If after 20 years you don't succeed.

April 24, 2008 1:58 AM

Maybe it's time to give up. Last year's failed clinical trial for Merck's HIV vaccine (which once appeared so promising) led many to claim that AIDS vaccine research is in crisis. According to an unprecedented poll conducted by The Independent most scientists involved in AIDS research believe that a vaccine against HIV is further away than ever and some have admitted that effective immunisation against the virus may never be possible.

Nearly two thirds believed that an HIV vaccine will not be developed within the next 10 years and some of them said that it may take at least 20 more years of research before a vaccine can be used to protect people either from infection or the onset of Aids.

Worse, the animal model – which uses genetically engineered simian and human immunodeficiency viruses in a combination, known as SHIV – failed to predict what will happen when a prototype vaccine is moved from laboratory monkeys to people. "We've learnt a few important things [from the clinical trial]. We've learnt that one of the animal models, the SHIV model, really doesn't predict very well at all." Of course animal advocates have been saying this for years.

posted by three blind mice (59 comments total)

I wouldn't pay too much attention to scientific predictions. Most scientists have so little confidence in their own predictive abilities that they insist on testing them.
posted by srboisvert at 2:18 AM on April 24, 2008 [20 favorites]

Maybe it's time to give up.

The article in Science you link to makes no mention of HIV investigators wanting to "give up", rather, to reallocate grant funds from vaccines to basic research until more preliminary knowledge is gained from which "new ideas" originate.
posted by Blazecock Pileon at 2:30 AM on April 24, 2008

The article in Science you link to makes no mention of HIV investigators wanting to "give up"

The title of article provided by the link to the Independent: Is it time to give up the search for an Aids vaccine?
posted by three blind mice at 2:40 AM on April 24, 2008

I guess I still don't see it. In fact, I see the same editorial view that Science reports:

[Dr. Fauci] said that one outcome of the meeting was a refocusing of the vaccine effort away from expensive clinical trials towards more fundamental research to understand the basic biology of the virus and its effects on the human immune system... "We'll be turning the knob more towards answering some fundamental questions rather than going into big clinical trials," Dr Fauci said.

That's not giving up, as near as I can tell.
posted by Blazecock Pileon at 2:51 AM on April 24, 2008

'animal advocates'? There's two issues - one is whether the animal models are useful or not, and one is whether or not you should experiment on animals from a moral and ethical standpoint. Having a particular view on one does not lend insight into the other. You shouldn't listen to an 'animal advocate' (which I would read as an animal rights activist) on the science of the efficacy of animal models any more than anyone else, and if they happen to get the right answer over anyone else it's as much luck as anything. In fact, from what I've seen their bias tends to lead them to get the science wrong.
posted by edd at 4:10 AM on April 24, 2008

The whole idea of pursuing an AIDS vaccine as a means of controlling the spread of the disease gives many pause, particularly in the face of the more than 50 year effort so far required in the still futile attempt to eradicate poliomylietis. The polio virus was well understood by many researchers as early as 1951, and reliable killed-virus (Salk) and live-virus (Sabin oral) vaccines were available by the mid-1950s. And yet, despite billions of dollars expended in polio vaccination programs with effective vaccines and solid methodology, polio remains endemic in parts of the world, and has shown in recent years, a remarkable ability to "break out" into transmission, from very isolated areas. Year to date in 2008, we are seeing, again, a three times greater case rate than in 2007 year to date. And every year, since the mid-1980s, the eradication of polio has been targeted by the WHO as an achievable goal, in that year. And yet, for 20 years, that goal has been frustrated, sometimes by political dawdling, but just as often, by the unexpected virulence of the virus itself, from apparently natural reservoirs.

The thinking by some immunologists is, that even if a reliable preventative vaccine could be developed against a retro-virus like HIV, that does not easily survive outside the human body, and that does not have a wild vector reservoir, that vaccination efforts may still take decades to even stop the net growth of AIDS cases, due to its transmission mode as an STD, with the resultant behavioral issues surrounding human sexuality. Moreover, as has been shown in Uganda, the money going to vaccine development, might be better spent on direct education and prophylaxis. Unlike polio, or smallpox, HIV is not a disease we require a vaccine to fight effectively. So, it makes economic and political sense to sundown government funding of efforts to develop vaccines, if they are not proving effective, in order to concentrate resources on methodologies that, in the meantime, have shown real world results in stemming AIDS.
posted by paulsc at 4:25 AM on April 24, 2008 [5 favorites]

Ah, the beauty of a reverse transcriptase with a high-degree of replicative infidelity. Natural selection wins again.
posted by i_am_a_Jedi at 4:26 AM on April 24, 2008 [2 favorites]

The title of article provided by the link to the Independent: Is it time to give up the search for an Aids vaccine?

Headlines are usually not written by the same people who do the stories.
posted by delmoi at 5:28 AM on April 24, 2008 [1 favorite]

Perhaps the CCR5 entry inhibitors will be more successful.
posted by kisch mokusch at 6:09 AM on April 24, 2008

so far required in the still futile attempt to eradicate poliomylietis.

There were 30-50K cases of polio per year in the US alone in the 50's. In 1993 there were an estimated 100K cases worldwide. Now there are under 2K per year worldwide.

Futility?

I'll take as much as that futility as i can get.
posted by srboisvert at 7:07 AM on April 24, 2008 [1 favorite]

"... I'll take as much as that futility as i can get."
posted by srboisvert at 10:07 AM on April 24

You might not want as much of it, if you understand the ongoing risk, however small, to millions of kids each year that polio vaccinations with live-virus oral vaccines continue to represent. That's one reason these cheaper to administer oral vaccines have been discontinued in the U.S. and other developed countries. If eradication had been accomplished, we could have dispensed with mass immunizations within a few years of the clear date of eradication.

