For so many years, the news about efforts to combat HIV/AIDS has been, in a word, depressing. It seemed that with every positive development would come news of escalating infection rates, or that some promising vaccine or therapy was less promising than we had hoped. But 2010 will be remembered as one of the first years where there seems to be almost universal optimism that real progress is being made in this war.
Perhaps the most optimistic front has been in the area of science. During this year, we have been uplifted with promising results of studies raging from the possible efficacy of microbicides, to the potential of gene therapy. At the International AIDS Conference, one of the major themes throughout the event was that effective HIV treatment IS prevention i.e., that reducing viral load may be an effective tool in reducing infection rates. Moreover, for many years, the idea of a pill that could prevent HIV infection was almost universally derided. Yet with the recent announcement of the National Institutes for Health study of pre –exposure prophylaxis in MSM, we now may have another tool to reduce infection rates in individuals at greatest risk.
Not all of the positive news has just been in the field of science. Thanks to President Barack Obama, the United States has its first National HIV/AIDS Strategy with an extra 30 million dollars added for HIV prevention (and 25 million for the struggling ADAP program). Moreover, with the reopening of the National AIDS Policy Office, the approval of needle exchange, the elimination of the travel ban for people with HIV and most importantly, the passing of the Affordable Care Act, the United States has finally taken a broad, visible leadership role in fighting this epidemic.
So while there is undoubtedly good news, there also remain challenges. Less than half of the individuals needing HAART are receiving it. Moreover, the global recession has caused historic belt tightening throughout the world. In the United States, many states and cities are either reducing or considering reduction in HIV/AIDS services. Even staunch HIV advocates are reflecting on the monumental task (not to mention the expense) of keeping tens of millions of HIV+ individuals alive with HAART indefinitely, a lifetime cost that a Cornell University study estimated at $600,000 per person.
So where do we go from here? Perhaps the greatest optimism during 2010 has been the belief from many HIV researchers that a cure may be on the horizon. There are several very promising areas of “cure” research with promising results. However, in this case, the ‘devil is not in the details,’ but in the dollars. In order to find a cure, whether a functional one that allows people to maintain an undetectable viral load without medication or an eradication cure, it will take a lot more money then is being expensed now. For example, the cost of researching and developing a single drug has been estimated at 500 million to 2 billion dollars.
The hundred dollar question is: will we demonstrate the commitment, through the economic resources and the will to revamp the infrastructure to facilitate cure and vaccine research, or will we keep looking around and hoping for some lucky, miraculous (and cheap) breakthrough? A wise man once coined the phrase to me that the history of AIDS is still being written. Let’s make this next chapter, 2011, the year where WE gave the bully a bloody nose.
Tuesday, November 23, 2010
Thursday, October 21, 2010
Disturbing New Information on MSM and HIV
One of the most frustrating aspects of working in HIV is addressing the many myths (as well as conspiracy theories) surrounding it-the most persistent of which is that AIDS is a "gay disease." Clearly this myth started early in the history of HIV in the U.S., yet has persisted despite clear evidence of how HIV is transmitted and the growing diversity of those whom become infected. Moreover, it has been convenient for many to affix the label of "gay" to anyone who has had sex with the same gender. However, a startling new report from the Centers for Disease Control (CDC) may add additional fuel to that myth. A CDC study conducted in 21 cities tested over 8,000 gay and bisexual men participating in the 2008 National HIV Behavioral Surveillance System.
The study found that almost one in five men having sex with men (MSM) was infected with HIV and that almost half of them did not know it. Black MSM were infected at a rate of 28%, as compared to 18% for Latino men and 16% for Caucasian MSM. Black MSM were even less likely to know their status than other races (59% were unaware) with young black MSM, a shocking 71% of which were unaware of their status. There was also a high co-morbidity with HIV status and socioeconomic variables-with HIV + status increasing as education and income decreased.
