When the HIV epidemic was first discovered in the U.S., as we have seen, it mostly afflicted stigmatized groups. President Ronald Reagan largely ignored it, as did his successor George Bush the First. The plague devastated gay communities across the country. But pervasive grief and loss turned into anger, and then action. AIDS Coalition to Unleash Power -- ACT UP -- was founded in New York in 1987 and went on to become a national and then an international organization, using direct action tactics to demand action to combat the epidemic, and counteracting false information and bigotry.
ACT UP founder Larry Kramer was initially at odds with Anthony Fauci, who Kramer thought was not devoting enough resources to HIV research, but they eventually became allies. The federal investment in HIV-related research in fact became disproportionate in some people's opinion, but it paid off when effective treatments were developed in 1996. Initially, the medications required complicated dosing regimens and had very unpleasant side effects. But over the years there have been great improvements and most people can now take a single pill a day, usually without significant side effects. Even better news is that people who take their medications on schedule and have suppressed viral loads are not infectious. Still, consistent condom use and not sharing injection equipment are the best way to prevent transmission.
And yes, heterosexual vaginal intercourse can transmit HIV, and that's mostly how it is transmitted in Africa. It does happen in the U.S. but it's less common. So why is the epidemic in the U.S. concentrated in these specific risk groups? Headley, next slide please.
So, it's really important to jump on an outbreak quickly -- once an epidemic gets established, it's much harder to get rid of. You may have noticed that recently. And . . .
That's why HIV incidence today is much higher among Black and Latino men who have sex with men, and why HIV is highly concentrated in specific, mostly low income communities. Effective HIV prevention requires a combination of behavioral biomedical, and structural interventions. Credit UN AIDS for the following slides.
Notice the importance of reducing stigma and discrimination. People who are stigmatized and fear discrimination won't come forward to get services. Cash transfer programs can both give people the resources they need to stay healthy (e.g. not having to engage in sex work, or doing so more safely) and act as incentives.
Note however that the Catholic Church opposes condom use and distribution, and conservatives in general oppose needle exchange programs.
Again, all of these have a political dimension. That's why I say that HIV has been a kind of natural experiment that has taught us a great deal about human society and culture as well as human biology. The lessons haven't always been pleasant, but on the other hand we have made a lot of progress since 1987.
3 comments:
I'm sorry, estemado Cervantes, but all this is really quite vague. Concentrated disadvantage isn't a monolith. Some parts affect transmission, some parts don't, or do so to a smaller degree. The biggest element of disadvantage I can see is incarceration rates. It was established 20 years ago that prisons (where straight men have sex with other men) are a huge transmission nexus and, since we incarcerate black men at orders of magnitude above whites...
It's also important to unpack transmission by vaginal intercourse: by and large that goes in one direction. Absent vaginal bleeding it's exceedingly difficult for the virus to move F > M. Thus, in the US this accounts for a minority of cases. Vis Africa, I vaguely recall reading something 20 years ago about the sexual preferences of men in some parts of the continent that would contribute to vaginal bleeding and thus F > M transmission.
Well sure, not every kind of concentrated disadvantage is related to HIV transmission. It's an existential statement, not a universal statement.
I was not aware of any reliable statistics on HIV transmission in prison. I did a quick PubMed search and I couldn't find anything. It would be a difficult question to study because by the time somebody is diagnosed it won't usually be possible to tell if they acquired the infection in prison. Someone might tell a counselor the only times he had sex with men was in prison, but that won't show up in the surveillance data. I do remember controversies about whether prisoners should be allowed to have condoms, and as far as I know the norm is still that they cannot, so that's a problem. Whatever the contribution of incarceration to the epidemic I would think it has to be fairly small since most PLWHIV have not been incarcerated. Of course IDU are more at risk out of prison than in.
I can't really think of any behavioral reason why F->M transmission would be more likely in Africa. I think it's rare in the U.S. mostly because there aren't a lot of HIV+ women in the first place. See my first point above. Even if the risk per occasion is low, if you have sex with somebody 100 times or more it's gonna happen eventually.
I think that's mostly a problem of how surveys are structured, really. As with Sars-Cov-2, it might be intuitively obvious to everyone concerned, but such a survey wouldn't point to incarceration as a transmission nexus unless they were diagnosed in prison. There are a number of holes in surveys like this due, I surmise, to the life experiences of the people who write them.
I really didn't want to go into the details but it was a preference for a "dry, hot, tight" vagina, which some women (such as prostitutes) seem to be achieving with chemicals. I would also guess that FGM plays a role here.
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