Sexual Moralizing Spreads AIDS

Andrea Lynch

Is there room for sexual moralizing in an honest conversation about AIDS? Not if that moralizing causes suffering, stigma, alienation, and excludes people needed to stop the spread of AIDS.

Helen Epstein, scientist-turned-journalist and author of The Invisible Cure: Africa, the West and the Fight against AIDS, has a sharp new article in the Guardian titled "There is no room for sexual morality in an honest conversation about Aids." It's an important message from someone who has focused many of her writings on HIV on the issue of fidelity, and it does an excellent job of unpacking the risks associated with a morality-based approach to fidelity promotion-particularly for women.

It also does a nice job of stepping outside the ideological platitudes that so often structure the HIV/AIDS conversation, and opting instead for an informed exploration of how complex change actually looks in practice. Epstein writes:

I've been thinking about this for nearly 15 years, and it's become increasingly clear to me that the key to fighting Aids lies in something for which public health has no name or programme. It is best described as a sense of solidarity, compassion and mutual aid that is impossible to quantify or measure. It has to be this way. Because our sexuality is shaped by society and because sex itself involves more than one person, behaviour change is a collective act, not one of individuals acting alone.

Nicely put. Epstein bases her analysis on her experiences as a scientist-researcher in Uganda in the 1990s, drawing a comparison (despite cultural and epidemiological differences) between Uganda's response to HIV/AIDS in the late 1980s and early 1990s (resulting in a 70 percent decrease in the infection rate) and the gay community's response to HIV/AIDS in the 1980s in the U.S. (resulting in an 80 percent decrease in the infection rate).

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Along the way, she makes some important points: first, she stresses that HIV rates in Africa are not high because Africans have more sexual partners than people in other regions of the world (research demonstrates that the contrary is true, in fact), but rather because Africans are more likely to have concurrent sexual relationships. It was the acceptance of this epidemiological reality-as well as a focus on the related reality that everyone is vulnerable to HIV/AIDS, not just truck drivers, sex workers, and other so-called promiscuous people-that made Uganda's first HIV prevention campaigns so effective.

Of course, things are different in Uganda now, and the country that was once hailed as Africa's greatest HIV prevention success story has now become a destination for HIV/AIDS carpetbaggers and ideologues worldwide. Most distressingly, now that Ugandan President Yoweri Museveni and his wife Janet have disavowed the practical, science-and-solidarity-based messages, opting instead to stump for abstinence and crusade against condoms. They are supported by the Bush administration and a slew of U.S.-funded right-wing Christian organizations with no experience in HIV prevention but plenty of experience in morality promotion. As a result Uganda's infection rate is on the rise.

It's an unconscionable situation. Putting aside the cooked-up conclusions from the right-wing cheerleaders at the Heritage Foundation, research has shown time and time again that abstinence-only programs are a complete and utter waste of time for everyone but the people getting paid to promote them. HIV-positive Ugandan activists like Beatrice Were have done an excellent job of articulating the dangers of a fidelity-based approach to HIV prevention, which often leads women into a false sense of security, failing to emphasize that fidelity only protects you if your partner is faithful too. As Epstein points out, it's one thing to talk about partner reduction in places where people commonly have concurrent partners, but talking about fidelity in moral terms (and thereby associating HIV with moral failure), is a strategy destined to make the problem worse.

Epstein highlights the perils of a morality-based approach through an analysis of a poster in Botswana that was part of a U.S. government funded HIV prevention campaign. The poster showed a condom and a boxing glove alongside the slogan, "It can take the fiercest punches." She reflects:

The ad reflected the prevailing view among epidemiologists at the time, that HIV was spread by "high risk groups" – meaning, typically, promiscuous people. This was true in most of the rest of the world, but not in Botswana. The boxing glove ad and others like it may have promoted a false sense of security, and by associating HIV with womanizing and violence, the ads may also have unintentionally reinforced the shame and denial that has made Aids prevention in southern Africa so difficult.

Good point. As Epstein's article emphasizes, there are two kinds of approaches to HIV prevention: those that divide people, and those that unite them against HIV. By dividing, we don't simply cause suffering, stigma, and alienation in a world that already offers enough of all three things during the average lifetime. We also silence and exclude, in the name of morality, those who could be our most powerful allies.

News Abortion

Study: Telemedicine Abortion Care a Boon for Rural Patients

Nicole Knight

Despite the benefits of abortion care via telemedicine, 18 states have effectively banned the practice by requiring a doctor to be physically present.

Patients are seen sooner and closer to home in clinics where medication abortion is offered through a videoconferencing system, according to a new survey of Alaskan providers.

The results, which will be published in the Journal of Telemedicine and Telecare, suggest that the secure and private technology, known as telemedicine, gives patients—including those in rural areas with limited access—greater choices in abortion care.

The qualitative survey builds on research that found administering medication abortion via telemedicine was as safe and effective as when a doctor administers the abortion-inducing medicine in person, study researchers said.

“This study reinforces that medication abortion provided via telemedicine is an important option for women, particularly in rural areas,” said Dr. Daniel Grossman, one of the authors of the study and professor of obstetrics, gynecology, and reproductive sciences at the University of California San Francisco (UCSF). “In Iowa, its introduction was associated with a reduction in second-trimester abortion.”

