wash your hands… and other health promotion and prevention messages

There’s a lot of really exciting news coming out about Pre-Exposure Prophylaxis (PrEP) for HIV prevention. We’ve already gotten exciting news about Post-Exposure Prophylaxis (PEP) that Sarah Palin famously failed to provide for rape survivors in
Alaska.  If PrEP is as effective as everyone thinks it may be, it could be huge.

Let’s work through some issues.
1.  Availability of PEP has not drastically changed the way we do HIV prevention (yet).  Still need testing, condoms, and ART; not a magic bullet.
2.  Availability of ART has changed the dynamic of the epidemic in some ways.  Some people take more risks after being on treatment, but this is a relatively small part of the population. (I learned about the MTV combo today – Meth, Tenofavir, Viagra – sounds like a big night!)
3.  PrEP is not going to be like a statin or the pill, other than the fact that people at risk for
{HIV, pregnancy, high blood pressure/cholesterol} can take a pill everyday to mitigate some of their risk. 
3a.  Stigma: a non-issue with statins.  An issue with the pill depending on your relationship and where you are.  A huge issue with PrEP – what if your partner found out you were taking it? (“…Awkward!”)  I’ll come back to this.
4.  Who do we give PrEP to?  … I really have no idea.
4a.  Discussions are around MSM and African-Americans.  Lower on my totem pole of concerns is that this *may* fuel (groundless) conspiracy theories that the government is behind AIDS.  What happens when/if something goes wrong?  Higher on my list is who we leave out by targeting only high risk groups.
4b.  See 3a.  When/If we give it to women, and her partner finds out she’s taking it, violence will ensue. 
5.  Does PrEP increase risky behavior?  Trials in West Africa indicate it “does not decrease condom use.”  I read this as “no significant difference in reported condom use pre/post.”  Even if they are looking at condoms bought/taken from public clinics or private pharmacies, I bet those numbers are tiny.  In my experience (working on family planning in Ghana) condoms were not that popular – because it introduced the idea that one partner could catch something “somewhere else” and bring it back.  She didn’t want to seem distrustful, he didn’t want to be accused of cheating.  Relationships are complex and power dynamics are tough.  I think we’ve got a long way to go in the area of gender dynamics before PrEP becomes a viable prevention solution. 
6.  So do I take PrEP if I’m partying tonight?  Someone equated it to taking malaria prophylaxis before traveling to endemic areas, and I’m going to have to disagree.  I doubt people plan unprotected sex acts the same way they plan trips to third world countries.  Mosquitoes don’t discriminate when they bite, but people should if they’re having sex.  See 3a.  I’m back to stigma, stigma, stigma. 
7.  Similar to issues in malaria with choloroquine resistance and now, the way ACT is failing, as chemoprophylaxis becomes available for HIV, it only facilitates the rise of resistant strains.  If it gets worse than what we can handle with ART, we’ve got bigger issues.

Keep your ears open, there will be a lot more to come on this topic.

I had a conversation with an anti-abortion friend a few weeks ago.  He seemed genuinely curious about what I had to say, and I think I made some points that he hadn’t ever thought of before.  I have probably been gloating too much about the global gag rule being overturned (!!!), but he sent me a letter that he clearly spent a lot of time on, telling me how he didn’t understand the logic of the pro-choice movement.

As I’ve spent the past week drafting the letter in return (it’s hard to write your manifesto!), it hit me that people almost never have this conversation.  People are on one side or the other, agree to disagree (or don’t) and walk away thinking the other side is an idiot/a baby killer.  I really don’t think I’ve ever had to fully outline my position like this before since I’m usually talking about this with like-minded people.

At first I thought what I was so fired up about was expanding and fulfilling rights for all people.  Then I thought about it some more, and I think we have more common ground than anyone on either side is willing to recognize.  I think we’d both like to reduce the number of abortions (no surprise there), but I really think the anti-abortion side firmly believes they are saving more lives than we are.  It’s still a work in progress, but I may have to explain what DALYs are.

