The War Against AIDS in Africa

The War Against AIDS in Africa

This May 9, 2010 New York Times article about how the war on AIDS is being lost in Africa includes a rather startling statement:

Science has produced no magic bullet — no cure, no vaccine, no widely accepted female condom. Every proposal for controlling the epidemic with current tools — like circumcising every man in the third world, giving a daily prophylactic pill to everyone contemplating sex or testing billions of people and treating all the estimated 33 million who would test positive — is wildly impractical.

And, most devastating of all, old-fashioned prevention has flopped. Too few people, particularly in Africa, are using the “ABC” approach pioneered here in Uganda: abstain, be faithful, use condoms.

Wow!  A strategy that works, and 2/3 of it is something those nasty, narrow-minded, evil Christians promote.  (And most evangelicals regard the last 1/3 as better than not even trying.)

Wow! This Is A Relief

Wow! This Is A Relief

This June 8, 2008 Independent article tells us something that most people who have been paying attention to AIDS for the last twenty years already knew:

Threat of world Aids pandemic among heterosexuals is over, report admits

A 25-year health campaign was misplaced outside the continent of Africa. But the disease still kills more than all wars and conflicts

A quarter of a century after the outbreak of Aids, the World Health Organisation (WHO) has accepted that the threat of a global heterosexual pandemic has disappeared.

In the first official admission that the universal prevention strategy promoted by the major Aids organisations may have been misdirected, Kevin de Cock, the head of the WHO's department of HIV/Aids said there will be no generalised epidemic of Aids in the heterosexual population outside Africa.
Dr De Cock, an epidemiologist who has spent much of his career leading the battle against the disease, said understanding of the threat posed by the virus had changed. Whereas once it was seen as a risk to populations everywhere, it was now recognised that, outside sub-Saharan Africa, it was confined to high-risk groups including men who have sex with men, injecting drug users, and sex workers and their clients.
Dr De Cock said: "It is very unlikely there will be a heterosexual epidemic in other countries. Ten years ago a lot of people were saying there would be a generalised epidemic in Asia – China was the big worry with its huge population. That doesn't look likely. But we have to be careful. As an epidemiologist it is better to describe what we can measure. There could be small outbreaks in some areas."
...
One of the danger areas for the Aids strategy was among men who had sex with men. He said: " We face a bit of a crisis [in this area]. In the industrialised world transmission of HIV among men who have sex with men is not declining and in some places has increased.
"In the developing world, it has been neglected. We have only recently started looking for it and when we look, we find it. And when we examine HIV rates we find they are high.
"It is astonishing how badly we have done with men who have sex with men. It is something that is going to have to be discussed much more rigorously."
The biggest puzzle was what had caused heterosexual spread of the disease in sub-Saharan Africa – with infection rates exceeding 40 per cent of adults in Swaziland, the worst-affected country – but nowhere else.
"It is the question we are asked most often – why is the situation so bad in sub-Saharan Africa? It is a combination of factors – more commercial sex workers, more ulcerative sexually transmitted diseases, a young population and concurrent sexual partnerships."
"Sexual behaviour is obviously important but it doesn't seem to explain [all] the differences between populations. Even if the total number of sexual partners [in sub-Saharan Africa] is no greater than in the UK, there seems to be a higher frequency of overlapping sexual partnerships creating sexual networks that, from an epidemiological point of view, are more efficient at spreading infection."
Low rates of circumcision, which is protective, and high rates of genital herpes, which causes ulcers on the genitals through which the virus can enter the body, also contributed to Africa's heterosexual epidemic.

This is no great surprise. Sexual promiscuity is a major problem in the spread of what is still primarily an STD.

But the factors driving HIV were still not fully understood, he said.
"The impact of HIV is so heterogeneous. In the US , the rate of infection among men in Washington DC is well over 100 times higher than in North Dakota, the region with the lowest rate. That is in one country. How do you explain such differences?"

Hmmm. Perhaps the fact that North Dakota is filled with narrow-minded, puritanical sorts who think that homosexuality and IV drug abuse are sinful?

Warning: Time Machine In Use!

