Because I still don't feel like making a personal entry.

[rivka]

Transmission Risk Behaviors in HIV Patients
Attending an Inner-City HIV Primary Care Clinic
RL Wald & LR Temoshok, Institute of Human Virology,
University of Maryland, Baltimore, MD.

HIV prevention efforts continue to under-target the problem of continued transmission risk behaviors by HIV-infected individuals. To assess the extent of the problem, we surveyed 150 patients (90% African-American, 50% female, average years since diagnosis 9.4) attending an HIV clinic serving a disadvantaged inner-city population. The most common HIV risk factors were injecting drug use (54.9%), heterosexual sex (26.8%), and men having sex with men (12.2%). 57% reported at least one sexual partner in the past six months, and 83% had at least one partner in the past two years. 66% reported a recent partner who was HIV-negative or had unknown serostatus. 19% had hidden their HIV status from a partner. Respondents generally abstained from the riskiest activities (anal sex, needle sharing), but most engaged in vaginal and/or oral sex. Condoms were rarely used for oral sex, and only half of those having vaginal sex said they “always” used condoms. Unprotected sex was more common with HIV+ partners than with partners of negative or unknown status. Our data indicate that transmission risk behaviors remain a serious and largely unaddressed problem among HIV-infected patients in this population. These behaviors are particularly troubling in light of widespread drug resistance and incomplete viral suppression among the clinic’s patients, which combine to increase the likelihood that these behaviors will result in the transmission of drug-resistant HIV, and an increasing number of treatment-naive patients who are already resistant to one or more HIV drugs.

Comments

[anisoptera.livejournal.com]

Our data indicate that transmission risk behaviors remain a serious and largely unaddressed problem among HIV-infected patients in this population.

In a philosphy class 10+ years ago, a phil prof from another school, who also volunteered with AIDS/HIV patients came to talk to us. She dicussed the mutation rate of HIV and how that meant a vaccine was not "just around the corner". She was desparing then about risk behaviors and the difficulty in changing them. She felt that more research should focus on finding effective ways to change the risk behaviors.

Does that fact that this is still going on mean that there has been little or no research in the previous 10 years, or a lack of money or will to pursue this kind of research?

[rivka.livejournal.com]

Does that fact that this is still going on mean that there has been little or no research in the previous 10 years, or a lack of money or will to pursue this kind of research?

Mostly it means that the vast majority of HIV prevention efforts have focused on helping HIV- people stay HIV-, and almost nothing has been done to encourage HIV+ people to take responsibility for not infecting others, or to help them change their behavior.

I'm not really sure why that is, but probably a number of things contribute: for example, telling people with HIV to have safer sex implies that it's okay for them to be having sex at all, and a lot of people aren't comfortable with that. Also, I think people can be reluctant to direct infection-control messages at HIV+ people for fear of sounding like the frothing right-wingers who argued for quarantine. There's also a pretty entrenched victim mentality among much of the AIDS establishment - I talked about that a while back, in the context of HIV+ folks who complain that their meds failed them but don't address their own nonadherence - which may interfere with patient-directed prevention programs.

Recently the CDC did call for much more attention to be given to prevention programs directed at HIV+ people, so hopefully this is changing. We do have good prevention science, especially for extended interventions targeting high-risk individuals. We've come a long way with that in the last ten years.

[kalmn.livejournal.com]

here's a vote for you not making these personal entries. i think it's fascinating to read.

[minnaleigh.livejournal.com]

That's an interesting abstract! Thanks for sharing it.

Although I'm not working directly on it, one of the potential applications of the work I do is in developing HIV vaccines- both preventative and therapeutic. For the review articles I'm (theoretically) writing at the moment on vaccines, I've been reading a lot of HIV vaccine research. It's brought up a couple of questions in my mind about the directions the reseachers are taking. First, of course, is the likelihood of some of the target populations receiving the vaccine when it becomes available. There's financial issues, of course, but mainly I've been thinking about the willingness of the population to be vaccinated and compliance if booster doses are needed. Of course, it's not my job to make sure people take a vaccine; I have no expertise in the area except my training as a pharmacist. It does offer interesting challenges for the researcher, though, to minimize side effects, to try and establish immunity with one vaccination to avoid compliance issues, to make it as easy as possible to deliver into the body. I contrast that with the work I've been doing on treatments for cancer where people will take almost anything for just a chance at survival. It's an interesting mental diversion during the writing process.