Studies such as these point to the glaring need for new creative strategies, not to mention social marketing approaches, to attract more and younger MSM to get tested. Moreover, despite all of the hoopla about '"men on the down low" as the culprit for rising infection rates with women, we cannot overlook the fact that many of the men in this study were bisexual and therefore, may have female partners. Previous studies have shown us that when someone knows their HIV status they are more likely to practice safer sex. Hopefully a renewed focus on HIV prevention targeting MSM may lead to a sorely need national dialogue revealing the diversity and complexity of the topic. Perhaps that discussion will help dispel the myth.
The study found that almost one in five men having sex with men (MSM) was infected with HIV and that almost half of them did not know it. Black MSM were infected at a rate of 28%, as compared to 18% for Latino men and 16% for Caucasian MSM. Black MSM were even less likely to know their status than other races (59% were unaware) with young black MSM, a shocking 71% of which were unaware of their status. There was also a high co-morbidity with HIV status and socioeconomic variables-with HIV + status increasing as education and income decreased.
Studies such as these point to the glaring need for new creative strategies, not to mention social marketing approaches, to attract more and younger MSM to get tested. Moreover, despite all of the hoopla about '"men on the down low" as the culprit for rising infection rates with women, we cannot overlook the fact that many of the men in this study were bisexual and therefore, may have female partners. Previous studies have shown us that when someone knows their HIV status they are more likely to practice safer sex. Hopefully a renewed focus on HIV prevention targeting MSM may lead to a sorely need national dialogue revealing the diversity and complexity of the topic. Perhaps that discussion will help dispel the myth.
Thursday, October 7, 2010
HIV may have been present for 32,000 years
Despite the persistent myth that HIV was a man-made disease, unleashed upon the unsuspecting, disenfranchised of our society (read gays and blacks), now comes more evidence that it may have been present in monkeys and apes for a millennia. New research, published in Science magazine last month, report the presence of the ancestor of the simian HIV virus in Africa possibly dating back as far as 78,000 years. This fascinating research, that studied monkey species on a volcanic island off of the coast of West Africa, who developed in isolation, found that four of the six species had been infected with HIV.
Although this study may help to answer certain questions, such as why HIV infects most simian species, but doesn't kill them, it fails to answer the main one: how did a relatively benign monkey virus become one of the greatest health crises in the history of mankind. Many still believe that the human HIV epidemic was caused by, purposely or inadvertently, human meddling.
Evidence of the great age of HIV does point to the likelihood that, over centuries, the virus killed off weaker monkeys leaving behind those who became resistant to it. However, does that mean that it will take thousands of years before we are able to adapt naturally to HIV? Can we survive that long with rising rates, declining government support and the aggressive mutation of the virus?
Our obvious advantage is, of course, our technological superiority. We now have over 30 medications to treat HIV and many believe that a cure is still possible. However, by following the path of HIV and other diseases, it hopefully reminds us of our fragility and vulnerability as we continue, sometimes in the interest of capitalism and expansion, to invade more exotic and isolated lands and interact with previously unknown species.
Although this study may help to answer certain questions, such as why HIV infects most simian species, but doesn't kill them, it fails to answer the main one: how did a relatively benign monkey virus become one of the greatest health crises in the history of mankind. Many still believe that the human HIV epidemic was caused by, purposely or inadvertently, human meddling.
Evidence of the great age of HIV does point to the likelihood that, over centuries, the virus killed off weaker monkeys leaving behind those who became resistant to it. However, does that mean that it will take thousands of years before we are able to adapt naturally to HIV? Can we survive that long with rising rates, declining government support and the aggressive mutation of the virus?
Our obvious advantage is, of course, our technological superiority. We now have over 30 medications to treat HIV and many believe that a cure is still possible. However, by following the path of HIV and other diseases, it hopefully reminds us of our fragility and vulnerability as we continue, sometimes in the interest of capitalism and expansion, to invade more exotic and isolated lands and interact with previously unknown species.
