Minisite

Promising new drug for treatment-resistant depression – esketamine

Treatment-resistant depression affects 1 in 3 of the estimated 16.2 million adults in the U.S. who have suffered at least one major depressive episode. For them, two or more therapies have failed and the risk of suicide is much greater. It’s a grim prognosis.

Promising new drug for treatment-resistant depression – esketamine
The chemical structure of esketamine.
Promising new drug for treatment-resistant depression – esketamine
The chemical structure of ketamine.

As there are few therapies for depression that resists treatment, the Food and Drug Administration has been considering a new treatment called esketamine. On Feb. 12, 2019, I participated in the FDA review of this drug. Practically speaking, esketamine is essentially the same as ketamine, which is a pain killer with hallucinogenic effects and used illegally. As a member of the Drug Safety and Risk Management Advisory Committee of the FDA, I voted with the majority of that panel 14-2, to approve esketamine only for people who have treatment-resistant depression.

For more than 20 years, I have researched illegal drug use and addiction. As a medical anthropologist, my work is oriented to understanding the perspectives and behaviors of people actively using illegal drugs. My research often involves fieldwork, which means participating in the lives of people as they go about their everyday routines. This has given me a personalized and practical outlook on illegal drug use. Many of the people I currently interview are heroin injectors who first started opioid use by misusing prescription drugs.

Not a street drug

But many drugs, especially those for the treatment of mental illness, have powerful effects on the central nervous system. How the drug is distributed and administered must minimize risk. What if the drug is addicting?

Some reports about esketamine have sensationalized this issue by referring to ketamine as a highly addictive street drug. In my research, this is not true. First, ketamine use is rare. The last time I interviewed a ketamine users was nearly 20 years ago and since its introduction in 1964, there have been no significant trends or outbreaks in its diversion or use.

Not all illegal drugs are sold “on the street.” Street drugs are staples of the illegal drug economy, which is run by drug trafficking organizations. Prescription opioids, heroin, cocaine, and marijuana are street drugs sold in open-air drug markets, where such markets exist. Hallucinogens and exotic, designer and other less popular drugs are rarely available in these settings. They simply do no appeal to enough users to make them profitable for drug traffickers to supply. Ketamine has always been in this second group. Why?

Is it addictive?

Ketamine is short-acting – between two and four hours – and produces euphoria, sustained pain relief and sedation mixed with powerful hallucinogenic effects. Taking this drug can be very unpleasant. Out-of-body experiences, time perception distortions, tunnel vision and dissociation are common. These effects limit the popularity of ketamine and make it difficult to use habitually.

A person can take heroin everyday and function. Ketamine is disruptive.

Promising new drug for treatment-resistant depression – esketamine
Esketamine is taken as a nasal spray. Kirill Linnik/Shutterstock.com

Another reason that ketamine isn’t popular on the street is that users do not have to keep using it to avoid withdrawal. There is no withdrawal syndrome associated with ketamine; when people stop using it, they do not get sick. This is actually a benefit, because fear of withdrawal is often a major motivation for the continuation of drug use. Unlike street drugs, its appeal is limited and its addiction liability is comparatively low.

On balance, the profile of ketamine is more like LSD than cocaine or opioids. People do not get addicted. This does not mean that ketamine or esketamine is safe. Its access should be restricted and use monitored by a physician. The manufacturer is placing important restrictions on the drug. It will not be available at local pharmacies and never for take-home use. A person receiving the treatment, which was developed by Johnson & Johnson and delivered as a nasal spray, will be under observation and care of a health professional trained in the therapy. The drug will be given in an office or approved health center, and the patient will not be allowed to drive until the day after treatment.

Given its effectiveness and the proposed risk evaluation and mitigation strategy, the benefits outweigh the risks of esketamine for the treatment of depression that has not responded to other treatments. Like any new treatment, as manufacturers make this product available, monitoring it will be important to make sure the benefits outweigh the costs. People living with the misery of treatment-resistant depression need more options, and this drug should help.

Hundreds of genes linked to blindness could lead to new therapies

Inherited diseases of the eye account for at least 2 million cases of blindness worldwide. A few hundred genes that cause eye disease have been identified, but in many cases the cause is unknown because not all eye disease genes have been identified.

As a result, genetic testing is only able to determine the mutation responsible for blindness in only 50 to 75 percent of blind children and young adults.

