Category Archives: Public Health

How the Female Condom Can Help the Women of Chile

Huge strides have been made in the understanding of how behavior drives HIV-infection. Notably, much of the coverage of how social constructs (and contexts!) contribute to the epidemic revolves around prevention education in the scope of proper – male – condom use. No doubt, comprehensive interventions in this arena have been instrumental in curbing infections. But it’s worth noting the limitations of this approach given the changing face of the virus.

Chile, a country with a prevalence of 28,963 notified people living with HIV (and an estimation of about twice that actually living with the virus), like many countries, is seeing an increasingly feminized epidemic.

Unfortunately (and perhaps unsurprisingly), most prevention and education frameworks neglect to take into consideration why this is.

In many cases, and specifically in Chile’s, women are contracting the virus via their husbands in relationships presumed to be safe and monogamous, and in which the negotiation of condom use on the part of the woman immediately presumes she is adulterous.

More nuanced approaches to prevention need to be undertaken with the understanding of how relationship dynamics – and the social climate in terms of perceptions of HIV+ individuals – contribute to the spread of the virus.

The International Community of Women Living with HIV/AIDS Chile is doing just that.

ICW Chile primarily works with women who contracted HIV from their husbands, have been subsequently widowed due to the illness, and are now attempting to forge their own way. This is difficult in a place where the stigma of HIV weighs heavily enough for most women to expect job termination if they disclose their status. While treatment is readily accessible – the Ministry of Health provides ARTs for all those in need, an initiative not to be understated – the social ramifications prompt many women to remain silent.

An organization dedicated to education, awareness raising, commemorations, and training in areas of women’s sexual and reproductive health and empowerment (and, importantly, with a board made up entirely of HIV+ women), they are embarking on an undertaking addressing the need for women to be able to protect themselves – by providing them with female condoms.

Female condoms aren’t entirely absent in Chile – but they can hardly be considered accessible when only one organization in Santiago is selling them – at $6 a piece. Of importance to note, they are desired – one organization that represents 2,000 sex workers in Santiago has shared that of the approximately 70 women a week coming to them for contraceptives and protection, female condoms are consistently requested.

The reason? They are often able to negotiate male condoms with clients, but not with their partners or husbands, putting both parties at risk. Female condoms can be inserted before sex by the woman herself, which precludes a negotiation conversation that comes with the use of the male condom (and is often ultimately refused).

This is where ICW Chile comes in.

Female Condom

The ICW Chile has already forged some of the essential partnerships to get this initiative off the ground. Groups like Fundacion Margen (a sex workers’ rights and advocacy group), in addition to their own five sub-regional teams around the country are prepared to help with raising awareness for the campaign as well as actually distributing the female condoms. Two HIV/AIDS organizations and two transgender health groups are also supporting ICW Chile’s efforts, and the Santiago Chapter of the National Women’s Service (SERNAM) has also offered their assistance. Creating a robust community of like-minded organizations, with resources and ties to mobilize is no doubt important here – but without the product, these connections run the risk of withering.

Luckily, one gift that’s helping them get off the ground is from the Female Health Company, one of the two primary female condom manufacturers, which recently pledged to donate 1,000 female condoms to the campaign, an instrumental and desperately needed move.

But it’s not enough.

When you reflect on the numbers above, it’s clear that ICW Chile needs our help in procuring the goods – and we’re going to make it as easy as possible to assist!

The goal is to distribute 30,000-35,000 female condoms in the next six months, and reach out to 60,000 people educationally. Showing a dedicated interest to the Chilean government, by region, and indicating how many people would utilize the female condoms if they were accessible (financially as well as physically!), could help prompt a firmer commitment from the Ministry of Health to provide female condoms on the scale of male condoms.

They’ve set up an Indiegogo page that details what your gift can provide, what you’ll get in return, and some of the important facts we’ve highlighted here. (I’m donating in the name of my mom for Mother’s Day!) They’ve gotten some buzz already, and this is a bandwagon worth jumping on.

I urge you to check out their Twitter and Facebook pages as well, and share widely with your networks. We’ve all seen what social media networks and crowd-funded projects can achieve, and I can think of no better project right now needing our crucial support.

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Filed under Epidemiology and Population Health, Feminism, Health Behavior, Health Education, International, Public Health, Reproductive and Sexual Health, Women's Health

Planned Parenthood Drops the Pro-Choice/Pro-Life Labels

And here is their video explaining why.

Thoughts?

