Can you protect your nation from HIV by testing immigrants for the virus? Even the United States now thinks that’s a daft idea; it finally dropped its HIV testing requirements for immigrants earlier this year. Now South Korea has followed suit, sort of. The country will drop HIV testing for some, though it has announced different rules for teachers and entertainment industry workers.

Should the International Union of Sex Workers start girding their loins to fight for equal rights for hookers? No. Seoul has decided that people applying for entertainment industry visas do not need to be tested for HIV. People wanting to teach English do. An official of the Ministry of Education, Science and Technology explained the decision thus: “Education is considered a very intimate relationship. According to an unofficial survey by the Prime Minister’s Office, the majority of parents wanted solid evidence of their children’s teachers’ HIV status.”

The implication — that English teachers from Wisconsin are more intimate with their clients that hookers from Vladivostock are with theirs — is clearly absurd, and the Korean authorities are squirming a bit about the silliness. But it reminds me of a piece of ancient history in the HIV industry’s cooking up of Stigma Soup.

Many years ago, we were trying to come up with ways of measuring HIV-related stigma in international surveys. We suggested three questions: Should HIV infected nurses be allowed to treat patients in hospital? Should HIV infected teachers be allowed to teach? Would you buy cooked food from someone with HIV? To everyone’s surprise, a lot of respondents in African surveys replied no, no, yes. So was HIV stigmatised, yes or no? A bit of qualitative work shed more light. HIV-infected nurses shouldn’t be allowed to treat patients because they had compromised immune systems and it was better for them not to be around sick people. Not all that stigmatising, then. Food sellers? What? Everyone knows you can’t pass on HIV in a pot of stew! No stigma there, either. But teachers, what about teachers? Well they’re always having affairs with the pupils; we don’t want our daughters to get anywhere near a positive teacher. It strikes me that’s stigmatising of teachers, though not necessarily of HIV.

While we’re on the subject of HIV and immigration, I do think it remains the great untouched subject of the UK HIV epidemic. A first glance at figures provided by the soon-to-be late and very much lamented Health Protection Agency shows us a great wave of heterosexual infections in the UK.

If you take away the infections that are diagnosed in people who were born in a sub-Saharan or Caribbean country with high HIV prevalence, the picture looks very different indeed:

The difference is assumed to be the infections that are “imported”. In fact, there may well be quite a bit of transmission within communties of African-born people in the UK. But there’s virtually no effective targeted prevention programmes for that group, because we’re all so scared of two things. [Note comment on this point] Firstly, the Daily Mail getting hold of the issue and beating up support for a “test the immigrants” campaign. Secondly, the idea that targeted prevention would be stigmatising. Imagine, it might engender a backlash from all those Pentacostal Churches in East London. And then we’d be in the same situation that so many African countries are in: community leaders choosing to deny a problem rather than help their people by dealing with it.

Until last Monday, America’s unfathomably illogical health service for the properly poor, Medicaid, refused to pay for HIV testing just as it refuses to pay for all sorts of other screening measures that could allow conditions to be treated early or in some cases prevented enitirely. Now, Medicaid has finally agreed to test its clients for HIV, if they fall into certain categories.

Here’s where the bad reporting comes in. This, for example, from The Goverment Monitor, which reports public sector news:

“The Centers for Medicare & Medicaid Services (CMS) today announced its final decision to cover Human Immunodeficiency Virus (HIV) infection screening for Medicare beneficiaries who are at increased risk for the infection, including women who are pregnant and Medicare beneficiaries of any age who voluntarily request the service.”

So, the two groups that they single out as being “at increased risk” for HIV are pregnant women, and people asking for a test. In fact, of people who have recently had unprotected sex in the United States, pregnant women are among the least likely to be infected with HIV.

