HIV, Depression, and Suicide

By: Ranier Simons, ADAP Blog Guest Contributor

In the early years of the HIV epidemic, a diagnosis was effectively a death sentence. There were no robust treatment regimens, and life expectancy was low. People suffered a great deal being overcome by opportunistic infections and lived in a great deal of isolation, whether in a hospital setting or at home. This resulted in a high prevalence of depression. Over the past few decades, medical advances in HIV treatment have transformed an HIV diagnosis into a manageable chronic health issue with people living long, healthy lives on antiretroviral therapy. But has mental health advances kept pace?

Photo Source: HIV.gov

Despite the advances, a high rate of depression and suicide remains among people living with HIV (PLWHA). Depression in PLWHA results in worsened disease states and poorer health outcomes. Data shows that depression can hasten the progression of AIDS, resulting in higher viral loads and lower CD4 counts.[1] Many PLWHA also have mental comorbidities that exacerbate their risk of suicide.[2] A recent study being presented at this year’s European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) in Copenhagen, Denmark (15–18 April), further examines depression and suicide in PLWHA.

The observational study utilized data from Denmark’s national health registers from 1995 -2021. The study compared 5,943 PLWHA with 59,430 sex and date-of-birth-matched controls from the general population. Researchers also investigated 5,807 siblings of PLWHA and 82,411 siblings of controls.[3,4] Overall, PLWHA had twice the risk of depression and treatment with electroconvulsive therapy, 1.5 times the risk of using antidepressants, and 3.5 times the risk for suicide.[3,4] These numbers were higher for the first two years after diagnosis. During this period, PLWHA had a threefold higher risk of depression and antidepressant use and a tenfold risk of suicide.[3,4] The study data also showed an increased risk of depression and suicide for the siblings of PLWHA compared to the general population, but it was not as high as the risk for PLWHA.

Photo Source: AIDSmap

This study was specific to Denmark. Other studies in the past, encompassing a global perspective, indicate that globally PLWHA have a 100 times higher risk of suicide than the general population.[5] Researchers agree that many more studies need to be conducted. The main weakness in the data from present and past studies is the variance. These observational studies try to normalize the data by comparing subjects to general population controls. However, past studies contain many differences in subject selection criteria. There are differences in cultural norms of the subjects, variance in types and availability of antiretroviral therapies or lack of them, and even societal factors that vary between continents.

What does not vary is the urgency of the need to address the mental health of PLWHA. Medical science has a focused, concerted effort to develop medications to treat and prevent. The same energy is needed to address psychological needs. Mental health screening of PLWHA must go hand in hand with treatment. PLWHA often have poor social support, face stigma, and don’t have access to trained mental health professionals.[2] Additional research also needs to thoroughly investigate issues such as long-term antiretroviral treatment's biological and cognitive effects or identifying pre-HIV infection mental comorbidities that may cause a higher incidence of depression and suicide once infected. 

Going forward, the mental health assessment and support of PLWHA must be on a continuum. It should start with psychological counseling and support when someone is about to be tested all the way through positive diagnosis, treatment, and long-term survival. Standardizing evidence-based mental health protocols for PLWHA will prevent suicides and improve the lives of PLWHA and their families and friends.

[1] Tran, B. X., Ho, R. C. M., Ho, C. S. H., Latkin, C. A., Phan, H. T., Ha, G. H., Vu, G. T., Ying, J., & Zhang, M. W. B. (2019). Depression among Patients with HIV/AIDS: Research Development and Effective Interventions (GAPRESEARCH). International journal of environmental research and public health, 16(10), 1772. https://doi.org/10.3390/ijerph16101772

[2] Liu, Y., Songtaweesin, W., Tucker, J., Sohn, A., Latkin, C., Hall, B. (2022). Suicide prevention research is crucial to achieving health equity for people with HIV. The Lancet HIV, 9(11),E745-E746, https://doi.org/10.1016/S2352-3018(22)00296-X

[3] American Association for the Advancement of Science. (2023, April 3). People living with HIV at substantially higher risk of depression and suicide, especially in first 2 years after diagnosis. Retrieved from https://www.eurekalert.org/news-releases/984677#.ZC75j2xKVyk.twitter

4) Medical Express. (2023, April 3). People living with HIV at substantially higher risk of depression and suicide. Retrieved from https://medicalxpress.com/news/2023-04-people-hiv-substantially-higher-depression.html

5) Pelton, M., Ciarletta, M., Wisnousky, H., et al. Rates and risk factors for suicidal ideation, suicide attempts and suicide deaths in persons with HIV: a systematic review and meta-analysis. General Psychiatry 2021;34:e100247. doi: 10.1136/gpsych-2020-100247

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.  

