Let’s Tell The Truth About Entitlements

“We have a welfare system that's trapping people in poverty and effectively paying people not to work,”House Speaker Paul D. Ryan (R-Wis.). Speaker Ryan continues to perpetuate the myth of the “welfare queen,” the lazy, mostly likely black or brown woman, popping out babies and gobbling up our hard earned tax dollars. Nothing could be farther from the truth. That is not to say that there are no lazy people collecting means tested benefits. But the poor do not have a monopoly on lazy people. Poverty in the U.S. is a complex phenomenon that has been orchestrated by a variety of policies that segregated large masses of immigrants as well as black and brown people and limited their access to opportunities that might otherwise help lift them out of poverty, such as quality schools, well-paying jobs, affordable housing and blatant discrimination. But the greatest determinant has to do with where you live. If you are born and raised in a high poverty area, you are more likely to remain in poverty, than not. So, contrary to Speaker Ryan’s demagoguery, welfare is not a permanent prison, but more of a temporary safety net to help low income people endure difficult periods of their lives. Moreover, the average participant, almost 40%, is a child.

Former presidential candidate, Mit Romney stated that 47% of Americans paid no federal income tax, implying a parasitic lifestyle, sucking away again, at our hard earned tax dollars. But he never mentioned that three quarters of those individuals simply benefited from tax provisions that benefit senior citizens and low-income working families with children.

Only 21.3 percent of the U.S. population participates in government assistance programs on any given month. Over 90% of these benefits go to the elderly, disabled or working class families. Another key fact that those, scheming to cut taxes to benefit the wealthy, won’t tell you is that for many participants, it’s a temporary visit.

According to the U.S. Census:

• Of people enrolled in Medicaid, 35.6 percent participated between one and 12 months and 35.3 percent participated between 37 and 48 months.

• At 38.6 percent, the largest share of SNAP (Food Stamps) recipients participated between 37 and 48 months.

• At 49.4 percent, the largest share of people receiving housing assistance benefits participated between 37 and 48 months.

• Of people enrolled in the Supplemental Security Income (SSI) program, 35.6 percent participated between one and 12 months, while 38.2 percent participated between 37 and 48 months.

• At 62.9 percent, the largest share of people participating in Temporary Assistance for Needy Families (TANF) participated between one and 12 months.

Cutting these vital programs won’t solve the poverty. Rather, it will deepen the struggle of the disabled and elderly. Moreover, if working class people don’t receive that extra help when they need it the most, they may be more likely to end up in poverty, with fewer options to help them escape it.

They still don't get it! Lessons not learned for the Indiana HIV/AIDS Outbreak

In early 2015, news began to spread about an outbreak of HIV infections in rural Scott County in Indiana, eventually becoming an international story. Dozens of intravenous drug users in the county's tiny city of Austin (population 2,500) became infected with HIV, primarily from sharing and reusing dirty needles to inject opiates. Since the start of the outbreak, over 210 in the county have been diagnosed with HIV, most in Austin. Moreover, almost 95 percent of those infected with HIV were also infected with Hepatitis C. Prior to the outbreak, Scott County had fewer than five new cases of HIV each year. The IV drug use did not come as a surprise to public health officials. Hep C rates had been on the rise in Scott County for years and it was widely assumed that it was linked to IV drugs.

The outbreak was fanned by the flames of ignorance. Former Governor (now Vice President) Mike Pence's policies helped degrade the public health capacity to prevent and respond to this growing epidemic through limited funding and an actual shutdown of Planned Parenthood offices that offered HIV and Hep C testing. Eventually, with more than a little nudging from the Indiana Health Commissioner (and now US Surgeon General) Dr. Jerome Adams, and a lot of pressure from the CDC, Pence grudgingly declared a public health emergency and authorized a short-term needle exchange program as a part of a multi-pronged approach to contain the outbreak.

Now, just two years later and despite demonstrated progress in reducing new HIV and Hep C infection, some of the Indiana counties are closing their needle exchange programs. Some of the politicians voting to close the programs defined it as a "moral" issue. Other complained that not enough users actually entered treatment programs. Bottom line: the programs worked. But now, despite lower rates of HIV and Hep C, it’s easy to declare victory and close the programs.