The March 12, 2008 Idaho Statesman also has an article about the high rate of STDs among American girls 14-19, and it includes one rather amazing statement:

Only about half of the girls in the study acknowledged having sex. Some teens define sex as only intercourse, yet other types of intimate behavior including oral sex can spread some diseases.
Among those who admitted having sex, the rate was even more disturbing - 40 percent had an STD.
"This is pretty shocking," said Dr. Elizabeth Alderman, an adolescent medicine specialist at Montefiore Medical Center's Children's Hospital in New York.
"To talk about abstinence is not a bad thing," but teen girls - and boys too - need to be informed about how to protect themselves if they do have sex, Alderman said.
The overall STD rate among the 838 girls in the study was 26 percent, which translates to more than 3 million girls nationwide, researchers with the U.S. Centers for Disease Control and Prevention found. They released the results Tuesday at an STD prevention conference in Chicago.
"Those numbers are certainly alarming," said sex education expert Nora Gelperin, who works with a teen-written Web site called sexetc.org. She said they reflect "the sad state of sex education in our country."
"Sexuality is still a very taboo subject in our society," she said. "Teens tell us that they can't make decisions in the dark and that adults aren't properly preparing them to make responsible decisions."

Huh? They used a time machine to interview someone from the 1950s?
Our society discusses sex endlessly--but seldom discusses the risks associated with it. There is almost no discussion of HPV--some strains of which cause cervical cancer, and are thus a major killer of women. And condoms, while better than nothing, are not sufficient to prevent the spread of HPV.
There is a reluctance to point out that a lot of girls are pressured into premature sex, and many are, if not forcibly raped in a legal sense, are still cajoled and badgered into sex a lot earlier than they are quite ready.
There is very little discussion of how widespread sexual abuse of girls is--and how this premature sexualization plays some part in later promiscuity and acceptance of themselves as sexual objects.
While less common, sexual abuse of boys is a problem, because where girls may turn inward in their destructiveness, boys often turn outward.
Sexuality isn't a taboo subject in our society. It is perilously close to an anti-taboo--where you are pretty much required to discuss it, endlessly. Honest discussion of the risks of premature or casual sexuality--that's the taboo.

Unsurprising, But Still Depressing

Unsurprising, But Still Depressing

This March 11, 2008 BBC report:

One in four teenage girls in the United States has a sexually-transmitted disease, a study has indicated.

The study, by the federal Centers for Disease Control and Prevention (CDC), found an even higher prevalence of STDs among black girls.

Researchers analysed data from a nationally representative sample of 838 US girls aged 14 to 19.

A virus that causes cervical cancer - HPV - was the most common, followed by chlamydia, trichomoniasis and herpes.

The CDC says the study is the first in its kind to examine the prevalence of common sexually transmitted diseases among adolescent girls.

It found that nearly half of the African-American girls surveyed had at least one STD, while the rate was 20% among white and Mexican-American teenagers.

Human papillomavirus, or HPV, affected 18% of the girls surveyed, chlamydia 4%, trichomoniasis 2.5%, and herpes simplex virus 2%.

Liberals are crowing that abstinence education (which this April 16, 2007 U.K. Guardian article indicates the Clinton Administration actually started) doesn't work. I find when I search scholar.google.com that there are some studies that show that it does make a difference, although sometimes with mixed results, such as this one:

Results: Intervention students reported increases in knowledge and abstinence beliefs, but decreases in intentions to have sex and to use condoms. Intervention did not influence sexual initiation or condom use; however, intervention students who had sex during the evaluation period reported fewer sexual episodes and fewer partners than did controls. Conclusions: Abstinence-until-marriage interventions can influence knowledge, beliefs, and intentions, and among sexually experienced students, may reduce the prevalence of casual sex. Reduction in condom use intentions merits further study to determine long-term implications.

More typical are the results of studies like this, evaluating ten different state programs--only five of which actually tried to measure changes in sexual behavior:

Sexual Behavior—Five programs measured long-term impacts on sexual behavior.

No evaluation demonstrated any impact on reducing teens’ sexual behavior at follow-up, three to 17 months after the program ended (Arizona, California, Minnesota, Missouri, or Pennsylvania’s LaSalle Program).

I will tell you that as much as I would like to think that abstinence-only education can work, it is sailing into a hurricane. The mass media strongly, strongly promote early sex. The very high rates of infection among black teenaged girls tells you that there is something terribly broken in the black community (as Bill Cosby keeps saying). Even if the media weren't promoting it, teenagers don't need any encouragement towards sex--that's pretty much the default setting for human beings. I've read studies of Puritan New England that demonstrate that 16% of brides were pregnant by the time they married.

Where I lived in Sonoma County, to my surprise, the school districts promoted something that the county schools superintendent called "abstinence-best" education. The theory was that it was good to tell kids to wait--and also to tell them what to do if they weren't going to wait.

You don't have to be religious to see that there are some significant advantages to delaying sex.