Culture War Against ACA Scores Win

By: Ranier Simons, ADAP Blog Guest Contributor

March 23, 2023, was the 13th anniversary of the signing of the Affordable Care Act (ACA). The landmark legislation forever changed the landscape for healthcare insurance and healthcare access in the United States. About 35 million people presently have ACA-related healthcare coverage, with 21 million of those enrolled in Medicaid expansion coverage.[1] The law enabled many to obtain robust healthcare coverage who were previously uninsured or underinsured. Most importantly, while not perfect, the ACA is an effective tool to support equity in healthcare coverage and treatment. Through the ACA, participants receive comprehensive and affordable care regardless of their income or lack of.

Unfortunately, from its inception to the present day, there have been political battles over the ACA that are ideological instead of evidence-based. Politicians, judges, and media personalities continually attempt to dismantle the ACA without having the plan to replace it. Opponents of the law have found an ally in Judge Reed O’Connor, a federal judge in Texas. In 2018, Judge O’Connor ruled that the entire ACA was unconstitutional. The Supreme Court eventually defeated the ruling. Judge O’Connor has previously made rulings against the ACA’s non-discrimination provisions, contraceptive coverage requirement, and regulation of insurance provider fees in states.[2]

Photo Source: Law.com

Judge O’Connor’s latest challenge to the ACA is in Braidwood Management Inc. v. Becerra. In this case, six individuals and Christian-owned businesses claim that private health insurance coverage requirements are unconstitutional. Additionally, they argue that being required to provide coverage for PrEP under their insurance plans violates their religious beliefs and thus violates the Religious Freedom Restoration Act (RFRA).[3]

The ACA requires insurers to cover certain preventative care services without any cost-sharing by the insured. Those services will be provided for free when obtained through a provider in an insurance plan’s network. The ACA uses guidance from the United States Preventative Task Force (USPSTF) to determine the aforementioned services. The USPSTF was created in 1984 by the U.S. Public Health Service Act to improve public health through evidence-based recommendations to prevent disease and increase life expectancy.[4] Sixteen national experts on preventative medicine and primary care comprise the USPSTF. They make their recommendations based on scientific evidence with no conflicts of interest or political influence.

Photo Source: Axios

In September 2022, Judge O’Connor ruled that the USPSTF violates the Appointments Clause because the members are not appointed by the President and subsequently confirmed by the Senate; nor are their recommendations reviewed by Constitutionally specified officials. Thus, he decided that the Braidwood Management plaintiffs should not be required to pay for conventional medical insurance plans that mandate coverage of preventative services recommended by the USPSTF because the entity and its recommendations are unconstitutional. Judge O’Connor further ruled that the PrEP coverage mandate violated Braidwood’s religious freedom rights under the RFRA. Braidwood argued that paying for coverage that included provisions for PrEP made them implicit in supporting homosexuality, drug use, and sex between a man and a woman outside of marriage. At the time of the initial ruling, legal remedies had not been specified, and both sides were instructed to present briefs relating to the scope of relief. Moreover, the initial focus was explicitly on Braidwood being required to pay for plans that provided PrEP without cost sharing and the non-religious plantiffs not being required to pay for preventative services such as contraception and std testing.

March 30, 2022, Judge O’Connor ruled on the case's legal remedy. He invalidated the ACA's HIV treatment mandate of providing PrEP, stating it violated Christian employers' rights under the RFRA. Thus, the government could not take any legal action requiring the Braidwood parties and religious objectors to pay for PrEP. He went a step further, stating that any recommendations for preventative services made by the USPSTF on or after March 30, 2010, are unlawful. Effectively, this is a national block meaning insurance plans no longer must cover many preventative services for free. These services include biennial mammography screening for women aged 50-74, cervical cancer screening in women aged 21-65, colorectal cancer screening in adults aged 45-49, and PrEP. The complete list of these services is here. 

Without coverage for PrEP, it is estimated that over 2000 preventable HIV infections will occur within a year.[7] For every 10% decrease in PrEP coverage, there would be an additional 1,140 HIV infections among MSM the following year. Generic PrEP costs $30 per month, and brand-name products that don’t have generic versions can cost over $20K annually. Additionally, there are lab work and provider visits associated with the administration of PrEP. Those expenses are around two thousand dollars a year. Blocking the HIV treatment mandate would result in cost-sharing or complete denial of coverage resulting in out-of-pocket costs that those needing help cannot afford.

Photo Source: NPR

Blocking the coverage mandate for other preventative services would also have dire consequences. Lack of certain screenings means that many conditions, including cancers, will go undiscovered until late stages. This would result in many preventable diseases, decreased healthcare outcomes, including death, and increased medical costs. Such a future is in opposition to the Institute for Healthcare Improvement’s “Triple Aim”: improving the individual experience of care, improving the health of populations, and reducing the per capita costs of care for populations.[8]

Judge O’Connor’s ruling is not the final law. There will be appeals, and it could reach the Supreme Court. Presently in 2023, no plans are affected since the current coverages are in place via the contracts policyholders have with their insurance companies. Additionally, it is possible a hold will be placed on the order as it makes its way through the courts. The American College of Obstetricians and Gynecologists, in a statement, said: "Allowing personal or political bias to interfere with the practice of medicine will cause harm to our patients."[6] Unfortunately, recent policy decisions in Tennessee, New York, and now Texas seem to be setting up the harm the American College of Obstetricians and Gynecologists warns against.