Note that I'm not against vaccinations; indeed, in a world where even small pockets of polio remain endemic, worldwide vaccination remains essential. Therein lies a big part of the futility of the polio eradication effort. At some point, we will have as much risk from vaccination itself, as we do from wild reservoirs. But, until eradication can be certified, we will have to continue vaccination programs at high levels, to prevent mass epidemics recurring. And because of the added expense of administration of killed vaccine (injection required), it will remain impractical to abandon oral vaccines in most under-developed countries. And for every year we must continue to vaccinate, we spend something like $1.5 billion in the developed, "polio free" world on polio vaccination, beyond the cost of eradication vaccination programs tracked by WHO.
posted by paulsc at 7:35 AM on April 24, 2008

Therein lies a big part of the futility of the polio eradication effort. At some point, we will have as much risk from vaccination itself, as we do from wild reservoirs.

Hold on a sec while I dig out my "[citation needed]" placard.
posted by jock@law at 7:40 AM on April 24, 2008

My grandfather had polio (and lived his entire long life with a paralysed arm), now in the same country there is effectively zero chance that I'll catch it. It really doesn't matter a shit that there are a handful (relatively speaking) of cases in various backwaters of the planet, compared to the damage that has been prevented.

I feel the same way about a hypothetical vaccine for HIV or AIDS, I've never met (as far as I know - there are only 1400 or so infected in my country) anyone with HIV or AIDS, but if there was a vaccine that could prevent HIV developing into AIDS, then I'd be all for treating 'only' those lucky enough to have been born in rich Western countries. At least to begin with. So, who gives a fuck about eradicating the virus? Isn't drastically reducing the damage enough?

Anyway, it looks like a tough job. However they do it, good luck to them.
posted by The Monkey at 7:48 AM on April 24, 2008

"Hold on a sec while I dig out my "[citation needed]" placard."
posted by jock@law at 10:40 AM on April 24

No need to wait:

"... Risk Factors for VDPV Emergence

The overriding factor for the emergence of all VDPVs is the same as for wild poliovirus (WPV) circulation, low immunity levels in a population. Where routine coverage with OPV is poor or where there is an absence of high quality supplementary immunization activities, a population can become susceptible to the emergence of VDPV. This is because the virus has time to change, replicate and exchange genetic material with other enteroviruses, while spreading through a population.

Importantly, if a population is fully immunized against polio, it will be protected against the spread of both wild and vaccine strains of poliovirus."

posted by paulsc at 7:54 AM on April 24, 2008

"... So, who gives a fuck about eradicating the virus? Isn't drastically reducing the damage enough? ..."
posted by The Monkey at 10:48 AM on April 24

It's precisely that attitude, writ large (actually, writ widely in the developed world), that has caused the WHO Polio Eradication Effort to miss funding targets in the last several years, and to still project that another $575 million dollars will be needed for 2008 and 2009 efforts, with no guarantee of eradication, still. Not that I'm criticizing WHO. Polio virus is a wily, tough thing, and much more difficult to get rid of finally, than anyone thought in 1988, when WHO estimated that it would be eradicated.

It wasn't, and now, 20 years later, it remains burbling along, claiming a few hundred dead a year, and few thousand more permanently disabled. But it continues to threaten us all, and we all have to continue to be immunized against it.

I brought this up, not to derail this AIDS vaccine thread, but to illustrate that a vaccination model isn't always effective against a disease, even one that is well understood, and for which effective vaccines exist. Without getting further afield, I'll point out that polio is only one such viral disease that vaccination has impacted, but failed, so far to eradicate. I chose it to contrast to AIDS vaccine efforts, only to make the point that, too often, we think that if there is a vaccine for something, the problem is solved, when actually, at some point, in some diseases, vaccines become as much an ongoing cost and risk to society, as the residual costs of the small number of cases that remain of the disease they control. But, once at that level, we can't get off of vaccination, without risking the whole population again.
posted by paulsc at 8:15 AM on April 24, 2008 [1 favorite]

It's precisely that attitude

If you mean the attitude that 'we should try even if we know we'll ultimately fail' then we're bang on, but I don't think that's what you think I think.
posted by The Monkey at 8:21 AM on April 24, 2008

But, once at that level, we can't get off of vaccination, without risking the whole population again.

Morbid thought: at some point, as immunization becomes more widespread, with a virus like HIV which is difficult to to get from wild reservoirs, the cost of continued vaccination may be high enough to justify just offing the infected. I feel bad even saying it, and obviously it's callous, but we make decisions about the cost-in-dollars of human life all the time ("are the costs in installation, maintenance, and poor traffic flow -- including costs in productivity loss and gas consumption -- worth the 1 person saved every 10 years by installing a stoplight here?").
posted by jock@law at 8:22 AM on April 24, 2008

the cost of continued vaccination may be high enough to justify just offing the infected. I feel bad even saying it, and obviously it's callous, but we make decisions about the cost-in-dollars of human life all the time

It's not just callous, it's idiotic. While public health is all about cost-benefit analysis, slaughtering infected people has never been a part of any mainstream equation for assessing that. Your comment suggests that you think maybe your thought is unspoken but prevalent, but I assure you that it isn't. Not every callous thought about human life and death represents a willingness to think clearly.
posted by OmieWise at 8:39 AM on April 24, 2008

Your comment suggests that you think maybe your thought is unspoken but prevalent, but I assure you that it isn't.

