Will New Hampshire open safe sites for people who inject drugs?

New Hampshire is still in the throes of one of the worst opioid epidemics in the country. Deaths are mounting, and mostly in young people.

As hospitals around the nation and our fair state scale up to provide medication assisted therapy and other evidence-based ways to help, safe injection sites remain controversial.

Based on data from Vancouver's Insite program showing lower public drug use, less needle sharing, and prevention of infectious diseases like HIV, I think it's time for us to get over our hangups and act to save lives.

It was fun and illuminating to talk with Laura Knoy's and guests on NHPR's Exchange. For a stream of the hour-long show, click here. 

Let Opioid Users Inject in Hospitals

It is a new world in health care as America grapples with an epidemic of opioid drug abuse. The Centers for Disease Control and Prevention reported that opioid overdoses killed over 28,000 people nationwide in 2014, more than ever before.

From heart-valve infections to drug overdoses, the casualties of this epidemic wash up in our hospitals. It has changed my hospital service significantly. Almost every day, we try to save a young person dying from infectious complications of injection drug use.

Addicted patients usually bond with their providers over the shared goal of healing. Yet these interactions, which often bridge divides of class, culture and personal psychology, can break down. When addicted patients inject drugs in the hospital, doctors and nurses can find themselves cast in the role of disciplinarians, even jailers.

Confining patients to their rooms, restricting their activities and posting guards is expensive. It may also compromise a patient’s well-being: Ambivalent providers may visit less often, educate patients less avidly and spend less time devising the best treatments.

The worst effect of confining addicted patients in the hospital may be the damage to the patient-provider bond. 

To read more, including my proposal to let opioid users inject in the hospital, check out my new op-ed at The New York Times. 

Also, check out my new 8-minute radio spot about the topic at for Word of Mouth by Virginia Prescott at NHPR. It was also a trip to appear on Sirius XM's widely-syndicated Michael Smerconish show, although a recording has not been archived. The controversy the post created was nicely covered in Concord's Union Leader.

Vaccines just aren't as easy to discover as they used to be

Edward Jenner had it easy. Swab some cowpox in 1796, scratch the nastiness into the arm of a little kid (see below), and, PRESTO, instant immortality. 

Vaccine success after vaccine success followed. Measles, mumps, rubella, polio... one after another global scourge quaked before the mighty pipettes of vaccine researchers.

I admit, the stalwarts who discovered those vaccines did more than transfer cow-pus to an un-consented minor research subject prior to doing a victory lap around the farm. Rather, they earned their laurels by working hard, and by being brilliant.

But ease wrought hubris, and as deadly viral menaces fell in succession, you could forgive one noted twentieth century sage, US Surgeon General William Stewart (pictured below), for saying, "It’s time to close the books on infectious diseases, declare the war against pestilence won, and shift national resources to such chronic problems as cancer and heart disease."

Whoops!

These early triumphs gave way to a long, hard slog. Vaccines against HIV, tuberculosis, herpes, staphylococci, and hepatitis C, among others, have proven far more elusive. Amid small successes, and spectacular failures, we have discovered an uncomfortable fact: we don't really know what makes a good vaccine tick. 

This week I was glad to contribute both heat and noise to the mix. In an op-ed in the Health Affairs blog, I write about the dangers of dogmatism and the lessons learned on the road to a new HIV vaccine. And, we also published preclinical data this week on a new scalable version of our tuberculosis vaccine. Data from our Phase 1 trial of the same vaccine should come out soon!

Who knows if all this will lead to glory. Probably not! Either way, it's been a pleasure to try. 

World AIDS Day 2016

As World AIDS Day approaches on Thursday, there is so much to be thankful for, and so much work yet undone.

People with HIV on effective treatment live as long as those without HIV, and almost never transmit HIV to their seronegative partners. Pre-exposure prophylaxis (PrEP) is safe and it works, and through it and other means of prevention we are slowing the epidemic, bit by bit. This fall a new vaccine aiming to build on the RV144 success story began testing in South Africa.

Despite those massive successes, 2 million more people are newly infected with HIV every year. Less than half of the world's HIV-positive population can access HIV therapy. In the United States, only 30 percent of people with HIV achieve the goal of full virological suppression on medications. A substantial fraction of people living with HIV don't know they are infected, and stigma is still a problem for people with HIV.

HIV is the defining health threat of our day. We have made real progress, but we cannot be complacent. It was a honor to discuss these issues and more for NHPR's Exchange radio show.

Will legislators defuse the ticking time bomb of dirty needle use?

