Science
Expert Panel Recommends New Options for H.I.V. Prevention
An influential expert panel has given its highest recommendation to an expanded menu of H.I.V. prevention strategies for adults and adolescents, a move that will require private insurers to cover the drugs without a co-pay or deductible under the Affordable Care Act.
The recommendation arrives as the Biden administration is fighting to preserve no-cost coverage of all preventive services under the A.C.A., after a Texas judge ruled the mandate to be unconstitutional.
The ruling was aimed in particular at medications approved for use as pre-exposure prophylaxis (or PrEP) to prevent H.I.V., arguing that requiring its coverage violated the religious rights of employers.
In the new recommendations, published on Tuesday in JAMA, the U.S. Preventive Services Task Force gave its highest or “grade A” recommendation to three medications approved for PrEP.
The new ruling updates the earlier endorsement of a single daily pill, Truvada or generic equivalents, for PrEP. The task force now has included Descovy, another pill, and cabotegravir (marketed as Apretude), an injectable drug given every two months.
Generic Truvada generally costs $1 per day, while the new options may cost more than $20,000 per year.
An estimated 1.2 million Americans are living with H.I.V. Thanks to powerful medications, the virus is not the death sentence it once was. Still, H.I.V. is not yet curable, save for a handful of extraordinary examples, and preventing new cases is a public health priority.
Nearly 31,000 people acquired H.I.V. in 2020, and nearly 70 percent of those cases occurred among adolescents and adult men who have sex with men. A 2018 study estimated that more than 12 percent of men who have sex with men in the United States are living with H.I.V.
“We already do a really, really crummy job in our country of providing preventive services,” Dr. Thomas Dobbs, dean of the University of Mississippi’s John D. Bower School of Population Health, said.
“If we don’t have no-cost access to some of the most essential preventive services, our poor health standing is only going to deteriorate.”
The new guidelines recommend that clinicians routinely ask patients about their sexual and injection drug use history. Doctors should offer PrEP to anyone who has a sexual partner with H.I.V., has had a bacterial sexually transmitted infection within the past six months, uses condoms inconsistently or never, injects drugs or has a drug-injecting partner with H.I.V., or engages in transactional sex, the task force said.
The C.D.C., on the other hand, recommends that clinicians discuss PrEP with all sexually active adults and adolescents, and prescribe PrEP to anyone who asks for it.
“It’s hard to tease out who might be a risk, and certainly sometimes those conversations are kind of tricky,” Dr. Dobbs said. “If people think that they need it, that’s all that we have to hear to say yes.”
In June 2019, the task force recommended the only drug available for PrEP at the time, Truvada. (Generic versions have since become available.)
In October 2019, the Food and Drug Administration approved another daily pill, Descovy, to prevent H.I.V. in men and transgender women; the drug is only now being studied in cisgender women. Descovy is thought to be safer than Truvada for people with kidney disease or osteoporosis.
And in December 2021, the agency approved the long-acting shot, cabotegravir, for PrEP. Cabotegravir is administered every two months and offers an alternative to people who are unable or unwilling to take a daily pill to prevent H.I.V. In two trials, the injection appeared to be more effective at thwarting H.I.V. than Truvada and its generic equivalents were.
To update its recommendations in 2019, the task force commissioned a systematic review of 32 studies, most of which clearly showed PrEP’s benefits.
The task force sometimes moves slowly, but in this case it “acted fairly swiftly to update the recommendation,” Amy Killelea, a consultant to the advocacy organization PrEP4All, said. The new stance “matches the evidence base that we have right now for PrEP.”
Several studies have also shown that cisgender men who have sex with men can use generic Truvada for “on-demand” PrEP. Two pills are taken two to 24 hours before sex, one pill 24 hours after the double dose and another 24 hours later. The International AIDS Society and World Health Organization endorse this approach as effective.
Adoption of PrEP has been slow for a number of reasons, including a lack of awareness and unwillingness to take the daily pills. It’s not yet clear whether insurance companies will stand up hurdles to the new regimens, such as offering generic Truvada as the first-line preventive and requiring prior authorization for the other options.
“Those prioritizations and stuff are a real impediment to having choice,” Dr. Dobbs said.
Clinicians will also need to combat striking racial disparities in PrEP use. In 2021, Black Americans accounted for roughly 40 percent of new H.I.V. diagnoses. That year, only 11 percent of Black people who were expected to benefit from PrEP received it, compared with 78 percent of white people who met the criteria.
The task force’s recommendation also does not ease access for uninsured people.