As an eye doctor and researcher, I am frustrated at the lack of treatments for my patients with genetic forms of blindness such as retinitis pigmentosa, Stargardt disease and age-related macular degeneration. To address this problem, my lab launched a study of genes required for normal eye formation and function. We discovered 347 genes that, if mutated, cause blindness in laboratory mice. Of these, 261 had never been linked to vision loss before our study, which we published recently in the journal Communications Biology.

Knockout mice help identify more blindness genes

Researchers first identified eye disease genes in the late 1980s by studying families in the United States with inherited forms of retinitis pigmentosa, a disease of retinal cells called rod photoreceptors in children and young adults, which leads to eventual blindness. Since then, more and more families have been studied to add to the list of blinding mutations in people.

To figure out which genes cause blindness, we took advantage of something called knockout technology. Researchers engineer a knockout mouse by deleting both copies of any single gene. This effectively deletes it from the mouse’s genome. Abnormalities result, and they provide clues as to the function of the “knocked out” gene. The mouse genome is similar to that of humans and contains roughly 22,000-25,000 genes. So far, scientists around the world have knocked out about about 7,000 genes in mice, and the process of studying these mice is ongoing.

The invention of knockout mouse technology in the 1990s led to the identification of eye disease genes by studying the eyes of mice with targeted deletions. The International Mouse Phenotyping Consortium (IMPC), which consists of more than a dozen mouse biology centers across North America, Europe and Asia, aims to create a knockout mouse for every gene in the mouse genome. The IMPC has created and carefully examined over 4,364 knockout mice.

By analyzing the recorded data from the mouse eye exams at all IMPC centers across the globe, my colleagues and I found that 347 of these knockout mice, each one representing a single deleted gene, had eye abnormalities as determined by trained ophthalmic experts. The abnormalities sometimes involved the anterior structures of the eye, such as the eyelids, cornea and lens, and sometime posterior structures, such as the retina and optic nerve.

Hundreds of genes linked to blindness could lead to new therapies
Researchers have discovered genes controlling all parts of eye development are linked to heritable eye diseases. solar22/Shutterstock.com

Testing mouse eye disease genes in humans

Since the mouse and human genomes are similar, it’s highly likely that these newly identified genes, if mutated, also cause human eye diseases. The next step is to study these newly implicated mouse genes in blind human patients. Specifically, we will analyze the genomes of patients whose prior genetic testing could not link their condition to one of the previously known eye disease genes.

The addition of hundreds of new eye disease genes in this IMPC study will help eye doctors like me around the world provide more precise genetic diagnoses to our patients. To validate these genes in humans, we plan to create a panel of these new 261 genes that can be scanned for mutations.

Furthermore, the knockout mice themselves will serve as publicly available research models for the newly discovered eye disease genes. All of these knockout mice are available to all researchers and can be ordered from the IMPC repository for additional scientific studies and therapeutic discoveries. These mouse models can be used to test new medications, gene therapies and stem cell approaches.

Knockout mice teach us about the genetics

The scientific discoveries of the IMPC are quickly advancing our understanding of the thousands of genes and molecules that underlie many human disease processes. In each organ system of the body, researchers are finding many genes that have never been linked with disease. The results of the IMPC project, including the eye disease genes, could advance the diagnostic capability, and identify new targets for novel therapies.

I hope that eye doctors at major universities and eye centers will cross reference our list of 261 new eye disease genes from mice with the genetic sequence of their human patients in whom they found no mutation that causes disease.

We hope our list of genes will guide our colleagues to the genetic culprit in many cases and provide both a specific diagnosis and a path forward toward eventual treatment for those families afflicted with inherited forms of blindness.

African-American women with HIV often overlooked, under-supported

The face of HIV in the United States has long been white gay men, even though the epidemic has had a devastating and disproportionate impact on African-American communities.

This is especially true among women; 60 percent of newly diagnosed cases of HIV in women in 2017 were African-American. Yet, African-American women’s voices are notoriously absent from the national discourse on HIV.

Largely invisible to a fractured health care system, these women are often breadwinners and matriarchs whose families count on them for support and care.

Treatments to help people who are HIV-positive manage their illness and survive into older age have improved greatly, yet the unique health needs of African-American women living and aging with HIV – estimated at about 140,000 – are often ignored.

While many are actively taking medication and receiving care, some do not know their HIV status. After diagnosis, many have difficulties managing their HIV, which can contribute to their other health challenges.