There's no suggestion like that anywhere in my comment. Don't be a douche.
posted by jock@law at 8:44 AM on April 24, 2008 [1 favorite]

It's one thing to forego actions that may save lives. It's something else to actively murder people.
posted by junesix at 8:59 AM on April 24, 2008

Huh, you suggest the slaughter of millions of human beings, and I'm a douche? I'll try to be more restrained next time.
posted by OmieWise at 9:16 AM on April 24, 2008

I thought it was semi-clueless of that Nature article to state that: Historically, AIDS research has been afforded especially strong public support in the United States. Ha ha ha! When was this person born? Does anyone remember that Ronald Reagan didn't even say the word "HIV" or "AIDS" until 7 years into his presidency (6 years into the AIDS crisis)? Effective, large-scale treatment and vaccine research was not adequately funded until about the 90s. A huge reason why things changed in the world of HIV was ACT-UP and like minded others who started doing their own research, barricaded themselves in the Wellcome offices, and showed up at the NIH offices demanding better research and more rapid trial processes. HIV activism changed the world of medicine. According to Anthony Fucci, the head of the NIAID who is quoted in that article, there are two eras in medicine. Before Larry[Kramer - founder of ACT-UP] and after Larry. One of the changes is that we now expect research to happen more quickly and to be readily accountable to the people who the research can benefit.

Last year's cancelled vaccine trial was in fact, a successful trial. It reached a clear result, and was conducted in an ethical and scientifically rigorous manner. I know of no criticisms of its methodology, and those running the trial did the right thing in cutting it off early when preliminary results showed that the vaccine was clearly not effective. After some hesitation they also "unblinded" the trial and told everyone whether they'd received a placebo or the vaccine. That is because of the way those who did receive the vaccine appeared more susceptible to HIV infection (this actually only applies to those who received the vaccine AND had been previously exposed to the strain of cold virus that researchers used to carry HIV DNA in the vaccine).

I do think there is a very important discussion to be had about research dollars versus basic health care dollars. In places without clean water or an adequate food supply, HIV is much, much more endemic, and kills people faster. Other, treatable health problems like malaria and TB worsen HIV, and adequate treatment is still lacking for these diseases for poor people around the world and here in the US. In my view, the majority of our money and time should go into improving basic health for the majority, as well as into safer sex education, drug treatment programs, harm reduction programs including needle exchange. These efforts would vastly reduce the impact of HIV. Still, with a disease of this magnetite, vaccine and treatment research should certainly continue. I don't think that's in question in the scientific or medical community.
posted by serazin at 9:35 AM on April 24, 2008

magnetite? I mean magnitude.
posted by serazin at 9:52 AM on April 24, 2008

Nobody suggested the slaughter of millions of human beings.
posted by jock@law at 9:54 AM on April 24, 2008

Thanks for being a voice of reason, serazin.
posted by Blazecock Pileon at 9:54 AM on April 24, 2008

Thanks for being a voice of reason, serazin.

That may be the first time someone has used that phrase in reference to me.
posted by serazin at 10:01 AM on April 24, 2008

Unlike polio, or smallpox, HIV is not a disease we require a vaccine to fight effectively.

That, sir, is a steaming pile of crap. What we're doing now is less effective than a vaccine would be by multiple orders of magnitude.
posted by Malor at 10:49 AM on April 24, 2008

Nobody suggested the slaughter of millions of human beings.

Well, I'll admit to being totally confused.

Your first comment in the thread said "the cost of continued vaccination may be high enough to justify just offing the infected," and seemed to suggest that because cost-benefit analyses are a prevalent way by which we make public health decisions, that it was a reasonable if distasteful possibility. ("we make decisions about the cost-in-dollars of human life all the time.") (prevalent adj. - 1 widespread; of wide extent or occurrence; in general use or acceptance.) I didn't want to assume right off the bat that you're a sociopath, and I assumed that you understood that the rhetoric about people with HIV already treads closely enough to the murderous line you were taking that the comparison with traffic accidents was specious. (We did, after all, until very recently in the US, have a presidential candidate who has previously suggested putting people with HIV in concentration camps.) So, I reasonably pointed out that, in fact, there is no prevalence to the kind of ideas you were voicing. You called me a douche for doing that. Which is strange, because it obviates the second part of your statement, the part that tries to assert reasonableness in the face of barbarity by reference to how often we use cost-benefit analyses to make public health decisions.

All of which kind of leaves no choice but to consider you a sociopath, suggesting that killing HIV infected folks will make societal (cost-benefit) sense if we develop a vaccine. But now you say that, no, you weren't making any suggestions. So, you aren't expanding on prevalent thought, in fact, you never thought there was any prevalence to your notion at all. And, you aren't suggesting killing people with HIV if we develop a vaccine.

So what the fuck are you saying? Can you explain why I shouldn't read your statement as a cost-benefit analysis of why it's would be appropriate to commit mass murder. Your several comments in the thread seem to suggest that it's your position that it's ok to make any hateful, murderous, idiotic, unsubstantiated statement you want about a sensitive subject like HIV without having it scrutinized. If that isn't your position, and you in fact didn't realize that you were being such an asshole when you suggested it would be worth it to murder millions of people, then perhaps you should stop accusing other people of being douches and just fucking withdraw your sociopathic statement already.
posted by OmieWise at 11:01 AM on April 24, 2008

Malor, I'm not sure I agree. Presumably we will always have STIs, and we truly need behavior change in order to avoid them. Behavior change is probably impossible without some structural changes though.

Think of it this way: the polio vaccine vastly reduced polio in the world to the point where in most of the world it has been eradicated. But the polio vaccine did not eliminated poor health or childhood disability or death. Focusing primarily on technological solutions to health problems ignores some basics that we know about the health needs of the majority: adequate and healthy food, clean drinking water for all, economic stability so families and communities are not broken up when wage earners leave to find work, basic rights for women so that they can say “no” to sex, access to education for children, access to condoms, these kinds of measures will improve health for the majority in ways that no vaccine can.
posted by serazin at 11:06 AM on April 24, 2008

"... What we're doing now is less effective than a vaccine would be by multiple orders of magnitude."
posted by Malor at 1:49 PM on April 24

That would only be true if an HIV vaccine conferred full, permanent immunity on a single, or limited number of doses. But, many vaccines don't confer permanent immunity, or at best, confer only partial immunity. In the case of other pathogens, like influenza, the wild reservoir mutates fast enough, that the only practical strategy is to try to pick a couple of prevalent strains in each infective season, and produce vaccine that might confer some protection for the weakest members of society.

