I've continued another blog: anotherstampinthepassport.blogspot.com.

I have been updating that blog. It's still about HIV/AIDS!!

Condoms-- Taboo

On my recent trip I had a lot of time in the car and remembered that I had downloaded a series done at Bethel College on HIV/AIDS. The speakers were very interesting and most of the sessions were very good. I was impressed with a conservative Christian College dedicating a whole seminar on HIV/AIDS. I listened to two speakers who had clearly not listened to each other. It was quite humorous and shed light on a lot of the problems and obstacles to moving forward with unity on prevention of HIV/AIDS.

Many of you know or have heard about HIV in Uganda and how it is one of the only nations in Africa where the incidence of HIV decreased for a period of time. When that happened it was up for grabs to take credit for the progress. Many advocates claimed that since they introduced the ABC (Abstinence, Be Faithful, Condom) strategy there was a decrease in HIV incidence. Recently, however, there has been an increase in incidence. One speaker highlighted the clear association with abstinence education and the decrease of HIV in Uganda using numbers and stats. He explained that once condoms were introduced the country went the way of the rest of Africa to increase incidence. Another speaker (who was himself African and a Christian) interpreted the events very differently. He said that the ABCs were initially used to promote behaviour change to use condoms . This was responsible for the decrease. He said that when PEPFAR (an initiative by President Bush) was introduced and abstinence only education was taught people stopped using condoms but did not stop having sex! And because of that the incidence in Uganda has increased.

Do you see how easy it is to use statistics and correlations to argue your point? Do you see how easy it is to see what you want to see? We need to get beyond promoting "our way" as the best and see that all ways have their place in different times and different locations. Uganda is a mystery to me. I have tried to do literature research on the studies done during the decline of incidence, but it is almost impossible to find an objective study or article published. I could argue both sides relatively easily but for what gain? I don't care to only see what I want to see in my perfect little box of how things should be. I need to see the truth and reality and move on from there.

Christian, what happens to your worldview if someone says that condoms are working well to prevent HIV? Can God allow condoms prevent HIV transmission among non-married people? Can God use condoms to prevent viral load from increasing in a married couple where one spouse has been unfaithful? Would/Could God allow a condom to protect a man who has sex with other men from acquiring HIV?

It comes down to how you let your worldview influence the way you see problems and solutions.

If I were the enemy

If I were the enemy I would create a horrible disease affecting the poor, marginalized, and underprivileged in society.

I would create the disease so it would slowly destroy the immune system of healthy people in 6-8 years so that no one would know they are infected until too late.

I would create the disease to mimic individual DNA so that a vaccine couldn't be developed.

I would create the disease so that it would affect young moms and dads who then couldn't care for their children and of course having the side benefit of wiping
out the most productive population in society.

I would create the disease so that it could be transmitted to babies in order to provide them with a slow, painful death within 5 years.

I would let it affect a continent that only produces 1% of the economic productivity in the world so that no one else would really care.

I would create it to be a sexually transmitted disease.
Then I would let it be discovered in gay people first to ensure a stigma would be attached to it.
By that time most Christians could justify not caring and they wouldn't get involved.

And of those Christians who decided to get involved I would distract them with controversial issues about sex and condoms and make them question their own morality and those with the disease.
I would distract them by providing a ton of conferences for them to go in order to make them feel like they are doing something.
I would ensure that Christian leaders would come out saying that it is God's judgment on those awful, immoral people.

And of the Christians who are helping and trying to make a difference I would have the other Christians judge them, not listen to them, and discriminate against them.

And then I would call it HIV/AIDS and sit back and watch 14,000 unassuming people get infected every day.

It would be one of my greatest accomplishments in history.

I am back! I'm pretty sure I've never seen so much of the United States of America than in the last few weeks.

First trip: To Boston and Grand Rapids, MI to see some wonderful friends and go to an amazing conference.
Second Trip: It was wonderful to go out west to South Dakota, Wyoming (Yellowstone and the Grand Tetons), Montana, and Minnesota with my family!
Third Trip: All through North Carolina (including the Cherokee Reservation that my GPS took me through) and TN to visit more friends!

I also have big news: I am have accepted a fellowship with the CDC (Centers for Disease Control and Prevention) as a program manager in Vietnam for at least a year. So I am now employed!

Through August I will continue writing about HIV/AIDS. I hope that you will continue to join the discussion.

Conversations

Kari, my twin sister, moved into my apartment about a month ago since she is in nursing school at Chapel Hill. It is a open loft apartment with one bedroom upstairs.