There is an important lesson to be learned from this situation. It seems clear that this was never about addressing a public health crisis as much as it was about saving face. Having HIV infection rates in a predominately white, rural town in a predominately white state that mirrored and, in some cases exceeded, some areas of Sub Saharan Africa just looked bad! Rather than merely being reactive, it was an opportunity to learn more about the intersections of opioid addiction, poverty and HIV/Hep C infection. It was also an opportunity to develop an infrastructure of prevention and treatment programs that would, over time, lesson the economic burden and human toll extracted by these twin epidemics. Without that infrastructure (which should also include safe injection sites) we will see more of these outbreaks, and not just in small rust belt towns.

A Tale of two States and their struggle with HIV

On the surface, Indiana and Florida could not be more different. Be it size (Florida is the 3rd most populous state, while Indiana is the 38th); location (Midwest vs Deep South) or diversity of the population (Indiana is 84.3% white while Florida is over 46% minority), one might assume their challenges to be very different. However, each state's struggle with their own outbreaks of HIV only serves to reminds us of power of one of the virus' closest allies; poverty.  

Most HIV activists agree that poverty plays a major role in the intransigence of the epidemic. According to the International Labor Office of UNAIDS: "HIV/AIDS is both a manifestation of poverty conditions that exist…, and the result of the unmitigated impact of the epidemic on social and economic conditions. HIV/AIDS is at the same time a cause and an outcome of poverty, and poverty is both a cause and an outcome of HIV/AIDS." So there is no coincidence that as each state struggles with growing poverty, so too has HIV increased. 

Much has been written about Indiana's HIV outbreak-largely because it seemed to come out of nowhere. Starting in February 2015 through April 2016, 190 cases have been documented. Long known as a religiously and socially conservative state, it seemed ill suited to generate headlines for one town, Austin (population 4,200) now has a higher incidence of HIV than "any country in Sub Saharan Africa." says CDC Director Tom Frieden. "They've had more people infected through IV drug use than all of New York City last year." Indiana's poverty rate of almost 21% is also above both the national average (15.9%) and for that of Midwestern states (14.1%) 

Florida too, has both soaring rates of poverty and HIV. Roughly 1 in 6 Floridians live in poverty and, according to the Business Insider, has three of the top 15 cities where poverty is increasing the fastest. Florida also has the highest number of new HIV diagnoses in the nation, with a 23% increase in 2015 alone. 

Despite the largely different primary modes of infection in Austin, Indiana and Florida (IV drug use vs MSM), both states' increases in HIV can be linked to a lack of sustained effort to promote safer sex. In Florida, prevention funding has been flat or cut, and still has prohibitions on talking explicitly about sexuality in sex education classes. Austin IN, like much of rural America, has few medical providers. There is only one doctor and the Planned Parenthood clinic in the county that used to provide HIV testing and referrals closed in 2013, as government funding declined. There is a great fear among HIV surveillance experts of a growing prevalence of HIV in many other rural counties- especially in the south- but also in areas such as Idaho, which had two rural outbreaks in 2008. 

The ongoing debates about income equality and jobs carry a much greater importance that just determining the type of housing in which one lives or the schools our children attend: it has a direct impact on our health. Poverty is the ultimate social determinant and until we have the will to aggressively address it, we will continue to have these pervasive health disparities, like HIV disease. In the meantime, we know what works against HIV. Access to HIV testing and treatment; condoms; needle exchange programs and prevention education can make a real impact on preventing or halting the outbreaks. When the Indiana state health department aggressively moved in and offered HIV testing and treatment as well as setting up a needle exchange in Austin, it effectively stopped its outbreak. Sadly however, "the horse was already out of the barn' and reactive policies are just that, often too little too late. 

State governments and health departments, such as those in Indiana and Florida need to shelve their conservative rhetoric and provide a real plan to prevent HIV infection and to address their burgeoning IV drug use epidemics. Otherwise, we will continue to see a resurgence of this eminently manageable disease, all over the country. 