And even in the case of something as innocuous as we generally think the flu vaccine is, a finite number of people who get the shot each year, have seriously reactions to it, or become sick from it. Moreover, only a small percentage of humanity gets the flu shots annually, as it is just too expensive to distribute to whole parts of the world.

But once there was a HIV vaccine available, even one of limited or partial efficacy, whole new sets of ethical questions come into play. Ultimately, for such partial solutions, in a world where health care resources are hugely constrained, choices have to be made. If, for $1 billion, you could prevent 100 million AIDS cases through education and prophylaxis, or vaccinate 10 million people with a vaccine conferring partial immunity for a 5 year period, what should be done? I think most people would argue for education and prophylaxis.

Moreover, if it costs us another $20 billion over another 20 years, simply to look for such a vaccine, with no guarantee of finding one that works to any extent, is that a wise investment, versus putting the money into care of existing cases, and vastly increased education and prophylaxis? Particularly where we have real world experience, in situations like Uganda, that such programs can actually decrease AIDS in a full population, starting from epidemic levels?
posted by paulsc at 11:21 AM on April 24, 2008 [1 favorite]

Bloody hell OmnieWise, pull your head out of your ass and read the entire fucking post. It's not just "the cost of continued vaccination may be high enough to justify just offing the infected".
posted by Riemann at 11:31 AM on April 24, 2008

Kind of an incidental point, but it is very naive to say that AIDS vaccine research has given us nothing for the last twenty-thirty years. The amount of man-hours spent on researching AIDS has been a boon for antiviral research in general, which was otherwise a historically weak field.

It isn't as if spending $20 billion dollars on AIDS research over the next 20 years is going to come up with nothing, so the basic health care versus clinical research care dichotomy is somewhat misleading.
posted by Weebot at 11:35 AM on April 24, 2008

OmieWise:

I think what jock@law was saying is that at some point, when only a small group of infected people remains infected, (much less than millions of people) the costs of vaccination will outweigh just killing those few people. Basically a cost-benefit analysis on murder, not mass murder.

which is still reprehensible, but its not the "lets round up all the dirty infected in camps and gas them tomorrow" rant that you want it to be. I would advise a closer reading of that which you want to rage against, so you can actually attack the topic in question, instead of a strawman.

On Preview: what Riemann said
posted by grandsham at 11:35 AM on April 24, 2008

"... It isn't as if spending $20 billion dollars on AIDS research over the next 20 years is going to come up with nothing, so the basic health care versus clinical research care dichotomy is somewhat misleading."
posted by Weebot at 2:35 PM on April 24

That may be true, and as a case, I didn't mean to exclude it from discussion by my previous comment. But it is also exactly where the political and resource allocation issues meet science. If there is an estimated 5% chance of finding a highly effective HIV vaccine in the next 20 years, maybe it makes sense to spend $1 billion looking for it, and take the other $19 billion we might devote, fruitlessly, at (near) current spending levels, and go hard and heavy on education and prophylaxis, supposing that $19 billion can be spent with linear improvement in AIDS rates, dollar for dollar. OTOH, maybe that 5% chance only looks possible at a minimum of 95% of the $20 billion funding pie, in which case, it is a much harder research proposition to sell governments and taxpayers.

I suspect that putting $19 billion into worldwide education and prophylaxis is not what is going to happen, because of Larry Kramer, as serazin pointed out. AIDS is now too political to resolve new science that is disappointing, without a strong backlash to spend more to overcome the setbacks. It's certainly human and understandable to try. But, at what point are such trials a sucker bet? And how many lives to we consign to life long anti-viral therapy, even at wholesale rates, for lack of simple educational measures, and condoms, at the right time?
posted by paulsc at 11:53 AM on April 24, 2008

I think what jock@law was saying is that at some point, when only a small group of infected people remains infected, (much less than millions of people) the costs of vaccination will outweigh just killing those few people. Basically a cost-benefit analysis on murder, not mass murder.

I've read it quite closely, and I've just reread it. You've interpolated the "small group of infected people." It isn't present in the original statement, and while I agree that it's a reasonable reading, mine isn't unreasonable. I read his statement as being about the difference between diseases in which there is and is not a "wild reservoir." (In the forner killing all the infected humans makes no difference, in the latter it does.) Since he hasn't clarified, I'm not sure what to think. I'm really not trying to pick a fight here, but when I tried to point out that there was no reasonable support for his view of how public health decisions get made, I was called a douche.

its not the "lets round up all the dirty infected in camps and gas them tomorrow" rant that you want it to be.

I don't want it to be anything of the kind, but spare me the notion that the history of outlandish and hateful rhetoric shouldn't be part of how such a statement is read. That rhetoric is not only part of the history of talking about HIV and people infected with HIV, as I pointed out we recently had a presidential candidate who has espoused some of it. Statements like his aren't separate from the history of statements like his, just because you and he would like them to be.
posted by OmieWise at 12:03 PM on April 24, 2008 [1 favorite]

You cannot, and I mean cannot, vaccinate against AIDS. HIV mutates too fast to be effective for vaccination, and the mutation in it is variable enough that trying to weaken copies of a few strains of the virus in order to produce immunity would be foolish.