People keep asking if we are getting along in such a small space. I keep telling them, "We shared a womb for 8 1/2 months together a while back."

I was telling Kari this today and she quickly replied, " Well...we didn't have to worry about beds and couches then!!" Hm... good point...I might have to revise my response!

In other news I am on my way to Boston, MA to visit my dear friend, Olivia B.







Then I'm flying to Grand Rapids, MI to go to an ecumenical, economics conference, called Acton, with another dear friend, Anneli M. It will be a great 10 days! I hope to write a few thoughts from the conference.

HIV prevention dance

In Malawi (Southeastern Africa) I was able to travel with a group called Action for Behaviour Change. I traveled with them a few days to do testing at a catholic school site. Then we traveled to another elementary school and they did a prevention presentation. The school didn't have any desks or chalk board. There were just a few open cement rooms. About 40 children followed in and sat down on the floor. The leader started singing a song and all of the children stood up and started singing along. One thing that I noticed about the children in Malawi is that they were always excited to sing and to sing as loud as they could. And I think they were all born with a beautiful rhythm! Later I found out that all of the songs were about prevention of HIV. These children were about 7-10 years old! I thought it was very clever to put the message to song. Because as we all know we don't forget songs and if they are really catchy we will get them stuck in our heads! Also, it is easy to memorize a song.

Who is at risk?

"An estimated 252,000--312,000 persons in the United States are unaware that they are infected with HIV and, therefore, are unaware of their risk for HIV transmission" (1). This is about a ¼ of all infected individuals in the United States.

That is pretty incredible considering free and rapid testing. Access to HIV testing is amazingly widespread and easy.

Some people don't want to get tested because they don't think they are at risk. Some people don't want to get tested because they just don't want to face the facts. In my masters paper I found that only 6%-7% of HIV positive women knew that their partners were infected (and 100% of their partners were infected in my sample). My question to you is… do you know who you are sleeping with?

My other question is who do you think are at most risk of acquiring HIV? MSM? IDU? White? Black? Hispanic?

1Glynn MK, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003 [Abstract T1-B1101]. Presented at the 2005 National HIV Prevention Conference, Atlanta, Georgia; June 14, 2005.

Drinking Methadone?

When I was in China last year our professor took us to several methadone Maintenance clinics.

As a way of definition: "Methadone is a rigorously well-tested medication that is safe and efficacious for the treatment of narcotic withdrawal and dependence... Heroin releases an excess of dopamine in the body and causes users to need an opiate continuously occupying the opioid receptor in the brain. Methadone occupies this receptor and is the stabilizing factor that permits addicts on methadone to change their behavior and to discontinue heroin use." (http://www.whitehousedrugpolicy.gov/publications/factsht/methadone/index.html)

Heroine (an injection drug) is still a huge problem in China especially where we were which was in the southwest near the drug triangle in Asia. Our professor traced the AIDS epidemic through the influence of the drug triangle through China in the late 1980s (before that China was very closed and didn't suffer from the AIDS epidemic that was ravaging Africa). We went to this Methadone Maintenance clinic in the southern part of Sichuan. There are about 68 in the Sichuan province and is considered a way to prevent HIV in China.

We walked in and sat down to talk with the director. An old man came into the clinic, drank his treatment, and sat down. He'd been coming for about 8 years (up to twice a day). About this time two ladies came in for their treatment. Amy (my friend who went with me to China) and I figured out that they were mother and daughter. They were dressed very scantily and they were acting pretty crazy. All of a sudden after they had the treatment our professor and the director were speaking very harshly with them. The interaction that was about to happen for 30 minutes was left for our interpretation. Over a few cigarettes the conversation was very animated back and forth. They had clearly done something very wrong and they wanted to leave but were not allowed to. After they eventually were able to leave our professor explained what happened.

They had put the methadone in their mouths but then spit it out into a towel that was under their clothes. They were going to sell it, probably for quite a high price on the black market. After a client takes the Methadone they are required to say something to make sure they actually drank the methadone. These women delayed in saying something because they were spitting the methadone out. Apparently this is quite a normal occurrence. Some people put cotton in their mouths to absorb the methadone so they can later sell it. Most don't get away with it because there the clinicians usually catch them. The mother most likely had been on heroine when she was pregnant and kept the daughter on heroine through her entire 20 something years! My sense was that they were not that interested in stopping anytime soon either!

Clean Needle Exchange?