I have been working on collecting oral histories from many older HIV-positive women in the Washington D.C. area, where I live and research. It is my hope that by focusing on the voices of African-American women themselves, we as a country are able to better understand the profound impact that HIV has had on black life.

HIV and African-Americans

Many believe the HIV epidemic in the United States is nearing an end, in part because increased funding, targeted prevention efforts, and better treatment have resulted in drastic reductions in new HIV-positive cases. Even President Trump, in his recent State of the Union address, discussed his goal of ending HIV by 2030. I am an HIV researcher, and I can say this is totally unrealistic, especially for African-Americans.

Despite comprising only 12 percent of the overall U.S. population, African-Americans represent 43 percent of all persons with newly diagnosed HIV and 42 percent of all people living with HIV. African-Americans living with HIV are nearly 10 times more likely to be diagnosed with AIDS and over six times more likely to die of complications of AIDS than their white counterparts.

African-Americans are also at a higher risk for other health conditions, which can make managing HIV infection more difficult. For instance, African-Americans are twice as likely to die from heart disease and 50 percent more likely to have high blood pressure than whites.

In Washington D.C., a place filled with public health experts and policymakers, the HIV prevalence rate is the highest in the nation, exceeding the World Health Organization definition of a generalized epidemic. African-Americans represent a staggering 75 percent of all HIV cases in D.C.

African-American women with HIV often overlooked, under-supported
Toya Tolson of Prince George’s County suffered trauma and abuse as a child only to battle addiction as an adult. She is one of more than 100,000 African American women who are aging with HIV. Aamir Khuller, CC BY-NC-SA

HIV in Washington D.C. is a regional epidemic, and crosses the jurisdictional border into Prince George’s County, Maryland. The sprawling suburbs of Prince George’s County are well known for their ranking as one of the wealthiest African-American-majority counties in the nation, but with HIV rates that are four to 10 times higher than those of white adults.

The high rates of HIV in Washington D.C. and Prince George’s County reflect a growing public health crisis in the United States, where the disproportionate burden of HIV is increasingly concentrated in the U.S. South. Southern states, where 55 percent of African-Americans live, have the highest rates of new HIV-positive diagnoses, the highest percentage of people living with HIV, and the lowest rates of survival for those who are HIV-positive.

Government investment in the domestic response to HIV tops more than US$26 billion per year, yet these health inequities in HIV for African-Americans continue to persist. These inequities are due in part to abstinence-only funding to schools with large minority populations and HIV-specific criminal laws, which undermine the health and well-being of African-Americans and perpetuate systems of inequity. Systemic racism in resource distribution, such as concentrated poverty and health care and funding disparities is also a significant driver of the epidemic within African-American communities.

Since the beginning of the epidemic in the 1980s, African-American women have carried a large burden of HIV, and more than 60,000 lost their lives. But not everyone died. My project of personal narratives of these women suggest that they live with multiple uncertainties brought on by HIV. Many worry about how their health, disability, and eventual death will impact their roles as mothers, grandmothers, daughters, sisters and wives.

Lives of suffering, strength and survival

African-American women with HIV often overlooked, under-supported
Shawnte’ Spriggs considers herself fortunate to be alive. Aamir Khuller, CC BY-NC-SA

Shawnte’ Spriggs’ story is typical of many African-American women living with HIV whom I spoke to. Many suffered trauma and abuse as children. Like everyone, however, she has her own unique story.

“My family stories are not pretty,” said Spriggs, 45, who grew up in northeast Washington D.C., in a neighborhood with open-air drug markets, crime and gang violence. “My mother had a very bad temper. If she had a bad day, or someone teed her off, or one of her boyfriends did something to her, I was abused pretty bad.”

Her father was around only intermittently. She later learned the reason for his disappearances: He was often in prison.

Looking for love and craving protection from her mother, she turned to her godbrother, a caring guardian whom she later married.

Three months into their marriage, beatings began. The first was in the middle of the night. She woke suddenly. Her ex-husband was still asleep but sat up as if he were awake and punched her in the face. They both laughed about it in the morning, as if it had been an accident.

The abuse continued.

Eventually Spriggs escaped the marriage. She moved to another state and created a rewarding life. She even found love again, and remarried. She changed careers. She also became an evangelist, traveling for religious conferences frequently.

In 2010, Spriggs accepted an invitation to speak at a women’s conference in Lynchburg, Virginia. The conference offered health screenings. Some of the women invited her to take an HIV test with them. “Sure, why not?” she thought, wanting to set an example for the young women attending.