The best way to eliminate AIDS is to enforce safe contact with fluids in hospitals, be stringent about HIV testing in blood transfusion, reduce the cost of anti-HIV drugs, make HIV prophylactics widely available, make laws which make the transmission of a deadly disease and non-disclosure of HIV status to a sexual partner without a barrier method a felony and FOR THE LOVE OF REASON GET PEOPLE TO USE CONDOMS. I don't give a fuck what you believe about contraception, condoms work, and you're not going to make people stop fucking.

There are some monsters we cannot tame.
posted by kldickson at 1:20 PM on April 24, 2008

make laws which make the transmission of a deadly disease and non-disclosure of HIV status to a sexual partner without a barrier method a felony

Seconded. With bells on. "Well s/he didn't ask" should not ever be a defence in that situation. While it is true that people must have agency for their own sexual health, disclosure of status should be absolutely required.

There is, of course, a difficulty[1]. Many people would turn down sex with an HIV+ partner. That isn't unreasonable; barrier methods do work, but not always, and we all have the right to minimize risk to ourselves in whatever (legal) ways we see fit. The problem, of course, is that many people with HIV don't take well to that, and feeling that they are more educated (often true) about safer sex practices they feel that it is discriminatory for HIV- people to say no[2]. Thus, they don't disclose. That needs to be addressed, somehow. I don't know how--the dual goals of 'it's okay to say no' (aimed at the HIV- population)and 'yes, s/he has the right to not have what s/he perceives, rightly or wrongly, to be risky sex and it's not a judgement of you personally' (aimed at the HIV+ population) would seem to be enormous obstacles. Hell, the idea that it's okay to say no is hard enough to get into some peoples' heads.

and FOR THE LOVE OF REASON GET PEOPLE TO USE CONDOMS.

Yes. Another difficulty.. there is a massive movement within the gay community against condoms. It has been warped from a 'safe sex is good' message to a rebellious, anti-authority, hedonistic message that sex without condoms is better and more fun. This is largely attributed to the fact that most gay men under thirty may have grown up with the 'safe sex is necessary' messaging, but weren't (for the most part) witnesses to the wave of deaths within the community. (Yes, I know that doesn't account for the large number of older gay men who insist on bareback sex). I don't know how to get around that--far better minds than mine have been applying themselves to that problem for some time, and don't seem to be getting anywhere. The advent of later-generation HIV/AIDS medications has rendered AIDS into having the perception of being a manageable illness, much like diabetes. On the surface this may be true, but in reality of course it is not.

I have more to noodle on here, but must run.

[1] I'm speaking from what I have seen and experienced in the gay community. Experience in other populations may differ.

[2] Of course, they fail to realize that all sexual partner selection is discriminatory in some way.
posted by dirtynumbangelboy at 2:21 PM on April 24, 2008

make laws which make the transmission of a deadly disease and non-disclosure of HIV status to a sexual partner without a barrier method a felony

Sometimes I hate metafilter.
posted by serazin at 2:28 PM on April 24, 2008 [1 favorite]

I don't follow, serazin. Knowingly putting someone at risk for, or actually infecting them with, a lethal disease shouldn't be punishable by law?
posted by dirtynumbangelboy at 7:49 PM on April 24, 2008

Why stop there? Why not jail people with HPV that can cause cervical cancer? Fine people with herpes? Send kids with chicken pox to juvie? Sneezing on someone can be a misdemeanor.
posted by gimonca at 8:45 PM on April 24, 2008

The best way to eliminate AIDS is to enforce safe contact with fluids in hospitals,
Occupational exposure to HIV is quite rare: as of June 2000, CDC had received voluntary reports of 56 U.S. HCP with documented HIV seroconversion temporally associated with an occupational HIV exposure. Needlesticks are a surprisingly ineffective means to transmit the virus. This isn't much of an issue.

be stringent about HIV testing in blood transfusion,
This is also a non-issue in most of the world with the known exception of China and to a much lesser degree Eastern Europe and sub-Saharan Africa. I believe WHO is still estimating that 5-10% of transmissions worldwide may be due to blood transfusions but the numbers are very difficult to determine here. The US and Canadian blood supply are most certainly safe.

reduce the cost of anti-HIV drugs,
This is absolutely one of the most important measures we can take with the available technology. There is strong evidence that those who have consistant access to antiretroviral therapy and are able to lower their viral load consistently are no longer sexually infectious. The same appears to be true for mother to child transmission.

make HIV prophylactics widely available,
What is an HIV prophylactic? The tenofovir studies aren't complete yet, but even if it proves effective, it isn't a working solution for the majority of people.

make laws which make the transmission of a deadly disease and non-disclosure of HIV status to a sexual partner without a barrier method a felony
This is the portion of your comment that makes me want to scream.
a) First of all, most people in the world who have HIV do not live here in the US.
b) Rates of HIV among prisoners (here in the US and elsewhere) are higher than the general population. HIV spreads quickly within prison because prisons offer an ideal environment for transmission (no condoms, chronic rape, lots of anal sex, general poor health including high rates of TB which make people more susceptible to HIV infection). Then infected prisoners eventually leave prison, spreading the virus to the larger community.
c) This country has a well documented problem of imprisoning black and brown people at a much greater rate than white people. Imprisonment for HIV would be unlikely to buck this trend.
c) Most people who have HIV do not know they have HIV.
d) If you tell someone they can be imprisoned for knowing their HIV status (and failing to share it with partners) do you think they'll want to know their HIV status?

HIV is a health problem, and it is all of our problem. It is not a weapon and blame for HIV cannot be placed on any one person or on any set of individuals. Sickness and infection are part of the human experience and we all bare a shared responsibility to care for each other and to work to reduce infection. Criminalizing HIV is unlikely to improve overall health for the community or even to reduce HIV rates. Can you point to one single example in the history of public health where criminalizing people has reduced the incidence of infection? Yet I can think of examples where criminalization led to stigmitazation and increased suffering for sick people.