I would like to address a question from my friend, Anneli..."Here is a Q: Vancouver has a safe injection site, and I have heard that they are safer and cleaner and may stop diseases from spreading as rapidly. Does the States support these sites? Is it good to support them? What do you think?"

• These are some quick stats for the USA (Policy Facts, June 2001):
  753,907 cases of AIDS (>200CD4 count—therefore this does not include HIV cases).
  25%-36% AIDS cases are related to Injection Drug Use (IDU)
  ~2.4 Americans use injection drugs
  Kaiser found that 66% of Americans are in support of clean needle exchange programs
  

Clean Needle Exchange Programs (NEP) or Safe Injection Facilities (SIF) offer a safe place to dispose of used and potentially infected needles used by injection drug users. Along with clean needle exchange these programs offered a combination of drug treatment referrals, Methadone Maintenance (I can address this later), peer education, HIV prevention (including testing) etc.

I did some literature research on this using PubMed and Google Scholar, two huge databases of journals. Some quick observations that I've made over the past few days: 1. Most if not all of the journal articles recommended instituting clean needle exchange programs. 2. Most of the articles referenced success as a decrease in HIV and Hep C. 3. The articles only briefly addressed any ethical implications resulting from condoning clean needle exchange programs and when they did the issues were dismissed very quickly as unreasonable.

The SIF that Anneli is referencing was cleared in 1998 by the Canadian federal government (http://www.city.vancouver.bc.ca/CTYCLERK/CCLERK/980421/a12.htm ), which waived its drug laws to allow pilot SIF in Vancouver. Follow up studies in 2003 showed (Beletsky,L. 2008).
- decrease in needle sharing
- decrease in reuse of syringes
- decrease in outdoor injecting (and a decrease injecting in public areas)
- increase clean water for injecting
- increase in filtering drugs before use
- Lastly they saw the SIF as a gateway for additional treatment and counseling

In the United States SIF have been in existence for a while (I couldn't come up with a specific date but I'm pretty sure it would be about the late '80s since the congress specifically addressed restricting funds for SIF in 1988) however they have been funded by private organizations and highly regulated (CDC, 2007). In 2001 there were 113 SIF in 80 cities and 38 states (currently I believe that Texas is the only state where SIF is prohibited). The approximate cost for one year of operation with of SIF is $169,000 the cost for the treatment of one case of HIV through their death is about $200,000. These are obviously very loose numbers depending on number of clients that visit the site but if 100 clients visit per day than that is about $9,400 per avoided HIV case (Policy Facts, June 2001).

So if it's cheaper than treating a case of AIDS and it seems to be an effective prevention tool against acquiring HIV we should do it! This is the thoughts of most researchers. On the other hand giving clean needles to injecting drug users seems like it would endorse and promote injecting drug use which is illegal and harmful to one's body. Are we as Christians to condone "sinning safely"? I don't pretend to have the answers here but I just want to show you that it is not a clean cut issue. Here is a statement from a Christian organization: "If [Jesus] knew there was a box of new needles in the corner, I can imagine him mentioning it. Not to promote the practice, but to save life until a time when the person may be looking for help out of addiction, and for reconciliation with God." (http://www.globalchange.com/ttaa/ttaa%2013.htm)

It should be noted that James Dobson, a leader in the Christian Right movement, deeply criticizes needle exchange programs (http://www.aidsmap.com/en/news/DBB3AF1A-ABAB-4D13-991F-99EC029491C5.asp ) But unfortunately I have only been able to find an indirect statement from Focus on the Family through another article that was written in 2000. "NEPs condone drug use, an `immoral' behavior"
(Gent, CE, 2000).

I struggle primarily with who should fund these programs. It is one thing for the government to allow the SIF to exist but it is another to fund them. The reason I struggle with this is because I realize that drug addicts are fully hooked and will get needles any way that they can. If there is a way to help them and prevent further damage to their bodies I find it hard to stand in the way. However, I understand and can sympathized with the sentiment of some who would prefer that their mandatory tax dollars go toward something other than funding needle exchange for injection drug users who are already breaking the law by using illegal drugs. While this is harsh I wouldn't put it past most people when given a chance to have a say in how their tax dollars are spent. The question I would pose to these people is: Would you rather fund the antiretroviral therapy for those who contract AIDS through IDU?

