I recently read "Everything is Tuberculosis". It describes a similar issue with the rich / poor country divide.

It's quite sad and difficult to read at times.

Tuberculosis is different, in a very dark, utilitarian way. 4% of new TB cases are multi-drug resistant (19% of recurrences).

Once it’s multi-drug resistant, if you’re poor then you get an incredibly depressing choice. Rich countries pay for expensive drug resistance testing.

Poor countries have to answer an impossible question. You either do nothing and see if they live, or you try to guess what drugs will work and give them those. However, if you’re wrong and the treatment doesn’t work then the risk that you’ve just made the strain immune to one or more of the drugs in that cocktail skyrockets.

They get asked to either do nothing, or do the best they can today knowing it will make tomorrow worse.

TB is also shockingly infectious, which is sad. You can at least take steps to dramatically reduce HIV risk, it’s much much harder to avoid TB.

> TB is also shockingly infectious

let's keep HN as a place where people usually do at least a cursory research before they state things with such confidence... or inject a few words of doubt to signal that you haven't done the homework.

if you feel the urge to fight this: i lived with someone infected with TB.

e.g. measles is shockingly infectious. TB is not.

A single, untreated person with TB will infect 1.5 to 4 people if public health interventions don’t happen. Measles sits at 12 to 18 people per infected person.

In case anyone was curious. Depending on what your priors were, 1.5 to 4 might be shocking.

don't forget that untreated TB runs for years, sometimes for many years.

measles heals in weeks (and 99.9% non-malnutrished survives without lasting damage; see France prior to 1983).

also note the exponential function here... and an exponent of 2 and 12 are very different animals.

Depends heavily on whether we're measuring in practical terms, or in "no medical intervention" terms.

If we're measuring in a vacuum without medicine, then absolutely, the measles is dramatically more infectious.

If we're measuring in the real world where medicine exists, the measles has a safe, cheap and effective vaccine. New case rates dropped 76% between 2000 and 2018 due to extensive vaccination campaigns, and new cases of the measles globally sits a hair below TB right now. The WHO has a plan to eradicate it (and rubella) just like polio.

Meanwhile TB is now the leading cause of infectious death in the world, and the WHO estimates 1 in 4 people globally have either active or latent TB. Despite having similar new case numbers, TB kills 13 people for every 1 person the measles does.

I would describe a disease that 1 in 4 people globally have and is the world's leading cause of death as "shockingly infectious". I doubt it is the most infectious, but I think shockingly infectious is apt.

> i lived with someone infected with TB.

If they were latent, no one would expect you to have contracted TB. Latent TB isn't infectious. If they had active TB, I would personally get tested for latent TB. Not showing symptoms isn't dispositive of contracting TB, it can lay dormant for a long time or forever. I'm not saying you would definitely have contracted it enough, but the odds are high enough and risks serious enough that I'd want it treated before it became active.

re TB: you think i wouldn't know? and it was found because it was active.

re eradicating measles: the terrain is much more complicated than presented. first, because the vaccine fades away, and without measles spreading in the young population, adults don't get natural reminders, and eventually there can be a big wave without poking everyone. and the disease is much more dangerous for adults. and all this unnecessary trouble for a disease that is not really dangerous when left alone and the population is not malnutrished.

and there's that cancer thing with measles, just to shed some light on the complexity:

MEASLES: Albonico et al found that adults are significantly protected against non-breast cancers — genital, prostate, gastrointestinal, skin, lung, ear-nose-throat, and others — if they contracted measles (odds ratio, OR = 0.45), rubella (OR = 0.38) or chickenpox (OR = 0.62) earlier in life. [Med Hypotheses 1998; 51(4): 315-20]. https://www.ncbi.nlm.nih.gov/m/pubmed/9824838/

MEASLES: Montella et al found that contracting measles in childhood reduces the risk of developing lymphatic cancer in adulthood [Leuk Res 2006; 30(8): 917-22]. http://www.lrjournal.com/.../S0145-2126(05)00466-2/abstract

https://www.ncbi.nlm.nih.gov/m/pubmed/16406019/

MEASLES: Alexander et al found that infection with measles during childhood is significantly protective — it cuts the risk in half — against developing Hodgkin’s disease (OR = 0.53) [Br J Cancer 2000; 82(5): 1117-21].

http://www.nature.com/bjc/journal/v82/n5/full/6691049a.html

https://www.ncbi.nlm.nih.gov/m/pubmed/10737396/

Measles to the Rescue: A Review of Oncolytic Measles Virus. MV Clinical trials are producing encouraging preliminary results in ovarian cancer, myeloma and cutaneous non-Hodgkin lymphoma, and the outcome of currently open trials in glioblastoma multiforme, mesothelioma and squamous cell carcinoma are eagerly anticipated. Aref S, et al. Viruses. 2016.

http://www.mdpi.com/1999-4915/8/10/294

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5086626/

"the only reason HIV transmission is high in poor countries is because, well, they're poor."

This is factually untrue.

Being poor does not equal a HIV transmission rate. There is no 1:1 correlation.

