At first glance HIVAZ looks like a foreign word or an incomprehensible acronym. However, it actually is the new HIV information clearinghouse for the state of Arizona. The site, which was developed in partnership with a local HIV foundation, aims to give the residents of Arizona all the information they need to deal with the possibility of an HIV infection. It includes information on locating free or low cost care, testing sites, and even places that distribute free condoms. It even has links to the Arizona insurance clearinghouse, to help people who are eligible sign up for Medicaid or other insurance programs under the Affordable Care Act.
The site isn't perfect, but it is thoughtfully designed in a way that makes it easy for all Arizona residents to access important information about HIV infection, whether they don't know their status, have just learned they're HIV positive, or are looking for other types of HIV/AIDS services. I wish that more states made it this easy to locate local resources for testing and treatment. If they did, perhaps people would be able to learn their status sooner and get treated more efficiently. That is, after all, one of the most important steps towards stopping the spread of HIV.
UPDATE: The ABOG has reversed their position. Obstetrician gynecologists are now allowed to treat male patients for sexually transmitted infections. This should include the type of care discussed below
Last week, I was horrified to read this N.Y. Times article about how gynecologists are being told to stop treating male patients with anal cancers or risk losing their board certifications. Instead of recognizing that the training they provide their specialists in the screening and treatment of cervical dysplasia makes them highly qualified to treat men with closely related anal lesions, the American Board of Obstetrics and Gynecology (ABOG) has stated that gynecologists are not allowed to practice on men*. If they do? Goodbye credentials.
I'd like to say that I understand where the ABOG is coming from, but I don't. I can respect that, as the Times article says, "the specialty's image was being tarnished by members who had strayed into moneymaking sidelines, like testosterone therapy for men, and liposuction and other cosmetic procedures for both women and men." I've railed against gynecologists pimping cosmetic procedures, such as hair removal, to their patients for years, and I actually fired my doctor because I found the fact that she did so inappropriate. However, forbidding the practice of purely cosmetic procedures is different than denying individuals quality care, care which would be within a gynecologist's field of practice, if the patient happened to have a female body instead of a male one.
If ABOG wants to protect the integrity of the specialty, there has to be a better way of doing it. A way that won't affect the ability of researchers to find better ways to screen and treat everyone for anal cancer. A way that won't put patients at risk, just because they're men.
*Except in very limited circumstances
In recognition of the fact that as many as 80% of patients in some HIV practices are living long, full lives with their virus well under control, the Infectious Disease Society of America(IDSA) recently updated their primary care guidelines for dealing with HIV positive patients. In addition to changing the viral load monitoring suggestion to once every 6-12 months instead of once every 3-4 months, the IDSA also recommended that doctors start helping patients think more about long term preventative care. That includes things such as screening for diabetes and osteoporosis as well as preventative vaccinations for common, and not so common, infectious diseases.
In short, the guidelines reflect the fact that now that it's possible to live a long, full life with HIV, primary care for HIV positive people has to go far beyond HIV treatment. Antiretroviral drugs are great for keeping HIV infections under control, but they aren't much help in protecting people against the chronic diseases that affect aging populations -- whether they have HIV or not. In fact, they can complicate management of such conditions. That's why one of the important elements of the new guidelines is a table showing how various HIV medications interact with statins - drugs commonly used to treat high cholesterol.
Perhaps more telling, though, is the researcher's data on how often drinking and drug use was combined with sex for women in different types of relationships. In romantic relationships, only 9 percent of sexual episodes occurred after drinking, 5 percent after heavy drinking, and 3 percent after marijuana use. However, 53 percent of casual encounters occurred after drinking, 38 percent after heavy drinking, and 15 percent after marijuana use. Even more striking was that 80 percent of sexual encounters with strangers occurred when women had been using alcohol, 63 percent after heavy drinking.
This research definitely supports the notion that it's dangerous to mix drinking and sex, both because heavy drinking can affect condom use and because it may make people more likely to engage in casual sex. Casual sex isn't necessarily a bad thing, but it can be if you're doing things drunk that you wouldn't do sober. That's why it's such a good idea to decide whether you're looking for casual sex before you even hit the town... and carry some latex if the answer is yes.
In an attempt to do the very important task of getting the young, healthy people of Colorado to sign up for insurance under the Affordable Care Act, an organization known as "Thanks Obamacare" has come up with some truly appalling advertisements. (And the equally grammatically appalling URL "Doyougotinsurance.com." I suppose that all the grammatically correct options were taken?)
Basically, in order to encourage young people to buy insurance on the Colorado health exchange they link getting insurance to making it easier to drink irresponsibly, act irresponsibly, and have unsafe sex. The ads imply such things as:
- Flu shots are cheap, so you can drink more shots.
- Birth control pills are cheap, so getting a guy into bed is less stressful.
