Policy Watch: Using Science, Abusing Science
Dr Gebbie is Elizabeth Standish Gill Associate Professor of Nursing and director of the Center for Health Policy, Columbia University School of Nursing, New York.
The Washington state legislature is being asked to authorize distribution of condoms to inmates of the state prison, acknowledging that sexual activity does occur among confined populations and that proper use of a condom during intercourse can prevent the transmission of HIV infection and other sexually transmitted diseases.1 Activists in the HIV community have long advocated such distributions and point out that this is already done in some other countries, as well as in a limited number of systems in the United States. This author has no problem with the policy: it makes perfect public health sense, although there are other concerns such as security and control of contraband that must be taken into account in jails and prisons, where health is not the first or only priority. The challenge is to present the case for condoms without abusing science.
What does this mean? It means careful reading of the data from the recently published analysis of HIV transmission in the Georgia prison system. Some of the press coverage could have led to an assumption that transmission, while not running riot, was at least relatively frequent; that is the conclusion I have heard expressed in some settings. Good epidemiology and an understanding of the denominator (the daily population over a multi-year period) point to a different conclusion: yes, some transmission occurs, but relatively little. Translating that information to the prison population of the state of Washington, the estimated transmission is 1 case in 4 to 5 years. Exaggerating the rate of transmission to make the case for a desired policy change is not good use of science.
On the other hand, neither are prisons any different from the rest of the community with regard to harm-reduction messages. The information from Georgia suggests that the prisoners studied there attempted some form of protection, with illicit condoms or other methods. The "don't make condoms available because it's a mixed message about sex" reasoning is no more appropriate for an adult prison population than it is for a group of adolescents, although that view was apparently expressed by a physician associated with the corrections system in the state.
We know from years of study that available information and condoms do not increase the rate of sexual activity and certainly may make it safer when such activity does occur. Sexual contact does take place in prisons–although probably with much less frequency than the television dramas would have us believe–and probably, much of it is consensual. For that reason, it is essential that, at a minimum, adequate information on harm reduction be available. However, misusing science, either by ignoring what we know about the effectiveness of prevention information and services or by exaggerating the risk of disease, carries the risk that HIV advocates are the current version of Chicken Little.
Another current news story confirms some of the risks of jumping ahead without careful consideration: the "epidemic that wasn't" of pertussis in a New England hospital.2 Use of a rapid test on large numbers of persons led to many false-positive results, none of which was ever confirmed by later, more accurate testing. More than 100 workers had been furloughed from work to limit the epidemic that was not even there.
Many of us are pleased that new techniques have sped up the process of identifying potentially serious conditions, either to facilitate access to treatment or to identify those who are ill and do not yet know it. Every screening test used to sort those likely to have a problem from those not likely to have it and open the door to more definitive testing has false-positives. If the test is so specific that it never mistakes a well person for an ill one, it will have false-negatives.
No screening test is perfect. But our world is full of demands for quick answers, and people are far too quick to begin using a new technique without careful understanding of the science on which it is founded and the degree to which one can make accurate decisions based on the findings or can only point toward some further source of information.
For a third example, the January 22 issue of Archives of Internal Medicine reported that selenium supplements can decrease HIV RNA level and increase CD4+ cell count.3 I predict a run on vitamin, mineral, and food supplements with selenium. However, a careful reading identifies this study as being based on analysis of results from 50 persons who took selenium for 9 months, compared with 83 who took placebo. The reported variations are relatively small and may be meaningless in a population with good access to current antiretroviral therapy. Should clinicians change prescribing/patient education practices based on this study? Probably not.
Why focus on these issues? Because with Congress back in session, most state legislatures meeting over the coming weeks, and a high turnover in policy staff due to the change of party or incumbent in state houses and legislative seats, a new group will have to be educated about the real issues facing those of us who are concerned about the HIV pandemic, its prevention, and the treatment of those who are ill.
If we do not get our science right and learn to speak and use it accurately, we will not be able to help our elected decision makers choose wisely. While we may have kept up-to-date, there are many who have not been attuned to either the epidemic or the current state of the science. Now would be a good time to update our "HIV 101" and "AIDS ABCs" handouts and be sure they are in the hands of those who will be making policy in the coming weeks and months.
References1. Washington state legislature to consider bill aimed at HIV transmission in prisons. Kaiser Daily Reports. January 22, 2007.
2. Kolata G. Faith in quick test leads to epidemic that wasn't. New York Times. January 22, 2007.
3. Hurwitz B, Klaus JR, Llabre MM, et al. Suppression of human immunodeficiency virus type 1 viral load with selenium supplementation: a randomized controlled trial. Arch Intern Med. 2007;167:148-154