Allison gives the inside scoop on pro-life counseling, and why she quit. 

Also, sign the National Family Planning and Reproductive Health Association’s petition against Bush’s new HHS regulations.

Here’s a classic puzzle in epidemiology (and I love the way the IHT frames it): goats go mute, roosts of chickens die, street dogs disappear.  Then children have a fever, start vomiting, then die, women give birth to stillborn babies, and no one has any idea what’s going on.  Cross off malaria, TB, HIV/AIDS, then they start looking to occupational or chronic hazards.  There they find the answer: lead poisoning. 

This all happened, and is still happening, in Thiaroye-sur-mer near
Dakar, Senegal.  A brief summary: as the population grows, so does the need for lead-acid car batteries to move all these people around, especially in Asia.  Old batteries are the new rubber tire for developing countries – that’s typically where they’re reprocessed since the work is dangerous and the labor is cheap and Senegal is no exception.  Thiaroye-sur-mer is like a graveyard for old car batteries.  Who knows which came first in this town - did the fishing get bad before the lead was being used for weights in fishing nets and millions of lead particles got into the air, soil and sand?  Either way, with the decline of the previous money-maker for the town, it only encouraged more lead abstraction for small local use here, and export to India and China. 

Another sad product of environmental racism, except for one thing: most of the discussion about lead, even the potential for lead poisoning, has been around leaded fuel, not lead abstraction.  Ironically, a conference in Senegal (resulting in the “Dakar Declaration”) got African leaders to commit to phase out leaded fuel by the end of 2005.  Senegal and Kenya were the only ones to come close, with the help of Partnership for Clean Fuels.

So here’s the deal with leaded fuel: it spews lead into the air and we know lead particles in the air are bad – they’re toxic.  This encouraged trade policies similar to the one adopted in Senegal, which prohibited importing cars made after a certain year, ensuring the cars had catalytic converters and thus no longer needed leaded fuel.  The flip side of this policy is the following:

Taken in Dakar, Senegal in 2004

Cars that should have been taken off the road a long time ago are held together with coat hangers and duct tape – because even though catalytic converters are clean, they’re pretty darn expensive.  People are also reluctant to change: “My cars have always used leaded fuel and my family is fine.”  Anecdotally, even people with new cars were skeptical of unleaded fuel, so they continued to use leaded fuel, ruining their catalytic converters.

One more point about Thiaroye-sur-mer.  When I lived in Sokone, Senegal in 2004, it used to take about 8 hours to get back to Dakar – in a car not so different from the one shown above.  At least two of those hours were always always spent idling in traffic, spewing lots of tiny lead particles into the air between Pikine and Rufisque, precisely where Thiaroye-sur-mer is located.  One way or another, citizens of this town have had problems with lead exposure for years. 

Maybe the worst part of this is that we don’t expect incidents like this to reduce the demand for lead production around the world.  People in Thiaroye-sur-mer won’t relocate because they think the government wants to capitalize on the rich soil.  As the safety regulations change (as they already have in the US and Europe), the work will stay with poorer workers so desperate for work that they’ll take on more risk – much like the people already living in these suburbs of Dakar.

I love statistics, partially because they’re so dangerous.  There is nothing like closing your eyes, crossing your fingers, and clicking ‘run’ in SAS – you’re about to get the answer that you’ve been waiting for months or years to find out.  Your entire argument shifts (it shouldn’t, but it does) based on the results on the output screen.  You can say so much with a well-placed miniscule p value. 

I’m more likely to trust the providers than I am the statisticians.  It may be easier to capture metrics like this for the purposes of evaluation, but it’s the statistician’s job to select appropriate indicators. 

Everyone has been talking about Rick Warren – I know I’m like a week late.  It’s obvious why he was chosen, and it’s obvious why everyone’s upset.  What I don’t get though is how people (bloggers, media) are using his HIV/AIDS work as a plus - sort of to say, “Maybe he hates gays, but he does work in
Africa.”  Without assessing whether or not he was an appropriate choice for Obama’s invocation - he can’t be that bad, right?