1. Think of how organized and clean the average 14 year old keeps his or her room, and then ask yourself, "Would you trust this kid to take birth control pills or use a condom correctly?"

2. A friend made the observation once that teenaged boys are willing to trade intimacy for sex; teenaged girls are willing to trade sex for love. There's a lot of truth to that. Teenaged years can be terribly confusing, with enormous highs and lows. Even waiting a couple of years to mature can make a huge difference, especially because contraception's availability has created a difficult situation for many girls, who are badgered into sex earlier than they really want to be.

3. From a health standpoint, waiting is a good thing. I was shocked to see even Planned Parenthood admit this:

Women who abstain until their 20s — and who have fewer partners in their lifetimes — may have certain health advantages over women who do not.

The harsh reality is that in a culture that glorifies sexuality, relatively few kids are going to wait until marriage. Relatively few even wait until they are 18. They need to be aware of contraceptive techniques. They also need to be aware that there are risks, and that no method of contraception works as well as abstinence. Condoms break; condoms fail to stop the spread of HPV; non-barrier methods create risks of potentially lethal STDs; and many of the alternatives to sexual intercourse include significant risks of disease and pregnancy.

This is definitely an unpleasant situation. You don't want to encourage kids to be sexually active--but contraception is better than abortion. Contraception is also better than a shotgun marriage, or illegitimacy.

STDs At Record Levels

STDs At Record Levels

From November 13, 2007 Associated Press:

ATLANTA - More than 1 million cases of chlamydia were reported in the United States last year — the most ever reported for a sexually transmitted disease, federal health officials said Tuesday.

A new U.S. record," said Dr. John M. Douglas Jr. of the Centers for Disease Control and Prevention.
More bad news: Gonorrhea rates are jumping again after hitting a record low, and an increasing number of cases are caused by a "superbug" version resistant to common antibiotics, federal officials said Tuesday.
Syphilis is rising, too. The rate of congenital syphilis — which can deform or kill babies — rose for the first time in 15 years.
"Hopefully we will not see this turn into a trend," said Dr. Khalil Ghanem, an infectious diseases specialist at Johns Hopkins University's School of medicine.
The CDC releases a report each year on chlamydia, gonorrhea and syphilis, three diseases caused by sexually transmitted bacteria.
Chlamydia is the most common. Nearly 1,031,000 cases were reported last year, up from 976,000 the year before.
The count broke the single-year record for reported cases of a sexually transmitted disease, which was 1,013,436 cases of gonorrhea, set in 1978.
Putting those numbers into rates, there were about 349 cases of chlamydia per 100,000 people in 2006, up 5.6 percent from the 329 per 100,000 rate in 2005.
...

Douglas said it doesn't look like the superbugs are the reason for gonorrhea's escalating numbers overall, but they're not sure what is driving the increase.

Not sure? Hmmm. Could it be a dramatic increase in people who are changing sexual partners more frequently than they change their cell phone provider? Yes, using condoms helps, but it isn't a sure method of avoiding STDs. There's a reason that cable television channels are awash in ads for drugs to help people suffering from herpes outbreaks, and who don't want to give it to their current sexual partner.

UPDATE: Shocking: the AP version of the story left out this detail that appears in the November 14, 2007 Los Angeles Times story about this:

Gay and bisexual men made up 64% of new cases of primary and secondary syphilis in 2006.

Hmmm. About 4-4.5% of men are gay or bisexual--so about 2-2.25% of the population has 64% of the new cases of syphilis. Who woulda thunk it?

An HIV Vaccine Study Raises A Question For Me

This article from the November 8, 2007 San Francisco Chronicle tells of an HIV vaccine study that not only didn't work--it may have increased risk for the study group:

Evidence is building that an experimental AIDS vaccine given to 1,500 volunteers not only failed to protect those who received it, but may have put some of them at higher risk of contracting HIV than those who were given a placebo.

At a Seattle meeting held Wednesday to discuss the latest findings, vaccine experts wrestled with the complex questions raised by the disappointing early results of the study, first disclosed by drugmaker Merck & Co. nearly seven weeks ago.

Enrollment in the study was halted at the time, but researchers are still tracking the HIV status of the participants.

"The data are disappointing and puzzling, but we don't have definitive answers" why the results turned out as they did, said Dr. Lawrence Corey of the Fred Hutchinson Cancer Research Center and leader of the study.