I generally agree that using labels in an incredible complex and nuanced decision like terminating a pregnancy is for the most part unhelpful. However, I never much liked “pro-life” for those opposed to abortion rights anyway, and preferred to use the term “anti-choice,” for the reasons that many have articulated – that a woman’s life must be considered above that of a fetus, that choosing to terminate a pregnancy based on one’s personal circumstances is in fact being pro-life and thinking of a potential child’s future, that a fetus is not yet an actual life, that a woman has a right to decide what goes on in her own body. As with all things, the weight and emotions of descriptors sometimes get too heavy, and I do hope that this will encourage more in-depth conversation around abortion rights.

Additionally, Guttmacher recently release a series of infogrpahics covering the racial/ethnic disparities in accessing abortion care, income disparities, how women pay for abortions, and a cross-sectional look at abortion in the United States. Check them out:

U.S. Women who Have Abortions

 

How do Women Pay for Abortions?

How do Women Pay for Abortions?

 

Racial and Ethnic Disparities

Racial and Ethnic Disparities

 

Abortion Concentrated Among the Poor

Abortion Concentrated Among the Poor

 

Barriers to Abortion Access

Barriers to Abortion Access

 

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Filed under Feminism, Public Health, Reproductive and Sexual Health, Women's Health

Retraumatization: The Increased Risk of HIV Transmission among Abuse and Assault Victims

While the transmission of HIV and the causes of HIV-related death are actually more complicated—and even more nuanced—than public discussion would let on, a few presumptions about it remain fairly accurate.

For women who are marginalized in their communities, who are victims of abuse or assault, and who are economically or socially dependent on a spouse, the risk of them contracting HIV or dying from multiple complications from AIDS is simply greater than that of women fortunate enough to not be subjected to these circumstances. Take these scenarios:

  • The power dynamic in an abusive relationship may prohibit women from being able to protect herself from a partner who refuses to wear a condom
  • Women in poverty and those who need to rely on a partner for financial support may have greater risk of comorbid infections than women of economic independence. They are less likely to have the health insurance and relationship with a healthcare provider that would support HIV testing and provide the essential—and expensive—HIV medications to ensure a healthy life and lower the risk of co-morbid infections
  • People without social support, living in fear of what an HIV-positive diagnosis means, or those who have reason to fear stigma around personal behavior when seeking treatment are less likely to know where to access treatment or seek it out because of that fear, stigma and lack of support

Common sense would seem to support these statements. But until recently, the pathways of infection were not always clear, and while the conclusions above seemed certainly reasonable, specific data to support them had been difficult to collect. Two recent studies led by a UCSF-researcher have changed that. One synthesized what is known about PTSD and exposure to trauma among HIV-positive women, and the other explored the root of this relationship.

The results were remarkable. HIV-positive women had between two and six times the rates of childhood and adult physical and sexual abuse, and PTSD. The snapshot of risk behaviors among HIV-positive women was sobering:

  Sample size Number (%) of participants with each characteristic
Sexual activity
Any sexual activity in the past 6 months 113 61 (54.0%)
 With a main partnerMedian number of main partners (if any) 61 43 (70.5%)1 (range 1–2)
 With casual partnersMedian number of casual partners (if any)a 61 23 (37.7%)1 (range 1–25)
Sex with any HIV negative or unknown serostatus partners (if sexually active) in the last 6 months 61 51 (83.6%)
 Disclosure of HIV status less than all of the time with these partners 51 29 (56.9%)
 Using condoms less than all of the time with these partners 51 31 (60.8%)
 Detectable viral load 51 30 (58.8%)
 Disclosure of HIV status less than all of the time, and using condoms less than all of the time, and a detectable viral load 51 16 (31.4%)
Substance use (any, recent)
Cigarettes 110 71 (64.5%)
Alcohol 111 50 (45.0%)
Marijuana 111 39 (35.1%)
Crack/cocaine, heroin, and/or methamphetamines 111 45 (40.5%)
IDUb 112 11 (9.8%)
 IDU who share needles 11 5 (45.5%)
 IDU who have a detectable viral load 11 6 (54.5%)

aOne participant had a very high number of sexual partners (N = 250) and was excluded from the analysis; b IDU injection drug use; ©2012 Machtinger, et al. (retrieved December 16, 2012.)