A single protected (condom) sexual act between a male and female averages somewhere around 0.1-0.5% chance of pregnancy, and during the fertile window it could still be around 1% or more even with a condom.

Chance of HIV from one act of unprotected vaginal sex with an HIV-positive partner: ~0.08% male-to-female.

The high HIV transmission rates are NOT correlated with wealth, but social behavior. Unprotected anal sex with many partners? High risk. Now, Africa - the practice of dry sex contributes a ton to HIV transmission. Cultural belief that a dry vagina increases pleasure, hence woman use sand, chalk or bleach to dry out their vaginas, massively increasing HIV risk. Needle sharing of drug users? High HIV risk.

Not a class issue, no reason to punch down on poor people. Poor people have agency and many do not infect themselves with HIV in the first place.

I don't think the original assertion is "punching down" on poor people. While you're correct that poverty isn't the "only reason" for high HIV transmission, poverty certainly contributes to it, via lack of access to health care and lack of access to education. How is it less "punching down" to attribute it to social behavior and culture? Isn't needle sharing associated with poverty, or would you also call that "culture"?

I was poor, grew up in social housing.

I did not use drugs.

"I share needles because I can't afford my own" is an INSANE take. Don't shoot drugs in the first place! Poor people are normal humans, they have willpower, agency. It is a rich people myth that poor people are cattle, devoid of any chance of doing the right thing.

It is culture, behavior, social norms. Being poor does not force you to abandon the nuclear family, does not force you to engage in criminal acts. (there is reverse causality though)

In the early 1960s South Korea had a per capita income lower than those of Haiti, Ethiopia, and Yemen, and about 40% below India's. Did all South Koreans become heroin addicts with HIV?

> Don't shoot drugs in the first place

like insulin? should a diabetic skip the insulin? In poor countries I wouldn't be surprised if the majority of HIV infections are not as preventable as you're imagining.

You can moralize, but even if only 10% of HIV infections are unavoidable, you're not contributing to solving the actual problem. (And by unavoidable I mean, unavoidable without investing in more needles, better sanitation, or prophylactics that the people "responsible" cannot afford.)

assume you have a population of IV drug users. as a society, would you prefer to spend nothing and see them develop HIV, or to spend some and control the HIV?

you don't have to care about the drug users at all. even if you treat them as pests rather than humans, we frequently vaccinate pests for public health measures. pathogens will spill over to populations you do care about, they'll create a drain on the healthcare system, they'll harbor other opportunistic infections. it's not sanitary.

this is completely leaving aside that some drug addicts can and do turn their life around, and that HIV is a horrible illness nobody should have to deal with, even if it's "their fault."

Thanks for your contribution. Gonna hop on a jet to Zambia tomorrow and tell kids with HIV there that it's their fault they were born with the virus and maybe they shouldn't have shared needles.

People enjoy drugs, people enjoy sex. If your solution to driving fatalities is not to drive, you have not solved anything.

Not having sex and not doing drugs isn't any sort of "right thing" other than because sex and drugs are dangerous. If sex and drugs were less dangerous (or made not dangerous at all) there would be no reason to tell people not to do them.

The wealthy use drugs and have sex all the time. They just have clean needles and nice doctors. You've completely bought into the moral explanation for poverty - which is that moral decay causes poverty, but poverty does not cause moral decay. But you think that this is a defense of the poor, rather than a defense of the exploitation and contempt for the poor by the rich.

The poor are not worse than the rich even if they do drugs, have sex, or swear on Sunday.

Lmao “South Korea never had a severe drug problem”

I’ve got bad news for you about methamphetamine in postwar east Asia

Being poor correlates with adverse health outcomes. If you insist (as you do) that those health outcomes are due entirely to culture and willpower, then you are forced to conclude that poor people have low willpower and are less moral. This is an unprovable assertion, based entirely on your own vibes, and is frankly a cruel thing to say. It basically asserts that these people deserve the things that happen to them, because they were avoidable and entirely due to their choices.

This is not a celebration of human agency. When people are treated badly, they behave badly. It is completely irrelevant that you were treated badly and happened not to behave badly. People are far too complex for you to say "well, we got treated the same, we should have behaved the same".

Dry sex in SSA may be one of the contributing factors, but it’s never been truly proven out as a key contributor in any study I have read; they always address it but say more needs to be done to be certain.

Your comment makes it seem like a key factor when it’s not.

In the Global Burden of Disease analyses, sub-Saharan Africa (SSA) had the highest age-standardized STI incidence rate of any world region — around 19,973 per 100,000 person-years, which is roughly double the global average of about 9,536 cases per 100,000.

Forecasts to 2030 expect sub-Saharan Africa to continue having the highest incidence rates of both HIV and other STIs of any region.

How come a specific region of the globe has this issue? "Poverty"?

Many regions in India are poor. Afghanistan. Pakistan.

Love the science based debate here, btw, thank you all for the downvotes. Facts, not feelings.

It comes with the territory; IMO if you don't occasionally have a few comments go negative, you're probably not saying anything of value.

I’ve never heard that before. That explains a lot.

I mean a big part of the issue in poor countries is lack of access to PrEP.