But the point is, don’t be fooled.  Warren shouldn’t get a pass on this.  Working from the heart doesn’t mean you have to lose your head.

He’s also bringing the issues home for a lot of families in the neighborhood.  At Obama’s suggestion, he’s holding a Town Hall meeting of sorts – a Neighborhood Open Health Care Forum – with the slogan “Make a difference.  Come to the meeting.”  Issues they promise to address include:

• Access – how do/should we cover everyone?
• Improving Quality – what kind of care do you want?
• Improving Costs – can we afford change?

He says that all ideas are welcome and that the main discussion points are going to be passed on to the transition team. 

I am literally blown away by this – I knew this happened in other parts of the country but I never saw it happening here.  I imagined these kinds of meetings to be a bunch of like-minded democrats getting together to talk about how ignorant everyone else is.  I know these meetings don’t promise to be fully representative (this is self-selecting, and it’s still not from a very diverse group) but at least it’s happening!  This neighborhood has never had a meeting like this, not that I (or my parents) can remember.  Maybe I’ve been underestimating them the whole time.

Kamiar Alaei and I went to grad school together.  Here’s a 2004 BBC article about the work he and his brother do: http://news.bbc.co.uk/2/hi/programmes/this_world/3791889.stm 

Please click around, sign the petition, and tell your friends.

“You know, while we’re at it…”
http://www.federalregister.gov/OFRUpload/OFRData/2008-30134_PI.pdf
That is the only thing I can imagine the Bush administration saying as it published today a new regulation broadening protections for health care providers who refuse to provide health care services on religious or moral grounds.  I really can’t think of anyone outside of pro-life lobbyists whose interests are served by this regulation.

I’ll tell you whose interests aren’t served… the same people who rely on government funding for Planned Parenthood. 

This regulation terrifies me.  While intended as legislation that prevented discrimination in training opportunities for providers who refuse perform abortions, the wording has evolved.  This expanded definition of abortion would mean that health care providers don’t have to provide even basic contraception if they “morally object.”  This could go further than denying access to the pill or Plan B - it could ultimately mean things like denying HIV testing or care for people whose ‘lifestyles’ providers don’t agree with. It is a giant step back for the rights of women, society, and the public’s health, and will leave many Americans without reliable access to reproductive health care. 

Now that this expansion of ”conscience” has passed, health care providers (particularly providers in reproductive health) don’t have to do anything they don’t want to if they receive funding from the government.  Not just providers – HMOs, pharmacies, other “health care institutions.”  What if your pharmacy just stopped selling the pill?  How far would you have to drive to find one that would?  What if this wasn’t about reproductive care at all – what if your HMO just didn’t morally agree with chemotherapy? 

A study by the ACLU surveyed the American public and found the following:(http://www.aclu.org/reproductiverights/religion/16544leg20020711.html)

• 89% oppose “allowing insurance companies to refuse to pay for medical services they object to on religious grounds.”
• 88% oppose “allowing pharmacies to refuse to fill prescriptions they object to on religious grounds.”
• 86% oppose “allowing employers to refuse to provide their employees with health insurance coverage for medical services the employer objects to on religious grounds.”
• 76% oppose “allowing [hospitals] to refuse to provide medical services they object to on religious grounds.”

The public’s insistence on access reflects its view that religious refusals jeopardize women’s health and lives. Seven in ten Americans are concerned, for example, that if “religiously affiliated hospitals are allowed to limit access to medical services, the health and lives of many women will be threatened.”

What happens now to providers who continue to provide contraception or perform abortions?  Can they admit it to their colleagues?  Can they advertise publicly without having their own “conscience” and morals judged?  This will effectively push abortion further and further underground, in a country where, in case anyone had forgotten, this procedure is still legal.