The Merck vaccine was made from a cold virus that was genetically engineered to carry three genes from HIV, the virus that causes AIDS. Scientists say it is absolutely impossible to contract HIV from the vaccine itself. The cold virus was also weakened so that it would not make the patient ill.

Additional numbers released Wednesday revealed a total of 49 new HIV infections among men who were assigned the experimental vaccine; and 33 among those given a placebo. A further breakdown of those numbers found that the risk of infection was doubled among a group of men who carried high levels of antibodies to a common cold virus - similar to the hobbled cold virus used as a component of the vaccine.

Now, there are diseases out there for which a vaccine seems like a darn good idea, especially diseases that are hard to prevent. For example, it is difficult, short of becoming a hermit, to avoid catching the flu, or a cold, or polio. These are all easily communicable diseases.

But AIDS? Take the following precautions, and your chances of catching AIDS now are effectively zero:

1. Do not share needles with others.

2. Do not engage in unprotected sex with someone unless you are sure of their HIV status. (Yes, that means that you may have to find out their name first, and delay sex until your third, fourth, or even fifth meeting.)

3. Change your sexual partners less often than you refinance your house or replace your car.

There are still going to be a small number of people that are going to follow all the rules, and still get infected. But this is a trivial number of people--perhaps a few hundred a year in the whole country at first, dropping down to tens a year as the number of new infections declines. Does it really make sense to devote any substantial resources to finding a vaccine for a disease that you can't easily contract without being beyond stupid? And especially when the vaccine turns out to be more dangerous than a placebo?

I know, I know, I'm going to get a bunch of nasty remarks about how homosexuals don't have the option of following rules 1, 2, and 3, because they can't get married. Sorry, I don't buy that. You don't need a marriage certificate to be monogamous, or at least to be careful in your promiscuity.

Would I be upset if enormous resources were being spent on developing a herpes vaccine? Or an HPV vaccine? Or a syphilis vaccine? Yes, and for the same reason. These aren't diseases that just "happen." They are the result of people engaging in relatively risky behaviors. It would be like spending billions of dollars to develop drugs that prevent smoking from causing cancer.

This August 28, 2007 CNN report warns that oral cancers are associated with HPV-16, and that as the number of oral sex partners a man has increases, the risk increases:

There are several strains of HPV, which cause ordinary warts but also genital warts. These in turn can cause cancer in some cases. The researchers looked at various studies and concluded that HPV 16 was especially likely to be linked with certain cancers of the tonsil and base of tongue.

Smoking is a well known risk factor but rates of these cancers are staying fairly steady, despite declines in tobacco use.

In one study cited by Sturgis and Cinciripini, Dr. Maura Gillison of Johns Hopkins University in Baltimore and colleagues studied 100 patients with oral or throat cancer and compared them with 200 healthy people. They found those who had six or more oral sex partners had a high risk of the cancer.

They found evidence of HPV-16 in 72 percent of the tumors.

U.S. health officials estimate that more than a quarter of U.S. girls and women aged 14 to 59 are infected with HPV.

This report from Journal Watch gives details on a similar study:

The investigators collected demographic information and determined HPV infection status in 100 patients with OPC and 200 age- and sex-matched healthy controls. Most patients (86%) were male. Family history of cancer (especially squamous-cell carcinoma of the head and neck), a personal history of oral papillomas, poor long-term oral hygiene, consumption of 15 or more alcoholic drinks per week for more than 14 years, and a smoking history of more than 20 pack-years were all associated with OPC. In a multivariate analysis, the following factors were also significantly associated with OPC: having had more than 26 lifetime vaginal-sex partners or more than 6 lifetime oral-sex partners and presence of serum antibodies to HPV-16b L1 capsid protein. Of 60 patients with available frozen tissue samples, 72% had HPV-16 DNA in tumor cell nuclei. Neither high tobacco use nor high alcohol use was an additive factor in HPV-induced OPC. The authors speculate that alcohol- and tobacco-induced OPC may follow a different pathway than HPV-16–induced disease.

Comment: The incidence of tonsillar and base-of-the-tongue cancers has been increasing since 1973. Understanding the contributing factors beyond the well-established ones of heavy alcohol and tobacco use is important. Warts have been implicated in oral cancer, and this epidemiologic and virologic investigation confirms an association between such cancers and HPV. The number of sexual partners appears to increase the odds of having an oral HPV-16 infection. Because most patients with this disease are males, protection during oral-genital sex is not straightforward. With a vaccine now available and effective in preventing HPV-16–associated cervical carcinoma, seeing whether the vaccine also decreases the incidence of oral and pharyngeal carcinoma will be interesting.