For years, Indiana had slowly dismantled its public health system, and needle exchange programs lacked both funding and legal safeguards. Then an HIV outbreak exploded into public view, and Republican Governor Mike Pence had to do some fancy footwork to undo the damage done. He allowed needle exchange programs to operate and provided some long overdue prevention funding. In the meantime, dozens of young Indianans were infected with hepatitis C and HIV. It was a sad case of politics overturning science and common sense.

Now, New Hampshire and other states are in the same boat: politically-minded legislators bloviate about punitive anti-drug stances while the opiate epidemic rages. Complications of injection drug use are on the rise, and it's only a matter of time before a new HIV outbreak comes to town. Needle exchange programs, proven over and again to prevent infections and thus to save lives, languish in the legal shadows.

Fortunately, new legislation is being considered to change help catch New Hampshire up to the 21st Century, and maybe save some lives in the process. I was proud to be quoted here about this overdue change.

Swipe right to connect young people to HIV testing

Midway through her sophomore year of high school, my patient told her parents that she had missed two periods and was worried she might be pregnant.

Stunned to learn that she was sexually active, her parents took her to the pediatrician, who had another surprise: She wasn’t pregnant but she did have H.I.V.

To learn more - including how my patient could have been protected from late H.I.V. diagnosis by a cool mobile app - check out my new post up at The New York Times. Many thanks to support from Dartmouth Public Voices Fellowship, a chapter of the Op-ed Project.

Why we shouldn't over-hype the use of PrEP to prevent HIV transmission

Recently we got great news from a real-world study of HIV pre-exposure prophylaxis (PrEP).

Researchers at San Francisco's Kaiser Permanente Medical Center reported on the real-world experience of 657 people who started PrEP between 2012 and 2015. Over 99% were men who have sex with men, 84% reported multiple sexual partners, and 30% had HIV-positive partners. Together they were observed for over 388 person-years of PrEP use.

The big news: Exactly zero patients contracted HIV infection! That's huge.

The problem is, the popular conversation about it has been over the top. From The Washington Post to FoxNews and the Huffington Post, people have been saying it's "100% effective" and lots of other undeserved superlatives.

PrEP works, this study was great, but there is real danger in all of this over-hype.

Read more in my new post over at TheBodyPro. 

New challenges of an aging epidemic

The AIDS activist Larry Kramer once said,

AIDS was allowed to happen. It is a plague that need not have happened. It is a plague that could have been contained from the very beginning.

The past 10 years we have witnessed innumerable incredible advances in HIV science and HIV treatment, but Mr. Kramer's words still ring true. We could have done more to stop it, and we still leave a lot of the work left undone.

This is particularly poignant since new challenges have now joined the old scourges of poverty and stigma and the wily habits of a historically pernicious virus. 

These new challenges include what one of my patients called the "Peter Pan Syndrome" and an uptick in injection drug use in many areas of the United States. The Peter Pan Syndrome is when patients told they did not have long to live at the beginning of the HIV epidemic now grapple with the accelerated effects of aging, a phase of life they never thought they would face. Additional challenges include complacency in youth who didn't grow up losing friends from HIV, and donor fatigue, and the short-term thinking of budget-conscious legislators who cut funding to HIV prevention programs that save lives.

These and other modern realities of the 2015 HIV epidemic are on full display in a new article in the Concord Monitor in which I was proud to be quoted, including:

The most pernicious myth in the HIV epidemic today is that people infected with HIV contracted the virus because they are somehow different – that in some way people with HIV deserved to get infected. This is hard-hearted and ill-informed, but I understand how the finger-pointing can be a defense mechanism against fear. The truth is, we are all vulnerable to this wily virus, and the only way we will win against HIV is to band together in compassion.

Twenty years from now will we look back and say we learned from our early mistakes, or will we rue the mistakes we made again and again?

So much has changed since the HIV test was first approved, 30 years ago today

Thirty years ago today, on March 2, 1985, the Food and Drug Administration approved a new HIV test. It was the result of nine months of round-the-clock labor by dozens of scientists. Immediately adopted by the American Red Cross and other institutions, the blood test marked the beginning of a new era in HIV medicine.

Since then, so much has changed. Check out my new post at The Conversation to learn more.

Why we shouldn't say we have a "cure" for HIV until it's really true

The Berlin patient, Timothy Ray Brown, is historically unique - he is the only person ever truly cured of HIV. 

But in recent years scientific journals and the popular press alike have published multiple claims of HIV cures. From the French "functional cure" to the Mississippi baby, we have seen the word "cure" used a lot -- as well as vague synonyms for it like "cleared" and "HIV-free" -- and yet each time we've had to walk the hype back. 

Check out my new post over at The Conversation on why we shouldn't overhype HIV "cures."