In conclusion it is hard to deny the public health advantage and the cost effectiveness of SIF. However, since there is still a lot of controversy surrounding the morality of the implementation of SIF, I would suggest that private funds should continue funding these sites until a time when either injection drugs are legalized or there the prevalence of HIV increases past 2% in the general population in a given area (this means that HIV has generalized throughout the population). The bottom line though is that Jesus' transforming power is probably one of the only ways that injecting drugs users can really stop using these highly addictive drugs. So to those Christians who are against SIF, if you aren't introducing these people to Jesus and His power to be released from drugs than you have little space to condemn researchers who clearly see that SIF are preventing HIV/AIDS.

References:
Beletsky,L.The law (and politics) of safe injection facilities in the United States. Am J Public Health. 2008 Feb;98(2):231-7. Epub 2008 Jan 2.
CDC.Syringe exchange programs--United States, 2005. MMWR Morb Mortal Wkly Rep. 2007 Nov 9;56(44):1164-7.
Policy Facts. June 2001. http://www.aidsaction.org/legislation/pdf/Policy_Facts-Needle_Exchange2.pdf

Gent, CE. Needle exchange policy adoption in American cities: Why not? Policy sciences. 33:2. 125.

China and Burma

In light of the disasters in Burma and China it seems hardly relevant to really talk about AIDS when so many people are suffering and dying in those countries from natural disasters. Last summer I spent the summer in the Sichuan province in west China. We have received e-mails from some of the students that we worked with and they said they were doing okay. It is hard to comprehend the devastation of over 20,000 people dying in one area especially when only 3 years ago Hurricane Katrina hit the US leaving a lasting impact and killing a little over 1,300. Please pray for these people in China and Burma. Pray that these closed governments will allow international relief aid to come in and help these very desperate people.

The masters paper was enormous and then it just finished. It's May 3rd today and I'm shocked that it's over.

I have a May list though. These are the things that I've wanted to do for a while but have put off until May. I'm sure a lot will be added to My May List but for now I just have a list and will stick to it.

Item #1: Respond to a post by John Stonestreet the Summit blog. My friend pointed me to this post since not only am I a previous summit counselor but I'm also very interested in HIV/AIDS. Having worked with HIV/AIDS in 4 different countries and having concentrated on HIV/AIDS during my masters education of public health I have quite the vested interest in entering into a knowledgeable discussion surrounding issues of the disease.
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Quick thought: I believe that Christians should be willing to invest thought, time, energy and money into the research, prevention, and treatment of HIV/AIDS starting with entering into the discussion wisely and intelligently.

Why invest?
HIV/AIDS has become a top public health around the globe but especially in Sub-Saharan Africa where prevalence has reached about 30%-40% in some areas(1). About 95% of the 40 million people living with HIV/AIDS (PLWHA) are in the developing world (2). One study in Tanzania recorded that only 20% of infected individuals are aware of their HIV status (3). In 2001 in some areas in Botswana, 44.9% of pregnant women are HIV infected. As a result about 10,000 infants were born with HIV in 2001 (1). Of the 600,000 infants born with HIV each year , 90% are living in Sub-Saharan Africa (4).

The US government has pledged 15 BILLION dollars (with an hope for $30) for PEPFAR (the president's emergency plan for AIDS relief) and they are currently heavily supporting faith-based initiatives.

The discussion/research/prevention is being navigated by researchers who don't have a Biblical worldview.

(1) G. Anabwani, W. Jimbo. Botswana Guidelines on Antiretroviral Treatment. Ministry of Health, Gabarone, Botswana 2002.(2) Geneva:UNAIDS. AIDS Epidemic Update. Dec 2004.(3) Bunnell R, Mermin J, De Cock KM. HIV prevention for a threatened continent: implementing positive prevention in Africa. JAMA 2006 Aug 16;296(7):855-858.(4) Adetunji J. Trends in under-5 mortality rates and the HIV/AIDS epidemic. Bull.World Health Organ. 2000;78(10):1200-1206.

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I hope that I can flesh out some of the issues surrounding HIV/AIDS. I hope I can dispel some of the myths surrounding the issues. I hope I can educate Christians on what it looks like to enter the conversation intelligently. Please ask your questions about AIDS and I will try to answer as many as possible.

What I hope to cover: Injection drug use (clean needle exchange and methadone maintenance clinics), MSM(Men who have sex with Men), MSM/W (MSM and Women), Sex workers, condoms, sexual networks, abstinence, NGOs (Non-government organizations) and FBO (Faith-based organizations) mandatory testing, opt-out/in testing, counseling, Antiretrovirals (ARV)