- You can occasionally do stupid stuff at Keg parties, but that doesn't matter if you have insurance.
Is that really how you want to be advertising health insurance, Colorado? Talk about playing into the counterproductive notion that having insurance encourages people to take more risks and incur more healthcare costs. I'm not impressed, and I say "No Thanks!" to Thanks Obamacare, even as I encourage everyone to research their best options for insurance.
A study recently presented at the American Public Health Association meeting in Boston, MA once again pointed out why people can't just talk about STD testing... they have to talk about it intelligently. The research, which surveyed almost 200 young men and women about how they discussed sex with their partners, found several disturbing things.
First, the likelihood of someone using a condom with a sexual partner had very little to do with whether or not they'd discussed testing. This is something that isn't particularly surprising as many people stop condom use after they've been dating a certain period of time -- even when they haven't discussed testing or other risks.
Second, many people tell their partners they're STD negative even when they haven't been screened.
Third, even people who do talk about STD testing rarely talk about either what STDs they were tested for or whether they've had any sexual partners since that test.
That's why it's so critical to not just ask someone for their "status" but to ask when they were last tested, what specific diseases they were tested for, and whether they've had any other partners since. If you don't, the information you get is very unlikely to be either useful or accurate, and that means it's no help for informed sexual decision making.
I love it when research confirms my instinctual approaches to improving sex education. That's true in general, but I was particularly excited to read that a new study has shown that men who are assigned "condom homework" do a better job of using condoms in their sexual lives. They not only use them more correctly, they also more consistently and report enhanced sexual pleasure.
The condom homework in question? Exactly what I recommend to just about every young man I encounter with questions about safe sex. If they want safe sex to be more pleasurable and fun, I suggest that they start out by getting a bunch of different types of condom and lubricant, possibly from one of the online condom merchants that sell sample packs, and practicing with them in the privacy of their own home.
Practicing and playing like that doesn't only help a guy feel more comfortable putting a condom on when he's with a partner. It can also show him which products he likes best and that condoms don't need to be a barrier to sexual pleasure. After all, although I generally tell men that no one brand of condom is best for everyone, there very well might be a condom that's best for them. Many men I know have favorite condoms, although they only rarely agree on what those favorites are.
The most recent issue of the American Journal of Public Health had a truly disturbing article about how HIV positive women on Medicaid are cared for during pregnancy. The study looked at data from over 3000 HIV positive pregnant women living in 14 southern states, and found that more than a third had never been treated with antiretroviral therapy, even though treatment during pregnancy drastically reduces the rate of mother to child transmission. The news was even worse for HIV positive Hispanic women, three quarters of whom received no antiretroviral treatment during pregnancy.
Hispanic women were, in fact, four times as likely to miss out on appropriate HIV treatment during pregnancy. This may be because of barriers to acquiring Medicaid for immigrants, and it represents a serious missed opportunity in HIV prevention and care. Medicaid has the reach, and resources, to screen and treat all pregnant patients for HIV. This can not only improve their health and care but reduce the risk of HIV transmission to the next generation... and thus significantly reduce their cost of care. HIV screening during pregnancy is a great way for the government to potentially save a lot of money on future health care, but it can't save anything if doctors aren't doing it. To make that happen, the government has to make it easier for pregnant women to get prenatal care, whether they were born in the country or not.
An interesting article published online in the American Journal of Public Health looks at the problem of injection drug use in non-urban environments. While the stereotype is that injection drug users are usually urban minorities, the behavior isn't confined to cities. Furthermore, injecting drugs in the suburbs doesn't magically make the behavior safe. The study examined the risk of hepatitis B (HBV), hepatitis C (HCV), or HIV infection for drug users living in suburban Connecticut and found that it was quite high.
Slightly more than half of the 450 injection drug users recruited for the study were infected with at least one of the viruses and 16 percent were infected with two or more, with most infections being either HCV or HBV. That's not as high as for drug users in urban settings, but it is still quite disturbing. Furthermore, suburban injection drug users may be harder to reach with traditional risk-reduction programs, such as needle exchanges, since they are more widely geographically distributed and such locations are not necessarily accessible by public transit.
On the upside, many more suburban drug users have health insurance, suggesting that they might have better access to care. Maybe this research will motivate doctors to do a better job of linking more adults to not just drug treatment services but preventative care - such as the HBV vaccine. There's no good reason that so many adults haven't been vaccinated, and this research provides a very good reason why that should be fixed.
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Results of the studies were uniformly positive, although some of them are still only preliminary. All oral regimens were at least as effective as existing treatments, and generally far more so. Furthermore, these regimens aren't only more effective. They're also much easier to take, as they don't require regular injections of interferon, and they tend to have fewer side effects. Some investigators are even looking at single-pill treatment regimens for HCV. That could simplify compliance even further for HCV patients, who frequently have few resources and many things on their minds.