Tuesday, September 14, 2010
Opt-Out and Eliminating Consent for HIV Testing
President Obama's new AIDS Strategy calls for a renewed effort to reduce new HIV infections by 25%, increasing the number of people who know their status from 79% to 90%. Crucial to the success of this benchmark is to test more people for HIV. This is consistent with the Center for Disease Control's recent recommendations (in 2006) to encourage HIV testing to become a routine part of medical care. However, one of the more controversial aspects of this push is the distinction between 'opt -in' vs 'opt-out HIV testing. Opt-in testing generally refers to an opportunity for the patient to be asked, by a provider, if s/he would like to be tested for HIV. Opt-out testing means that a patient will be given an HIV test unless s/he chooses not to have one. The CDC has recommended opt-out testing as well as the elimination of written consent (a medical consent form that authorizes HIV testing).
As one might imagine, this is a pretty contentious topic, even among HIV advocates and medical providers. Supporters of opt -in testing and informed consent argue that people need to understand what they are being tested for and why. Moreover, they argue that eliminating written, or even verbal consent fails to address the reasons why so many people fail to be tested, at the expense of expediency. Ignorance, apathy, stigma and discrimination are still alive and well, they claim, and cannot be ignored. Opt-out testing proponents point to the growing members of people who do not know their HIV status, present for treatment in the latter stages of their disease and the glaring disparity of HIV among the poor and communities of color as evidence that the present system isn't working and that we need new strategies to address the soaring epidemic. They also minimize the impact of stigma and discrimination, due in part to the efforts to make HIV testing more routine.
Nowhere is this debate raging more than in New York City, which still hold the crown for the highest incidence of HIV of any US city. New York State requires written consent, but the current policy is being reexamined. So what is the right policy? One thing is clear: both sides seem to be focused on the same outcome, a reduction of HIV infection. Unfortunately, in an era of dwindling resources it is sad that there is not more consensus on this issue. What isn't clear if if the present policies around informed consent aren't working. There is evidence that many medical providers are not offering HIV testing to their patients, due in part to their discomfort with the subject. Moreover, there is evidence, some of which comes from New York itself that HIV testing is rising under the current rules.
I am concerned that if people are not given an opportunity for consent for HIV testing and to have the conversation that would likely take place with that medical provider, that much of the ignorance and misconceptions about HIV will remain. Moreover, if provider feel a conversation about HIV testing is uncomfortable, then how will they feel about giving someone a positive result? We clearly have a long way to go before our society sees HIV/AIDS as just a medical condition. Before eliminating informed consent, I feel that more training for medical providers, more and robust social marketing to reduce HIV stigma and a renewed emphasis to ensure that HIV testing is being offered in routine medical settings are more effective measures to increase HIV testing.
As one might imagine, this is a pretty contentious topic, even among HIV advocates and medical providers. Supporters of opt -in testing and informed consent argue that people need to understand what they are being tested for and why. Moreover, they argue that eliminating written, or even verbal consent fails to address the reasons why so many people fail to be tested, at the expense of expediency. Ignorance, apathy, stigma and discrimination are still alive and well, they claim, and cannot be ignored. Opt-out testing proponents point to the growing members of people who do not know their HIV status, present for treatment in the latter stages of their disease and the glaring disparity of HIV among the poor and communities of color as evidence that the present system isn't working and that we need new strategies to address the soaring epidemic. They also minimize the impact of stigma and discrimination, due in part to the efforts to make HIV testing more routine.
Nowhere is this debate raging more than in New York City, which still hold the crown for the highest incidence of HIV of any US city. New York State requires written consent, but the current policy is being reexamined. So what is the right policy? One thing is clear: both sides seem to be focused on the same outcome, a reduction of HIV infection. Unfortunately, in an era of dwindling resources it is sad that there is not more consensus on this issue. What isn't clear if if the present policies around informed consent aren't working. There is evidence that many medical providers are not offering HIV testing to their patients, due in part to their discomfort with the subject. Moreover, there is evidence, some of which comes from New York itself that HIV testing is rising under the current rules.
