In case you missed it, Betty Price, a Georgia state representative, said the following last week:
If you head over to the Youtube page with the above video, and read the comments (yes, I know, wading in such waters can give one a dim view of humankind), you'll see she's hardly alone in holding this view. The stigma, fear, and ignorance associated with HIV are still very strong; those of us who do this work on a daily basis might forget this sad fact.
And I suspect Price was well aware that she'd have some supporters before she made this public statement. It's all the more remarkable that she said these things as a physician (she was an anesthesiologist before entering politics), but then again her husband Dr. Tom Price didn't exactly distinguish himself when the topic of vaccines came up during his brief tenure as secretary of Health and Human Services.
So what should we, as infectious diseases/HIV specialists, say about this regressive and anachronistic perspective?
How about taking the high road and sticking to the science?
Credit: Centers for Disease Control and Prevention
There are multiple proven ways to prevent HIV transmission. Condoms, pre-exposure prophylaxis, and treating people with HIV all work really, really well -- and new infections are substantially down in the USA because of them. Do you think that Rep. Price knows that everyone who takes HIV treatment becomes uninfectious to others?
Quarantines for infectious diseases should be reserved for conditions that are an immediate threat to the public health. It's an extreme measure, one that is both expensive and logistically difficult, so mandating a quarantine should not be undertaken lightly. The CDC graphic on the right depicts diseases for which isolation and quarantine may be warranted. The most recent important example was Ebola (a viral hemorrhagic fever), which is highly contagious, especially during the acute illness, and potentially lethal. Back in 2002, it was SARS. HIV infection, with its long clinical latency period, lack of transmissibility except during sexual or blood contact, and effective therapy does not fit into this category.
There are no data that an HIV quarantine would even work, or be even feasible. Before undertaking such a costly program -- costly not only in dollars, but also in the enormous loss of personal freedom -- shouldn't we at least have some evidence that it would reduce HIV incidence? And what criteria would she propose for the quarantine? All 1.1 million people with HIV living in the USA? Only those not on treatment? Or only those not on treatment who are sexually active or sharing needles with others? How would she prove these claims? (Amazing what web cams can do these days, but still.) Would the program provide food, treatment, and housing? If so, where would these sites be, and how would they be funded? (I guess there might be some money that's no longer being used for private jets,)
She certainly drew attention to the dire situation in Georgia, where the ongoing HIV epidemic is considerably worse than in most other states -- it has the second highest rate of new cases, after Louisiana. The primary driver is Georgia's large, underserved, and mostly minority population that cannot access regular care.
It's people there -- and everywhere -- who are not on treatment and both get sick and sustain the epidemic, a lose-lose situation.
Grady Memorial Hospital is the famous Atlanta safety-net institution affiliated with Emory. In an account of his experience as an ID fellow at Grady, Dr. Jonathan Colasanti wrote the following:
After finishing 2 weeks on the general ID consult service, I was astonished as I prepared my patient log for submission to the Program Director. One-third of our 62 consults were patients infected with HIV. ... All of the patients were black. Excluding a patient with acute infection, the mean CD4 T-cell count was 64 cells/µL and over half the patients had <50 cells/µL. The mean viral load was 4.2 log copies/mL. ... Half of the patients were admitted with OIs or AIDS-defining illnesses, whereas many of the others suffered from processes directly related to living with a suboptimal immune system.
Until we have an HIV vaccine, the solution to stopping the HIV epidemic is to get people tested, on treatment, and keep them in care -- regardless of race or ability to pay.
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