“We have a huge access problem for people who are uninsured in this country, and we have a growing health equity crisis,” Ms. Killelea said. “A federal national PrEP program would help to solve that problem.”
PrEP does not reduce the risk of other sexually transmitted infections. Clinicians should counsel patients about taking their medications on time, practicing safe sex, including condom use, and testing regularly for H.I.V. and other sexually transmitted diseases, the task force said.
Science
Cluster of farmworkers diagnosed with rare animal-borne disease in Ventura County
A cluster of workers at Ventura County berry farms have been diagnosed with a rare disease often transmitted through sick animals’ urine, according to a public health advisory distributed to local doctors by county health officials Tuesday.
The bacterial infection, leptospirosis, has resulted in severe symptoms for some workers, including meningitis, an inflammation of the brain lining and spinal cord. Symptoms for mild cases included headaches and fevers.
The disease, which can be fatal, rarely spreads from human to human, according to the U.S. Centers for Disease Control and Prevention.
Ventura County Public Health has not given an official case count but said it had not identified any cases outside of the agriculture sector. The county’s agriculture commissioner was aware of 18 cases, the Ventura County Star reported.
The health department said it was first contacted by a local physician in October, who reported an unusual trend in symptoms among hospital patients.
After launching an investigation, the department identified leptospirosis as a probable cause of the illness and found most patients worked on caneberry farms that utilize hoop houses — greenhouse structures to shelter the crops.
As the investigation to identify any additional cases and the exact sources of exposure continues, Ventura County Public Health has asked healthcare providers to consider a leptospirosis diagnosis for sick agricultural workers, particularly berry harvesters.
Rodents are a common source and transmitter of disease, though other mammals — including livestock, cats and dogs — can transmit it as well.
The disease is spread through bodily fluids, such as urine, and is often contracted through cuts and abrasions that contact contaminated water and soil, where the bacteria can survive for months.
Humans can also contract the illness through contaminated food; however, the county health agency has found no known health risks to the general public, including through the contact or consumption of caneberries such as raspberries and blackberries.
Symptom onset typically occurs between two and 30 days after exposure, and symptoms can last for months if untreated, according to the CDC.
The illness often begins with mild symptoms, with fevers, chills, vomiting and headaches. Some cases can then enter a second, more severe phase that can result in kidney or liver failure.
Ventura County Public Health recommends agriculture and berry harvesters regularly rinse any cuts with soap and water and cover them with bandages. They also recommend wearing waterproof clothing and protection while working outdoors, including gloves and long-sleeve shirts and pants.
While there is no evidence of spread to the larger community, according to the department, residents should wash hands frequently and work to control rodents around their property if possible.
Pet owners can consult a veterinarian about leptospirosis vaccinations and should keep pets away from ponds, lakes and other natural bodies of water.
Science
Political stress: Can you stay engaged without sacrificing your mental health?
It’s been two weeks since Donald Trump won the presidential election, but Stacey Lamirand’s brain hasn’t stopped churning.
“I still think about the election all the time,” said the 60-year-old Bay Area resident, who wanted a Kamala Harris victory so badly that she flew to Pennsylvania and knocked on voters’ doors in the final days of the campaign. “I honestly don’t know what to do about that.”
Neither do the psychologists and political scientists who have been tracking the country’s slide toward toxic levels of partisanship.
Fully 69% of U.S. adults found the presidential election a significant source of stress in their lives, the American Psychological Assn. said in its latest Stress in America report.
The distress was present across the political spectrum, with 80% of Republicans, 79% of Democrats and 73% of independents surveyed saying they were stressed about the country’s future.
That’s unhealthy for the body politic — and for voters themselves. Stress can cause muscle tension, headaches, sleep problems and loss of appetite. Chronic stress can inflict more serious damage to the immune system and make people more vulnerable to heart attacks, strokes, diabetes, infertility, clinical anxiety, depression and other ailments.
In most circumstances, the sound medical advice is to disengage from the source of stress, therapists said. But when stress is coming from politics, that prescription pits the health of the individual against the health of the nation.
“I’m worried about people totally withdrawing from politics because it’s unpleasant,” said Aaron Weinschenk, a political scientist at the University of Wisconsin–Green Bay who studies political behavior and elections. “We don’t want them to do that. But we also don’t want them to feel sick.”
Modern life is full of stressors of all kinds: paying bills, pleasing difficult bosses, getting along with frenemies, caring for children or aging parents (or both).