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Maine and Minnesota also provide medication abortion via telemedicine. Clinics in four states—New York, Hawaii, Oregon, and Washington—are running pilot studies, as the Guardian reported. Despite the benefits of abortion care via telemedicine, 18 states have effectively banned the practice by requiring a doctor to be physically present.

The researchers noted that even “greater gains could be made by providing [medication abortion] directly to women in their homes,” which U.S. product labeling doesn’t allow.

In late 2013, researchers with Ibis Reproductive Health and Advancing New Standards in Reproductive Health interviewed providers, such as doctors, nurses, and counselors, in clinics run by Planned Parenthood of the Great Northwest and the Hawaiian Islands that were using telemedicine to provide medication abortion. Providers reported telemedicine’s greatest benefit was to pregnant people. Clinics could schedule more appointments and at better hours for patients, allowing more to be seen earlier in pregnancy.

Nearly twenty-one percent of patients nationwide end their pregnancies with medication abortion, a safe and effective two-pill regime, according to the most recent figures from the U.S. Centers for Disease Control and Prevention.

Alaska began offering the abortion-inducing drugs through telemedicine in 2011. Patients arrive at a clinic, where they go through a health screening, have an ultrasound, and undergo informed consent procedures. A doctor then remotely reviews the patients records and answers questions via a videoconferencing link, before instructing the patient on how to take the medication.

Before 2011, patients wanting abortion care had to fly to Anchorage or Seattle, or wait for a doctor who flew into Fairbanks twice a month, according to the study’s authors.

Beyond a shortage of doctors, patients in Alaska must contend with vast geography and extreme weather, as one physician told researchers:

“It’s negative seven outside right now. So in a setting like that, [telemedicine is] just absolutely the best possible thing that you could do for a patient. … Access to providers is just so limited. And … just because you’re in a state like that doesn’t mean that women aren’t still as much needing access to these services.”

“Our results were in line with other research that has shown that this service can be easily integrated into other health care offered at a clinic, can help women access the services they want and need closer to home, and allows providers to offer high-level care to women from a distance,” Kate Grindlay, lead author on the study and associate at Ibis Reproductive Health, said in a statement.

News Abortion

How Long Does It Take to Receive Abortion Care in the United States?

Nicole Knight

The national findings come amid state-level research in Texas indicating that its abortion restrictions forced patients to drive farther and spend more to end their pregnancies.

The first nationwide study exploring the average wait time between an abortion care appointment and the procedure found most patients are waiting one week.

Seventy-six percent of patients were able to access abortion care within 7.6 days of making an appointment, with 7 percent of patients reporting delays of more than two weeks between setting an appointment and having the procedure.

In cases where care was delayed more than 14 days, patients cited three main factors: personal challenges, such as losing a job or falling behind on rent; needing a second-trimester procedure, which is less available than earlier abortion services; or living in a state with a mandatory waiting period.

The study, “Time to Appointment and Delays in Accessing Care Among U.S. Abortion Patients,” was published online Thursday by the Guttmacher Institute.

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The national findings come amid state-level research in Texas indicating that its abortion restrictions forced patients to drive farther and spend more to end their pregnancies. A recent Rewire analysis found states bordering Texas had reported a surge in the number of out-of-state patients seeking abortion care.

“What we tend to hear about are the two-week or longer cases, or the women who can’t get in [for an appointment] because the wait is long and they’re beyond the gestational stage,” said Rachel K. Jones, lead author and principal research scientist with the Guttmacher Institute.

“So this is a little bit of a reality check,” she told Rewire in a phone interview. “For the women who do make it to a facility, providers are doing a good job of accommodating these women.”

Jones said the survey was the first asking patients about the time lapse between an appointment and procedure, so it’s impossible to gauge whether wait times have risen or fallen. The findings suggest that eliminating state-mandated waiting periods would permit patients to obtain abortion care sooner, Jones said.

Patients in 87 U.S. abortion facilities took the surveys between April 2014 and June 2015. Patients answered various questions, including how far they had traveled, why they chose the facility, and how long ago they’d called to make their appointment.

The study doesn’t capture those who might want abortion care, but didn’t make it to a clinic.

“If women [weren’t] able to get to a facility because there are too few of them or they’re too far way, then they’re not going to be in our study,” Jones said.

Fifty-four percent of respondents came from states without a forced abortion care waiting period. Twenty-two percent were from states with mandatory waits, and 24 percent lived in states with both a mandatory waiting period and forced counseling—common policies pushed by Republican-held state legislatures.

Most respondents lived at or below the poverty level, had experienced at least one personal challenge, such as a job loss in the past year, and had one or more children. Ninety percent were in the first trimester of pregnancy, and 46 percent paid cash for the procedure.

The findings echo research indicating that three quarters of abortion patients live below or around the poverty line, and 53 percent pay out of pocket for abortion care, likely causing further delays.

Jones noted that delays—such as needing to raise money—can push patients later into pregnancy, which further increases the cost and eliminates medication abortion, an early-stage option.

Recent research on Utah’s 72-hour forced waiting period showed the GOP-backed law didn’t dissuade the vast majority of patients, but made abortion care more costly and difficult to obtain.

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