(This is an interesting article on the current laws that already criminalize HIV here in the states. Interestingly, they don't seem to lower HIV rates!)

and FOR THE LOVE OF REASON GET PEOPLE TO USE CONDOMS.

Sure, we're on the same page here. Condoms are the only known method to prevent HIV transmission during penetrative sex. They should be delivered in gross quantities to every doorstep on the planet. It would certainly be a better use of our tax dollars than this fucking war in Iraq.

PS to dirtynumbangelboy: lots of gay sex happens without condoms, but consider that before HIV virtually no men used condoms when having sex with each other. This is a fairly successful public health project in that light - although clearly we have a long ways to go. It's also worth noting that in this country most men who have sex with men get tested for HIV. Regularly. They use knowledge of their serostatus to negotiate sex which is pretty sophisticated and a valid method really)
posted by serazin at 9:15 PM on April 24, 2008

Why not jail people with HPV that can cause cervical cancer?

HIV is fatal. Cervical cancer may or may not be. One may or may not develop cervical cancer from HPV. Plus, unless I am mistaken, there isn't a test to determine whether a man is infected with (asymptomatic) HPV, much less identify the strain.

Fine people with herpes? Send kids with chicken pox to juvie? Sneezing on someone can be a misdemeanor.

Not fatal, not fatal, not fatal. One could actually argue (and many have) that having chicken pox as a child is far preferable to shingles later.


It's also worth noting that in this country most men who have sex with men get tested for HIV. Regularly. They use knowledge of their serostatus to negotiate sex which is pretty sophisticated and a valid method really

Not really, no. It's a valid method when you actually know your HIV status. You can only know what your status was 6-12 weeks before your last test (unless, of course, you're positive). In the real world, what your statement means is that most gay men go 1-2 times a year to be tested, and then say "Oh yeah, I'm negative, and I only sleep with negative people." Which is what everyone who is barebacking is saying. Which is why HIV transmission rates among MSM in Toronto have taken a violent (according to a study I was part of until recently) upswing in the past few years. It's that whole "sleeping with everyone your partner has slept with" thing that has somehow fallen out of favour.

This is not a Toronto-centric phenomenon. It is happening all over the world, and nobody who is engaging in this behaviour has any interest in any dialogue about the issue. It's gay hedonism writ large, and they don't give a good goddamn about anybody or anything but their own transitory pleasure.

PS to dirtynumbangelboy: lots of gay sex happens without condoms, but consider that before HIV virtually no men used condoms when having sex with each other.

Yep. And pre-HIV the worst thing you'd get would be syphilis, which is treated with a course of meds. Or warts, I guess. Now, you have a life-long chronic illness that will kill you.

If you tell someone they can be imprisoned for knowing their HIV status (and failing to share it with partners) do you think they'll want to know their HIV status?

Your parentheses there are disingenuous. The statement should be "they can be imprisoned for failing to disclose their HIV status."

HIV testing should be a public health concern. I remember back in grade 8 or something we were all tested for TB. The rationale behind mass TB testing is clear: it is a public health issue with wide-ranging and deadly consequences. I fail to see how HIV is any different.
posted by dirtynumbangelboy at 6:35 AM on April 25, 2008

A thought: I had hoped, way back when, that Magic Johnson's public disclosure of his HIV status would go some way towards helping end the stigma associated with HIV.

Another: They locked up Typhoid Mary when she wouldn't stop infecting people. Does anyone now, really, think that was a bad idea?
posted by dirtynumbangelboy at 6:51 AM on April 25, 2008

dirtynumbanelboy -

You're responding pretty selectively to my points. Imprisonment is not an effective way to control a disease (nor do I personally think it is moral - clearly we differ on that point). Just as the death penalty is a symbolic (yet in my view immoral) measure against murder, imprisoning carriers of disease will not reduce transmission rates. For one thing because in the heterosexual population where most HIV spreads - few people even know their HIV status. Criminalizing HIV further stigmatizes the disease. For everyone. Even the "responsible" people who use condoms every time they have sex.

I'd love to see the results of the Toronto study. Most of the recent studies of msm that I know of show that most gay men use condoms sometimes (most often with "casual" partners), get tested regularly, and also understand the impact of viral load on transmission rates. Pretty sophisticated but I agree with you that we're not where we need to be yet. But let me ask you, do you really think criminalization will change that? I bet none of your friends smoke pot, right? No meth users in your crowd? Criminalization stigmatizes - it doesn't solve the problem.
posted by serazin at 7:31 AM on April 25, 2008

Also, my parentheses there aren't disingenuous. I understand that you want to imprison people for failing to disclose their HIV status. For me though the important part of the equation is the possibility of offering a disincentive for knowing your HIV status.
posted by serazin at 9:00 AM on April 25, 2008

Imprisonment is not an effective way to control a disease

It didn't stop Typhoid Mary?

imprisoning carriers of disease

That's what I meant about being disingenuous. It's not imprisoning carriers of disease, it's imprisoning people who are knowingly infecting others. The necessary precursor being large-scale HIV testing. I really don't understand why HIV gets such a free pass--it is one of the dominant public health issues of our time, but certainly in North America there's no treatment of the issues as a public health issue. I categorically don't agree with those who say that everyone who is HIV+ should be quarantined, but I understand where they're coming from.

I think one of the best analogies is that HIV is much like smoking. For pretty much everyone in North America (I recognize that the African epidemic has different issues at play, and thus requires different approaches), contracting HIV is a matter of choice in their sexual behaviour. Yes, some people are forced into that choice--they are raped, or born to HIV+ mothers, or their partners are screwing around. But most gay men are simply choosing to screw without condoms. Just as there is a social stigma against smoking (which may or may not work), there should be--need to be--a social stigma against fucking around without a condom. Part of the issue in the straight world, I think, is that the dominant concern is that unwanted babies not be produced. The Pill largely takes care of that, and (relatively) few women have the agency to force their partners to wear a condom. I'd hoped that the advent of the female condom would change some of that.

