One part of ending the epidemic: AIDS & Alcohol

In recognition of World AIDS Day, we should keep in mind that excessive alcohol consumption is a considerable – yet often underrecognized – risk factor in the transmission and course of HIV/AIDS.  Reducing excessive alcohol consumption should be one part of a multi-pronged strategy to eliminate HIV/AIDS.

Consider:

-  Alcohol consumption has been linked to an increased likelihood of high-risk sexual behaviors, including unprotected sex, multiple partners, and sex with high-risk partners. (1)

- HIV acquisition and onward transmission are worsened by heavy drinking through increased viral replication (2),  increased vaginal shedding (3) , and disruption of immune barriers in the gastrointestinal & respiratory tracts (4).

-  Excessive alcohol consumption has been shown to lead to impairment of immune function, with heavy alcohol consumption found to cause declines of CD4 cell counts and nonsuppression of HIV viral load (5).

-  One especially strong body of research shows that risky drinking has adverse effects on antiretroviral treatment (ART) adherence (6).

-  Because of this, Braithwaite and colleagues found that even nonhazardous alcohol consumption decreased survival rates for HIV-positive individuals, with hazardous consumption decreasing survival rates considerably more (7).

Furthermore, the alcohol environment can play a role in HIV/AIDS transmission:

- States with liquor sales in drug and grocery stores were found to have greater odds of risky drinking among HIV-positive residents than states without such sales (8).

- Neighborhoods with higher concentrations of on-site alcohol outlets (e.g. bars, nightclubs) have been found to have higher HIV/AIDS rates among 2 high-risk groups:  men who have sex with men (MSM) and intravenous drug users (IDU) (9).

It follows that  stakeholders in the battle against HIV/AIDS should support evidence-based approaches to reducing excessive alcohol consumption, including modifying alcohol environments to promote healthier choices.  Stakeholders should also push back against the redwashing corporate marketing strategies of alcohol brands like Belvedere Vodka.

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(1)

Rehm, J., Shield, K. D., Joharchi, N., & Shuper, P. A. (2012). Alcohol consumption and the intention to engage in unprotected sex: Systematic review and meta-analysis of experimental studies. Addiction, 107(1), 51–59. doi:10.1111/j.1360-0443.2011.03621.x

Heath, J., Lanoye, A., & Maisto, S. A. (2011). The role of alcohol and substance use in risky sexual behavior among older men who have sex with men: A review and critique of the current literature. AIDS and Behavior. doi:10.1007/s10461-011-9921-2

McEwan, R. T., McCallum, A., Bhopal, R. S., & Madhok, R. (1992). Sex and the risk of HIV infection: The role of alcohol. British Journal of Addiction, 87(4), 577–584.

(2)

Poonia, B., Nelson, S., Bagby, G. J., & Veazey, R. S. (2006). Intestinal lymphocyte subsets and turnover are affected by chronic alcohol consumption: Implications for SIV/HIV infection. Journal of Acquired Immune Deficiency Syndromes, 41(5), 537–547. doi:10.1097/01.qai.0000209907.43244.ee

Theall, K. P., Amedee, A., Clark, R. A., Dumestre, J., & Kissinger, P. (2008). Alcohol consumption and HIV-1 vaginal RNA shedding among women. Journal of Studies on Alcohol and Drugs, 69(3), 454–458.

(3)

Theall, K. P., Amedee, A., Clark, R. A., Dumestre, J., & Kissinger, P. (2008). Alcohol consumption and HIV-1 vaginal RNA shedding among women. Journal of Studies on Alcohol and Drugs, 69(3), 454–458.