My guess is that this increase in cancers since 1973 is because of:

1. Increased number of sexual partners increasing the chance of running into someone infected with HPV-16. Yes, I know that before 1973, every adult didn't stay celibate until marriage, and remain faithful for life. But I don't think anyone seriously believes that fear of pregnancy (which had risks for both woman and man back then) and the prevailing notions of sexual morality didn't act as something of a constraint. Remember that the percentage of a population that will be infected with an STD increases exponentially with the number of different sexual partners. Double the number of different sexual partners over a particular period, and you octuple the number of STD cases.

2. My impression from reading literature of the period is also that oral sex became a more mainstream activity in the 1970s, perhaps because of the increased exposure to it in pornography and sex manuals.

Did This Gal Read This Article After She Wrote It?

It's from the student newspaper of the University of West Florida. She describes (in rather more graphic language than I will quote here) sex in a public restroom at a bar with a guy that she doesn't know all that well, and then gets upset at how others regard her behavior:

Yet that day, while attending a wedding, I joked with a friend, whom I view as a big sister in many ways, about the night before; however, she seemed rather disturbed upon hearing about my exhausting night.

At the reception, and in front of another girl who sat eavesdropping on the conversation while all of the other wedding guests were otherwise entertained, my friend surprised me with her reaction to my talking about the event. She asked me this, "What are you going to tell the guy you want to marry about your choices?"
To speak plainly, an argument ensued. She proceeded in an almost scolding manner to speak against what she termed promiscuity as I spoke in defense of myself, arguing that one night of impulsiveness was hardly promiscuous.

Oh heavens no!

Does this gal know that even if she used a condom, she's playing Russian roulette? Admittedly, instead of five empty chambers and one loaded, it's more like a hundred empty chambers--and instead of sudden death, it may be a slow, painful process with years of suffering--but the analogy still fits.

Thanks to the Bitch Girls for pointing me to this example of rationalization.

Another Reason to Not Change Sex Partners As Often As Your Socks

This paper from the May 10, 2007 New England Journal of Medicine won't make some people happy, of course, because it suggests that monogamy and fidelity aren't just old fashioned ideas:

ABSTRACT

Background Substantial molecular evidence suggests a role for human papillomavirus (HPV) in the pathogenesis of oropharyngeal squamous-cell carcinoma, but epidemiologic data have been inconsistent.

Methods We performed a hospital-based, case–control study of 100 patients with newly diagnosed oropharyngeal cancer and 200 control patients without cancer to evaluate associations between HPV infection and oropharyngeal cancer. Multivariate logistic-regression models were used for case–control comparisons.

Results A high lifetime number of vaginal-sex partners (26 or more) was associated with oropharyngeal cancer (odds ratio, 3.1; 95% confidence interval [CI], 1.5 to 6.5), as was a high lifetime number of oral-sex partners (6 or more) (odds ratio, 3.4; 95% CI, 1.3 to 8.8). The degree of association increased with the number of vaginal-sex and oral-sex partners (P values for trend, 0.002 and 0.009, respectively). Oropharyngeal cancer was significantly associated with oral HPV type 16 (HPV-16) infection (odds ratio, 14.6; 95% CI, 6.3 to 36.6), oral infection with any of 37 types of HPV (odds ratio, 12.3; 95% CI, 5.4 to 26.4), and seropositivity for the HPV-16 L1 capsid protein (odds ratio, 32.2; 95% CI, 14.6 to 71.3). HPV-16 DNA was detected in 72% (95% CI, 62 to 81) of 100 paraffin-embedded tumor specimens, and 64% of patients with cancer were seropositive for the HPV-16 oncoprotein E6, E7, or both. HPV-16 L1 seropositivity was highly associated with oropharyngeal cancer among subjects with a history of heavy tobacco and alcohol use (odds ratio, 19.4; 95% CI, 3.3 to 113.9) and among those without such a history (odds ratio, 33.6; 95% CI, 13.3 to 84.8). The association was similarly increased among subjects with oral HPV-16 infection, regardless of their tobacco and alcohol use. By contrast, tobacco and alcohol use increased the association with oropharyngeal cancer primarily among subjects without exposure to HPV-16.

Conclusions Oral HPV infection is strongly associated with oropharyngeal cancer among subjects with or without the established risk factors of tobacco and alcohol use.

Wouldn't it be cool if the entertainment industry found some subtle way to work into movies, music, and television shows the idea that promiscuity is dangerous? Or would that force some introspection from America's most depraved industry?