Monday, December 24, 2007

New camera & national vaccine strategy

Well, I might as well admit it.
When I went back to Providence around Thanksgiving, I lost the beautiful camera that David & Tim gave me for my trip over.

It took me a long time to get over that loss, but I finally went out and got a new camera that's similar, but not nearly as nice.

In the meantime, you can see how much my avocado trees have grown. They're now maybe 20cm or so, with full leaves!

My next gardening project is to try rooting eucalyptus trees of various sorts from clippings I grab while walking Tuna.

The rosemary bush is about the same as it was, about a meter high & wide.
A strange thing has happened since I moved here, though.
When I first arrived, everything smelled vibrant and alive, even though it was in the middle of the dry season. When I bought the rosemary plant, the strength of the beautiful smell it gave off was almost overwhelming.
For some reason, either I've gotten so used to the smells of the city that I don't even notice them, or the level of air pollution has so corrupted my olfactory sense that I just can't smell anything unless it is very strong.
The only exceptions are when I pass near eucalyptus trees, which still smell wonderful, just much less vibrantly. And also cigarettes and especially pot are very irritating. The stench of pot is so overwhelming and nasty as you walk by certain houses that I've learned to gulp a breath of fresh air before passing them.

Here's an obligatory shot of the tree at city hall, right around the corner.
It's pretty, eh?

Minor Health Scare
I debated whether or not to discuss this, because it feels a little too personal, but here goes. After I got back from Providence in November, I started getting itchy "down there". I tried washing thoroughly, which made it burn. As the days & weeks went by, it just got redder and more painful, but not itchy anymore because of the cleaning. One morning as I was soaking in the tub, I took a closer look, and I could swear I saw three pimple-like things on the base of the head of my penis, and I thought. "Great, I've got HPV."
So, I called my doctor to have it looked at, and got an "urgent" visit ten days hence. At least it was faster than my initial "urgent" visit when I first got here, which was about a month away.
At any rate, I started washing with a milder soap (thank you Dr. Bronner for your lovely almond soap), which seemed to help somewhat.
When I finally made it in to see the doctor, he took one look, barely even that, and pronounced that I in fact had a yeast infection. Yes, boys. A yeast infection. It's possible. With all the three letter acronyms and 19th century sounding afflictions out there, I had worked myself into quite a froth, and was naturally relieved.
He prescribed a cream, but my co-pay was over $35 for the stuff, so I just bought an over the counter remedy for $11. It's working, but slowly. I'm a patient guy, so I don't mind.

HPV vaccine
I think the reason my mind jumped so readily to HPV is that I've had HPV on my brain for a while now.
A vaccine for HPV is now available (I haven't seen the TV ads yet, but apparently they are inescapable for people who have a television), and I was hoping against hope that the same huge mistakes that they made rolling out the hepatitis B vaccine wouldn't be repeated.
Unfortunately, they've gone even farther away from an effective vaccination strategy, which infuriates me. Still, I thought my doctor, in a practice predominantly consisting of HIV patients, would be more understanding.
Alas, no. He told me in no uncertain terms that he would not give me the vaccine.
I said I understood that my insurance company wouldn't cover it, but that I would pay for it.
He said that he still wouldn't recommend it, because I'm not a girl under the age of 20. And that even if I did want him to give it to me (which I still did), the best he could do would be to give me a prescription (because they don't have the vaccine in the office), which I could then fill at one of three pharmacies in the city that carry the vaccine, bring it back to him, take another day off work, and pay another co-pay so that he could inject it into me. Why does it have to be so damn difficult?

The HBV vaccine story
Maybe I should back up.
In the late 1970's gay men volunteered to take part in studies of a new vaccine against hepatitis B virus. It took the better part of a decade to get the studies in full swing, because the medical establishment refused to believe that gay men would be reliable enough to do such a study in. Anyway, flash forward to dramatic evidence that the vaccine worked, and worked really well.
Now, you'd think that making the vaccine available for gay men and injecting drug users, among who the rates of infection were highest would be a priority.
The opposite occurred. Once the utility of gay men as test subjects was no longer required, they were virtually ignored. It became almost impossible for a gay man to get the hepatitis vaccine, even among those who were aware that they should get it. The myth of unreliability was one obstacle - doctors were reluctant to give the vaccine to someone who couldn't show up exactly 28 days later and 5 months to the day after that. Insurance was an obstacle - insurance companies refused to pay for the vaccine. When they did pay, they demanded documentation of an individual's "high risk" profile. Most health care providers didn't know that this was an option, or how to provide the documentation, for that matter. Many gay men weren't comfortable having their "high risk" documentation become a permanent marker in their insurance and medical files either. And, then the demand was low, so very few offices even carried the vaccine in stock, requiring elaborate planning to be done in those few cases where the vaccine was to be administered in a doctor's office.

