An End to HIV by 2030?

In his recent State of the Union speech, President Trump made an ambitious pledge in the area of public health: to eliminate the HIV epidemic in the United States within ten years. The actual plan, released that week by the Department of Health and Human Services, aims to end new HIV infections by 2030. HHS proposes to do this by targeting “geographic hotspots”: forty-eight counties, plus Washington, DC and San Juan, Puerto Rico that account for more than 50 percent of new HIV diagnoses, as well as seven states with high rates of infection in rural areas. The plan calls for diagnosing the disease quickly, starting treatment as soon after as possible afterward, and increasing the use of PrEP (pre-exposure prophylaxis), a medication for people at high risk for HIV.

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Researchers and HIV/AIDS advocates call the initiative aggressive but achievable, as all of its medical components—diagnostics, anti-retroviral therapies, PrEP—have been available for some time. However, many remain skeptical of the Trump administration’s actual level of commitment to ending HIV, given its ongoing assault on LGBTQ communities, immigrants, and people of color, populations with high rates of new infections. Furthermore, the administration has continually attacked and undermined the Affordable Care Act and Medicaid, making health insurance both more difficult to obtain and more expensive to use. Premiums continue to rise, and seven states have implemented work requirements that have had the effect of kicking people off Medicaid, with applications pending in eight more.

As both a social and a medical endeavor, public health must engage communities, where local norms and cultural attitudes can affect disease transmission. Take for example the recent measles outbreak in Clark County, Washington, a state that allows exemptions to mandatory vaccinations for medical, religious, and philosophical reasons. As NPR has reported, some schools have vaccination rates under 40 percent, rather than the 90 percent or so required for a community to be protected. Parents who are responding to inaccuracies and rumors on social media and from other parents forego vaccinations for their children, placing entire communities at risk. Combating such fears requires not only a tightening of applicable laws, but also a campaign to address vaccine misinformation in locations where it can itself spread like a virus.

If the Trump administration is truly committed to eradicating HIV, then it must combine social with medical approaches. It’s not enough simply to diagnose more people and subsidize new PrEP prescriptions. Resources must also go toward affordable housing, nutrition assistance, and counseling to ensure that patients are emotionally supported and are adhering to regimes of treatment. Stigma and discrimination remain obstacles to meaningful care in affected populations; any far-reaching plan must tackle social attitudes among those affected, including families and healthcare providers. We may have in hand the medical tools to end new transmissions, but success will not rest on these components alone. The Trump administration must understand this if it genuinely wants to succeed in its goal.

Addiction News: E-Cigarettes vs. Nicotine Patches; OxyContin and Recovery

Here are two recent noteworthy items in addiction news.

In Smoking Cessation, E-Cigarettes Trade One Form of Nicotine Addiction for Another

A study by British researchers published last week in the New England Journal of Medicine found that e-cigarettes were nearly twice as effective as traditional nicotine-replacement methods at helping smokers to quit. After one year, 18 percent of e-cigarette users were still not smoking, compared with about 10 percent of those who used nicotine patches, gum, lozenges, and inhalers. Without any kind of aid, the success rate for smoking cessation is around 3 percent.

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The downside of using e-cigarettes to quit is that people often ended up addicted to them. Vaping is less harmful than lighting up a conventional cigarette, which contains numerous toxins including tar, formaldehyde, arsenic, and carbon monoxide. In terms of harm reduction, e-cigarettes are an improvement over regular cigarettes. But nicotine itself is a highly addictive chemical that can be lethal in concentrated doses; for centuries, it has been used as an insecticide. Furthermore, vaping products often contain flavoring agents to make them taste of mint or cinnamon or different kinds of fruit, and no long-term studies have been done on their safety.

When e-cigarettes were first introduced in the US a decade or so ago, I wondered if they would re-normalize the act of smoking—or inhaling a nicotine-laden vapor—in a culture where it had become increasingly disparaged. E-cigarettes are popular among young people and have been specifically marketed to them by manufacturers such as Juul, which until an FDA crackdown last fall, sold vaping pods in flavors of mango, cucumber, fruit, and creme at gas stations and convenience stores. Even if e-cigarettes may be useful in weaning some adults off tobacco, they’re not being used that way by young people. Instead, they’re introducing a new generation to nicotine addiction through an act that mimics conventional smoking, popularizing anew a behavior that public health advocates worked for decades to stigmatize.

OxyContin Maker Sought to Enter Addiction Recovery Business

In Massachusetts, attorney general Maura Healey has filed a lawsuit accusing Purdue Pharma, the manufacturer of OxyContin, of creating and perpetuating the opioid crisis. The suit claims that the company, and the Sackler family which controls it, aggressively marketed the medication while knowing that it was addictive, promoted higher doses to increase profits, and hired the management consulting firm McKinsey & Co. to boost its image in the fact of negative publicity. The allegations are disturbing and have been covered previously; Patrick Radden Keefe’s article in the New Yorker, in particular, is a comprehensive look at the Sackler family and how it made OxyContin into a blockbuster drug.

