year was "Getting to Zero: zero new HIV infections; zero deaths from AIDS-related illness and; zero discrimination. While these may sound like lofty goals, the last year has shown some real progress. Internationally, there are approximately 34 million people living with HIV, two thirds in so-called developing countries. In 2011, 2.5 million people were newly infected with HIV. An estimated 1.7 million people died. That is 700,000 fewer new infections worldwide than ten years ago, and 600,000 fewer deaths than in 2005. In the United States, there are approximately 1.1 million people living with HIV with about 50,000 new infections annually. Currently, only 33 percent of those who are HIV positive in the US are on anti-retroviral treatment and only 25 percent have a suppressed viral load. Perhaps the most disturbing news has been the impact of HIV/AIDS in young people. According to a CDC report, young people ages 13 to 24 years accounted for more than a quarter of new HIV infections in the United States in 2010. That amounted to approximately 12,000 cases, but only about a third of the persons in that age group had been tested. Every month, approximately 1,000 youth are becoming infected with HIV. One of the major implication of this new data is the increasing future healthcare burden: approximately $400,000 over one's lifetime. There has also been some significant new developments: * Oraquick- The first rapid at-home HIV test that does not require the sample to be mailed in to obtain a result. * Pre-Exposure Prophylaxis (PrEP)-an FDA approved medication (Truvada) to reduce the risk of sexual transmission from the infected to the uninfected. * Stribilid: the first HIV medicine to combine four separate drugs and is the third HIV drug that can be taken once daily. * The number of antiretroviral drugs tentatively approved or approved for use under the President’s Emergency Program for AIDS Relief, or PEPFAR, has surpassed 150. PEPFAR is a program to treat those infected with HIV/AIDS in countries that lack the tools needed to fight the HIV/AIDS epidemic. Yet with all of the progress being made and the advances in medical treatment, we continue to have millions of new infections every year and over a millon deaths. Over two thirds of HIV+ people throughout the world who need antiretrovirals do not take them including in the United States. We cannot allow ourselves to be lulled into a false sense of security with our successes. We still have a lot of work to do.

Do the Needs of the Many Outweigh the Needs of the Few?

Does Leonard Nimoy's famous quote (the titile of this blog) from Star Trek II: The Wrath of Khan, apply to people living with HIV in the prisons of two southern states? Not according to the American Civil Liberties Union, who has brought a class action suit against the Alabama Corrections Department where HIV+ inmates are isolated from the general prison population. South Carolina is the other state with the same policy. In Alabama, inmates are tested for HIV when they enter prison. HIV+ men and women are housed in special dormitories; eat alone (not in the cafeteria); cannot hold jobs around food; and have to wear white armbands that identify them as being HIV+. The policy is designed to to limit the spread of HIV through consenual sex, rape, or when inmates tatoo each other, even though most medical experts say that isolation is unnecessary. It is also counterituiative to treat HIV differently than other, more rampant, viruses such as Hepatitus C and B. According to the Bureau of Justice Statistics there were a little over 20,000 inmates in state and federal prisons in the U.S. at the end of 2010. The rate of HIV/AIDS among state and federal prison inmates declined from 194 cases per 10,000 inmates in 2001 to 146 per 10,000 at year end 2010. A study, published by the Centers for Disease Control and Prevention in 2006 found that although male prisoners have a relatively high rate of HIV infection, very few of them acquire the virus while behind bars. For example, about 90 percent of HIV-positive men in Georgia's prison system -- the nation's fifth largest -- were infected before they arrived, the study found. Over a 17-year period, 88 men became infected in prison by the virus that causes AIDS, chiefly through same-sex intercourse. Therefore, if there is a declining number of HIV+ inmates in prison, and if few acquire it there anyway, why the draconian policies in Alabama and South Carolina? Sadly, the answer has as much to do with our own attitudes about HIV/AIDS as it does with those two prison systems. There is not a lot of sympathy about the incarcerated in general and certainly even less for those infected with HIV. The point missed here is that treating HIV+ prisoners as lepers only exacerbates their shame and disgrace at being incarcerated. It also continues to foster the stigma that drives HIV underground and prevents people from getting tested. As a society, we should criticize any excessive policy that limits the rights of human beings to live in basic dignity. If not, we too might find ourselves on that 'slippery slope.'

Preventing HIV Transmission with Youth Infected at Birth

As we reach a certain age, many of us long for the vitality of youth, without of course, the consequences for our youthful discretions. It is a time of learning and discovery. For many, it is also a time for sexual exploration. Adolescents, in 2012 have lived their entire lives with the HIV epidemic. They may have learned about it in health class, read about it on the internet, or perhaps learned that someone close to them have been infected. Now imagine that at age 15 or 16 you are told that you are HIV+; not because you became infected through risky behavior, but because you have had it all of your life. More troubling: what if you have been sexually active before you found out? There are three primary ways for newborns to become infected with HIV: while growing in the uterus; during delivery; or while breastfeeding. Antiretroviral treatment of pregnant mothers has been shown to reduce mother to child infection rates to about 4%, significantly reducing the number of children being born with HIV worldwide. Yet, according to the Centers for Disease Control (CDC), there are approximately 10,000 people in the United States who are living with HIV acquired at or before birth. A new study of adolescents infected with HIV from birth, found that 20% were unaware that they were HIV+ until after their first sexual encounters. The study of 330 HIV-positive 10- to 18-year-olds was conducted at clinical sites nationwide as part of the Pediatric HIV/AIDS Cohort Study, which is funded by the NICHD and several other NIH institutes and offices. On average, participants who had initiated sexual activity reported having their first sexual experience at age 14. Most of the sexually active youth in the study reported some incidents of sexual activity without condom use (62%). Only one-third of these said they had disclosed their HIV status to their first partner. Another troubling statistic was that young people who did not take anti-HIV medication regularly were more likely to initiate sexual activity than were those who were more consistent. There are many lessons to be learned through this research, but one obvious point: 'kids are kids.' In other words, the adolescents in this study simply behaved like most adolescents who are experimenting with their sexuality do. Therefore, it is imperative that they be made aware of their HIV status before they become sexually active and of the importance of adhering to their antiretroviral medication. While I can understand caregivers wanting to delay disclosing HIV status to a young person until they are mature enough to handle it, delaying that disclosure risks them exposing other young people to possible infection. They should also receive robust risk reduction education, especially geared to disclosing their status to there sexual partners and the proper use of condoms.

