Saturday, July 03, 2004

Is The Sky Falling? New CDC Guidelines For HIV Prevention

No fewer than four of my regular readers have written recently to ask me about the CDC's proposed guidelines for the content of HIV prevention literature, prompted by this terrifying Doug Ireland column in last week's L.A. Weekly:
Lethal new regulations from President Bush’s Centers for Disease Control and Prevention (CDC) in Atlanta, quietly issued with no fanfare last week, complete the right-wing Republicans’ goal of gutting HIV-prevention education in the United States. In place of effective, disease-preventing safe-sex education, little will soon remain except failed programs that denounce condom use, while teaching abstinence as the only way to prevent the spread of AIDS.
I've read the proposed new guidelines, and re-read the old 1992 guidelines the new ones are meant to replace. Here are the main points where they differ:

(1) The content-review process established in the old guidelines is now extended to information posted on the web.
(2) The new guidelines require "medically accurate information regarding the effectiveness or lack of effectiveness of condoms in preventing the sexually transmitted disease the materials are designed to address."
(3) The new guidelines clarify that program materials need to be judged acceptable by a community advisory board which reflects the demographics of the group being served, not just the demographics of the general population, and require that the advisory board be selected by the health department.
(4) The new guidelines specify that public health officials need to certify that the average person would not find the content of HIV prevention curricula "obscene" according to the Miller standard.

Items 2 and 4, obviously, are the ones that have Doug Ireland up in arms. Let's look at them one at a time.

Condoms: Ireland says, "they demand that all such materials include information on the 'lack of effectiveness of condom use' in preventing the spread of HIV and other STDs — in other words, the Bush administration wants AIDS fighters to tell people: Condoms don’t work." But Ireland's tightly edited quote is a substantial distortion of the actual proposed guidelines, as you can see by comparing it to my item (2) above. Prevention materials are actually required to provide medically accurate information about condoms, whether that information focuses on their effectiveness (for example, in preventing HIV) or their lack of effectiveness (for example, in preventing herpes).

Here's what the CDC considers to be medically accurate information about condoms and HIV, taken from their own factsheet:
HIV, the virus that causes AIDS: Latex condoms, when used consistently and correctly, are highly effective in preventing the sexual transmission of HIV, the virus that causes AIDS.

AIDS is, by far, the most deadly sexually transmitted disease, and considerably more scientific evidence exists regarding condom effectiveness for prevention of HIV infection than for other STDs. The body of research on the effectiveness of latex condoms in preventing sexual transmission of HIV is both comprehensive and conclusive. In fact, the ability of latex condoms to prevent transmission of HIV has been scientifically established in “real-life” studies of sexually active couples as well as in laboratory studies.
So the CDC is going to require that HIV prevention literature explicitly state that "condoms are highly effective in preventing the sexual transmission of HIV," that being the "comprehensive and conclusive" medical opinion. I'm okay with that. Nothing in the proposed guidelines for community organizations requires an "abstinence only" approach or devalues condoms as HIV prevention. Nothing. Ireland's extrapolating from the Bush Administration's preferred approach to high school sex-ed programs to interventions for high-risk communities, and that extrapolation is unwarranted.

Obscenity: Here's Ireland: "These new regs require the censoring of any 'content' [...] They require all such 'content' to eliminate anything even vaguely 'sexually suggestive' or 'obscene' — like teaching how to use a condom correctly by putting it on a dildo, or even a cucumber." With all due respect, that's simply nonsense.

The only place the phrase "sexually suggestive" appears in the new guidelines is the requirement that "educational sessions should not include activities in which attendees participate in sexually suggestive physical contact or actual sexual practices." And the guidelines specify that, although prevention materials are not supposed to directly promote either heterosexual or homosexual sex, that requirement "may not be construed to restrict the ability of an educational program [...] to provide accurate information about various means to reduce an individual's risk of exposure to, or to transmission of, the etiologic agent for acquired immune deficiency syndrome." In other words, it's perfectly allowable to teach people how to put on a condom.

The Miller standard for obscenity requires that an average member of the community would find the material "prurient" and "patently offensive," and that a reasonable person would find that the material has no scientific value (or artistic value, et cetera, but that's not important right now). It is by no means the case that all sexually explicit material is obscene according to the Miller test, yet Ireland writes about the proposed guidelines as if they prohibit any sexual explicitness in HIV prevention literature. Just as the "how to insert a tampon" line drawings inside every box of Tampax aren't considered prurient, and illustrated urology textbooks aren't considered patently offensive, "how to put on a condom" illustrations will certainly pass the Miller test.

Finally, Ireland complains that "the CDC will now take the decisions on which AIDS-fighting educational materials actually work away from those on the frontlines of the combat against the epidemic, and hand them over to political appointees," by which he means public health departments. As someone who does consulting work for a public health department, I'm insulted on behalf of my colleagues. Who the hell does Ireland think is "on the frontlines" if not the people who staff STD clinics and counseling and testing services?

At any rate, the guidelines specify that only one member of the review panel should be an employee of the health department, and that the rest should be representative members of the community being served. (Which means, for example, that you can't have a review panel made up of old white men deciding what information is appropriate for young black women.) Again, Ireland is extrapolating well beyond what the guidelines actually say.

There's plenty of outrage to be found in the Bush Administration's approach to HIV prevention - say, in their relentless pushing of abstinence-only sex ed programs for teenagers and their political scrutiny of NIH grants. It's not surprising that people immediately leap to think the worst of anything associated with the present government. But in this particular case, I think that Doug Ireland is frothing up a lot of public anxiety over very minor changes.

[Otter's note: Sorry to have disappeared on y'all without warning. We've taken a Spanish exchange student for the month of July, and I underestimated how much time Instant Parenthood would consume.]