[1] U.S. Department of Health and Human Services. (2022, April 29). New Reports Show Record 35 Million People Enrolled in Coverage Related to the Affordable Care Act, with Historic 21 Million People Enrolled in Medicaid Expansion Coverage. Retrieved from https://www.hhs.gov/about/news/2022/04/29/new-reports-show-record-35-million-people-enrolled-in-coverage-related-to-the-affordable-care-act.html

[2] Sneed,T. (2022, January 28). Judge notorious for anti-Obamacare rulings has another crack. Retrieved from https://www.cnn.com/2022/01/28/politics/obamacare-reed-oconnor-biden-doj-health/index.html

[3] Sobel, L., Ranji, U., Pestaina, K., Dawson, L., Cubanski, J. (2022, October 26). Explaining Litigation Challenging the ACA’s Preventive Services Requirements: Braidwood Management Inc. v. Becerra. Retrieved from https://www.kff.org/womens-health-policy/issue-brief/explaining-litigation-challenging-the-acas-preventive-services-requirements-braidwood-management-inc-v-becerra/

4) USPSTF. (2021). USPSTF: An Overview. Retrieved from https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/task-force-resources/uspstf-overview#:~:text=The%20U.S.%20Preventive%20Services%20Task,prevent%20disease%20and%20prolong%20life.

5) Braidwood v. Becerra, 2022,  https://storage.courtlistener.com/recap/gov.uscourts.txnd.330381/gov.uscourts.txnd.330381.92.0_2.pdf

6) Pierson, B. (2023, March 30). U.S. judge blocks Obamacare coverage mandate for some cancer screenings, PrEP. Retrieved from https://www.reuters.com/business/healthcare-pharmaceuticals/texas-judge-blocks-obamacare-coverage-mandate-prep-cancer-screening-2023-03-30/

7) Klein, H. (2023, March 29). PrEP court ruling could lead to thousands of preventable HIV cases. Retrieved from https://www.ajmc.com/view/prep-court-ruling-could-lead-to-thousands-of-preventable-hiv-cases

8) IHI.(2023) The IHI Triple Aim. Retrieved fromhttps://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx   

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.  

Switching from Efavirenz to Dolutegravir Presents Health Challenges for Black Patients

By: Ranier Simons, ADAP Blog Guest Contributor

It is indisputable that the advent of antiretroviral treatment (ART) has saved many lives and improved the health outcomes of people with HIV. Treatment has advanced over the past few decades from toxic regimens like AZT to more tolerable cocktail regimens like Biktarvy (bictegravir/emtricitabine/tenofovir alafenamide). Side effects vary between drugs and even between people who take the same drug. As such, people who stay on ART for extended periods sometimes switch medication regimens due to undesirable side effects that develop from long-term use or acute responses to cocktail components. Infectious disease doctors weigh the pros and cons of medications for patients in an effort to enable the highest benefit with the least harm. This is why medical science constantly studies and evaluates drugs to reach a consensus of therapeutic value versus harm.

Photo Source: Cleveland.com

A recent study addresses the concern of weight gain for some patients of black African ancestry due to ART. The March 2023 issue of eClinical Medicine contains a study examining the effect of switching from efavirenz to dolutegravir in adults living with HIV in Johannesburg, South Africa. The study published in March was a prospective cohort study of adults (16 years or older) of black African ancestry who started ART between January 2010 and December 2020.[1] The study subjects were ART naïve patients who started fixed-dose regimens of tenofovir disoproxil fumarate (tenofovir), efavirenz, and lamivudine or emtricitabine which were established first-line regimens during the study period. The World Health Organization recommended dolutegravir, an integrase strand transfer inhibitor (INSTI), as an alternative to efavirenz in first-line ART in 2016, updating it as the preferred drug in 2018.[2] The change came because dolutegravir was proven more effective at long-term viral suppression, had less resistance, and increased tolerance over efavirenz.[1]

Dolutegravir became available to the clinic of the patients in the study cohort in 2019. There were 794 patients who were switched to dolutegravir and 794 who remained on efavirenz. All of the patients continued with the fixed doses of tenofovir disoproxil fumarate with lamivudine or emtricitabine and were observed for 12 months. The only change was swapping dolutegravir for efavirenz in one group compared to no swap in the other group. Results showed that those switching to dolutegravir had a mean weight change of 2.8kg (SD: 6.7kg), contrasting with 1.5kg (SD: 5.2kg) of those remaining on efavirenz.