However, HIV is unlike smoking in that it can affect so many more people. Anti-smoking laws (please, I beg you, let's not get into a debate on the ethics or whatnot of them) have gone an enormous distance towards keeping people away from second-hand smoke. How do you keep people away from second-hand HIV? Education, sure, but that is manifestly failing. The confluence of abstinence-only 'education', homophobia (especially in the African-American community, where as you know rates of infection amongst women are worryingly high), prison rape (and refusal to publicly accept that it happens and take steps to make it end or at least provide condoms), and in the gay community the total absence of anything resembling personal or communal responsibility all conspire to create the problem we have now.

And yes, obviously, more education is needed in a lot more sectors. But what would be effective is enormous cultural shifts in so many different populations that the problem is largely insurmountable.

So. Containment of some sort is necessary. Yes, okay, someone's going to get all hand-wavy and compare me to Hitler. I'll save you the time by saying that containment of the camp sort is abhorrent. What I don't understand is why knowing you are HIV+ and not disclosing to your partner(s) before unprotected sex shouldn't be illegal. Knowing that you are drunk and getting behind the wheel is illegal, and it's roughly the same; the other people on the road have consented to safe driving, they haven't consented to someone being out of control on the road.

I am not saying that we should live in a risk-free society. But the reality is we take measures to mitigate and minimize risk where possible. Consent to sexual activity is predicated on the concept of informed consent--you know what you're doing and what can happen. When your partner is not telling you that they have a fatal disease, your consent is compromised.

Allow me to put it in a different way, continuing my driving analogy: when you get in a car with someone, there is a reasonable assumption that your driver is both capable and sober, and you will be relatively safe. When you get in a car with someone you know to be drunk or otherwise incapacitated, you are choosing to assume a certain level of risk. However, when you are seated in a car with someone and don't know that they are incapacitated, your ability to properly evaluate your risk is severely compromised.

Or, okay, let's take it away from emotionally-charged subjects. When you get on a rollercoaster, you have a reasonable expectation of safety. How compromised is that when the operator has paid off the inspector? Would the operator not be at criminal fault for knowingly putting your life at risk, injuring or killing you?

Likewise, if you are HIV+ and have barrier-free sex with someone who is HIV- without disclosing your condition (or worse, lying, which is why one of my friends is now HIV+), you are putting their life at risk without giving them the option to say no. Under our legal system, harming people has consequences. Why should HIV be any different?
posted by dirtynumbangelboy at 9:51 AM on April 25, 2008

Typhoid Mary was not the cause of Typhoid. She didn’t cause a significant number of Typhoid cases in this country and certainly not in the world. And imprisoning Typhoid Mary did not control the typhoid epidemic. Public sanitation, antibiotics, and an effective vaccine did.

Imprisonment is not an effective public health measure. No respected professional in the public health field is advocating criminalization for HIV or for any other contagious disease. It doesn’t stop the spread of disease and it could make it worse by increasing stigmatization. When HIV is stigmatized people do not seek testing or treatment. A feeling of inevitability takes over and people die without support. This has been studied extensively in sub-Saharan Africa. And prison? Put people with HIV in prison and you increase the rate of HIV in prisons. Then it spreads to the general population as people are released. Is your goal to punish a few people here, or to actually stop the spread of HIV. If you’re interested in stopping HIV then look at what measures have controlled other contagious diseases throughout history.

Containment of some sort is necessary. Can you be specific about what you mean here? Are you talking about creating prisons that are explicitly for people who are HIV positive and knowingly had barrier-free sex? Are you specifically talking about gay men as candidates for imprisonment or would you also imprison needle sharing drug addicts? DO you seriously believe that the presence of such prisons would have a positive impact in the gay community or for people who are living with HIV or on transmission rates in our communities? Has prison helped decrease drug addiction? Do you have any reason to believe that black and brown people and poor people wouldn’t be imprisoned at levels disproportionate to population levels in the larger society under your proposed plan? Do you really think this is a useful or fair solution?

in the gay community the total absence of anything resembling personal or communal responsibility all conspire to create the problem we have now.
Quite a generalization. Studies show that most gay men get tested regularly and have safe sex at least some of the time. Again, I agree that we still need more condom use. We need more access and more education. We need gay men to feel valued by society and by themselves. And we need to be realistic about what measures most people are going to take and always new and creative solutions.
Using condoms is everyone’s responsibility. Couldn’t you just as easily make an argument that the person who ends up receiving an HIV infection in a sexual encounter bears responsibility for failing to wear condoms? Remember also that even in North American, HIV is now primarily a heterosexual disease.
posted by serazin at 11:41 AM on April 25, 2008

serazin, until you actually address my questions, I don't see much point in continuing to talk past each other. To wit: if I harm you without your consent, why should I not be punished for it? Where do we draw the line? If someone isn't punished for knowingly infecting someone with HIV, why should we punish drunk drivers?
posted by dirtynumbangelboy at 11:44 AM on April 25, 2008

I'm interested in controlling HIV. Punishment is not an effective means to control an infection.

Besides, punishment is applied unevenly, and in that sense it is unjust. And in my view prison doesn't work: it doesnt' prevent criminal behavior. What is the point? What is the value? Especially if your goal (and I hope this is your goal) is to have less HIV infection.

I want a fair, just world where no one has to get sick from HIV. I don't think imprisoning people for transmitting the disease will do anything to bring us closer to that world. WIll it bring back the dead? It only offers a symbolic satisfaction - the satisfaction of revenge.
posted by serazin at 12:15 PM on April 25, 2008

I want a fair, just world where no one has to get sick from HIV be killed by a drunk driver. I don't think imprisoning people for transmitting the disease killing people while driving drunk will do anything to bring us closer to that world. WIll it bring back the dead? It only offers a symbolic satisfaction - the satisfaction of revenge.