Homans, J., Christensen, S., Stiller, T., Wang, C.-H., Mack, W., Anastos, K., et al. (2012). Permissive and protective factors associated with presence, level, and longitudinal pattern of cervicovaginal HIV shedding. Journal of Acquired Immune Deficiency Syndromes, 60(1), 99–110. doi:10.1097/QAI.0b013e31824aeaaa

(4)

Molina, P.E.,  Happel, K.I., Zhang, P., Kolls, J.K., & Nelson, S. (2010). Focus on: Alcohol and the immune system.  Alcohol Research & Health, 33(1-2), 97-108

Lackner, A. A., Mohan, M., & Veazey, R. S. (2009). The gastrointestinal tract and AIDS pathogenesis. Gastroenterology, 136(6), 1966–1978. doi:10.1053/j.gastro.2008.12.071

(5)

Hahn, J. A., & Samet, J. H. (2010). Alcohol and HIV disease progression: Weighing the evidence. Current HIV/AIDS Reports, 7(4), 226–233. doi:10.1007/s11904-010-0060-6

Shuper, P. A., Neuman, M., Kanteres, F., Baliunas, D., Joharchi, N., & Rehm, J. (2010). Causal considerations on alcohol and HIV/AIDS—A systematic review. Alcohol and Alcoholism, 45(2), 159–166. doi:10.1093/alcalc/agp091

Chander, G., Lau, B., & Moore, R. D. (2006). Hazardous alcohol use: A risk factor for non-adherence and lack of suppression in HIV infection. Journal of Acquired Immune Deficiency Syndromes, 43(4), 411–417. doi:10.1097/01.qai.0000243121.44659.a4

(6)

Baum, M. K., Rafie, C., Lai, S., Sales, S., Page, J. B., & Campa, A. (2010). Alcohol use accelerates HIV disease progression. AIDS Research and Human Retroviruses, 26(5), 511–518. doi:10.1089/aid.2009.0211

Shuper, P. A., Neuman, M., Kanteres, F., Baliunas, D., Joharchi, N., & Rehm, J. (2010). Causal considerations on alcohol and HIV/AIDS—A systematic review. Alcohol and Alcoholism, 45(2), 159–166. doi:10.1093/alcalc/agp091

(7)

Braithwaite, R. S., Conigliaro, J., Roberts, M. S., Shechter, S., Schaefer, A., McGinnis, K., Rodriguez, M. C., et al. (2007). Estimating the impact of alcohol consumption on survival for HIV+ individuals. AIDS Care, 19(4), 459–466. doi:10.1080/09540120601095734

(8)

Collins, R. L., Taylor, S. L., Elliott, M. N., Ringel, J. S., Kanouse, D. E., & Beckman, R. (2010). Off-premise alcohol sales policies, drinking, and sexual risk among people living with HIV. American Journal of Public Health, 100(10), 1890–1892. doi:10.2105/AJPH.2008.158543

(9)

Scribner, R. A., Johnson, S. A., Cohen, D. A., Robinson, W., Farley, T. A., & Gruenewald, P. (2008). Geospatial methods for identification of core groups for HIV/AIDS. Substance Use & Misuse, 43(2), 203–221. doi:10.1080/10826080701690607

Sexual Violence, Alcohol, and Authentic Feminism

The Harvard School of Public Health’s Amy Gutman has penned what may be the most clear and concise feminist defense for public health action on alcohol.  Her post should be required reading for anyone caught in the false choice between moralistic victim-blaming and the myopic relegation of alcohol to side issue status.

Her conclusion:

Sexual violence is a women’s issue, and so is alcohol, and in their Venn diagram overlap sit the critical topics of women’s health and personal agency. This isn’t an either/or. We need to talk about both. And we need to find ways to talk about them in the same (feminist) conversation.

The full piece is here.

Alcohol Industry Interference: A Report from the Global Alcohol Policy Conference 2013

GAPC2013The following is my report from the Global Alcohol Policy Conference, cross-posted from Corporations and Health Watch:

On October 7-9, the city of Seoul, Korea served as host for the third Global Alcohol Policy Conference.  At the conference, more than 850 participants from 45 countries discussed the current state of science-based alcohol policies, recent successes in the alcohol policy field, the prospects for improvement, and the challenges facing alcohol policy advocates.

One important theme running through the conference was the role of the global alcohol industry in maintaining and intensifying alcohol-related harm through its tactics and practices.

Read the full report here.

Reversing the Ratchet in Essex County

Sometimes even a small step forward is impressive when it is made against strong headwinds.  Such is the case when the Essex County Board of Supervisors voted 15-1 to roll back closing hours* for bars and nightclubs from 4 a.m. to 3 a.m.  The New York State Liquor Authority (SLA) will now vote on the measure, following a public hearing.  (Typically, the SLA will honor the will of the county board in these matters.)