Photo Source: AIDS Map

Weight gain is of concern because it could lead to other health issues, such as an increased risk for hypertension and diabetes. Typically some HIV patients experience wasting in some stages of disease progression, and ART results in weight gain as the body’s immune system strengthens.[1] This is desirable, especially since treatment initiation of patients in low and middle-income countries is frequently delayed until advanced disease states. However, weight gain is not good in HIV patients who are already overweight or may become overweight due to the dolutegravir.[1]

The prospective cohort study was done in response to two large clinical trials done in sub-Saharan Africa in 2020. The New Antiretroviral and Monitoring Strategies in HIV-infected Adults in Low-income countries (NAMSAL) trial and The ADVANCE trial displayed notable weight gain in people treated with dolutegravir compared to efavirenz.[3] The prevalence of obesity and ART utilization are both increasing in sub-Saharan Africa.[1] 

It is crucial to continue clinical trials to verify if weight gain is caused by dolutegravir in efavirenz’s absence or if efavirenz somehow holds back weight gain in the absence of dolutegravir. It is also essential to determine if dolutegravir-related weight gain is sustained over time and if it increases other disease risks. Dolutegravir is cost-effective, has high efficacy, and is tolerated better, thus reducing the need to switch patients to more expensive second-line regimens. Since it is presently here to stay, examining how to mitigate its potential for adverse risk increases of other conditions is imperative.

[1] Brennan, A., Nattey, C., Kileel, E., Rosen, S., Maskew, M., Stokes, A., Fox, M., Venter, W. (2023). Change in body weight and risk of hypertension after switching from efavirenz to dolutegravir in adults living with HIV: evidence from routine care in Johannesburg, South Africa. eClinicalMedicine, Vol 57. https://doi.org/10.1016/j.eclinm.2023.101836

[2] Update of recommendations on first- and second-line antiretroviral regimens, World Health Organization, Geneva, Switzerland (2019). Retrieved from https://apps.who.int/iris/bitstream/handle/10665/325892/WHO-CDS-HIV-19.15-eng.pdf

[3] Volny-Anne, A. (2020, July 17). 96 weeks results from two African studies confirm dolutegravir non-inferiority but highlight continued weight gain. Retrieved from https://www.aidsmap.com/news/jul-2020/96-weeks-results-two-african-studies-confirm-dolutegravir-non-inferiority-highlight

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.  

PEPFAR for the Win!

By: Ranier Simons, ADAP Blog Guest Contributor

What happens when a country realizes the importance of global collaboration in the fight against HIV and AIDS? PEPFAR happens. PEPFAR is the acronym for President’s Emergency Plan for AIDS Relief. This year marks the 20th anniversary of the initiative, the largest commitment ever made by a country targeted at fighting a single disease. The George W. Bush Administration brought PEPFAR into existence via H.R. 1298, the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003.[1] PEPFAR was initially a five-year plan with Congress appropriating $15 billion to combat the HIV/AIDS epidemic globally.[2] Since its inception and three reauthorizations, the U.S. federal government has invested over $110 billion in PEPFAR.[3] 

Photo Source: HIV.gov

H.R 1298 created PEPFAR, defined its structure and funding, and created a new position of U.S. Global AIDS Coordinator at the Department of State, with the rank of Ambassador.[4] The legislation defines the duties of the Coordinator as to: “(1) operate internationally to carry out prevention, care, treatment, support, capacity development, and other activities for combating HIV/AIDS; and (2) provide grants to, and enter into contracts with, nongovernmental organizations, including faith-based and community-based organizations, to carry out such activities.”[1] PEPFAR funding also includes contributions to the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Significant PEPFAR endeavors include expanding access to HIV treatment and prevention, strengthening health systems, and providing services to children with HIV/AIDS. Many of the children are vulnerable and orphaned. The initial motivation behind PEPFAR was the devastation President George W. Bush saw occurring with the HIV/AIDS epidemic in Africa.

Providing antiretroviral therapy (ART) is a strong focus of PEPFAR. As of 2022, 20 million patients in 54 countries have received PEPFAR-funded ART. This is a 300-fold increase from 66,500 people in 2004.[5] The initial goal was to treat 2 million people, prevent 7 million infections, and provide humane care. At PEPFAR’s inception, it was estimated that 30 million people in Africa were infected with HIV, but only 50,000 were on ART.[5] To date, it is estimated that over 25 million lives have been saved with ART, and millions of infections prevented. ART not only preserves the lives of those living with HIV but prevents its spread through sexual contact and mother-to-child transmission through birth. Of those on PEPFAR-funded ART, viral suppression has increased from 80% to 95%.