35 Years of HIV/AIDS

June 5, 2016 represented a solemn birthday as HIV/AIDS turned 35. On July 3, 1981, the New York Times published a groundbreaking article about a rare and often fatal cancer called Karposi’s Sarcoma, which was found in 41 cases of homosexual men in California and New York; eight of the sufferers died less than 24 months after the diagnosis was made. Due to the rarity of the cancer, it was believed at that time that earlier cases might not have been detected. An astounding 71 million infections later, and with over 34 million deaths, the HIV/AIDS epidemic is second in lethalness to the Bubonic Plague of the 14th century, which is estimated to have killed 75 to 200 million people. I began working in the field of HIV/AIDS in 1987, six years after its coming out party. During that time, an HIV diagnosis seemed akin to a death sentence. There was so much that we did know about HIV, and there was only one medication available to specifically treat HIV/AIDS. The medication, called AZT, was prescribed in such toxic doses that many felt more ill from the AZT treatments than they did from AIDS. People were so desperate for something to extend their lives that they would have taken almost anything. Needless to say, a fair number of individuals and "clinics" began to pop up with "cures" for AIDS. While a cure has continued to elude us to this day, we have dozens of medications that have extended the lives of millions of people throughout the world. The challenge now is to provide access to these life preserving medications for all who need them, and to ensure (or facilitate) people taking them. Several years ago I had an opportunity to meet with a group of female HIV activists from South Africa. When I informed them that not everyone in the US with HIV were taking anti-retrovirals, they were stunned. It was their understanding that HIV medication was widely available, and that everyone who needed them were taking them. I explained that health insurance plans in some states provided limited coverage for certain medications, and that some people (as many as 19%) living with HIV were unaware of their infection. While they understood this, they could not understand how so many who were aware of their diagnosis and had access to medications were not on medication. Various studies have shown that as few as 30% of people living with HIV in the US have suppressed viral loads, the gold standard for HIV care. While viral load suppression has risen in HIV+ individuals in care, there remains an alarming number of individuals not receiving consistent HIV disease management (ex. in and out of care, or not in care at all). While we cannot cure HIV, we have built a better toolbox that can help keep people alive for a long time, and there are even more tools in the pipeline. In spite of the tools at hand, however, issues of poverty, homelessness, substance abuse, and mental illness continue to disproportionately impact those most at risk for HIV. Thus, our goal at year 35 of the HIV/AIDS epidemic is to get people into care, and to help them stay there.