I am concerned that if people are not given an opportunity for consent for HIV testing and to have the conversation that would likely take place with that medical provider, that much of the ignorance and misconceptions about HIV will remain. Moreover, if provider feel a conversation about HIV testing is uncomfortable, then how will they feel about giving someone a positive result? We clearly have a long way to go before our society sees HIV/AIDS as just a medical condition. Before eliminating informed consent, I feel that more training for medical providers, more and robust social marketing to reduce HIV stigma and a renewed emphasis to ensure that HIV testing is being offered in routine medical settings are more effective measures to increase HIV testing.
Tuesday, July 27, 2010
Day Five of the International AIDS Conference of 2010
The conference is starting to wind down. From a personal and environmental perspective, you can feel the air slowly ‘leaving the balloon.’ The palpable energy level has dropped appreciably. Many of us are just overloaded. There is so much information being disseminated, as well as events, press conferences, and activities, many occurring concurrently, that it is physically impossible to attend but a fraction of it. One of my greatest regrets is that I haven’t had an opportunity to have any substantive conversations with my brothers and sisters from other counties. There has just been so little time. I have had the opportunity to speak with a couple of the gentlemen in my traveling party who work for organizations that have similar programs to my owe. I have found those conversations to be enlightening and helpful.
I had the opportunity to attend The Other City,’ Sheila Johnson’s independent film about HIV in Washington D.C. Suffice to say, because I don’t want to spoil the movie, it is well worth seeing and I am going to work hard to bring it to the Philadelphia area. After the movie, we have a brief discussion period which included some convention delegates from Africa and Haiti. While it certainly wasn’t the first time I heard it, they remarked at how surprised they were that HIV was a problem in the United States. Their perception of the U.S. is that we are wealthy and that the HIV epidemic is under control here. The real irony here is that most Americans, including many black Americans, feel the same way. I can’t keep track of the number of conversations I have had with American black folks who have told me that they didn’t think that HIV was a problem because they hardly hear about it. While I acknowledge that there is not enough HIV reporting, there is plenty of information available for those who seek it. So therein lies the problem, why don’t we want to know. Clearly, some of us don’t believe that we are at risk. Others still hold on to the myths (that it’s a gay disease) and conspiracy theories (that there is an actual cure). Still others find it depressing and feel that they already have enough to deal with.
So what do we do? How do we get black folks attention, especially with the next International HIV Conference in Washington D.C., looming? Think about it: What message do we want to take to that conference? Will it be that we are still dragging our feet and HIV in the US has worsened? Or will we begin to live up to the hype, the international image that we have HIV better managed and might actually be in a position to show other folks how to do it? I ran into actress Sheryl Lee Ralph here. She suggested a million person march on HIV. Hmmm, not a bad idea. Volunteers?
Goodbye from Vienna. This will be my last official Vienna blog, but please follow my blog, called unabashedly, ‘Gary’s Blog at www.bebashi.org and at The Body website (www.thebody.com).
Auf wiedersehen!
I had the opportunity to attend The Other City,’ Sheila Johnson’s independent film about HIV in Washington D.C. Suffice to say, because I don’t want to spoil the movie, it is well worth seeing and I am going to work hard to bring it to the Philadelphia area. After the movie, we have a brief discussion period which included some convention delegates from Africa and Haiti. While it certainly wasn’t the first time I heard it, they remarked at how surprised they were that HIV was a problem in the United States. Their perception of the U.S. is that we are wealthy and that the HIV epidemic is under control here. The real irony here is that most Americans, including many black Americans, feel the same way. I can’t keep track of the number of conversations I have had with American black folks who have told me that they didn’t think that HIV was a problem because they hardly hear about it. While I acknowledge that there is not enough HIV reporting, there is plenty of information available for those who seek it. So therein lies the problem, why don’t we want to know. Clearly, some of us don’t believe that we are at risk. Others still hold on to the myths (that it’s a gay disease) and conspiracy theories (that there is an actual cure). Still others find it depressing and feel that they already have enough to deal with.
