Good News and Bad News on HIV/AIDS

My time at AAAS has come to an end, and today, I just want to feature one session.  (The post on the Dialogue on Science Ethics and Religion panel will be up later this week).

The AIDS Quilt in DC

Julio Montaner: Toward the Control of HIV and AIDS: Comprehensive Treatment as Prevention

We think of the mark of success for a new medical treatment as scoring a significant result when all the data are in. That’s pretty good, but there’s an even better prize: having your study called off part-way through because your new treatment is so good that it would be immoral to keep people in the control group.

That’s what’s happened in almost every study of using antiretroviral drug therapy to lower the chance of HIV transmission. According to these studies, here are some ways you will almost certainly not contract HIV if the HIV+ person you’re exposed to is using highly active antiretroviral therapy (HAART):

  1. Having unprotected sex
  2. Sharing needles
  3. Being born

We have all the medical tools we need for eradication now. Unfortunately, as you might remember from discussion of contraception (99% effective when used correctly, but, with typical use it fails 8.7% of the time) the problem is compliance and logistics.

British Columbia has made ART available for free to every HIV+ person in the province.  This intervention got them to an estimated 60% coverage of all eligible infected people.  In the US, which doesn’t make this kind of commitment, we’re only at around 30% coverage.

This is why I like the coercive power of the government to be linked to healthcare. People in the early stages of HIV/AIDS are asymptomatic, so they need to be screened. Even once they’re identified, they may not want to pay for treatment, since, subjectively, they don’t feel sick.  You need a major actor to change the incentives.  In developing countries, you can add in all the problems of outreach, education, and follow-up (which also exist in the developed world when you consider transient or illegal populations).

I asked the speaker where he recommended donating, since this is one of the biggest opportunities to over the next decade to make medical research pay enormous dividends. He recommended the Global Fund to Fight AIDS, TB, and Malaria. But he cautioned that no private charity will ever be able to build up an entire parallel health care network to solve this problem. It needs the government to universalize it.

About Leah Libresco

Leah Anthony Libresco graduated from Yale in 2011. She works as a statistician for a school in Washington D.C. by day, and by night writes for Patheos about theology, philosophy, and math at www.patheos.com/blogs/unequallyyoked. She was received into the Catholic Church in November 2012."

  • http://last-conformer.net/ Gilbert

    Wait a minute, I think you’re burying the lead here.
    Did I get it right that you want to use the coercive power of the government to screen the population for HIV? In other words force everyone to have regular HIV tests with or without consent?

    I’ll admit I agree. The standard first counterargument is that there would be more false positives than actually infected people. But at modern specificities that is simply no longer true.

    Thing is, lefties to whom I suggest this policy tend to call me a fascist. It probably doesn’t help that I also support punishing people who knowingly infect others, but the nominal focus of outrage is always the forced testing.

    Now I’m really looking foreword to the perverse voyeuristic pleasure of seeing you fight this out with the rest of your tribe.

    • Patrick

      There are a lot of people on the political left who favor mandatory public health measures. Like vaccinations for school children.

      Its not a unanimous thing, by any means, and the degree of culture war relevance of the issue tends to shape which portion of the right and left are given the most media attention. For example, on the issue of HPV vaccinations, the most common media perspective is that the political left favors mandatory vaccination, and the political right is against.

      • deiseach

        Although I will mention one government initiative over here which was for the good of the public health and which aroused a great deal of debate: the 2004 ban on smoking in the workplace.

        That included pubs, and the Vintners’ Federation of Ireland were very much opposed; they said that if people couldn’t smoke in pubs, they wouldn’t go to pubs and that would have a knock-on effect where small pubs would close down and people would lose their livelihood. They also challenged the official statistics that over 7,000 Irish people die each year from smoking and claimed that there had been “Serious and embarrassing manipulation and exaggeration of statistics in relation to environmental tobacco smoke and its so called health effects.”

        Other people said that it was unwarranted interference with people’s rights; if you couldn’t smoke while out at a place of entertainment, what kind of infringement on civil rights was this?

        On the other hand, the ban was (surprisingly) popular with the public and you do have to admit, forcing staff to be exposed to second-hand smoke was a health risk. Coming up to eight years on and people have adjusted. And speaking as someone who had a close family member die of lung cancer due to smoking, believe me, that is not how you want to die. Being hit by a train is preferable. Anything is preferable to going that way.

    • leahlibresco

      I’d certainly like to make it the default position, just as it’s the default for my doctor to test my cholesterol. People should be able to opt-out, but the onus should be on them if they’re going to make decisions that endanger public health. Of course, it’s only possible to consider this now because a lot of the stigma of HIV has faded. At the beginning of the epidemic, you could lose your job if people knew you were positive or just that you were worried enough to get tested.

      • http://last-conformer.net/ Gilbert

        And the onus would consist solely in actively making the decision to endanger public health and not in suffering any enforcible restrictions on behavior?

        In that case I’m willing to bet money that the refusal rate in the high risk group will be high enough to frustrate any eradication plan.

        • leahlibresco

          No, the onus would be meant to be onerous, probably some frustrating forms and bureaucracy, just like for parents who want to opt out of vaccinations but keep their kids in public school.