Do you see my point yet? Why does fucking without protection when HIV+ get a free pass, and drunk driving does not?
posted by dirtynumbangelboy at 12:36 PM on April 25, 2008

Repeat yourself as much as you want. I don't agree with you. I'm in the middle of revising this book and I'm also trying to get into nursing school right now - just finished my prerequisites including microbiology and anatomy and physiology classes. Based on a lot of reading on the topic, this is what I understand about HIV and public health: Prison. Will. Not. Reduce. HIV. Rates. That's pretty much what I care about here. So fucking what if we arrest people for driving drunk? I’m interested in stopping AIDS. I want to take measures that will actually, you know, stop AIDS. Not just give people who do not have HIV a sense of satisfaction.

I happen to believe that prison doesn't solve ANY social problems and I think there's good evidence for that. You don't seem interested in the way prison unfairly impacts certain people, or the arbitrariness of sentencing, but I think that's pretty significant especially if you’re suggesting imprisoning people for a disease that already disproportionately impacts certain groups. I don't have any expertise about drunk driving and I have no idea how prison impacts drunk driving rates. But if sending people to jail for drunk driving doesn’t stop the problem then I don’t think we should do that either. I’m willing to bet there are other measures which could have better impact on drunk driving rates, starting with public health measures like readably accessible alcoholism treatment programs.
posted by serazin at 12:46 PM on April 25, 2008

You don't seem interested in the way prison unfairly impacts certain people

I do, but that's not particularly relevant to my point.

But if sending people to jail for drunk driving doesn’t stop the problem

There you go again. You're omitting the important point. It's not "Oh, you blew 1.6 on a Breathalyzer, off to jail with ye!"

It's "You just killed/injured someone by driving drunk. Off to jail with ye."

Do you honestly not see the difference? Why do people who deliberately infect others with HIV--a fatal disease, let's not forget--get a free pass?
posted by dirtynumbangelboy at 1:37 PM on April 25, 2008

Repeat yourself as much as you want. I don't agree with you.

No, you don't listen to me. There's a difference. Disagree as much as you like, but stop with the straw men. You've done it twice now; first was 'imprison people with HIV' (which I didn't say), second was 'sending people to jail for driving drunk' (which I also didn't say).
posted by dirtynumbangelboy at 1:38 PM on April 25, 2008

I'm not convinced that sending people to jail for killing someone while drunk driving is an effective means to prevent drunk driving deaths. And I'm positive that sending people to jail for knowingly having unprotected sex while HIV positive is NOT an effective means to stop HIV transmission. I believe in solutions that work. If its not working, it shouldn't be national policy. Supposed straw-man removed enough for you? (I don't think it was a straw man in the first place because the effect of laws that you describe is also to give the general population the sense that spreading HIV - knowingly or not - is criminal which I believe is a dangerous perception. And judges and juries make decisions in arbitrary ways. There's not always a clear answer about whether someone "knowingly" transmitted a virus.)

Let me ask you something. If I have TB, and I know it, should I stay home in my house, not work, not grocery shop etc? If I go out into the world (say for example because I need to support my family) and accidentally (but theoretically with knowledge of the risk) give TB to someone else, should I be put in prison? I don't get how your proposed HIV laws differ from this. TB can certainly kill you! And you could make a strong argument that HIV no longer kills most people who have treatment. How do you decide which disease is a deadly weapon and which is a social problem that should be solved with public health measures?
posted by serazin at 2:03 PM on April 25, 2008

dirtynumbangelboy: A problem (among many of them) here is that you would be disincentivizing people from getting tested in the first place. Knowing your serostatus becomes much less appealing when there is legal liability involved. Wasn't the advent of anonymous HIV testing a response to the possible repercussions testing positive would entail? It seems counterproductive from the standpoint of public health.
posted by Weebot at 9:56 PM on April 25, 2008

Which is why, as I said above, massive-scale public testing would be necessary before such a law could be reasonably implemented. Yes, it's authoritarian, yes I have qualms about that. But here's thing: once everyone's status is out on the table, nobody has any goddamn excuse anymore for fucking other people and getting them infected.

Knowing your serostatus becomes much less appealing when there is legal liability involved.

The only liability would be--do I really need to say this again?--if you fuck someone without barrier protection and don't disclose your status first.
posted by dirtynumbangelboy at 11:42 PM on April 25, 2008

dirtynumbangelboy: Even after a large-scale public screening, the problem I stated would still be there. How would a list of people HIV+ be relevant even a year or two afterwards? To make the idea even theoretically workable, the entire public would have to be forcibly tested into perpetuity, or you would have a lot of new infections that would just go undocumented (until the newly infected person volunteers for testing—and here you run back into the disincentivizing problem again). And we haven't even gotten into the logistical nightmare that testing the American public would be, let alone trying to screen African nations. It's just not workable.

I haven't even touched on the ethics of all this, but I will say that if we're going to be authoritarian about public health, AIDS would hardly be the first choice disease to target. Mandatory flu shots would probably have a larger and more immediate effect on mortality rates and public well-being.
posted by Weebot at 2:31 AM on April 26, 2008

Given the incredibly low number of people who die every year from the flu--as opposed to having a few awful days in bed--I'd think not. Visit an AIDS ward sometime and tell me it's comparable to the flu.
posted by dirtynumbangelboy at 2:40 AM on April 26, 2008

36,000 people die in the United States from the flu every year. About 15,000 people with HIV/AIDS die each year in the United States.
posted by Weebot at 2:56 AM on April 26, 2008 [2 favorites]