Antiretroviral therapy(ART) can be an incredibly effective way of treating HIV. When people take it properly, and are on the right cART regimen, they not only live longer, healthier lives, they also reduce the likelihood of transmitting their virus to others. However, the key phrase in that sentence is "when they take it properly." Not everyone on ART is great at taking it when they should and how they should, in part because not every doctors is great at communicating how important that is.
Enter the world of computerized counseling. Computerized counseling basically streamlines the treatment training process. Is it as good as an extended face-to-face session with a well-trained, highly-skilled counselor? Probably not, but then again, a face-to-face session with such a person is not actually the default. That's why it was exciting to read an article in JAIDS showing that computerized counseling not only increased people's ability to take their medication properly, it also decreased their viral loads and increased their safer sex behaviors. Furthermore, patients felt more confident about their health and, perhaps not surprising to those who have spent a lot of time in medical offices, many of them actually preferred the computer based counseling to dealing with a human being.
If these results can be repeated, and this counseling intervention used more widely, it would be great news for everyone. Patients would be happier and healthier, because they'd be getting the information they need. Doctors wouldn't have to stress as much about whether they're communicating well, because they'd know that patients were learning what they needed to about their care. Even the budget offices would likely be happier, since drug compliance decreases long term costs, and computers are a heck of a lot cheaper than paying for trained educators and counselors, such as myself. Okay, maybe it isn't quite great news for everyone...
An interesting new study published in the ANNALS of the American Academy of Political and Social Science examined the role that pimps actually have in the sex trafficking of minors. The common narrative, fueled by many a movie and tv show, suggests that most young women are lured into prostitution by pimps. However, this study -- which combined research on 250 street sex workers under the age of 18 who were living in the NY area, another 150 sex workers aged 16-24 who were living in Atlantic City, and 85 pimps -- suggested that might not be the case. The researchers found that, in their NY sample, only 10 percent of the minors had a pimp at the time of the research and almost half said that they didn't know any pimps, let alone have one of their own. Numbers were similar in Atlantic City, although the questions were different. Only 16 percent of young female sex workers were initiated by pimps, and almost no males or transgender sex workers. Instead, it turned out that almost half of young sex workers were brought into the profession by a friend, and another quarter by a customer.
So why then do young people engage in sex work, and why do they continue to do so even when the vast majority state that they'd like to get out of the profession? Most of the youth spoken to cited concerns that had nothing to do with being under the control of a pimp. Instead, they talked about a lack of education, problems finding jobs, and not having housing. In other words, they were economically vulnerable, and many of them were homeless as well. Furthermore, often the adults who help them survive were seen as parental figures, rather than being controlling or violent, which made the youth resistant to seeking help from aid workers who claimed those same adults were out to do them harm.
So what does this have to do with sexually transmitted diseases? On the face of things, not much. However, it does speak to larger issues about agency and sexuality, particularly given the number of young people who reported choosing to go into sex work, for financial or other reasons. Those were not choices made freely, but they also generally weren't choices that were made because some dark figure was luring them into selling their bodies. Instead, they were choices made by young people who needed homes, income, escape, and ways to survive. The authors of the paper suggest, and I agree, that maybe the best way to help such youth isn't by focusing on their sex lives. Instead, it's by figuring out ways to give them the skills and resources they need to have a broader range of options for what to do with their lives. Only then can they truly make informed and active choices about what they want to do with their bodies.
As I've blogged about numerous times before, antibiotic resistant gonorrhea is becoming a growing problem around the globe. The data is more than a little frightening, but some recent research suggests that while untreatable gonorrhea may be inevitable, that doesn't mean the inevitable can't be delayed. Work in England and Wales suggests that careful monitoring of resistance, and choosing appropriate replacement antibiotics, may be able to postpone the development of more bacterial strains that are resistant to the last oral drug regimen that is still generally considered to be fully effective.
That said, prevention is still the best choice. Fortunately, it's a relatively straightforward task for dealing with gonorrhea infections. Consistent condom use, for anal, oral, and vaginal sex, is a very effective way at arresting transmission. Combined with regular screening for anyone not in a mutually monogamous relationship, it should keep most people from having to worry about whether or not there is an effective cure.