The one place that it was relatively easy to get the vaccine was in a hospital. The one population that had a relatively easy time getting it was health care workers, in order to protect them from the hordes of gay men and injection drug users who threatened them on a daily basis with the potential for infection. But even gay men and injecting drug users who were lucky(?) enough to be hospital patients had a hard time getting the vaccine in hospitals, even though they had the vaccine in stock, because hospitals generally deal with serious and urgent issues, not repeat visits for vaccinations, which from their perspective should be the purview of community clinics.

The next group that started getting access to hepatitis B vaccines, nearly 15 years after they first became available was children and infants. The model for this was the vaccines against childhood illnesses that are routinely administered during infancy (even though hepatitis B is rarely a childhood disease). Finally, a broad population strategy for vaccinations against hepatitis B began, under the presumption that these infants would be coming back anyway for other vaccines and periodic examinations, so that the vaccine would be in sufficient demand for it to be stocked and available. But the population over 18 was still left out to dry.
Even adults with HIV were (and still are) unlikely to be protected against HBV. What's the sense in that?

Recently, gay men's health organizations have tried to increase vaccinations among gay men by 1) increasing demand by informing gay men of their need to get protected (a strategy that is very limited if we have nowhere to go to get the vaccine affordably), and 2) to increase accessibility of vaccines in venues that gay men are at, such as HIV clinics, and sex establishments (like AIDS Project RI's bathhouse vaccination project).
Efforts to get hepatitis vaccines into injection drug users are woefully inadequate, despite frequent contact with health care providers and opportunities to distribute vaccine at needle exchange venues or even in incarceration settings.

Still, the most successful potential strategy, of just lifting the insurance restriction on documenting "high risk" status, seems to have escaped serious consideration by anyone at this point.

OK, so that's a brief history of HBV vaccines.

What's wrong with the HPV strategy?
So, what's even worse about the HPV (human papillomavirus) vaccine strategy is that not only are adults left out of the potential pool of people to be protected, but so are boys of any age.
There is a big controversy over the vaccine, which is portrayed as a battle between common sense and the religious right. The main complaint of the religious right groups is that vaccinating young girls implies that one is preparing for them to become sexually active (I'm still having trouble with why that's a problem, but anyway...).

Nowhere in the debate are the issues that seem more important to me. Where are these girls getting HPV? If one followed the logic of the vaccination strategy of only vaccinating girls aged 9 to 13, you would think that HPV is predominantly spread through girl-on-girl action at sleepovers. Although I don't want to imply that this is inconsequential, it is obvious that the vast majority of girls with HPV get it from boys, and often older boys at that.

From a traditional public health perspective, the goal of a vaccination strategy is to achieve "herd immunity" a state in which such a large proportion of the population (say 80% or so) is immune, so that even when the virus gets introduced, it is so inefficiently spread that there is virtually no chance of a widespread outbreak, even among the people who aren't yet immune.
The HPV vaccination strategy has as it's goal making (at best) half the population immune, and not the half that is the primary source of infection, so it is doomed to fail from the get-go.

As a man who is at risk of getting HPV from other men, and who is at risk of giving it to other men, there are no options for me in this strategy.

My question is why didn't we learn from the spectacular failures of the HBV vaccination strategy? To some degree these failures are becoming less relevant with the march of time, as men who are dying from liver cancer and other impacts of HBV are slowly being replaced with a younger immune population. But that's such a defeatist perspective! Are not the lives of older gay men worth protecting?

How many decades of mushing around with the HPV vaccine will it take before we get a comprehensive and effective vaccination strategy?

Vaccination Policy Risks Making an Effective HIV Vaccine Impotent ...
Now here's the real kicker. The HIV vaccine, when we get finally get it, will be more expensive, and require more booster shots than any vaccine in history. My fear is that the failed vaccine policies of the past will be multiplied in magnitude when it comes time to actually deliver the HIV vaccine.

Money is pouring into HIV vaccine research (as well it should). Some great research has been done on whether gay men would tolerate three, six, ten, twenty shots, whether they think it would have a high priority in their lives, etc. But these aren't the great obstacles to getting a vaccine out into the population.

The real obstacles are:
1) ensuring that the vaccine is not recommended to select "at-risk" population(s).
2) ensuring that insurance coverage does not require documentation of risk status to cover payment of the vaccine.

We have a great opportunity to address these issues now, before the waters get muddied with the specifics of the vaccine when it becomes available.

If the vaccine is targeted to select groups, then availability of the vaccine will be limited to hospitals and a handful of clinics that have sufficient demand. Those are not the venues that most of the "at risk" populations go. Even when they do, they rarely say "Hey, I'm a big walking risk factor. Why don't you give me a vaccine?". But without that kind of self-deprecating self-advocacy, they won't get the vaccine, even in those settings where it is available.

So, please do us a favor, and stop targeting us. It doesn't work.

For a concrete example of how lifting the targeting of high risk populations has succeeded, look at my diatribe about HIV testing below.

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