The vote effectively reverses the Board of Supervisors vote in May of 2005 to extend hours to 4 a.m.   Although the measure has been described as “largely symbolic” – since only a few bars in Lake Placid are actually open that late – it functions as a firewall against existing bars or new bars extending their hours past 3 a.m. Currently, the closing hours in adjoining Clinton County are 2 a.m.

Essex_Co_Sign

Some key takeaways for alcohol policy advocates:

1.  When the facts on alcohol policy are presented, most people get it.

When open-minded, disinterested people see the evidence, they usually understand that reasonable controls on the availability, accessibility, and affordability of alcohol are in the public interest.   In this case, Mac MacDevitt – Community-Based Prevention Educator for The Prevention Team (and New York Alcohol Policy Alliance stalwart) – presented the considerable body of research about the impact on public health and safety of restricting hours of sale.  The Prevention Team provided a resource booklet and guide to each member of the Board of Supervisors, the Lake Placid Village Trustees, the county attorney, local police chiefs and the county sheriff, media reporters and local advocates.  Key elements included data showing the disproportionate number of alcohol-related car crashes happening in early morning hours, the Community Preventive Services Task Force systematic review, and specific research linking longer on-premises alcohol business hours in New York State with an increased reported incidence of aggravated assaults and non-gun violence.  That research report also found that “the cost of assaults associated with business hours beyond 1 a.m. was $194 million.”  Also presented was general information on binge drinking and the public health and public safety impact of alcohol consumption in NYS.

2.  Passionate pragmatism wins the day.

The Prevention Team provided close support to Gerry Morrow, the Chesterfield Town Supervisor, who introduced a measure calling for a closing hour of 2 a.m. (in line with the law enforcement truism that “nothing good happens in a bar after 2 a.m.”). After much discussion, well covered by local media, board members settled for the compromise to move the closing hour back to 3 a.m.  While opponents of evidence-based alcohol policies prefer to set up a false dichotomy (a “free market” vs. “neo-Prohibitionists”), in reality alcohol control is about negotiation along a continuum.  That negotiation requires balancing the economic benefits of businesses and the interests of adults to drink in low-risk ways with the protection of public safety and public health.  Well-designed regulations are necessary in order to develop a safe and orderly marketplace.  That is the strength of American-style alcohol control systems, which have been steadily eroded by big alcohol producers and retailers, and their allies.

3.  The ratchet can be reversed.

Noted international alcohol policy expert Robin Room has aptly described alcohol deregulation as “ratchet mechanism”:

In the absence of strong public sentiment, state regulatory powers tend thus to be a ratchet mechanism, wound in only one direction — in the direction of gradually looser controls — by the vested interests the state has licensed.

In this case, however, the ratchet moved back – thanks to the passionate promotion of the measure by Supervisor Morrow, and the willingness of board members to give the resolution their full consideration. The Prevention Team provided advocacy and technical assistance to the Board of Supervisors, so that the public health and public safety issues impacted by binge drinking could be fully considered in the decision-making process.

* Technically, the limit is on serving hours (“last call”), as patrons are given time to finish their beverages before leaving the establishment.

Risky(er) Business

In the midst of the unsettling events of the past few weeks, former NYC Mayor Rudy Giuliani, in an interview on Hardball with Chris Matthews, made an important point about the relative risk of an American dying from a terrorist attack:

The reality is people in this country do not face – as the greatest risk to them – terrorism.  There are far more risks that we face that are much greater than terrorism.

This is reminiscent of an address given by the late C. Everett Koop in 2003:

The mayor of Baltimore, Martin O’Malley, was asked what people could do to protect themselves from terrorism.  He answered: ‘To protect yourselves from harm, the most important things you can do are to wear your seatbelts, don’t drink and drive, and don’t smoke.’  I don’t think anyone thought he was trivializing terrorist threats, but it was an important reminder to keep things in perspective.

