When you are too sick to fly

Air travel is a great way to get free peanuts, a deep vein thrombosis and the worst cold of your life. Plus: baggage fees!

Ever since Andrew Speaker took to the friendly skies with drug resistant tuberculosis, and brave Ebola outbreak workers returned sick to the United States, avid international attention has focused on the infectious risks of air travel, too.

Could the next pandemic spread on planes? 

We should care more about the people who live in areas where millions of people get sick from infectious scourges without having to invoke international travel. Yet it is reasonable for people who travel in rich countries to want to stay healthy as well. 

Proudly quoted in this brief article by Allison Fox of HuffPo.

What's the best way to incentivize immunizations?

Vaccination saves lives.

Yet, resistance to immunization has become entrenched in some sociodemographic strata. Wealthy, educated liberals who care about organic food and "natural" products among them. 

Under-immunization of school-aged children in turn has led to outbreaks of measles and other transmissible infections, and contributes to  thousands of preventable influenza deaths in children each year. 

It's not enough to tout the benefits of vaccines, and then stand back with syringe in hand. Potential vaccines want to know vaccines are safe, and hear misconceptions about the low risks of vaccines. A seminal article by my Dartmouth colleague Brendan Nyhan showed that trying to disabuse vaccine skeptics of their misconception too may fail. 

Many states and countries are piloting various incentive programs designed to enhance immunization rates without engaging in potentially polarizing debate. From making immunizations mandatory to attend school to linking welfare benefits to vaccine receipt and even straight up cash incentives, lots of experiments are happening. Some of them even work.

Check out this great article by Susan Scutti of CNN and its accompanying video. I was proud to be quoted in it.

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.

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. 

HIV doesn't happen here

The rural state of New Hampshire has some of the lowest HIV incidence and prevalence rates in the United States. That's great news, but it comes with a price. 

Many at risk people in New Hampshire think HIV is a third world or city problem and not something they need to worry about personally. That means they are less likely to take precautions against HIV. 

At the same time, people who have been diagnosed with HIV in New Hampshire face stigma from neighbors and friends who may be less familiar with HIV than people living in urban areas where the disease is more prevalent. Geography adds to those challenges: the ~650 people cared for at Dartmouth-Hitchcock HIV Program come from a much wider geographic area than patients in similarly sized clinics in metropolitan areas. That translates to longer travel times and more complicated access to care.

Not surprisingly, HIV patients living in rural areas have been shown by Sam Bozzette and others to receive substandard care, probably because HIV experts are not sufficiently accessible.

In formal analyses at the Dartmouth-Hitchcock HIV Program, our HIV expert providers  delivered outstanding care equivalently to rural and urban patients  But despite this my colleagues and I showed that our rural patients have higher rates of depression and even higher mortality. New Hampshire might be a lovely place to live, but living with HIV infection anywhere is no walk in the park. 

Todd Bookman of NHPR touches on these and other issues in nice  radio story in which I was quoted. There are still plenty of battles remaining in the war against HIV in New Hampshire.