Chagas Disease: A New Health Disparity

Ever heard of Chagas Disease? Well, you're not alone. There may be as many as 10 million people, including an estimated 1 million in the United States, who have it. Chagas is a disease cause by a parasite; Trypanosoma cruzi, which lives inside a certain insect native to Central and South America. This insect, the Triatomabug, thrives in tropical areas, especially poor housing conditions where they come out and infect their victims at night. While it may seem that the impoverished conditions where these insects reside would confine it to certain areas, or even countries, immigration and the lack of familiarity of most physicians with the disease has exacerbated its spread. Another complicating feature of Chagas Disease are its two stages: Acute and Chronic. The early "Acute" stage may last may be asyptomatic and last for a few weeks or months. During the "Chronic" stage, most infected people "enter into a prolonged asymptomatic form of disease (called "chronic indeterminate") during which few or no parasites are found in the blood." (Centers for Disease Control) While most people will remain asymptomatic for life, up to one-third of those infected, 3 million, are at risk of Chagas’ worst complications, enlarging of the colon, esophagus and heart, cardiomyopathy and heart failure. Chagas disease is treatable, but clearly the longer its goes undetected, the more difficult it is to treat. Which leads me to the public health implications. A recent paper in PLoS by Sarkar and Strutz entitled: Chagas Disease Risk in Texas stated that Chargas is "endemic in the southern United States, especially in Texas" where, curiously enough, it has not been designated as reportable. Of course the State of Texas has never been a leader in public health, evidenced but their failure to adequately screen their own blood supply. If we have learned anything from HIV/AIDS, its that we generally have a short window in which prevent these types of diseases from becoming epidemic. Well, that window may have closed. However, the authors of the above article note that Chargas has so many ways of being transmitted including blood tranfusions, organ donations, ingestion of tainted food and a variety of animals from dogs, to raccoons to rodents. It's time for an aggressive campaign to produce a vaccine for humans and animals. Moreover, we need more research so that we have a better idea of how many people are infected, how tainted the blood supply may be and how widespread it has become in various animal species. Finally, we need to dissiminate "INFORMATION," eg... a social awareness campaign to educate the public.The horse may already be 'out of the barn,' but lets get him back before he runs too far away.

What Does An Undetectable Viral Load REALLY Mean?

There are many well documented benefits to reducing the viral load of an HIV+ individual to an undetectable level. Unfortunately, there also remains a some haziness about the term "undetectable." In actuality, it is somewhat of a misnomer. For someone to truly have undetectable HIV would mean that the battery of sophisticated tests available could not find any virus in a person's body. Thus far there is only one case of an HIV+ individual, a German who received a bone marrow transplant from a donor who had a genetic resistance to the virus, who seems to have cleared HIV entirely from one's system. An undetectable viral load means that the HIV virus in one's blood has been suppressed to the point where either the HIV RNA is not present in your blood at the time of testing or that the level of HIV RNA is below the threshold needed for detection. Another factor is the sensitivity of the specific test that is utilized.

Viral suppression, as its called, may allow for the partial rejuvenation of one's immune system, thereby making one less vulnerable to certain opportunistic diseases. Perhaps one of the most intriguing recent findings (HPTN 052) is that viral suppression may help to reduce HIV transmission in sero-discordant heterosexual couples (where only one of the two is HIV+) by as much as 96%. An earlier study with MSM found an approximately 60% reduction. However, 60 or even 96 percent is not 100%.

The 2010 International AIDS Conference highlighted the following:

• With heterosexuals with one or both using antiretroviral treatment the risk of HIV
transmission is low, but not zero.
• In male same-sex partnerships, HIV transmission risk gets higher with repeated
exposure.
• In presence of other sexually transmitted infections (STIs), HIV transmission is
increased. STI seem to have a synergy with HIV and can increase the genital viral
load in a HIV+ person. Moreover, a person who is HIV- but already has other STIs
is actually more susceptible to HIV infection.

Now, a recent study of HIV+ MSM by Boston University School of Medicine found the presence of detectable HIV in the semen of approximately one-quarter of the men studied people with supposedly undetectable (through blood tests)viral loads. The researchers added that a major factor in the results of this study had to do with the high level of STIs in the study participants. While the study did not specifically look at whether these men were more likely to transmit HIV, it should serve to remind us that aggressive HIV treatment alone will not stop HIV transmission and that the importance of knowing one's status, treatment for STIs and condom use all remain as very important tools.