The positive outcomes of PEPAR are not just HIV related. Due to the initiatives, public health infrastructures have been created and strengthened. Thus, countries were better prepared to deal with labs and testing necessary for COVID-19. Additionally, H.R. 1298 contained provisions to help with debt cancellation and restructuring of underdeveloped, heavily indebted countries overburdened by the HIV/AIDS epidemic and other public health crises.[1] PEPFAR has been hailed as one of the greatest achievements of the Bush Administration.

Photo Source: The Borgen Project

Data shows that in 2021 approximately 38.4 million people were living with HIV, 28.7 million people were on treatment, 1.5 million became newly infected, and 40.1 million have died from  AIDS-related illnesses since the start of the epidemic.[6] The fight against HIV/AIDS is far from over. It is imperative that Congress reauthorizes PEPFAR. Is it up for its fourth reauthorization this year. If Congress does not reauthorize PEPFAR, funding for it will not end. However, not reauthorizing it would mean that specific key time-bound provisions would sunset. This could adversely affect the way funds are allocated, the way oversight is conducted, and even how studies concerning its effectiveness and outcomes are conducted, ultimately affecting the appropriation of funds.

[1] H.R.1298 - United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003. Retrieved from https://www.congress.gov/bill/108th-congress/house-bill/1298

[2] Cohen, J (2023, March 14). On Its 20th Anniversary, Reflecting On PEPFAR’s Success In Saving Millions Of Lives In Developing Nations From The Scourge Of HIV/AIDS. Retrieved from https://www.forbes.com/sites/joshuacohen/2023/03/14/on-its-20th-anniversary-reflecting-on-pepfars-success-in-saving-millions-of-lives-in-developing-nations-from-the-scourge-of-hivaids/?sh=44e55f494873

[3] Kaiser Family Foundation. (2022, July 12). The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Retrieved from https://www.kff.org/global-health-policy/fact-sheet/the-u-s-presidents-emergency-plan-for-aids-relief-pepfar/

[4] Moss, K., Kates, J. (2023, March 13). PEPFAR Reauthorization 2023: Key Issues. Retrieved from https://www.kff.org/policy-watch/pepfar-reauthorization-2023-key-issues/

[5] CDC. (2023, March 14). Vital Signs: Progress Toward Eliminating HIV as a Global Public Health Threat Through Scale-Up of Antiretroviral Therapy and Health System Strengthening Supported by the U.S. President’s Emergency Plan for AIDS Relief — Worldwide, 2004–2022. Retrieved from https://www.cdc.gov/mmwr/volumes/72/wr/mm7212e1.htm?s_cid=mm7212e1_w

[6] UNAIDS. (2023) Global HIV & AIDS statistics — Fact sheet. Retrieved from https://www.unaids.org/en/resources/fact-sheet

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.  

Amid COVID-19, Misinformation and Disinformation Target HIV

By: Ranier Simons, ADAP Blog Guest Contributor

One of the most dangerous forms of misinformation and disinformation is public health. Misinformation is defined as inaccurate or false information spread among large groups of people as fact. Misinformation is believed to be accurate and based on unsubstantiated rumors, misguided anecdotal evidence, misinterpretation of fact, and even bias stemming from universally shared cultural beliefs. Disinformation is deliberately targeted malicious misinformation propagated to deceive people into believing something for financial profit, political gain, or even malevolent ideological destabilization of evidence-based foundational norms. HIV isn't immune from either one.

Photo Source: Stanford Medicine

Medical misinformation has dire consequences. It can be a matter of life and death. It maintains confusion, mistrust of fundamental science and undermines public health efforts. People who believe in medical misinformation and disinformation lose their power to make decisions in the best interests of their health. As a result, they turn down well-established life-saving treatments, engage in harmful or potentially deadly treatments, and exacerbate conditions that would typically benefit from early intervention by delaying proper treatment.

A plethora of medical misinformation and disinformation continues to circulate regarding HIV and COVID-19. Recently circulating is a false causal claim linking HIV and COVID-19 vaccines. Conservative commentators such as Hal Turner, a right-wing radio host, claim that there has been a 500% increase in military new HIV infections due to COVID-19 vaccines being instituted.[1] 

In an effort to combat this misinformation, The Associated Press published data fact-checking the false claim. According to the U.S Department of Defense and the Congressional Research Service, 1,581 service members, including the National Guard and Reserves, have been diagnosed with HIV infections since 2017.[1] Approximately 317 service members were diagnosed with HIV in 2017; 280 in 2018; 314 in 2019; 237 in 2020; 309 in 2021; and 124 in 2022.[1] 

There were 72 more cases of HIV diagnosed in 2021 compared to  December 2020, when COVID-19 vaccines became available to the public.[1] That was only a 30% increase, not 500%. Moreover, in 2022 when the vaccines had been widely adopted, there were 185 fewer diagnosed HIV cases. That was a 60% drop from 2021.[1] Right-wing conservative media reported numbers they claimed came from leaked data from DMED, the Defense Medical Epidemiology Database. DMED is an internal database accessible only by military medical personnel. 