So what do we do? How do we get black folks attention, especially with the next International HIV Conference in Washington D.C., looming? Think about it: What message do we want to take to that conference? Will it be that we are still dragging our feet and HIV in the US has worsened? Or will we begin to live up to the hype, the international image that we have HIV better managed and might actually be in a position to show other folks how to do it? I ran into actress Sheryl Lee Ralph here. She suggested a million person march on HIV. Hmmm, not a bad idea. Volunteers?
Goodbye from Vienna. This will be my last official Vienna blog, but please follow my blog, called unabashedly, ‘Gary’s Blog at www.bebashi.org and at The Body website (www.thebody.com).
Auf wiedersehen!
Day Four of the International AIDS Conference of 2010
‘Charity begins at home.’ A cliché? Certainly! But with dwindling resources for everything and a raging HIV Epidemic in Black people in the United States, should we concentrate more of our efforts here? This question, which has created an ongoing tension for many HIV/AIDS advocates in the U. S., was the proverbial ‘elephant in the room during a breakfast meeting I attended with billionaire philanthropist Sheila Johnson this morning. Ms Johnson acknowledged coming to the same conclusion through her international work with CARE upon learning of the devastation that HIV was causing in Washington DC. For years, we (Black U.S. HIV advocates) have witnessed the constant flow of wealthy celebrities overseas, often to Africa, to attempt to make some small impact in the epidemic. We have struggled with the dichotomy of two virtual epidemics: one here ad the other overseas. If we are truly our brother’s keepers, how can we begrudge anyone helping our brothers and sisters in the ‘motherland?’ No one will discount the devastation of HIV in Africa.
As I travel throughout the conference and look into the many faces of its participants, it is clear that most, if not all, are very, very passionate about the impact of HIV in there respective countries and/or, for the constituents they represent: women, transgender, MSM (men having sex with men), sex workers, etc... Few seem to advocate for resources to be sent elsewhere. Therefore, is it selfish for those in the U.S. who have more resources and clearly have an edge in terms of access to life sustaining antiretroviral therapy, to place most of our emphasis on home? While no one would argue that we have more in the U.S., for black people, we clearly do not have enough. Moreover, we now recognize that HIV rates in some areas of the U.S.: parts of the rural south, the Bronx, North Philadelphia and of course Washington DC, rival countries in Sub Saharan Africa. Therefore, do we now have the justification to advocate more vociferously for more of our resources to remain at home? Did we ever need to ‘justification?’ And if we don’t advocate, what will the consequence be?
Well, ladies and gentleman, we are living the consequences of not just diverted resources, but our own ignorance and apathy. We have very little margin for error. While we certainly have no right to tell Oprah, or Alicia Keys how to spend their money, we can and we must continue to educate them and others (including those of more moderate means) that our own house is on fire and that if we run down the street to help our neighbors than we just might not have a home to come back to. It is a difficult conversation to have. But I’m ready. Let’s talk about it!
Goodbye from Vienna. Will be in touch tomorrow!
As I travel throughout the conference and look into the many faces of its participants, it is clear that most, if not all, are very, very passionate about the impact of HIV in there respective countries and/or, for the constituents they represent: women, transgender, MSM (men having sex with men), sex workers, etc... Few seem to advocate for resources to be sent elsewhere. Therefore, is it selfish for those in the U.S. who have more resources and clearly have an edge in terms of access to life sustaining antiretroviral therapy, to place most of our emphasis on home? While no one would argue that we have more in the U.S., for black people, we clearly do not have enough. Moreover, we now recognize that HIV rates in some areas of the U.S.: parts of the rural south, the Bronx, North Philadelphia and of course Washington DC, rival countries in Sub Saharan Africa. Therefore, do we now have the justification to advocate more vociferously for more of our resources to remain at home? Did we ever need to ‘justification?’ And if we don’t advocate, what will the consequence be?
Well, ladies and gentleman, we are living the consequences of not just diverted resources, but our own ignorance and apathy. We have very little margin for error. While we certainly have no right to tell Oprah, or Alicia Keys how to spend their money, we can and we must continue to educate them and others (including those of more moderate means) that our own house is on fire and that if we run down the street to help our neighbors than we just might not have a home to come back to. It is a difficult conversation to have. But I’m ready. Let’s talk about it!