There were striking findings in terms of both HIV treatment failure and the impact of the above risk behavior in these women, bringing us the first real data hoping to explain this relationship. Those who suffered from recent trauma had more than four times the odds of anti-retroviral (ART) failure while on treatment than HIV-positive non-victims—and this was seemingly not due to self-reported poor adherence to the medication. One potential explanation offered by the study authors is that abuse and trauma interfere with an individual’s ability to stay on a consistent medication schedule, which is essential for control of the virus. Other studies have confirmed that abuse manifest as control, in which a male partner prevents his HIV-positive female partner from accessing services at a clinic out of fear that the stigma of HIV would be attached to him.

HIV-positive victims of recent trauma also all reported experiencing what the study calls “coerced sex,” and have over three times the odds of un-traumatized women of having sex with HIV-negative or status-unknown individuals. They had greater than four times the odds of inconsistent condom use, potentially exposing those casual partners to the virus. While high-risk sex behavior is always a factor in HIV-transmission, HIV-positive individuals who adhere consistently to HIV treatments are significantly less likely to infect HIV-negative partners during sex. So the lack of treatment adherence among traumatized HIV-positive women combined with the risky sex behavior is a great concern.

Interestingly, these figures were only significant among women who experienced recent trauma, indicating that the ongoing—not merely one occurrence—circumstances of abuse are the key to the relationship between HIV-infection and HIV-related illness and death. This can actually be seen as a snapshot of hope—if we are able to offer abuse, assault, and PTSD victims the appropriate support to heal from the experiences, we may be able to weaken the HIV/trauma relationship.

These studies draw a clear line between victims of assault and trauma and both the spread of HIV within their communities and the increased risk of HIV-related illness and death. But interestingly, the risk goes much deeper than these socioeconomic circumstances. The conversation around HIV transmission is generally split into one of two categories: social and behavioral—risky activity, injection drug use, the prejudicial judgment of sex workers; and medical and clinical—how the virus infiltrates the immune system, takes over cells, and how it is and isn’t suppressed with antiretroviral medications. What isn’t usually discussed is the possible combination of these two categories and how together they create a perfect storm for potential infection.

Recent studies have shown that those individuals suffering from PTSD had significantly higher rates of cytomegalovirus (CMV) in their body. A virus that is found in between 50%-80% of adults in the United States, CMV remains largely undetected—latent, suppressed, unproblematic—in healthy individuals. It’s also seen as a marker of immune health and function, and of the body’s ability to control potential infections. Given that 30% of American women with HIV/AIDS have PTSD (five times the national average), the potential relationship between their HIV-status and even further compromised immune function could lead to a myriad of comorbid infections and premature death. Other research has also shown that additional biological mechanisms may prevent ART-treatment from being as effective as possible, including high cortisol (stress hormone) levels. Not only do these victims have to fight against abuse and assault, they have been left without the essential social support to decrease risky behaviors that may expose others to the virus, and their own bodies are in revolt.

Collecting this kind of information is difficult. It requires consistent and positive communication between women and providers, unobstructed access to medical care and uninterrupted ART treatment, and of course, in this example, most importantly—removal from an abusive environment.

The combination of immunosuppression due to PTSD, the detectable rates of HIV in traumatized women whose viral loads are not suppressed by consistent anti-retroviral treatments, and the concurrent risk behaviors of abused HIV-positive women, all contribute to higher rates of HIV-infection in communities, as well as the potential for co-morbid infections and HIV-related death. Until these women are able to find the essential social and community support, free from abuse and trauma, and until their access to care and preventative measures are fully realized, the relationship between trauma and HIV will only deepen.

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Filed under Epidemiology and Population Health, Feminism, Health Behavior, Mental Health, Public Health, Rape and Sexual Assault, Reproductive and Sexual Health, Violence Against Women, Women's Health

The Staggering Incidence of Breast Cancer in the Bay Area

Check out this piece in Tuesday’s edition of my hometown paper, the San Francisco Chronicle, discussing research by the Public Health Institute on the bizarrely high incidence of breast cancer in Bay Area counties. It’s fascinating. Marin County has for years been considered a hotbed for this disease, without much explanation as to why, but now it seems that multiple Bay Area counties – with the exception of San Francisco County itself – are showing similar rates. No research was undertaken in this project to determine why, but getting a handle on which regions have the highest incidence rates is a good first step for further exploration.

This image shows the counties and regions in which invasive breast cancer is 10%-20% higher than in other parts of the state – two other regions were seen with similar incidence rates in Southern California:

Picture copyright of San Francisco Chronicle

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Filed under Epidemiology and Population Health, Public Health, Women's Health

Countries Facing a Critical Healthcare Worker Shortage

A fantastic interactive graphic by the Guardian highlights which countries are in the most dire straits. Check it out here, and hover over a country’s name to get the statistics.