The Associated Press reported that the Defense Health Agency’s Armed Forces Surveillance Division explained there had been data corruption which resulted in the appearance of a significantly increased occurrence of all medical diagnoses in 2021 because of the under-reported data for 2016-2020. The cause of the corruption was identified, and the database was made whole. No evidence exists that COVID-19 vaccines have caused HIV or other immune deficiencies. Conservative right-wing media has also linked COVID-19 vaccinations to a non-existent fabricated condition called VAIDS, vaccine-acquired immunodeficiency syndrome, in an attempt to shed doubt upon factual COVID-19 vaccine data.

Other disinformation campaigns from conservative sources regarding COVID-19 were the Ivermectin and Hydroxychloroquine treatment fallacies. Former President Donald Trump also explicitly promoted both. In a November 2020, Journal of Medical Internet Research study, researchers quantified the potency of his misinformation. For example, their Twitter analysis found that his first tweet on March 21, 2020, promoting hydroxychloroquine and azithromycin, had 385,700 likes and 103,000 retweets. This equates to an estimated impression reach, or user views,  of 78,800,580.[2]

America’s Frontline Doctors (AFLD), a scam group of right-wing physicians, also perpetuated misinformation and profited from it. AFLD used telemedicine scams to make a profit promising telemedicine appointments for people who wanted to be prescribed Ivermectin for COVID-19.[7] Patients were charged for virtual visits whether they received them or not. They are also billed hundreds of dollars for Ivermectin and Hydrochloroquine prescriptions filled by third-party mail-order vendors. AFLD was created by the Council For National Policy, a clandestine network of conservative activists.[7] TIME Magazine found no proof that any physicians involved had expertise in directly caring for COVID-19 patients.

Photo Source: The University of Chicago Medicine

An Ohio State study found that conservatives are more susceptible to believing false information than liberals.[3] Overall, liberals and conservatives tend to believe claims that support their views. Additionally, both liberals and conservatives are able to adequately distinguish between falsehood and truth when the truth is presented as politically neutral. Neutral means that the factual truth does not overwhelmingly support the political views of either side. However, researchers found that liberals are much better at distinguishing falsehoods from truths that support liberal ideology. Conservatives in the study were significantly biased toward false information that supported a conservative political agenda, even when the claims were deemed outlandish and starkly in contrast to evidence-based facts. Researchers also explained that the odds were stacked against conservatives being able to distinguish fact from fiction because there is a much higher volume of right-leaning misinformation in the American media and information environment.[3]

The most effective way to combat medical misinformation and disinformation is to be just as proactive about promoting factual and truthful information. In an effort to battle misinformation, the U.S. Surgeon General. Dr. Vivek H. Murthy, issued a 22-page advisory in 2021.[4] The advisory details specific ways the media, health professionals, the public, and even technology platforms can effectively take action. Regarding the media, YouTube has partnered with providers and organizations like the Mayo Clinic, the American Public Health Association, and Mass General Brigham to create evidence-based content and highlight videos from high-quality sources when people search for health subjects using Google.[5,6] 

At the grassroots community level, educational outreach must extend to people face-to-face, especially in access-challenged marginalized communities and populations. The best way to see how people live, what information they consume, and what messages are pervasive in their social circles is to go to them directly. Misinformation and disinformation will not end. It is imperative that the energy behind the truth is just as aggressive as the energy behind the falsehoods.

[1] Tulp, S. (2023, March 8). No, the military hasn’t recorded a 500% increase in HIV cases. Retrieved from https://apnews.com/article/fact-checking-ap-check-619347436728

[2] Niburski, K., & Niburski, O. (2020). Impact of Trump's Promotion of Unproven COVID-19 Treatments and Subsequent Internet Trends: Observational Study. Journal of medical Internet research, 22(11), e20044. https://doi.org/10.2196/20044

[3] Grabmeier, J. (2021, June 2). Conservatives more susceptible to believing falsehoods. Retrieved from https://news.osu.edu/conservatives-more-susceptible-to-believing-falsehoods/

[4] Office of the U.S. Surgeon General. (2021). Confronting Health Misinformation. Retrieved from https://www.hhs.gov/surgeongeneral/priorities/health-misinformation/index.html

[5] Landi,H. (2021, July 20). YouTube partners with Mass General on health content amid misinformation backlash. Retrieved from https://www.fiercehealthcare.com/tech/youtube-partners-mass-general-health-content-amid-misinformation-backlash

[6] Vaidya, A. (2021, January 14). YouTube teams up with providers, healthcare groups to combat health misinformation. Retrieved from https://medcitynews.com/2021/01/youtube-teams-up-with-providers-healthcare-groups-to-combat-health-misinformation/

[7] Bergengruen, V. (2021, August 26). How 'America's Frontline Doctors' Sold Access to Bogus COVID-19 Treatments—and Left Patients in the Lurch. Retrieved from https://time.com/6092368/americas-frontline-doctors-covid-19-misinformation/

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.  

