Preventing HIV Prevention

About a half century before Sir Arthur Conan Doyle had the chance to chronicle the adventures of Sherlock Holmes, an unassuming anesthesiologist named John Snow informally introduced the wonders of deductive reasoning to the people of London. Snow, an English physician who pioneered much of the work regarding the use of Ether and Chloroform in surgical anesthesia, was practicing in London when the great Cholera outbreak of 1854 took place and he was less than enthused about contemporary explanations as to how the disease was spreading. Popular wisdom and “science” held, at the time, that diseases such as Cholera and Chlamydia were transmitted through pollutants and impurities lingering in the air. Dr. Snow, who was also one of the founding members of the Epidemiological Society of London, decided to begin making his own observations on the Cholera epidemic, primarily through interviews with local residents and systematic mapping of all reported cases of Cholera to try and identify any patterns in how the disease was spreading. Snow quickly discovered that the majority of Cholera cases were occurring near a public water pump on Broad Street and asked local authorities to have it removed. Within a few days the incidence of Cholera in the area had plummeted.

A 19th Century Illustration of Death Manning a Local Water Pump

A 19th Century Illustration of Death Manning a Local Water Pump

As it turns out, the Broad Street Pump had been constructed about three feet from an old cesspit, which had begun leaking into the public well water that was being pulled up by the pump. Snow ultimately discovered that the cesspit in question used to reside under the house of a local family who had lost an infant to Cholera and who had washed the used diapers of the child in that cesspit. Similarly, Snow found out that the Southwark and Vauxhall Waterworks Company had been supplying Londoners with water taken from a portion of the Thames River that was downstream from a sewage dump and which inadvertently caused a spike in Cholera cases. All Dr. Snow had managed to do over the course of a few weeks was save thousands of lives, give birth to the field of epidemiology and introduce the world to the idea of germ theory.

I bring up this origin story of our modern approach to public health primarily to illustrate the importance of targeted prevention in stopping the spread of disease. By eliminating two public water sources, the Broad Street Pump & the Southwark & Vauxhall water removal site on the Thames, Snow was able to end an infectious disease epidemic in a couple weeks. While I will grant you that Cholera seems like a fairly simple disease to prevent in hindsight (“don’t drink poo water”), the lessons learned from Snow’s research in the mid-19th century are still extremely relevant today. And, while physicians and epidemiologists are well aware of the values of targeted prevention, it is often the first thing to get axed from local, state and federal budgets because the effects of such a cut won’t be felt for another 5, 10 or 20 years. In these lean economic times and with a federal government that has never met a can it didn’t want to kick down the road, it shouldn’t be shocking that prevention programming in general health and substance abuse have suffered mightily in recent years.

So, I was rather encouraged the other day when I got a message from a fellow Queen City ex-pat friend of mine that the University of Cincinnati was starting a new clinic that would be distributing the HIV drug Truvada as a form of prevention for populations that are at particularly high risk for contracting the virus. Still a controversial practice among HIV health care providers, the Food & Drug Administration approved the use of Truvada for Pre-Exposure Prophylaxsis (PrEP) in July of this past year based off of a series of studies showing that targeted use of the drug in combination with other prevention measures such as regular condom usage and HIV testing could greatly reduce the likelihood of becoming HIV positive. The controversy lies not in the drug’s efficacy, but in its price tag—$13,000 a year—and its intense array of side effects, which range from the usual nausea and diarrhea to insomnia and kidney failure. At the end of the day, the proper prescription of Truvada lies as much in art as it does in science, as it falls on the individual physician to determine at what point a client’s risk behaviors have reached a level where prescribing this medication becomes the lesser of two evils.

Regardless of the controversy surrounding the drug, all but the most ardent opponents of pharmacotherapy would concede that there are a number of groups who could benefit from such a treatment. The population that has seen the most severe growth in HIV incidence rates and that would seem to be best suited for Pre-Exposure Prophylaxsis would be young, African-American Men who have Sex with Men (MSMs). In 2010, the rate of new HIV infections among African-Americans was nearly 8 times that of Whites, while MSMs made up nearly two-thirds of new HIV infections, despite making up a scant 4% of the overall population. As the confluence of these two disproportionately affected groups, young black MSMs account for more new infections than any other subgroup by race/ethnicity, age, and sex. To make matters worse, HIV has become a bellwether of sorts for all manner of inequality in contemporary America, meaning that HIV positive men and women are increasingly coming from communities where access to health care and support services is conspicuously absent. Luckily for Cincinnatians at elevated risk for contracting HIV, the Infectious Diseases Center at the University of Cincinnati Medical Center is located in the heart of Corryville/Mt. Auburn, an area that ranked in the top 5 for HIV incidence in the city and is adjacent to 3 of the other 4 highest HIV incidence zip codes.

But UC Health isn’t offering their newest HIV prevention service in the epicenter of infectious activity in the city. No, they’ve placed their clinic out in West Chester, Ohio, a full 20 miles from downtown Cincinnati. Dr. Judith Feinberg, a professor in the division of infectious diseases at UC, told the Business Courier that the decision was made in order to accommodate clients who might feel uncomfortable going to a clinic specifically for HIV positive patients. According to Feinberg, “West Chester serves as a neutral location,” that provides discretion for clients along with a number of other conveniences that couldn’t presumably be offered at the Cincinnati location. Of course, the one thing that the West Chester clinic won’t have is patients, which I’ve been led to believe are kind of important to running a good medical practice.

West Chester Hospital - Located in Scenic Middle of F---ing Nowhere

West Chester Hospital – Located in Scenic Middle of F—ing Nowhere

For those of you not from the tri-state area who might need a point of reference for just how far away West Chester is from the City of Cincinnati, it might be important to note that the two cities reside in different counties. The township of West Chester is located in the largely rural Butler County, while Cincinnati makes up the majority of metropolitan Hamilton County. According to Google Maps, it takes 26 minutes to get from the heart of downtown Cincinnati to the UC Health clinic in West Chester. Of course, that’s assuming you have a car or can get a friend or family member to drive you. If you have to take public transit, you’re pretty much screwed because there’s only one Metro bus that goes that far outside the city and the only way you can afford to take it is if you have an entire day to give up, because you’ll be stuck in scenic West Chester all damn day waiting for the return bus.

The forgiving among you might be wondering if West Chester has an HIV epidemic of its own that necessitates placing the clinic way out in the hinterlands. They don’t. According to the Ohio Department of Health HIV/AIDS Surveillance Program1, there were only 276 Butler County residents living with HIV/AIDS in 2011 and, of that number, 77 had been newly diagnosed in the past 4 years. Hamilton County on the other hand, recorded in excess of 2,300 residents living with HIV/AIDS, of which 550 were newly diagnosed cases. So, for those of you keeping score at home, Hamilton County has racked up twice as many new HIV cases since 2007 than there are total HIV cases in all of Butler County. Ultimately, it seems like the only thing UC Health is going to end up preventing is access to care for thousands of Cincinnatians at risk for HIV infection.

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1The Ohio Dept of Health has done a hell of a job with their interactive HIV/AIDS Surveillance Program. Check out their website for 2011 data on HIV/AIDS data from every county in the state: http://www.odh.ohio.gov/healthstats/disease/hivdata/hcty1.aspx

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