Putting risks in perspective was the impetus for a display that we assembled for the Alcohol Awareness Event put on by our colleagues at the Partnership for a Healthier New York City.  It showed the numbers of deaths in 2009 in NYC attributable to 5 causes:  tobacco, excessive alcohol consumption, HIV/AIDS, firearms, and motor vehicle accidents.  Of course, some of these causes overlap (e.g., the role of alcohol consumption in HIV/AIDS treatment adherence).  But the overall point stands: the greatest threats to the health of New Yorkers (and all other Americans) are behavior-driven and exacerbated by community conditions.  Furthermore, in the cases of tobacco and alcohol, some of the most troubling consequences are borne by people other than the smoker or drinker.

RiskStairs

And where did the idea for this display come from?  Believe it or not, from a display at the Behind-the-Scenes Tour at SeaWorld Orlando showing the relative rarity of deaths due to shark attack in relation to deaths by lightning strike, ski accidents, deer-vehicle collisions, bee stings, and mosquito disease transmission.

Excessive Alcohol Consumption: Dangerously Diverse, Insufficiently Addressed

Back on April 4, CDC Director Dr. Tom Frieden presented on “The Role of Public Health in Preventing Excessive Drinking” during the Luncheon Plenary at the Alcohol Policy 16 conference.  In that presentation, he offered a powerful quote from the late, noted epidemiologist Geoffrey Rose.  While searching for the source of that quote, I came across this interview with Dr. Frieden on 7/19/2012 at FiveBooks.com.

I’m excerpting the portion of the interview that addresses alcohol, but I encourage everyone to read the full interview here:

According to Dr Rose’s criteria and your own, which diseases does the world community overspend on and which threats to public health are being insufficiently addressed?

I have my underlined copy of Rose in front of me, open to a certain page, which I’ve often thought of because Sir John Crofton mentioned something similar.  I underscored a passage where Rose wrote, “Of all the threats to human health, it is alcohol which causes the widest range of injury. It shortens life, being variously held responsible for between 1% and 10% of all adult deaths in industrialised countries.  It shrinks the brain and impairs the intellect.  It causes failure of the liver, heart and peripheral nerves.  It contributes to depression, violence and the breakup of personal and social life.  It has been blamed for a quarter of all deaths on the road – divided about equally among drunk drivers, drunk pedestrians and innocent victims.”

Image

Alcohol is a really tough area.  Sir John always encouraged me to do more on alcohol control.  The issue is problem drinking.  In the US, binge drinking causes a huge proportion of the harms. Yet problem drinking is a challenge to address.  I think we can at least begin to address this problem with a focus on kids and understanding that you want people to make decisions that are going to affect the rest of their lives when they’re adults, not when they’re kids.

The Unintentional Irony of the Crawl for Cancer

The Crawl for Cancer describes itself as “a fundraising organization driven to plan and host events that support lifesaving research and those affected by cancer while having a little fun doing it! Though not a charity, we are a for-profit company that donates 100% of our profits to the charities we serve.”

Meaning, of course, that it celebrates the excessive ingestion of a Group 1 carcinogen* in order to raise money to “cure” cancer.  Awareness of the role of alcohol consumption in cancers of the head/neck, female breast, liver, and colon/rectum is growing – but not fast enough, apparently, to permeate the consciousness of the “philanthropies dedicated to fighting cancer” who receive money from this farce.  (Would any source of money be off-limits?  Cigarette sales?  The Indoor Tanning Association?)

Bar/pub crawls are nothing new, of course, and by their very nature are typically synonymous with binge drinking. (Case in point: the infamous Bridge Street Run in Oswego, NY).  They are also sometimes associated with violence and other mayhem, as with recent tragedies and near-tragedies in Chicago and Methuen, Massachusetts.

The Crawl for Cancer itself is no longer welcome in the Bricktown area of Oklahoma City, after its crawlers engaged in verbal assaults on families, public urination, and serious violence.

But the saddest irony of the entire enterprise is nested in its promotion of excessive alcohol consumption for the sake of raising money for a disease whose risk factors include … excessive alcohol consumption.  Like with the pinkwashing phenomenon, this is another case of confusing causes of disease with cures for disease.

* The International Agency for Research on Cancer of the World Health Organization has determined definitively that alcoholic beverages are carcinogenic to humans, a designation shared with only 108 other agents – including tobacco, benzene, asbestos, estrogen therapy, wood dust, and certain types of salted fish.

