I'm baaaacckk

Sorry, didn't have connection to Intertubes at the conference site yesterday and I was too tired when I got home to put anything up. Having recharged the batteries and refreshed the attitude, and being stuck here on a very gloomy, rainy day, I give you a rare Saturday post.

First, Kathy, not to mention the rest of you, may be interested in this health insurance story from hell. The protagonist/victim is a medical resident, no less, and she can't get the insurance company to understand that yes, they are supposed to pay her claim and she does not actually owe $6,000. For years she can't get them to understand that, maybe, just maybe, because they don't want to. My advice, Kathy? I can't remember whether it was Keith Olbermann or Jon Stewart who came up with this originally, but it's good: send the bill to Max Baucus.

Now, as for HIV, the news is pretty much on the same trajectory it's been on since I reported back from Mexico City last summer. Treatments continue to get easier to take and less toxic, but no cure and, sorry, no vaccine is in sight. The trial in Thailand that caused all the flapdoodle and hoohah last week? All the information we have is a press release, which is very bad form to begin with, but from what we can tell, there are some puzzling features of the result. The rate of new infections in the active arm appears to have been somewhat lower, but people who did get infected had the same degree of acute viremia and the same disease progress whether they were vaccinated or not. It's all very technical but what this seems to mean is that if the combination vaccine worked, it worked on a different component of the immune system than hypothesized.

However, we are all still wondering if it really worked at all. The number of infections in both arms was very low, which means that very subtle methodological problems could compromise the finding. The degree of efficacy could well be overestimated just because of chance, and by a lot; even the published estimate is not good enough to make this something that could every be deployed. Any vaccine is still a good ten years away, and unfortunately, ten years has been the Friedman Unit in this field for the past twenty years.

There is work going on on new prevention strategies, such as giving low-dose antiretrovirals to people at high risk, such as sex workers and HIV-negative partners of HIV-positive people. The problem is that these strategies also are less than 100% effective, which means you need to continue to use condoms, but maybe if people think they're protected by the pills they will decide they don't need the condoms after all, plus which they might not always take the pills, not to mention the expense -- you get the idea.

This is all very frustrating. Not that we haven't made some lemonade out of it all. HIV has turned out to be a highly revealing natural experiment which has taught us a great deal about the human immune system, and a great deal about the sociology of health and illness as well. Much of what we have learned has helped us deal with other diseases, and other social problems. On the social front, I would even go so far as to say that the HIV epidemic was in considerable part responsible for stimulating the activism which has led to such dramatic changes in our own country and Europe in attitudes toward the diversity of human sexuality; and the movement (as limited as its success may be so far) to adopt non-punitive, harm reduction approaches to addiction.

In other words, this is a challenge to which many people have risen, although many, sadly, have responded disgracefully, most of them on the political right I might add. But it is a challenge that is still with us and will be for a long time. And oh yeah -- the rate of new infections in the world continues to exceed the rate at which the availability of treatment expand by more than 2 to 1. We're still deep in the woods.