Know what you are talking about

I was recently asked if I felt that we, in the black community, could now decelerate our efforts to fight HIV due to so much progress with treatment. My answer, quite to the questioner’s surprise, was a resounding NO! Her question was predicated on the belief that the black community had previously issued a 'call to arms' and had mobilized, much like the LGBT community had in the 80's and 90's, to educate our community and advocate for more funding. It is downright depressing to think that the black community might be breathing a collective sigh of relief and backing off on whatever feeble efforts we are able to marshal, believing that we have won something. Has progress been made? Absolutely. Are we out of the woods yet? Absolutely not. Two recent reports have demonstrated that we still have a long way to go. While HIV has continued to wreak havoc on the black community (representing 44% of new HIV cases), the landscape is even bleaker for black gay and bisexual men in the United States. According to the Centers for Disease Control (CDC), one half of black MSM (men who have sex with men) “will be diagnosed with HIV in their lifetime” if current trends continue. To put this another way, if America’s black gay and bisexual men comprised a nation unto themselves, that nation would soon have the world’s highest rate of infection — twice as high as its closest rivals in Sub-Saharan Africa (CDC). If this isn't dire enough, the average survival time for African-Americans with AIDS is lower than for other racial or ethnic groups despite dozens of effective medications including a HIV prevention pill (PrEP). The main reason for this seems to be inconsistent treatment. From 2011 to 2013, only 38 percent of black HIV patients received consistent treatment, whereas about 50 percent of whites and Hispanics with the virus had continuous care (CDC's Feb. 4th Morbidity and Mortality Weekly Report). This disparity is consistent with the statistics regarding viral suppression, which is the gold standard for HIV care. In general, it is understood that the lower the amount of HIV virus in one’s blood, the lower the risk of opportunistic infections and the greater the life expectancy. Only about 25 percent of people living with HIV in the United States have achieved viral suppression, with African Americans being the least likely to do so at a rate of 21% compared to 26% among Hispanics and 30% of whites. Additionally, the 25-34 age group (one of the hardest hit among black MSM) is the least likely to have achieved viral suppression compared to other age groups, with only 15 percent of individuals 25-34 reaching this goal. The causes for this include the usual suspects of poverty, substance abuse, lack of access to health care, homophobia, stigma, etc. But, and back to my original premise, I have NEVER seen a true sense of urgency in the black community about HIV/AIDS. Oh sure, the Congressional Black Caucus has successfully fought for more money to address HIV in black and brown communities. Many black churches, civic and fraternal organizations have stepped up, and even a few celebrities have raised their voices (as well as money) for and about this epidemic. Our President has even released comprehensive HIV strategies, with specific objectives and time-frames. Nevertheless, we continue to get caught up in stereotyping and conspiracy theories that undermine the severity and urgency of this issue. I cringe when I read statistics about the terrible impact in black gay and bisexual men, because I know that gives our community more 'cover,' enabling us to bask in the warm waves of the delusion that HIV/AIDS is someone else's problem. We can no more stop HIV infection by building imaginary walls between ourselves and people who, well, are not 'like us' (gays and bisexuals), as we can stop terrorism and immigration by building brick and mortar walls. There is no simple solution to this. But, for starters, I suggest that we take the time to learn more about it. Something I hear over and over in my conversations about HIV/AIDS is that people don’t realize ‘how bad it is,’ despite the wealth of information available. I can't help but think about the words of two truly different, yet wise, black men. Chris Rock tells us (and I paraphrase) that books are like Kryptonite to black folks, and if you want to hide something from us, put it in a book. On a more serious note, President Obama, speaking to the 2016 graduating class at Rutgers University, said that “ignorance is not a virtue…It's not cool to not know what you are talking about. That's not keeping it real or telling it like it is. That's not challenging political correctness. That's just not knowing what you are talking about." Before we start dismissing HIV as only a “gay disease” or believing that there’s this secret cure for rich people, open a book or a suitable internet page (try the CDC.gov for starters) and begin to know what you are talking about.

"Kick and Kill"

The International AIDS Conference, this year in Melbourne, Australia, is one of the very few times that we can expect to read or hear about HIV in the regular media. For many years, the news was dominated by rising infections and mortality rates. However, the last few conferences have been dominated by new, promising results from studies that seem to confirm more and more that HIV is a manageable, chronic disease. Moreover, the "cure" word is also being tossed around quite often. For example, one recent study of six patients by Danish researchers seems to have taken a step towards addressing one of the more frustrating barriers towards curing HIV: the reservoirs of HIV that linger even after a person has an undetectable viral load. The researchers used the anti-cancer drug Romidepsin to activate the virus and bring it out of hiding. This potentially exposes the virus to the “killer” T-cells, which are responsible for attacking and eliminating pathogens in the blood stream but can’t detect the virus hidden in the CD4 cells. Unfortunately, in this study, even though the immune system detected the virus, it did not attack it. Nevertheless, the researchers are optimistic that in the next phase they can teach the immune system to recognize and clear these HIV cells. In closing, this study is indicative of the complexity of developing new therapies to combat or cure HIV. Yet, as we learn more about HIV, we get closer to that word, which decades ago seemed unrealistic, a cure.

