Map of life expectancy at birth from Global Education Project.

Thursday, March 13, 2008

Funny you should ask

The CDC has asked a colleague of mine to participate in a consultative group on HIV prevention for Latinos, and she asked me to contribute my thoughts on the four big questions they are asking. My pleasure, I do happen to have some opinions.

Based on your knowledge of HIV/AIDS among Hispanics in the United States;

1. Identify at least two community and two societal-level factors that place Hispanics/Latinos at disproportionate risk for acquiring HIV. How should CDC
address these factors?

Much of the disproportionate risk for HIV among Latinos in the northeast is related to injection drug use. While primary prevention is certainly what we would most want to achieve, unfortunately the evidence base for primary prevention is limited. (See below.) We do know that treatment can be effective, and furthermore, as IDU must be transmitted from users to non-users, treatment of current users does constitute a form of primary prevention as well. (Think of it as analagous to infectious disease control. Current users are infectious; get them into recovery, and you stop transmission.)

Right now, we do not have treatment on demand for anybody, but the availability of culturally and linguistically competent treatment for Latinos is even more limited. Furthermore, the courts are much more likely to deal with Latino drug abusers punitively than they are people of other ethnicities. Here in Massachusetts, Latinos are highly disproportionately incarcerated but the disproportion is entirely due to drug offenses. Drug addicts should not, in general, be incarcerated, they should be in treatment, but that is not happening.

Latina women are sometimes at risk due to injection drug use or MSM behavior by their spouses or partners. Sometimes they are truly unaware of these behaviors, in other cases they are unaware by choice, as it were, or choose not to address the risk behaviors. This has to do with gender role norms, stigmatization of homosexuality, and norms about privacy. The prevalence of HIV among Latina women in our region is even more disproportionate than the prevalence among men, and this is largely accounted for by IDU, IDU by sexual partners, and what CDC classifies as "unknown" risk but Mass DPH generally classifies as probable heterosexual transmission.

2. Identify at least two gaps in HIV prevention services and research targeting Hispanic/Latinos in the United States and Puerto Rico. How should CDC address these gaps?

Primary prevention of IDU among Latinos. Difficult to study, we should start with more ethnographic and qualitative research to better understand the process of induction into IDU.

Better understanding of norms and behaviors related to MSM among Latinos and culturally competent approaches to risk reduction.

The way to address these gaps is to put up some money for scientifically sound investigation by culturally competent investigators. Get over the fetish for quantification.

Note that the focus needs to include positive prevention. Latinos living with HIV frequently face substantial obstacles to disclosure to family members and others in the community. The difficulty of mobilizing natural supports and the burden of stigma are obstacles to positive prevention. This means that counseling approaches cannot be rigidly standardized, the time required and the process required to achieve disclosure and manage its consequences has to be variable and specific to the individual and his or her family and community context. Proposal reviewers have a rigid and counterproductive concept of what constitutes a "scientifically" valid trial. Effective interventions have to be highly flexible and responsive to individual circumstances, and evaluation studies must allow for this.

3. Which prevention research approaches and program resources are currently available to address HIV/AIDS among Hispanic/Latinos but not supported by CDC? Identify two prevention research approaches and two program resources that CDC should use.

The approach to IDU must be informed by the harm reduction philosophy. The current policy of the federal government is based on an extremist ideology which purports to be morally superior but in fact is uncompassionate and murderous. People with addiction problems do not deserve to die because of their behavior, regardless of what some morally self-righteous people seem to believe. The federal government must support harm reduction approaches including needle exchange. We must end the policy of incarcerating millions of people who have substance abuse disorders, which is counterproductive. We must provide treatment on demand, and understand that addiction is a relapsing-remitting condition which often requires multiple attempts to achieve stable recovery.

4. How should CDC, Hispanic/Latino leaders and other external partners work together to implement HIV prevention activities? What are the expected outcomes of this proposed partnership?

We need to take an approach to HIV prevention which is based on reality, not faith. The moralistic and punitive approach currently underlying much of federal and state policy to the problems underlying the HIV epidemic is neither effective, nor truly moral. A moral approach to HIV must have the objective of preventing HIV transmission, and that means encouraging condom use, comprehensive sexuality education, and harm reduction approaches to substance abuse. I haven't discussed it previously, but the "abstinence only" sexuality education project is a hoax, an expensive and cruel fraud perpetrated on the taxpayers and on our youth. It absolutely does not work and it has contributed to the growing epidemic of STDs among young people. We also have a serious and growing epidemic of heroin and prescription opioid abuse in this country. The entire philosophy and approach of the past 7 1/2 years has been a manifest failure.

What I would expect from any partnership for HIV prevention is a return to reality based public health policy.

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