The actual decision reads as follows:

CMS will cover both standard and U.S. Food and Drug Administration (FDA)-approved HIV rapid screening tests for:

1. Annual voluntary HIV screening of Medicare beneficiaries at increased risk for HIV infection per USPSTF guidelines:

* Men who have had sex with men after 1975;
* Men and women having unprotected sex with multiple [more than one] partners;
* Past or present injection drug users;
* Men and women who exchange sex for money or drugs, or have sex partners who do;
* Individuals whose past or present sex partners were HIV-infected, bisexual or injection drug users;
* Persons being treated for sexually transmitted diseases;
* Persons with a history of blood transfusion between 1978 and 1985;
* Persons who request an HIV test despite reporting no individual risk factors, since this group is likely to include individuals not willing to disclose high-risk behaviors; and

2. Voluntary HIV screening of pregnant Medicare beneficiaries when the diagnosis of pregnancy is known, during the third trimester, and at labor.

In other words, perfectly sensibly, pregnant women are NOT classified as at high risk for HIV infection, but are offered tests in any case since services to prevent transmission to their babies are available if need be. Now look at the list of those who ARE considered at higher risk. Again, it is mostly perfectly sensible. I’d prefer to see some sort of time stamp on number two — the overwhelming majority of Americans have had more than one partner in their lives, and most will probably have had unprotected sex with at least two of them. But that really doesn’t put them into a “high risk” category unless they are having sex with those multiple partners during overlapping time periods. Because HIV isn’t highly infectious for very long, you’d really like something more precise, such as “unprotected sex with multiple partners in any given three month period”. The biggest group at higher risk missing from the list is “men who have been incarcerated”. I agree that it is not the incarceration but the behaviours while incarcerated that put people at risk for HIV, and those behaviours are covered elsewhere on the list. But many people zone out what happens in jail — they are unlikely to report having sex with other men if it is something that they only do when they are banged up, for example. And yet we know many people in jail are infected with HIV, and we also know that many of them are having anal sex and shooting up drugs, and therefore likely to pass the virus on to other prisoners.

Another piece of good sense: the decision specifically authorises rapid tests. We know that people are far more likely to get their results and to be tied in to the support and care services they may need if they are offered on-the-spot tests, rather than having to come back or call in for results a week later. It would be nice if other countries (with generally better records on preventative medicine) followed this lead. Any Canadians reading this…?

Blog comment is divided between “HIV is everyone’s problem”, “HIV is a gay problem” and “HIV is a black problem”. I have the highest respect for DC’s attempts to get to grips with this long-neglected issue, but I was frankly disappointed to hear city HIV director Shannon Hader take the “everyone is at risk” approach in an interview with NPR. So much so, that I went and made a little graph from the data:

I’ve just looked at blacks and whites, I’ve included gay men who inject drugs in the gay men data, and I’ve ignored unknown modes of transmission — the full data are in the table at the end of this post if you’re curious. But essentially, these data show fairly dramatically that in DC HIV affects black people far more than white people, and it affects gay men far more than straight men. A significant number of black women but virutally no white women are infected through drug injection, but more black women are infected because they have sex with black men. That’s the way it is, and saying that there are some infections in every demographic therefor everyone is at risk won’t change that. I should note that these are individual diagnoses, not rates — if we had denominators, the rates among men who have sex with other men and among drug injectors would dwarf heterosexual tranmission.

I was also surprised by NPR’s handwringing over low rates of condom use. Apparently, though the data are not in the report, one in three adults in DC used condoms the last time they had sex. That’s neither low nor high; it’s meaningless. We don’t need people to use condoms every time they have sex. We need people to use condoms with every partner who is remotely likley to be of a different infection status than themselves. As you can see from the graph, lots of potential partners including most white heterosexuals who don’t shoot up drugs and have sex with others like them don’t fall into that category.

One thing that shocked me in the report was the astoundingly high proportion of people who are still testing very, very late (within a year of being diagnosed with clinical AIDS, so when they’ve been walking around with undiagnosed infection for an average of eight or nine years). It’s still an astoundingly high two thirds. It does, however, look like the DC health department’s valiant efforts to increase testing and pick up more cases in settings where they are most likely to be found are bearing fruit in at least one way. The average CD4 count at diagnosis has risen from under 200 in 2004 to 332 last year. The CD4 count is a measure of how damaged your immune system is at the time of diagnosis. If the health system doesn’t catch you and put you on anti-retrovirals until it’s fallen below 200, you’ve got a much lower chance of survival than if treament starts earlier.