Thank you Mr. Sterling

Strange title, eh? After all, why would I thank someone attributed to insensitive racial comments about African Americans in 2014? With an African American president, thousands of African Americans now listed among the elite, but elusive, top 1% (over a dozen of whom, by the way, who actually work for Mr Sterling) don't we now live in, as many idealistic pundits and scholars call it, a 'post racial' society? Well, this blog is not intended to thank him for reminding us that racism is alive and well. I am thanking Donald Sterling for getting HIV back in the news. Now, one would think that the greatest epidemic in modern history alone, would remain in the headlines by virtue of well, it being the greatest epidemic in modern history. Its amazing to think that 75 million total infections, over 36 million deaths and over 2.3 million new infections annually rarely makes the news. Nor is it the fundraising leadership of 'twinBill" of Bill Clinton and Bill Gates; or the dramatic breakthroughs in HIV treatment that have enabled millions to live longer, more productive lives; or even the tenacity of the advocates who have fought for access for these treatments. No, it takes the uniformed comments of an 80 year old man about one of the most iconic figures in the history of this epidemic, Magic Johnson, to justify front page news. So thank you, Mr Sterling for reminding us that HIV infection is not the same thing as AIDS and that people can LIVE with HIV. Thank you for reminding us that many people still blame the victim ( 32%- according a 2012 survey by the Kaiser Family Foundation). And last, but not least, thank you for reminding us that we still have a long way to go to reduce the crushing stigma still associated with HIV. The attention that you brought to this issue, misguided as it may have been, has produced the rare public 'teachable moment" that we HIV advocates and educators so often yearn for. Now, I guess we will just have to wait for the next major, public faux pas to get in the headlines again.

Ignorance is Bliss (Not!)

As someone working in the field of HIV/AIDS, I have had many conversations about the topic with people ranging from politicians to middle school students. However, I will never forget the recent conversation that I had with a long term (25+ years)survivor who shared how he could manage the symptoms, the side effects of the medication and even accepting that he may not live as long as he planned; but it was the stigma that he struggled with the most. So why, at the ripe old age of 32, does the stigma of HIV/AIDS remain so devastating? A new survey by the National AIDS Trust demonstrated how the lack of knowledge about HIV/AIDS, despite our access to social media and the internet, remains significant. For example: * 20% of the survey respondents believed that HIV/AIDS is a death sentence and that the life expectancy of a newly diagnosed person is about 10 years; * Over one-third of the respondents believed that people living with HIV were not allowed to work in schools, hospitals or restaurants; * Over 25% believed that people living with HIV are legally required to disclose their status. After reading these results, I recalled a conversation that I had with a Miami cab driver. I often share what I do for a living, partially to gauge the reaction, but also to ascertain what they know about HIV/AIDS. I was mortified when this cab driver, who looked to be in the 25-35 year old range and was deftly welding the GPS on his smartphone to navigate, said that he knew that there was a drug to treat AIDS: AZT! For those of us even remotely familiar with HIV, to hear someone express that s/he knew of only one medication to treat it-which happens to be the first anti-retroviral medication to treat HIV/AIDS AND was introduced in 1984! Is it fair to expect people to know more about HIV/AIDS? At what point does personal safety take over? Doesn't over 25 million deaths, with over 34 million people living with HIV/AIDS at least inspire some curiosity? I am a little biased of course, but it would certainly make my work and others like me, not to mention the lives of the tens of millions living with it a little easier if more people took the time to avail themselves of the tons of information available to them. Isn't it worth the time?

Were Michael Douglas' comments about HPV helpful?

Megastar actor/director Michael Douglas recently caused a stir when he implied that his stage 4 throat cancer was caused by the Human Papillomavirus (HPV), which he believe he contracted through oral sex. He went on to say that cunnilingus was also the "best cure for it." As I have written previously, one tract of HPV (HPV16) is known to be linked to oral cancer, manifesting itself in the back regions of the throat and mouth. HPV, the sexually transmitted virus best known as a cause of genital warts as well as being linked to cervical and anal malignancies, is thought to be responsible for an increasing proportion of oral(oropharyngeal) cancers, including throat cancer. However, lifestyle may present even greater risk factors and Mr. Douglas' tobacco habit, coupled with, at times, excessive alcohol consumption appear to be the most likely culprits. In 1992, he was hospitalized for an addiction which some at the time claimed to be sex. Douglas himself denied this and said he was in rehab for alcohol abuse. He has also spoken of recreational drug use. Many believe that the rise in HPV related cancers may be the result of a change in sexual behavior, especially an increase in oral sex. Oral sex may seem for many to be a safer alternative to penetrative sex, which are know to result in a host of sexually transmitted infections (STI'S) , including HIV. Most people seemed surprised to learn that STI'S such as Gonorrhea and Syphilis, not to mention HPV, may be transmitted through oral sex. A physician once said to me that the throat is an almost perfect breeding ground for infection. To his credit, Mr Douglas later backtracked and acknowledged that his cancer may not have been caused by HPV-he was just sharing how oral sex may lead to throat cancer. However, were his comments helpful in raising awareness in the public about HPV? Certainly his assertion that more oral sex can help cure it, was not. My fear is that many people do not take the time to read or even listen to the whole story and are more likely to get the gist of it from headlines and sound bites. Nonetheless, even if he had to pull his foot from his mouth (no pun intended), I am grateful to him for having the courage to bring to light an important issue. Now it is up to the rest of us to make sure that we provide the accurate information to the public.