The second concern I have is with the actual formulation of the vaccine. Researchers are working very hard on a vaccine that is orally or nasally administered because mucosal immunity is easily transferred to other sites in the body, i.e. if your intestinal lining is making antibody then the walls of your vagina are also making antibody. Everything they're working on is geared towards developing mucosal immunity which is the most effective way of preventing sexually transmitted disease. Which would be great if HIV was just a sexually transmitted disease.

There's a lot of other issues from a virology and immunology point of view but those are shared with a lot of other microorganisms These issues are relatively unique, shared only with things like hepatitis b. I'm rambling now but your post just connected with a few things I've been turning around in my mind lately.

[rivka.livejournal.com]

First, of course, is the likelihood of some of the target populations receiving the vaccine when it becomes available. There's financial issues, of course, but mainly I've been thinking about the willingness of the population to be vaccinated and compliance if booster doses are needed. Of course, it's not my job to make sure people take a vaccine; I have no expertise in the area except my training as a pharmacist. It does offer interesting challenges for the researcher, though, to minimize side effects, to try and establish immunity with one vaccination to avoid compliance issues, to make it as easy as possible to deliver into the body.

You're right, of course, and the problem may be greater than you realize. In the segments of the US population in which HIV infection is spreading most quickly, there's profound suspicion of science, and of government - which I have to admit is not entirely unfounded. Of course there's been a history of goverment-sponsored research on "disposable" populations, ranging from the poor rural blacks with syphillis in the Tuskeegee experiments to the mentally retarded children who were (in various studies) fed radioactive materials or infected with hepatitis. While most inner-city Baltimoreans probably can't identify the Tuskeegee experiments by name, you can damn well be sure that they've heard the essentials. We have a lot of trouble getting people to sign up for vaccine trials, and we pretty much have our scientific forebears to blame.

We've included a question in this study: "Do you think the government was involved in starting the HIV problem?" About two-thirds of the patients say yes. I've heard various theories - some people say it's deliberate genocide, while others believe it was an experiment gone wrong - but the majority of them believe that the US goverment was somehow the source of HIV. How well will a government HIV vaccine program is going to go over?

Researchers are working very hard on a vaccine that is orally or nasally administered because mucosal immunity is easily transferred to other sites in the body, i.e. if your intestinal lining is making antibody then the walls of your vagina are also making antibody. Everything they're working on is geared towards developing mucosal immunity which is the most effective way of preventing sexually transmitted disease. Which would be great if HIV was just a sexually transmitted disease.

Wow, that's fascinating. I didn't know that. Of course, as you can see from my abstract, the majority of my patients and research subjects got HIV from IV drug use. A vaccine which primarily protects mucosally will be a lot better than nothing, but you're right - it will only benefit certain constituencies. Huh.

I heard recently about research being done to develop a "chemical condom" - an insertable substance that essentially acts as an entry inhibitor. I only heard about it secondhand, so I don't know if it works against other viruses or if it's HIV-specific, but that seems like it would have interesting possibilities. I talk to a lot of women whose male partners simply refuse to use condoms. It would be so great if women could have a private, invisible, self-controlled means of protection. Not to mention that it would allow women to use protection while they're trying to get pregnant - which is a major reason why many stop using condoms. Obviously this is something I should find out more about.

I'm rambling now but your post just connected with a few things I've been turning around in my mind lately.

Ramble away. It's really interesting.

[sashajwolf.livejournal.com]

I talk to a lot of women whose male partners simply refuse to use condoms.

Then the women should simply refuse to have sex with said partners, no?

[tammylc.livejournal.com]

That's like saying that all battered women should simply walk out the door. There are too many extenuating circumstances that leave women feeling like they can't simply say "no."

Should they? Yes. Can they? Not always. If it's a choice between being beaten up for refusing sex (an immediate threat) or the possibility of getting infected by an HIV positive partner and dying sometime in the future (a much more distant threat), many women (heck, people) will choose to take their chances.

[sashajwolf.livejournal.com]

I think it's important to emphasise that it *is* a choice they're making, and that they could choose differently, even if it's a hard choice. Saying that they can't refuse gives too much power to the male partner, and needs to be questioned, IMO.

Re:

[rivka.livejournal.com]

Then the women should simply refuse to have sex with said partners, no?

Yeah, absolutely. Not all of them feel that they can, or have the right to - that's where my job comes in, when they're my clients - but that's certainly what should happen. It doesn't always, though.