The wonderful Xtra gives us strategies for putting the lid back on the can of legal worms that this opens. They come courtesy of Ryan Peck, the executive director of the HIV/AIDS Legal Clinic (Ontario) (HALCO)

“He suggests HIV-positive people consider disclosing their status in front of friendly witnesses or a counsellor or support worker who’s taking notes.

He also suggests double-checking. “Have a friend ask the sex partner if they know about your status,” he writes. “If disclosure takes place online, make sure it is done clearly, ie not using code words. The sex partner should acknowledge the disclosure, and a copy should be saved and printed.”

Peck suggests that having a sex partner sign an acknowledgment would be legally ideal but unlikely. “Get your sex partner to sign a document before sex that says that he knows you are HIV-positive and that he knows what it means,” Peck writes. “The document should include the date and the partner’s name and signature. This is a good way for you to protect yourself. But it is also the most unrealistic strategy.”

Yes indeed. It reminds me of being hauled in front of a couple of buzz-cut marines at the US embassy in Jakarta for a mandatory security briefing. “We don’t care who you sleep with; men, women, whoever. But we do advise you to ask us to run a security check on them first, especially if they are a foreigner.” So hang on, I’m dancing in a club in Jakarta on a Saturday night and I find some nice Cuban guy who might actually consider having sex with a white girl over 40 (Alhamdulillah!) and I’m supposed to say: “Nice thought, but would you mind waiting until 9 am on Monday, when I can check with the marines?”

It’s not going to happen. Not the interested Cuban, very probably. But certainly not the pre-fucktual check. Just as pre-fucks won’t become the norm for HIV-infected people. Nor should they have to. There is not a shred of evidence that the criminalisation of HIV transmission has any impact on the spread of the virus. It’s nicely put by the Canadian HIV/AIDS Legal Network in their info sheet on the criminalisation of HIV transmission.

“In the big picture, criminal charges do little or nothing to stem the spread of HIV. However, they divert resources and attention away from the policies and initiatives that make a real difference (e.g., education, testing, support services, access to safer sex information and condoms, needle exchange programs etc….) The history of prohibitions on alcohol, drugs, sex between men and prostitution demonstrates that the criminal law is ineffective in deterring such fundamental, complex human behaviour. As for the few who act maliciously or with disregard for the welfare of others, there is little reason to think that a legal prohibition will have much or any deterrent effect. Finally, for people who are unaware of their HIV infection, the threat of criminal prosecution will simply be seen as irrelevant and of no deterrent effect at all.”

On the subject of daft and counterproductive efforts at criminalisation, this nice post from Tim Worstall about the upcoming battle to jail men for buying sex in the UK.

Thanks to Ickaprick and Ironpussy, and to Mark Zip.

As the Jakarta Post pointed out yesterday (in a profile that called me a “raging dinosaur” — a compliment, I think) I was wrong to dismiss Indonesia’s “anti-pornography” bill as so silly it would never get passed. (It did.) I had the same reaction when I heard several weeks ago of a bill to implant people with HIV in Papua with microchips. The brain-child of an Indonesian doctor who has served for years in the country’s easternmost province of Papua, it was too silly even to comment on. Apparently, I was wrong again.

The Post now reports that the bill has the support of local legislators, and may be passed into law. Not all people with HIV will get silicone implants, you understand. Just those who are “sexually aggressive”. Who qualifies as sexually aggressive? “Aggressive means actively seeking sexual intercourse,” the good doctor, one John Manangsang, is quoted as saying. Oh, so perhaps that is everyone, after all.

Predictably, and entirely appropriately, HIV activists are railing against the bill. So are many others, including Papua’s former Vice Governor Constant Karma, a very sensible vet whose position as head of the provincial AIDS council may be threatened because Dr Manangsang’s bill reserves the post for a medic such as, oh, himself perhaps. I’ve got nothing to add to their cries for common sense. This sort of nonsense is hardly worth commenting on from a public health point of view. But I think it might give pause for thought to those who are pushing rapid decentralisaton and local democracy as a development model.

