New Spreadsheet on Under Five Mortality Rates (with some thoughts on disease advocacy)

Here is an excellent spreadsheet made available through some listserve discussions through the CORE group. The spreadsheet is being used by the Child Health Epidemiology Reference Group (CHERG), Partnership for Maternal, Neonatal, and Child Health (PMNCH), and the Countdown to 2015 Group. Its modeling methods are explained in the 2003 Child Survival Lancet series (another excellent resource). The 2003 version was updated recently and this is the latest version (2007).

This data is objective and comes as a great resource in the midst of a heated discussion with regards to disease advocacy and funding wars currently raging in the global health realm. The battle really was set off after Roger England questioned HIV/AIDS funding. For example, this mortality data shows HIV/AIDS as the number cause of mortality in one country, South Africa. Some diseases (especially HIV/AIDS) get more social arousal than the very unflattering diarrhea. Should funding ever be disease-specific?

Rethinking HIV/AIDS Prevention

In a recent article published in science magazine, HIV/AIDS prevention is reconsidered. I thought this was fascinating, but if you want the quick version:

• Condom distribution works for certain demographics: particularly high risk groups such as sex workers and men who have sex with men (MSMs).

• Abstinence is efficacious but not effective. This means that abstinence prevents transmission of HIV/AIDS, but as a prevention technique has only been shown effective at times with youth under 20. Most new cases of HIV/AIDS are from already sexually active individuals in their 20′s and 30′s.

These two aspects of HIV/AIDS prevention have their place, but in order to have a widespread epidemiological impact on heterosexual adults (the vast majority of HIV/AIDS cases in the world) two less-known, but proven prevention strategies should be considered:

• Male circumcision – Over 45 observational, biological, and other studies from the last 20 years have shown that MC significantly reduces the risk of heterosexual HIV infection.

• Reducing multiple sexual partnerships – Another preventive measure that has had a powerful impact and that could have even greater effect, if it were more widely and assertively promoted, is partner reduction.

The largest investments in AIDS prevention targeted to the general population are being made in interventions where the evidence for large-scale impact is uncertain.

The following graph shows that funding for proven, effective measures like promoting and provision of male circumcision is very disproportionate.

Source:

Malcolm Potts, Daniel T. Halperin, Douglas Kirby, Ann Swidler, Elliot Marseille, Jeffrey D. Klausner, Norman Hearst, Richard G. Wamai, James G. Kahn, and Julia Walsh. PUBLIC HEALTH: Reassessing HIV Prevention.
Science 9 May 2008: 749-750.

Reconciling Moral Issues with Effective Policy by Aaron Anderson

I feel that one of the greatest complications facing public health officials today is reconciling “moral issues” with effective policy. I came to this conclusion while studying the efforts of the Thai government in its fight against HIV/AIDS.

Because of Thailand’s “vibrant” sex industry, HIV/AIDS spread rampantly in the country. Between 1989 and 1991, HIV infections rose from 3.5% to almost 22%. Infections in army conscripts rose six fold. Thailand appeared headed for a health disaster. However, thanks to the heroic, if not controversial, efforts of Thailand’s National AIDS Committee and its “100% Condom Program,” HIV was brought back under control.

Many health leaders in Thailand recognized that it would be impossible to stop people from visiting sex workers, so they sought a more pragmatic approach—they would make sex safe.

The so called “condom czar” of Thailand, Mechai Viravaidya spearheaded the effort. I watched a video of his efforts in which he explained that in order for the program to work, sex had to become less taboo. He explained that comedy had to become part of the campaign. Mr. Viravaidva impressed me with his efforts, however controversial they might have been. I was struck by images of him blowing up condoms like balloons in front of school children, handing out condoms wholesale in bars, and, most strikingly, him giving speeches in between strip shows about safe sex.

Viravaidva was primarily responsible for stopping the AIDS crisis in Thailand, however, I do not believe that such tactics would ever fly in the United States—and many other countries for that matter. Viravaidva created an innovative and successful program for his native Thailand, but replicating his tactics elsewhere probably won’t work. I think Thailand provides an excellent case study not necessarily for HIV prevention, but for demonstrating the importance of local leaders developing their own solutions for their own constituencies.

World’s AIDS Day and the LDS Church

Today is World’s AIDS Day, an opportunity for “people worldwide to unite in the fight against HIV and AIDS.”

Last year, Elder Robert C. Oaks gave an interview about the Church’s response to HIV/AIDS. He said:

The AIDS pandemic is an everyday reality in Africa. We didn’t have to persuade anyone that this is a horrendous societal and personal health problem. The people we worked with were hungry for answers. When we started to pull these materials together, people working on this issue had begun to see from their own statistics that the “safe sex” approach of explicit education and free condom distribution wasn’t working. They were looking for a better answer, and the best answer is found in gospel principles of morality, strong families and understanding who we are as Heavenly Father’s children.

I will soon post (Q&A) the best data answering the following questions:

-How effective is condom distribution in reducing HIV prevalence in Africa?
-How effective are abstinence campaigns in reducing HIV prevalence in Africa?

(Please note that my purpose is not to analize the Chruch’s programs. Indeed, the most effective public health intervention may not be the “best answer,” to borrow Elder Oak’s words, especially from an eternal, spiritual perspective. My purpose is to simply answer public health questions using the best evidence.)