The stress that stems from politics isn’t fundamentally different from other kinds of stress. What’s unique about it is the way it encompasses and enhances other sources of stress, said Brett Ford, a social psychologist at the University of Toronto who studies the link between emotions and political engagement.
For instance, she said, elections have the potential to make everyday stressors like money and health concerns more difficult to manage as candidates debate policies that could raise the price of gas or cut off access to certain kinds of medical care.
Layered on top of that is the fact that political disagreements have morphed into moral conflicts that are perceived as pitting good against evil.
“When someone comes into power who is not on the same page as you morally, that can hit very deeply,” Ford said.
Partisanship and polarization have raised the stakes as well. Voters who feel a strong connection to a political party become more invested in its success. That can make a loss at the ballot box feel like a personal defeat, she said.
There’s also the fact that we have limited control over the outcome of an election. A patient with heart disease can improve their prognosis by taking medicine, changing their diet, getting more exercise or quitting smoking. But a person with political stress is largely at the mercy of others.
“Politics is many forms of stress all rolled into one,” Ford said.
Weinschenk observed this firsthand the day after the election.
“I could feel it when I went into my classroom,” said the professor, whose research has found that people with political anxiety aren’t necessarily anxious in general. “I have a student who’s transgender and a couple of students who are gay. Their emotional state was so closed down.”
That’s almost to be expected in a place like Wisconsin, whose swing-state status caused residents to be bombarded with political messages. The more campaign ads a person is exposed to, the greater the risk of being diagnosed with anxiety, depression or another psychological ailment, according to a 2022 study in the journal PLOS One.
Political messages seem designed to keep voters “emotionally on edge,” said Vaile Wright, a licensed psychologist in Villa Park, Ill., and a member of the APA’s Stress in America team.
“It encourages emotion to drive our decision-making behavior, as opposed to logic,” Wright said. “When we’re really emotionally stimulated, it makes it so much more challenging to have civil conversation. For politicians, I think that’s powerful, because emotions can be very easily manipulated.”
Making voters feel anxious is a tried-and-true way to grab their attention, said Christopher Ojeda, a political scientist at UC Merced who studies mental health and politics.
“Feelings of anxiety can be mobilizing, definitely,” he said. “That’s why politicians make fear appeals — they want people to get engaged.”
On the other hand, “feelings of depression are demobilizing and take you out of the political system,” said Ojeda, author of “The Sad Citizen: How Politics is Depressing and Why it Matters.”
“What [these feelings] can tell you is, ‘Things aren’t going the way I want them to. Maybe I need to step back,’” he said.
Genessa Krasnow has been seeing a lot of that since the election.
The Seattle entrepreneur, who also campaigned for Harris, said it grates on her to see people laughing in restaurants “as if nothing had happened.” At a recent book club meeting, her fellow group members were willing to let her vent about politics for five minutes, but they weren’t interested in discussing ways they could counteract the incoming president.
“They’re in a state of disengagement,” said Krasnow, who is 56. She, meanwhile, is looking for new ways to reach young voters.
“I am exhausted. I am so sad,” she said. “But I don’t believe that disengaging is the answer.”
That’s the fundamental trade-off, Ojeda said, and there’s no one-size-fits-all solution.
“Everyone has to make a decision about how much engagement they can tolerate without undermining their psychological well-being,” he said.
Lamirand took steps to protect her mental health by cutting social media ties with people whose values aren’t aligned with hers. But she will remain politically active and expects to volunteer for phone-banking duty soon.
“Doing something is the only thing that allows me to feel better,” Lamirand said. “It allows me to feel some level of control.”
Ideally, Ford said, people would not have to choose between being politically active and preserving their mental health. She is investigating ways to help people feel hopeful, inspired and compassionate about political challenges, since these emotions can motivate action without triggering stress and anxiety.
“We want to counteract this pattern where the more involved you are, the worse you are,” Ford said.
The benefits would be felt across the political spectrum. In the APA survey, similar shares of Democrats, Republicans and independents agreed with statements like, “It causes me stress that politicians aren’t talking about the things that are most important to me,” and, “The political climate has caused strain between my family members and me.”
“Both sides are very invested in this country, and that is a good thing,” Wright said. “Antipathy and hopelessness really doesn’t serve us in the long run.”
Science
Video: SpaceX Unable to Recover Booster Stage During Sixth Test Flight
President-elect Donald Trump joined Elon Musk in Texas and watched the launch from a nearby location on Tuesday. While the Starship’s giant booster stage was unable to repeat a “chopsticks” landing, the vehicle’s upper stage successfully splashed down in the Indian Ocean.
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