Crawl for What?

Crawl for What?

Alcohol & the Costs of Chronic Disease

Why do we need a social movement to reduce excessive alcohol consumption in New York State?

Because despite the enormous progress that’s been made over the last few decades with regard to our understanding of what really works to reduce alcohol problems, that knowledge hasn’t yet fully broken through our society’s cultural cognitive dissonance around alcohol.

And that disconnect is alive and well and on display in New York State.

Consider these unavoidably interrelated facts:

1)  Runaway health care costs are the biggest threat to the fiscal solvency of New York State and the nation.

As US House of Representatives Majority Leader Eric Cantor (R-VA) bluntly states:

Health care costs are the primary driver of debt … [without restraining these costs] it doesn’t matter what we do with defense spending, Social Security or other government programs; we will have failed to get the deficit under control.

In New York State, similarly, Medicaid spending is “crowding CDC CD Chartout other needs,” according to the State Budget Crisis Task Force chaired by Richard Ravitch and Paul Volcker. Indeed, the NYS Association of Counties has decried the fact that local Medicaid costs consumed nearly one-half of the entire county property tax levy statewide (outside of New York City) in 2010.

Furthermore, it’s unclear whether some of the state provisions to reduce Medicaid spending growth will actually remedy underlying health care costs or rather “simply shift costs to providers, and result in adverse consequences for quality or access to care.”

2) Chronic diseases are the biggest driver of health care costs, with more than 75% of national health care costs attributable to chronic conditions.

New York State is no exception, with conservative estimates that 63% to 69% of NYS’ $160 billion in health care expenditures are due to chronic diseases.  Moreover, NYS Medicaid recipients with substance abuse issues and concurrent chronic conditions are especially costly to the health care system (and alcohol is by far the most abused substance in NYS).

According to the Milken Institute, at our current course (calculated in 2007), chronic diseases will cost New York State over $232 billion in treatment expenditures and lost productivity in 2023.

3) The “Big Four” modifiable risk factors for chronic disease are smoking, poor diet, physical inactivity, and excessive alcohol consumption.

In fact, according to the Global Burden of Disease project, alcohol ranks behind only hypertension and smoking as a cause of death and disability worldwide.  It kills more people in the U.S. than microbial agents and 5 times as many people as all illicit drugs combined.

Thus, the only rational way to arrest this slow-motion financial death spiral is to embrace evidence-based, population-level prevention strategies to reduce alcohol-related harm and other underlying risk factors of chronic diseases.  The Council on State Governments puts it plainly: “without aggressive intervention into the root causes of these chronic diseases and their costs, these trends are expected to continue to worsen.” [emphasis mine]

And yet, many of our leaders in NYS want to treat beer, wine, and liquor as just another easy engine for economic development, as if they were talking about tires and mayonnaise, instead of a commodity that needs to be regulated with special care.

Tinkering around the margins isn’t going to cut it here.  The health, safety, and financial future of our state depend on us taking serious action to reduce alcohol-related harm.

Alcohol Policy … Expert?

Image: Fletcher Prince via Flickr

Do you have “Gravitas, confidence and the ability to build relationships and credibility…”?

Are you interested in building the “credibility and authority” of a major brewer as “a contributor to the debate on the role of the brewing industry in managing irresponsible alcohol consumption”?

Would you like a position where you manage the “repercussions to the industry” of the “ongoing alcohol debate”?

And would you like to do this without actually reducing alcohol problems?

If so, then this job is for you!

Alcohol Free Lent: The Social Costs of Alcohol

The following is cross-posted from the Faith In Action newsletter from the General Board of Church & Society of the United Methodist Church:

A great deal of public health research over the past few decades has pointed to the value of control policies in limiting alcohol-related problems. These policies include increasing the price of alcohol, limiting the concentration of outlets, limiting hours and days of sale, enhanced enforcement of underage drinking laws, and others.

And yet, despite the confirmed value of these policy solutions, they are rarely put into practice. Bringing about lasting change is far from easy, due mainly to political resistance from those with a financial stake in keeping things as they are: the alcohol industry and its allies.

The full article is available here

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