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.

African Americans Stand to Lose from the War on Contraception

According to Webster’s Dictionary, “Contraception” is defined as the deliberate prevention of conception or impregnation by any of various drugs, techniques, or devices or; birth control. However, with the prevalence of sexually transmitted infections, many people tend to incorporate their contraceptive and sexual health prevention methods under a concept of risk reduction.

There are at least 25 know sexually transmitted infections (STIs) and infect about 15million people annually. As the debate rages about the need for and availability of contraception, we in the African American community should understand the huge stake that we have in this discussion.

African Americans have been disproportionately impacted by sexually transmitted infections, especially HIV. We represent ½ of the new HIV infections, those living with HIV and those who succumb to it each year in the United States. We also have higher rates for other STIs. We represent 50% of the 2.8 million new Chlamydia infections and our infection rates for Gonorrhea and Syphilis are 16 and 23 times those of whites respectively. Nowhere is this impact greatest than in young people, especially young women. A recent CDC study estimated that 48% of black adolescent girls in the United States had at least one STI. Moreover, many are unaware of it. Teenage pregnancy rates have risen to 42 births per 1000 females. Programs such a Planned Parenthood which offer free or low cost contraception services also provide comprehensive risk reduction services as well, services that are desperately needed in our community.

According to the National Center for Health Statistics, teen pregnancy and out of wedlock births are one of the major causes of infant mortality and are often cited as helping to keep the US infant mortality rates higher than in many industrialized countries.

Many studies point to the impact of poverty in exacerbating these rates. The latest recession has had a devastating impact of black people. Unemployment rates have risen as high as 15.9% (26.4 in youth). We have seen a significant decline in home ownership, and median household income. Poverty rates for blacks are double those for whites. And Africans Americans have consistently lower levels of health care than do whites.

In closing, African Americans definitely have a ‘dog in this fight.’ We cannot afford the impact of more unplanned pregnancies to more young women let alone the physical and economic hardship caused by sexually transmitted infections, especially HIV. We can and we must demand more, not less, ownership in our own sexual health.

And the beat goes on...

As the controversy about HIV criminalization continues to rage, the state of Maryland has decided to 'up the ante,' so to speak, by proposing to add more teeth to their current HIV-specific criminal law, according to a recent article in the American Independent newspaper. Presently, a person convicted of knowingly transmitting or attempting to transmit HIV to another person may result in an $2500 fine and up to a three year prison sentence. However, Maryland state legislators are considering changing the law from a misdemeanor to a felony with an up to 25 year sentence. Despite the absence of evidence that these types of punitive methods are a deterrent and that people who know their HIV status, especially if they have achieved viral suppression with anti-retroviral therapy, are less likely to infect others, fear and and the desire for retribution continues to reign.

Another interesting article in the Philadelphia Daily News ("Its Payback Time," 3/6/12) chronicles William Brawner, an HIV+ man who knowingly had unprotected sex with several women while a student at Howard University. He eventually contacted all of the women and disclosed his HIV status. Fortunately, it does not appear that any of the women became infected. Mr. Brawner has gone on to start a non profit organization to help other HIV+ young people. I can't help but wonder if we would have ever heard his story and would he have had the opportunity to help other confused young people, as he was at one time, if he had been thrown in jail for 25 years. While there in no condoning his behavior, won't many more people benefit if he is a contributing member of society?