Goodbye from Vienna. Will be in touch tomorrow!
Day Three of the International AIDS Conference of 2010
With yesterday’s release of the CDC’S report on the relationship between poverty, and another study on morbidity and mortality released by the University of California, Day three of the International AIDS Conference of 2010 began on a more somber note. To be blunt: It’s about Poverty, stupid. While the CDC’s report demonstrated a clear link between HIV infection and poverty in urban centers, the UC report focused on dramatically heightened mortality rates of ‘disadvantaged’ (read poor back folks) who have been linked to care and started on state of the art antiretroviral therapy-rates that were in excess of third world countries. None of the deceased patients ever received viral suppression, despite robust supportive and case management services to help them. In short, even getting low income minorities into care is, as Winston Churchill would say (and I paraphrase); ‘Is not the end, is not the beginning of the end, but the end of the beginning.’
Many of us have been impacted in many ways by the global financial recession. We probably know people who have lost their jobs or perhaps even their homes. We are all pinching pennies to make ends meet. But, no where may the effects of the recession be felt more greatly than in HIV prevention and care. Think about it: if we have more minorities falling into poverty, or becoming more entrenched in it, then we may see greater HIV infection rates in those urban areas where most of them (and us) live. Moreover, even if we link them into care, how will we ensure that they stay in care and take their medication? So many of us have become comfortable thinking about HIV disease as a chronic, manageable condition; much like diabetes. But we all know black folks, probably in our families, who have ‘sugar’ (what some of our seasoned citizens call diabetes) who slide up to the table and eat those greasy chicken wings or smack on that sweet potato pie. And we watch those same folks lose their vision, or even some toes, because of uncontrolled diabetes. However, with HIV, they may lose a lot more than some toes. Moreover, unlike most other ‘chronic conditions like diabetes, HIV is transmissible.
So the reality of my work, (which I am never unrealistic about), hit a little harder today. It also reminds me that the US National Strategy on HIV/AIDS will require unprecedented coordination and cooperation by not just HHS, the CDC and SAMSHA, but from other agencies that (should) focus on the poor such as HUD and the Departments of Labor and Education. With drop out rates of 50% in Philly and unemployment rates in the black community more than double the national rate’ we must do more to address poverty in order to have an impact on health disparities, especially with HIV.
Goodbye from Vienna. Will be in touch tomorrow!
Many of us have been impacted in many ways by the global financial recession. We probably know people who have lost their jobs or perhaps even their homes. We are all pinching pennies to make ends meet. But, no where may the effects of the recession be felt more greatly than in HIV prevention and care. Think about it: if we have more minorities falling into poverty, or becoming more entrenched in it, then we may see greater HIV infection rates in those urban areas where most of them (and us) live. Moreover, even if we link them into care, how will we ensure that they stay in care and take their medication? So many of us have become comfortable thinking about HIV disease as a chronic, manageable condition; much like diabetes. But we all know black folks, probably in our families, who have ‘sugar’ (what some of our seasoned citizens call diabetes) who slide up to the table and eat those greasy chicken wings or smack on that sweet potato pie. And we watch those same folks lose their vision, or even some toes, because of uncontrolled diabetes. However, with HIV, they may lose a lot more than some toes. Moreover, unlike most other ‘chronic conditions like diabetes, HIV is transmissible.
So the reality of my work, (which I am never unrealistic about), hit a little harder today. It also reminds me that the US National Strategy on HIV/AIDS will require unprecedented coordination and cooperation by not just HHS, the CDC and SAMSHA, but from other agencies that (should) focus on the poor such as HUD and the Departments of Labor and Education. With drop out rates of 50% in Philly and unemployment rates in the black community more than double the national rate’ we must do more to address poverty in order to have an impact on health disparities, especially with HIV.
Goodbye from Vienna. Will be in touch tomorrow!
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