Until 1999, Indonesia’s 13,000 islands were held together by one of the most centralised administrations in the world. Then, by fiat of the erratic and short-lived president Habibie, it decentralised, virtually overnight. Not to the level of the then 27 provinces, but to the level of the then 300-and-something and now 400-and-something districts (the total changes almost monthly as local luminaries seek to consolidate their power and their bank balances by heading up a new district). Pimps of decentralisation sell it as taking decision-making closer to the people — making administrations more responsive and accountable to the electorate and the tax-payer. Which is all well and good, provided you have an educated and informed electorate, and an administration which is willing to listen to them rather than to impose absurd (and sometimes populist) measures at will.

One hopes that the people of Papua will take their leaders to task for suggesting daft measures such as electronic implants. But Papua’s literacy rate is just 72%, against an average for the rest of Indonesia of well over 90%. It’s HIV epidemic is very different, too. In terms of patterns of both infection and sexual behaviour, it looks a lot like East Africa, circa 1992. Men who buy sex are most likely to be infected, but unlike the rest of Indonesia (where drug injection and sex between men compete with commercial sex to spread HIV) there is every indication that patterns of sexual networking may support the spread of the virus beyond high risk groups and their immediate sex partners. Most importantly, perhaps, the people of Papua have been too long accepting bad government. Bringing bad government closer to the people does not make it any better.

A CD4 Molecule

A new study suggests that people with HIV have a 70% greater chance of staying alive if they start taking antiretrovirals when their CD4 count is as high as 500. That’s good news for people who know they are infected early on and who have easy access to drugs. It’s also potentially good news for the people who make the drugs, bumping up their market size quite substantially.

CD4 molecules are attached to T-cells that defend the body against infection. CD4-bearing T-cells get knocked out by HIV infection; so the number per microlitre of blood is used to track the progress of HIV as it cuts its destructive swathe through the body. The US currently recommends starting antiretroviral treatment when the CD4 count hits a low of 350. The new study, which pools data from a large number of north American patients, suggests that a significant number of people die before they hit 350. The study’s author Mari Kitahata was involved in developing the existing guidelines, but in view of the new data she suggests people should start taking drugs when their CD4 count hits 500. Kitahata, a highly respected researcher at the University of Washington who provides advice to several pharmaceutical firms, is now investigating whether there’s anything to be gained from taking drugs even earlier in the course of infection.

This news will cause consternation in a lot of developing countries, where current guidelines recommend starting people on meds at a CD4 of 200 — a level which more or less goes hand in hand with symptomatic AIDS. Raising the threshold to 350 would mean hundreds of thousands more people would need to be put on meds. A threshold of 500 would mean millions more people needing uninterrupted access to expensive drugs. This would cost a fortune; at the risk of sounding callous, I think we would be very well advised to make careful estimates of exactly how many additional lives would be saved. Obviously, doctors treating people with HIV want to keep their patients alive. To them, and of course to the patients, a 70% decrease in the chance of dying is pretty persuasive. But in real terms, not all that many people are dying in the US cohorts (3 per 100 person years among those who took drugs earlier, against 3.2 per 100 person years among those who took drugs later). Kitahata and her colleague Daniel Kuritzkes were abit vague about the costs and benefits of getting people started on drugs earlier; check out the transcript of a press conference discussing the study results over at The Body. (The transcript also contains newer data than the published abstract.)

One thing that wasn’t discussed at the presser was the potential downside of being on antiretrovirals for longer than is necessary. I’d be curious to know more about the long-term effects of taking antiretrovirals, how many extra years of drug-taking a higher threshold would imply, and whether, at a population level, the extra years of drug-taking would mean a lot more discomfort and sickness related more to the drugs than the virus. It’s a very difficult thing to look at, not least because drug regimes have improved so much over time. But I’d welcome information from anyone who has looked at these issues.