HIV & Shigella: What Patients Need to Know

By: Ranier Simons, ADAP Blog Guest Contributor

Another microscopic threat to public health has come to light. The Centers for Disease Control & Prevention (CDC) recently warned about the evolution of the common bacterial infection, Shigella. Public health officials are alarmed because of a reported increase in the number of Shigella infections in adults that are drug-resistant. Shigella bacteria cause a condition called Shigellosis, an infection of the intestines. 

Photo Source: Health Jade

Shigellosis can cause bloody diarrhea, stomach pain, cramping, fever, nausea, or vomiting.[1] Infection occurs when someone ingests minimal amounts of the bacteria from the stool of an infected person. Pathways to infection include eating infected food prepared by someone with shigella, swimming in or drinking unsafe water, and having sexual contact.

Shigella is very contagious. Typically, it is seen in children under the age of five, although people of any age can be infected. Adults commonly are infected by poor handwashing after handling diapers or helping small children with toilet training. Adult transmission also happens due to direct or indirect oral-anal contact during sexual activity.[1] Usually, Shigella infection clears up without the need for medical intervention. However, physicians prescribe antibiotics when necessary to speed up recovery or avoid more severe complications in vulnerable patients such as those with compromised immune systems.[2] Complications include dehydration, seizures, rectal prolapse, reactive arthritis, and bloodstream infections.[1]

Annually the United States has about 450,000 cases of Shigella infection. The CDC is alarmed because the percentage of antibiotic-resistant strains has increased from zero in 2015, to 0.4 percent in 2019, to 5 percent in 2022.[2] A pathogen is considered antibiotic resistant when it does not respond to any recommended first-line or alternative antibiotics.[2] The most troubling trait of drug-resistant Shigella is its ability to transfer its drug-resistant genes to other forms of bacteria that infect the intestines.[3] 

Photo Source: Labtoo

The CDC notes that the increase in adult drug-resistant Shigella includes men who have sex with men (MSM), international travelers, homeless populations, and people living with HIV.[4] Between January 2015 and January 2023, the CDC documented 239 drug-resistant cases. Patient information was available for 232 of them, indicating 82% were men, 13% were women, and 5% were children. Forty-one of the patients responded to questions about sexual activity, with 88% of those disclosing male-to-male sexual contact.[4] 

The United Kingdom also reports the spread of drug-resistant shigella among men who have sex with men.[2] This trend is reminiscent of what was written about meningococcal disease and MPOX last year. Both had a notable spread among MSM. Unfortunately, unlike meningococcal disease and MPOX, Shigella has no vaccine.

Because it is so easily transmitted, the CDC emphasizes the importance of shigella infection control. Healthcare professionals are urged to be vigilant in documenting drug-resistant cases of shigella to prevent global spread. As with all infectious diseases, the first defense is prevention.

[1] Mayo Clinic. (2023). Shigella infection. Retrieved from https://www.mayoclinic.org/diseases-conditions/shigella/symptoms-causes/syc-20377529

[2] Ryan, B. (2023, March 1). CDC warns about the rise in almost untreatable Shigella bacterial infections. Retrieved from https://www.nbcnews.com/health/health-news/drug-resistant-stomach-bug-cdc-warns-shigella-outbreak-rcna72784

[3] Radcliffe, S. (2023, February 28). CDC warns about drug-resistant shigella: What to know. Retrieved from https://www.healthline.com/health-news/cdc-warns-about-drug-resistant-shigella-what-to-know#:~:text=Limited%20antibiotics%20are%20available%20to,the%20intestines%2C%20the%20agency%20said

[4] Murez, C. (2023, February 27). Drug-resistant shigella infections on the rise, CDC warns. Retrieved from https://www.msn.com/en-us/health/medical/drug-resistant-shigella-infections-on-the-rise-cdc-warns/ar-AA180ims

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.  

HIV Cure: Trial and Error Sheds New Light

By: Ranier Simons, ADAP Blog Guest Contributor

According to the World Health Organization (WHO), at the end of 2021, about 38.4 million people globally were living with HIV/AIDS.[1] Medical science has advanced through the years, creating novel treatments for many illnesses, eradicating diseases from the global population, and finding cures for others. However, a permanent cure for HIV remains elusive. Researchers have recently announced a fifth person that has been cured of HIV. While the news is exciting and further adds to knowledge about the virus, the mechanism of the cure is not scalable. Additionally, it is important to note that a promising HIV-vaccine also recently failed advanced-stage clinical trials. 

Photo Source: Scientific Scarsdalian

A 53-year-old man, known as the "Dusseldorf patient", is the fifth and latest person to be cured of HIV due to a blood stem cell transplant.[2] This is the exact mechanism by which four other people have been cured of HIV. This man and the others received a blood stem cell transplant as an aggressive late-stage effort to treat leukemia. 