I got a lovely e-mail the other day from a young man who was thinking about having sex for the first time and had a few questions. The questions were good ones, but what I found particularly interesting was that he'd talked to his parents about his concerns and they told him that they "didn't know of any history of STDs in the family." On one hand, I thought it was great that he could talk to his parents about this type of decision. I wish more parents and teens were comfortable enough having "the talk" in a way that could actually empower young people to make positive, active choices about whether or not they want to have sex. However, the message they gave with that one statement was highly problematic. Saying they didn't know of a history of STDs implied:
- That they'd know if either one of them had an STD, presumably without testing
- That STDs are the sort of things that run in families, rather than being behaviorally acquired
- That testing isn't something they think about, or talk about, even when their teen is bringing sexual health questions to them
Talking to teens about sex is a wonderful thing, but the conversation should be about more than whether the teen is ready, emotionally, to engage in vaginal sex or any other form of sexual activity. That's a huge part of it, but so is talking about protection -- not just in the sense of using condoms, but in terms of knowing what the risks of sex are and how to evaluate which of them someone is willing to take in any given circumstance. That includes a recognition that many STDs have no symptoms, and you can't tell if someone has an infection just by looking at them or asking if it hurts when they pee. You have to ask them about testing, and they have to actually know what they've had done.
It was approximately 5 year ago that Farrah Fawcett, actress and pinup, died of anal cancer. Now, the Farrah Fawcett foundation is supporting research to help improve the lives of others affected by HPV-related cancers. It's a great legacy for the movie star, who helped raise awareness of the role of HPV in non-cervical cancers before she died, and whose foundation continues to work to increase awareness of anal cancers in women and men.
Anal cancers are most commonly seen in gay men, due to the association with HPV infection and anal sex, but they can affect anyone. Unfortunately, screening is rare even for high risk populations. An anal Pap smear is available, and minimally invasive; it's just not widely recommended or used. Fortunately, as with all HPV-related cancers, there are risk-reduction options. Two HPV vaccines are now available and consistently using barriers for anal, oral, and vaginal sex is also an effective way to lower the risk of virus transmission.
A study looking at the health of HIV positive kidney transplant patients after transplantation may have accidentally stumbled onto something quite interesting. Their research, which was recently published in the American Journal of Transplantation, suggests that an anti-rejection drug and immunosuppressant known as sirolimus may have reduced patients' viral reservoir when it was given to them after transplantation. Over time, patients on the drugs saw a decrease in the number of HIV infected blood cells seen in their bodies. This suggests that the ways in which sirolimus modulates the immune system may have been able to impact the health of the viral reservoir, a possibility which had been previously brought up by other in vitro studies.
If it turns out that such a hypothesis is correct, it could open an entirely new area of HIV treatment research. However, first these results need to be confirmed. The transplantation study wasn't actually designed to look at how sirolimus affected the course of HIV disease. It was just fortunate that the researchers had the data to reanalyze when other researchers suggested that sirolimus might be a new way to attack the virus.
I wanted to draw your attention to the fact that Trojan Condoms and the American Sexual Health Association have put together a cute website at FactsAboutCondoms.com. With April being the official Sexually Transmitted Infections Awareness Month, now is a great time to check it out. (Around here, EVERY month is Sexually Transmitted Infections Awareness Month, but I can't expect the rest of you to share my all consuming passion for the subject.)
The site looks like it will be particularly useful for college students, RAs, and sex educators working with the collegiate population, as they have a number of nice handouts and posters that would perfect for use on campus. However, they also have some fun videos about condoms - both their history and use - that a broad range of people may enjoy watching. I actually found the video about how condoms are made to be fascinating, even if it is a bit of a glorified commercial for Trojan!
According to news reports, Iowa is currently considering revamping its laws around the criminalization of HIV transmission. Right now, a person with HIV can be sentenced for up to 25 years in jail for failing to disclose their HIV status to a partner, even if they practiced safe sex and had a viral load so low that infection was extraordinarily unlikely.
Personally, I think that revamping such laws is an excellent plan. Intentional, malicious exposure to HIV or other STDs is a rare thing. Far more often, people put off disclosing their status because of fears of stigma, violence, or rejection -- fears that are often quite legitimate.
While I'd love for disclosure to be easier for people, criminalizing lack of disclosure isn't the way to make that happen. It just makes people more scared of keeping track of their status - knowing that having sex while knowingly positive could mean they were breaking the law. After all, what people don't know, they probably can't be arrested for. At least not when it comes to transmitting HIV.
Although I don't always trust The Huffington Post as a news source, this article about J.P. Morgan Chase refusing to serve as the credit card processor for a condom marketing site has enough evidence to render it seriously disturbing. Apparently the bank's credit card payment service Paymentech considers condoms to be "adult-oriented" products and thus prohibits supporting their sale. That's not only offensive to me as a health educator, it's also highly hypocritical. Chase presumably provides payment services to a number of drugstores and similar locations that stock condoms on their shelves. Why should someone trying to make them more acceptable to women be penalized for focusing on safe sex and empowerment? If you agree that it's all a bit ridiculous, the founder of Lovability has started a Change.org petition in protest. Maybe getting enough publicity will encourage Chase to consider changing their policy on supporting the sales of products that are undeniably good for public health.