If we are going to try to provide drugs earlier, it’s one more reason to push for more routine HIV testing among the people most likely to have been exposed to the virus. Even in the highest risk groups — in the US and the UK that would be gay men — between a fifth and a quarter never learn of their HIV infection until an AIDS-related condition lands them in hospital or at the doctor’s clinic. That’s usually way after the CD4 count has crashed through 500 and even 350. Earlier treatment depends on earlier diagnosis. In countries which might just put people on treatment earlier, these data might just persuade more people to find out if they’re infected.

Malawi is suspending its payments to HIV-infected civil servants because so many uninfected people are trying to cash in, according to AFP (via Cryton Chikoko). A third of Malawi’s 120,000 civil servants have registered as HIV positive. That puts HIV prevalence among government workers at twice the national rate of 14 percent.

Infected civil servants top up their salaries by US$ 35 a month –that’s a 50% slab on top of their average earnings — enough to make many of us change our behaviour. Obviously enough to overcome the stigma that is so often said to stand in the way of any effective HIV programming. It reminds me of stories that surfaced in China when the government started providing free schooling for the kids of people with HIV. China being China, it wasn’t long before there was a secondary market in HIV-infected blood.

Stigma exists because we allow it to, because we reinforce it by tiptoeing around it. The bulldozer of personal incentives can break through stigma in exactly the same way as it can break through corruption, poor productivity and other areas of human endeavour. If we have to bribe our way into greater openness about HIV, why not?

Well, maybe because peverse incentives are a dangerous thing. We want to make it worth people’s while to be more open about their HIV status, without making it worth their while to be infected with HIV. And we don’t want to do anything to reduce the motivation that uninfected people have to protect themselves (which, judging from high rates of new infections in many populations, it already pretty slim). This came up in an interesting discussion I had with the Oxford Global Health group recently. One person mentioned that people in South Africa who get disability payments linked to their TB infection are reluctant to be fully cured, because they don’t want to lose the payments. I’m all for using bribery to change attitudes and behaviour. But one does have to remember that the sword of incentives can have many edges.

The NYT story elicited this comment from a friend of mine, a journalist who is much more informed about HIV than most. “The trouble with this story is it doesn’t say WHY they want to do testing nor indeed WHO has HIV! So are they testing people needlessly ? Is it good surveillance or bad public health? For us lay people, v confusing!”

It’s pretty confusing for a lot of non-lay people, too. I can safely say that is it NOT good surveillance. Surveillance aims to track trends in infection, to guide prevention and care programmes. This is case-finding, which is quite different. The Bronx is trying to identify individuals infected with HIV, so that it can get them onto treatment if need be. It OUGHT to be trying to identify people in need of prevention services, too, but that doesn’t seem to be on the agenda.

So is this mass testing good public health? Not if we ignore prevention needs, certainly. But even if we don’t, I’m dubious. To me, good public health implies protecting the greatest number of people at the lowest possible cost. Mass testing doesn’t do that. In the United States, as in virtually every country outside of sub-Saharan Africa, new HIV infections are concentrated very largely among people who have pretty well-defined risks: they inject drugs or they’re active on the gay scene. People who sell sex or buy it will be at higher than usual risk, too. As is anyone who has recently immigrated from one of the handful of countries in sub-Saharan Africa where HIV prevalence is very high. The Bronx could scoop up a very significant proportion of infections by targeting its testing at those groups.

The problem is, of course, that targeted testing is perceived as “stigmatising”. The United States in general, and the Bronx in particular, has decided that it is better to test everyone than to risk making someone feel uncomfortable by pointing out that their behaviour puts them at higher than average risk for HIV infection. Fair enough, if you’ve got unlimited budgets. But this will mean spending US$ 12 a pop testing several hundred thousand people who are highly unlikely to be infected, to spare the feelings of those who might. I’d be interested to know whether residents of the Bronx who have difficulty accessing other basic health services think it’s a good investment.

While we’re on the subject, MTV is airing rap artist Common performing lyrics written by 18 year-old Jose Rivera from Ewing, Nebraska. They’re hoping to encourage young people to get tested across the country on June 27th, National HIV testing day. Watch Common bring them in for testing right here. Think of me rolling my eyes in time to the music.