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To me, the most intriguing part of the lawsuit is the allegation that Purdue Pharma at one point considered getting into the addiction recovery business. In an initiative code-named Project Tango, company executives and at least one member of the Sackler family proposed acquiring the rights to sell Narcan, a medication used to reverse overdoses, and Suboxone, which is used to treat opioid addiction. The project was later abandoned. But it highlights the ways in which actual people shaped the making and the contours of the opioid epidemic. Employees at the company and members of the Sackler family were aware of the growing crisis, yet they acted cynically and shirked any moral responsibility in perpetuating it, even aiming to profit off it by expanding their business to treat those who were suffering from it.

We often think of addiction in terms of individual behavior: a man who starts taking oxycodone to treat pain after a car accident and becomes dependent on it; a young woman who starts smoking to relieve stress and finds herself unable to quit. But those who work for pharmaceutical companies, cigarette manufacturers, and advertising agencies have played and continue to play an active role in creating and promoting desire for their products. They help to determine access to them, and, in the case of tobacco companies, cover up research about their harms. Addiction is a disease, but it doesn’t originate solely in brain chemistry or physiology. It exists within a broader social environment that affects one’s exposure to addictive substances, as well as one’s experiences of addiction and recovery. That’s why I find the lawsuit against Purdue Pharma so fascinating. It reveals the usually invisible workings of those individuals behind the scenes whose decisions affect people’s physical and emotional health in ways that are neither natural nor inevitable.

DNA and Identity

I’ve had identity on my mind lately, apropos of the news last week that Elizabeth Warren, the Democratic senator from Massachusetts, took a DNA test that confirmed her Native American ancestry. As the test showed, she probably had a single Native American ancestor six to ten generations ago, corroborating the stories about her family’s history that she’d heard growing up. This makes her some percentage Native American—a small one, but probably more than most white Americans of predominantly European ancestry, according to the science writer Carl Zimmer. And while the test supports some amount of indigenous ancestry, there’s no way to tell if her ancestor was Cherokee, as she believes according to family lore, because tribe-specific DNA tests don’t exist. Moreover, she has been justifiably criticized for affirming a link with a heritage to which she has no cultural connection. For Native Americans, in particular, the question of tribal membership is politically and historically fraught, with real consequences for sovereignty and distribution of resources. Different tribes have different citizenship requirements, which often, but not exclusively, take into account one’s ancestry. The Cherokee Nation reacted to Warren’s DNA results by calling them “inappropriate” and “useless to determine tribal citizenship.” And Kim Tallbear, a professor of Native Studies at the University of Alberta and the author of a book on Native Americans and the uses of DNA, said Warren’s stunt is another example of “Non-Indigenous Americans…making claims to all things Indigenous.”

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Warren isn’t asserting Native American identity right now, although she has in the past. At some point in the 1980s, she self-identified as a “minority” in a directory of American law professors, which prompted the University of Pennsylvania, and later Harvard Law School, to classify her as Native American. It was an ill-advised move for which she should take responsibility and gravely apologize.

While DNA is material within our genes that determines what we look like and shapes many of our characteristics, identity is a social category based in family relationships, history, politics, and experience. But the two are often conflated, as illustrated by the popularity of genetic testing sites such as 23andMe and Ancestry.com, which invites visitors to “[t]ake a DNA test and uncover your origins.” It may be a fun game to find out which geographic populations your DNA most closely matches, but without additional context and lived experiences, they’re no more meaningful to our personal stories than random places on a map.

We have long been fascinated by the idea that our bodies can offer some truth about who we really are, that within our blood and bones reside clues about ourselves that are only accessible through careful scientific measurement. Identity, in this construction, is something to be uncovered. It’s especially precarious when this knowledge is related to race or ethnicity, and our genes are then perceived as a way to definitively locate this information within the body. But our DNA, our blood types and our physiologic markers are merely data that are assigned meaning through social context. My genes may have given me dark hair, brown eyes and a taste for bitter foods, but the importance ascribed to these traits and how they shape my life are social phenomena. Even markers for diseases such as Huntington’s or Parkinson’s may tell us our risk of developing a particular malady, but they are infinitely less useful in predicting our experience of illness, which is shaped by social relations. Our bodies may offer us all kinds of information about our health, and DNA can tell us who our ancestors might have been. But it doesn’t tell us anything about what it means to identify as a member of a community, a process shaped by history, family, and the experiences one accumulates during one’s lifetime.