Some of the facts I found most interesting:

The Democratic Republic of the Congo has one physician and five nurses per 10,000 people and the infant mortality rate is 199 deaths before age five per 1,000 births.

Tanzania has less than one physician and two nurses per 10,000 people and an infant mortality rate of 103.

Chad also has less than one physician and three nurses per 10,000 people, and an infant mortality rate of 209.

Highest infant mortality rate? Afghanistan.

Check it out.

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Filed under Epidemiology and Population Health, International, Public Health

Teens + Smart Phones = More Sexual Activity?

A new study by researchers at my alma mater, University of Southern California, found that young people with smart phones were 1.5 times more likely to be sexually active than those without. Results were presented at this week’s American Public Health Association annual conference. I’ve written before about the relationship between media and imagery and its particular impact on healthy human development, so I found this study particularly interesting.

The lynchpin is the internet access, obviously, since that’s where smart phones differ from regular cell phones. The key findings pulled from the study are:

  • young people with smartphones are two times as likely to have been approached online for sex — and more than twice as likely to be sexually active with an Internet-met partner;
  • 5 percent of high school students used the internet to seek sex; and
  • non-heterosexual high school students were five times more likely to seek sex online — and more than four times as likely to have unprotected sex during their last intercourse with an online-met sex partner.

The odds of having unprotected sex with a casual and perhaps anonymous partner are of course the most troubling to public health professionals. It’s not surprising that non-heterosexual students were five times more likely to seek sex online than heterosexual teens, since those findings have been seen before and highlight the difficulty that many non-heterosexual students may have come out, the lack of social support they may feel, and the isolation that coming out may have brought on.

The researchers used a sample of 1,839 Los Angeles high school students between the ages of 12-18, and they controlled for age, race, gender, and sexual orientation. Since this is the first study to really explore this,  I’d be really interested in follow-up studies looking at other markers of sexual behavior in teens in relation to these findings. I’m also fascinated by the fact that 5% of high school students used the internet to seek sex, and am really interested in seeing how that number changes as smart phones become ubiquitous even in high school.

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Filed under Health Behavior, Media, Public Health, Reproductive and Sexual Health, Technology

How Public Health Works to Save Lives

I love infographics, as regular readers of this blog know. Today, the American Public Health Association came out with a great one showing the intersections of public health and how various initiatives, supported by policy, save lives and money. Prevention is key!

Courtesy of APHA

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Filed under Epidemiology and Population Health, Health Policy, Public Health

Scientific American: We Are Getting Fatter and Drunker

Scientific American released a couple of interesting interactive graphs and infographics showing the rise of poor health behaviors among Americans, focusing on the changes between 1995 – 2010. Pretty interesting findings – overall, Americans are drinking more heavily, binge drinking more frequently, and overeating more regularly – but we are also smoking less, overall.

Vermont was the worst state for heavy drinking in 2010 (Tennessee had the fewest heavy drinkers), Wisconsin was the worst for binge drinking (Tennessee again had the fewest!), West Virginia was the worst for tobacco use (Utah had the fewest smokers), Mississippi was the worst for obesity (Colorado had the lowest obesity rates), and Oregon did the best in terms of exercising and physical activity (Mississippi was the worst).

You can toggle between health behaviors divided by regions in this piece, and here is the infographic showing the trends:

Image via Scientific American

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Filed under Epidemiology and Population Health, Health Behavior, Health Education, Public Health

Who’s Left Out of the ACA?

Check out my post over at 2×2 about how the most vulnerable Americans remain at risk even after the Affordable Care Act was passed.

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Filed under Health Policy, Public Health

The 2×2 Project

It’s been a long while since I’ve written again, and the reasons are similar to my absence back in April—while I wasn’t writing another dissertation, my fellowship has just launched our website!

The 2×2 Project aims to increase discussion, debate, and understanding around current public health and epidemiological trends. Based at the Mailman School of Public Health at Columbia, we have a great team of writers and fellows. Come check us out! My latest post on abstinence-only education is up, along with some commentaries on the recent New York city soda ban, social networks and health, mobile apps, and climate change. We update a lot during the week, so make sure to subscribe, like us on Facebook, and follow us on Twitter! I’ll have some pieces about the Affordable Care Act up shortly.

Happy Monday!

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Filed under Health Policy, Media, Public Health