HIV Criminalization

In May 2008, a homeless, HIV+ man was sentenced to 35 years in prison for assaulting a police officer with a "deadly weapon, his saliva! Willie Campbell, who was clearly intoxicated at the time, has been HIV+ since 1994 and has a history of aggressive behavior with public servants, will have to serve at least 17.5 years to be eligible for parole. The police officers were not infected. According to the Centers for Disease Control (CDC), although there have been a few rare cases of transmission through severe bites, “contact with saliva, tears or sweat has never been shown to result in transmission of H.I.V.”

Thirty four states, 2 U.S. territories and numerous other countries (including Russia, Finland, Australia, England and 20 countries in Sub Saharan Africa) have HIV specific criminal statutes. Other U.S. States and some other countries have used non-HIV specific charges such as assault with a deadly weapon and attempted murder. Many of these laws and prosecutions do not differentiate between whether an HIV+ person used a condom or even whether the virus was transmitted. All of this begs the question: Should we even be on this slippery slope?

Being HIV+ is not a crime. With the new developments in treatment, it is no longer a death sentence. Moreover, recent studies have demonstrated that one of the most effective methods of prevention is aggressively treating individuals with HIV, thereby lowering their viral load so that they may be less infectious. Studies have also shown that people who know there status tend to behave more responsibly. Unfortunately, the CDC estimates that as many as 1 in 5 people who are HIV+ are unaware of their status. Therefore it is crucial that people know their HIV status.

I understand the fear and demagogory that has dogged the HIV epidemic. And, I am certainly not making the case for irresponsibility when it comes to having sex. I get it! But we have made significant gains in this country, not just in treatment, but in making HIV testing a routine part of medical care. The last thing that we need is to arm prosecuters with powerful laws to 'punish the victim,' eg... to lock away hundreds, if not thousands of HIV+ people to protect us from them. And what responsibility does the 'partner' have in all of this. Does a person have to be told that their potential partner is HIV+, before they will use a condom?

Unfortunately, this issue is much more complex that the time and space that I will currently give to it. Perhaps the greatest concern is that these laws, which were no doubt designed to prevent infection, will more likely have the opposite effect of scaring people away from getting tested. After all, what is to stop a scorned ex-lover from pressing charges, stating that they WERE NOT TOLD of their partner's HIV status. Haven't we learned that punitive action is not always the answer. In other words, in our efforts to prevent the spread of HIV, the shield is mightier than the sword.

AIDS Denialism

Recently, someone named Curtis Cost wrote an article assailing the importance and validity of African Americans knowing their HIV status. Since the first widely reported cases in 1981, HIV has been mired in controversies, ranging from its origin to the possible existence of a cure. Sadly, over thirty years later, we continue to have many of the same conversations. What should NOT be in doubt any longer is that HIV disease is having a devastating impact on the African American community. Although African Americans represented only 14% of the US population in 2009, we accounted for 44% of all new HIV infections in that year. Overall, African Americans account for a higher proportion of HIV infections at all stages of disease—from new infections to death, than any other racial of ethnic group. Moreover, as many as 21% of people living with HIV are unaware of their status and, consequently cause up to 70% of the new infections. So why then, would Mr. Cost write such an impassioned plea for African Americans to NOT get tested for HIV? In short, we refer to people like Mr. Cost as AIDS Denialists. AIDS Denialists represent individuals or groups who deny that the human immunodeficiency virus (HIV) is the cause of Acquired Immune Deficiency Syndrome (AIDS). While the link between HIV and AIDS has long been established in the scientific community, AIDS Denialists continue to dismiss HIV as a harmless passenger virus and assign the cause of AIDS to anything from malnutrition to the drugs used to treat it. Now, before you dismiss the Denialists as just foolish or uninformed, let me remind you about Thabo Mbeki, the former President of South Africa and once a poster child for AIDS Denialism. By some estimates, his alleged 'fiddling while Rome was burning' may have led to as many as 330,000 AIDS deaths as well as almost over 200,00 new HIV infections.

The greatest weapon against AIDS Denialists is knowledge, ours. AIDS Denialists prey on our own cynicism, ignorance and, yes, our denial. It always amazes me how willing we are to jump on the bandwagon of someone offering very little in the way of proof and disavow decades of scientific evidence. Healthy skepticism can be a good thing. However, use that cynicism to motivate yourselves to seek more information. In other words, do your own homework!