In 2013, doctors destroyed the patient's cancerous bone marrow and subsequently healthy bone marrow as well and replaced it with donor stem cells from a person who had a mutation that rendered them resistant to HIV infection.[3] The mutation was in the genes for the CCR5 receptor, a receptor HIV needs to enter immune cells. The mutation prevents the CCR5 receptor from being expressed on the surface of immune cells. The transplanted stem cells grew and replaced the old bone marrow, giving the patient a new HIV-resistant immune system. In 2018, the Dusseldorf patient stopped taking ART and has remained HIV-virus-free.[3]

The first person to be cured of HIV/AIDS as a result of a stem-cell transplant to treat blood cancer was Timothy Ray Brown in 2007. He was known as the "Berlin patient", and his cure was confirmed in 2009. Another patient, the "London patient", was reported as being cured in 2019. A 63-year-old man known as the "City of Hope" patient and a woman known as the "New York patient" were reported in scientific literature in 2022 as being cured. The "City of Hope" patient, thus far, has been the person who has lived with HIV the longest. At one point in his HIV journey, he had an AIDS diagnosis, having had HIV since 1998.[4] 

Unfortunately, blood stem cell transplantation is not a scalable solution, and it is only used in extreme cases for people battling blood cancers with no other options. It cannot be used as a cure for all patients living with HIV because the risks are too significant. It is not guaranteed to work and is very dangerous since it requires wiping out a person's entire immune system, and that state leaves a patient open to infections with no protection. Additionally, it is possible a person's body could reject the donor stem cells as well.

Photo Source: POZ Magazine

January 2023 also brought news of a failed HIV-vaccine clinical trial. The Mosaico Study, a phase 3 clinical trial conducted by the HIV Vaccine Trials Network(HVTN), was ended due to the results of an interim review.[5] The Mosaico Study vaccine was what is known as a 'mosaic vaccine.' This means that it contains genetic material from a variety of HIV strains prevalent worldwide to trigger a broad immune response.[5] The study focused on cisgender men and transgender people who have sex with cisgender men and/or transgender people from around the world. The failure of the trial was reported when it was found that the vaccine was ineffective in preventing infections compared with the placebo.[6]  Over the past 40 years, clinical trials on HIV vaccines have reached phase 3 only eight times.[6] All have failed.

A significant factor in why HIV is so challenging to cure is how it operates. When HIV enters the body, some of the immune cells it infects are long-lived immune cells that soon become latent. Those sleeping cells can stay dormant for years. While those infected immune cells are dormant, they are not replicating HIV. Antiretroviral therapies target infected cells that are actively replicating new copies of HIV. Thus, the "sleeping cells" are not being targeted. The latent or "sleeping" cells are what scientists refer to as HIV reservoirs in the body. Those infected cells can wake up and become active at any time. That is why it is essential to be consistent with antiretroviral adherence. 

We may not have a cure for HIV/AIDS. However, the disappointing vaccine trials and the science learned from the extreme stem cell transplants are still valuable and push us closer to conquering the virus. Trial and error will eventually produce powerful tools to beat HIV/AIDS.

[1] World Health Organization. (2023). HIV. Retrieved from https://www.who.int/data/gho/data/themes/hiv-aids#:~:text=Globally%2C%2038.4%20million%20%5B33.9%E2%80%93,considerably%20between%20countries%20and%20regions

[2] Sathyakumar, K. (2023, February 20). 5th person confirmed to be cured of HIV. Retrieved from https://abcnews.go.com/Health/5th-person-confirmed-cured-hiv/story?id=97323361

[3] Reardon, S.(2023, February 21). Third patient free of HIV after recieving virus-resistant cells. Retrieved from https://www.nature.com/articles/d41586-023-00479-2

[4] Marquez, L.(2022, July 27). Patient achieves HIV and blood cancer remission three decades after HIV diagnosis through stem cell transplant at City of Hope. Retrieved from  https://www.cityofhope.org/patient-achieves-hiv-and-blood-cancer-remission-three-decades-after-hiv-diagnosis-through-stem-cell#:~:text=Known%20as%20the%20City%20of,is%20now%2066%20years%20old

[5] Fred Hutchinson Cancer Center. (2023, January 27). Phase 3 Mosaic-Based Investigational HIV Vaccine Study Discontinued Following Disappointing Results of Planned Data Review. Retrived from https://www.hvtn.org/news/news-releases/2023/01/phase-3-mosaic-based-investigational-hiv-vaccine-study-discontinued-following-disappointing-results-planned-data-review.html

[6] Loewy, M. (2023, February 13). Researchers Voice 'Frustration' at Failed HIV Vaccine Trial. Retrieved from https://www.medscape.com/viewarticle/988191#vp_1

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.