          • deiseach

            But if a high-risk group is intravenous drug users, then how are you going to compel them to undergo regular tests seeing as they’re already breaking the law by using illegal drugs and will not be eager to volunteer for tests based on illegal drug usage, which would leave them open to possible charges and prosecution?

            If you tie testing in to things like needle exchange provision programmes, then there is the risk that people will opt out of such programmes, and then you have to calculate is the risk of increased needle sharing and use of dirty/infected needles enough to counterbalance any benefits of mandatory testing?

            I mean, I’d love to see people getting proper medical treatment but if it’s going to be the worst of both worlds (you are forced to undergo mandatory testing but you have to buy your own drugs and if you don’t, you can be liable for penalties in law for, I dunno, being a risk to public health) then I can’t see this being much help.

          • leahlibresco

            Well, one benefit of socialized medicine is that it becomes a lot more standard for people to get regular checkups, so then it’s just a question of one more test for the blood draw. Doing outreach to drug users probably requires something more than needle exchange, something more like this: http://www.nytimes.com/2011/02/08/health/08vancouver.html

          • deiseach

            I have to admit, I’m just stubborn enough to go through any onerous, frustrating bureaucratic form to avoid such mandatory testing, because I am not engaged in any high-risk behaviour (plus I have small veins which means every time a doctor or hospital has to take blood for a test, it’s Fun With Needles time and calling in two or even three different nurses to try and get blood from my one accessible vein).

            So trying to force me to be tested for something for which I am not at risk would not work :-)

          • deiseach

            Re: socialized medicine and more regular checkups – excuse me while I wipe away tears of laughter.

            We have (thank God!) a national health system over here in Ireland, but whatever the case is in America, people here tend not to go to a doctor unless they’re sick. The notion of the “yearly physical” has not yet permeated into the greater public consciousness (same way with dentists; person goes to dentist for toothache/filling, dentist reminds them that they should come in for a check-up every six months, person agrees and then on way out the door thinks to self ‘Not bloody likely!’).

            In other words, the people most at risk – the poor and the working class – won’t avail of checkups for health problems, so the blood testing for HIV or whatever is going to have to be a workplace thing (if you’re really going to be serious about checking everyone you can get your hands on) and most people are going to resent that as an imposition on their privacy.

            America is probably different, as I said, but over here – well, it’s hard to know.

          • http://last-conformer.net Gilbert

            I’ll second deiseach on the regular checkup thing. In Germany (universal but not fully nationalized health care, basically a half way house between Obamacare and a nationalized system) about 2/3 of the eligible population forgo their checkups. The perspective is probably not quite as bleak as that number suggests, because there are still lots of passive-aggressive ways left to improve it. But clearly nothing near full compliance is in the cards even without the HIV test. And specifically for HIV I think there is significant population that is likely infected and doesn’t want to know for sure. So I’m pretty sure eradication without outright compulsion is illusory.

            Still lowering the rate of new infections is of course a worthwhile goal even without a chance at eradication. And if non-compulsive coercion is all you support on vaccines then supporting the same for HIV tests is the consistent position to take. It means your paternalism is softer than I thought it to be though, because I had you pegged as opposing the exemptions on public school vaccinations, particularly since they are mostly accessible only by lying about religious reasons.

            That leaves your position more consistently liberal than I thought and I’ll have to give up my hopes of intra-liberal fighting. :( Just register my grumble that your position leaves actual eradication a pipe dream.

  • http://prodigalnomore.wordpress.com The Ubiquitous

    To be grossly partisan, two points:

    1. Scuttlebutt has it that the Vatican helps a great deal in donating and funding AIDS drugs. In tangential support, I did find a link to an archbishop criticizing the high price of AIDS drugs.

    2. For what it’s worth, and though materialists out there won’t be persuaded that it does anything, the Pope’s prayer intention for July 2011 would seem to give credence to the point that the Vatican does as much as it can — within the moral precepts of the Church — to alleviate the physical and spiritual suffering of those with AIDS.

    Argue rightness or wrongness of the moral precepts of the Church all you want, but if you grant these two points it cannot be said that the Church withholds support she feels she can give.

  • keddaw

    but there’s an even better prize: having your study called off part-way through because your new treatment is so good that it would be immoral to keep people in the control group

    Except when the figures are grossly manipulated such as with the circumcision vs AIDS study.

    This is why I like the coercive power of the government to be linked to healthcare. People in the early stages of HIV/AIDS are asymptomatic, so they need to be screened

    And have what done with them? The fact that we have treatment that allows people to live longer, virtually asymptomatically, increases the opportunity to pass on the disease so perhaps we should segregate such people. Isn’t that similar to what people in favour of coercive government suggest for people who refuse immunisation (for themselves) due to the need for herd immunity?

    I’m sorry, forced testing is just not an option. It leads to perverse incentives and those most at risk are the least likely to get themselves tested. The only way it could begin to work is if the government monopolised the intravenous drug trade and made screening the only way you could buy drugs. A bit like the sex industry in LA has made screening mandatory before an adult actor can go on set. And they’re now instituting a condom-only policy that will ultimately drive the industry underground or out of town where sexual health requirements will not be required. Unintended consequences…


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