The last thing she expected was to test positive.

Her initial reaction was that she was going to die. She researched to learn more about HIV and began to realize that many people in her life probably died of it even though it was being labeled as something else in the community. She was terrified, especially because she feared returning to the pain and trauma from her past.

“I was so afraid of going to a dark place, from my childhood. I know my triggers,” Spriggs said.

She took action, signing herself up for both inpatient and outpatient mental health care, which helped her with her healing process. She attended HIV support groups, where she was the only woman among gay men.

Spriggs counts herself fortunate. She knows that many others have fewer resources, more responsibilities, and a lack of accessible and culturally appropriate care.

Editor’s note: Read the stories of other women living with HIV in tomorrow’s edition of The Conversation.

Stories of African-American women aging with HIV: ‘My life wasn’t what I hoped it to be’

Sophia Harrison, 51, is a single mother of two, with an extended family to support. She has lived with epilepsy her entire life; she suffers from hypertension; and she is a breast cancer survivor.

Yet more challenging than any of these was learning she was HIV-positive.

“I was crying for at least six months,” she said of learning she was HIV positive 10 years ago. “It hurt me real bad.”

Harrison’s story is far from unusual. She is one of about 140,000 African-American women living and aging with HIV. While she is grateful to be alive, she faces multiple health challenges in addition to HIV, like hypertension, diabetes and breast cancer, that disproportionately plague African-American women. And they often struggle to take care of themselves and their families because of limited resources. In working with older African-American women who are HIV-positive, I learned about their individual stories.

Stories of African-American women aging with HIV: 'My life wasn’t what I hoped it to be'
Sophia Harrison has lived with epilepsy, breast cancer and HIV and is surviving all three. Aamir Khuller, CC BY-NC-SA

Victims of HIV’s early days

In the 1980s and 1990s, an HIV diagnosis often equated to a death sentence, with many given weeks or months to live. Much of the public health focus in the early years was on white gay men in urban centers.

Early stories of women living with HIV focused on sex workers and injection drug users, those who were highly stigmatized by society for behaviors it deemed immoral. Conversations about women with HIV were silenced and shamed, causing delays in testing and treatment for women. HIV research specifically excluded women, perpetuating the myth that women were not at risk for HIV. Even today, women represent less than a quarter of clinical trial participants for HIV medications, and prevention strategies for women lag far behind those for men.

As a result, African-American women living in places like Washington, D.C. and Maryland were not tested routinely or well informed about HIV until they fell seriously ill, I found as part of my research. Many who were in their 20s and 30s when they were first diagnosed were in a state of shock and denial, certain that they would not live to see their next birthday.

My research, which has involved ethnographic and oral history interviews with 45 women over five years, reveals that HIV for African-American women has never been a single issue, separate from histories of addiction, trauma and poverty.

For some, an HIV diagnosis signaled death and an end to the future they had imagined for themselves. While for others, diagnosis was a form of redemption and a second chance at life.

Regardless of how HIV altered their lives, these women, now in their 50s and 60s, suffer from debilitating health problems, a result of living a lifetime with HIV and the toxic effects of long-term medication use. Many rely on fragmented public safety nets and will need even more health and disability benefits as they age.

While public health officials and politicians are focused on ending HIV in the next decade, very few resources are available to those already living and aging with HIV. Amid the uncertainty that life with HIV brings, African-American women, like those featured here, live with hope and strength. “I’m a survivor,” Harrison told me.

‘I didn’t care what happened to me’

Stories of African-American women aging with HIV: 'My life wasn’t what I hoped it to be'
Marcella Wright has been living with HIV for decades. She was recruited to be in one of the first HIV treatment programs and was the only woman in the group. Aamir Khuller, CC BY-NC-SA

Marcella Wright was born in Washington, D.C. in 1943. She has suffered from debilitating asthma for as long as she can remember. When she was growing up, her neighbors grew wild cannabis and treated her with the vapor. She eventually learned to smoke cannabis to ease the pain of her asthma. She later added alcohol to the mix.

After graduating from high school, she found out that her boyfriend of two years was going to marry an older woman. “After that I didn’t give a damn. I didn’t care what happened to me.”

She became pregnant by a man who would eventually end up in jail, and she gave birth in a home for unwed mothers. She recalled: “I had the baby all alone in the cold. It seemed like one of the most horrifying moments of my life. And I have had guns to my head, I have been choked, and all that. But this particular time, having this baby. All alone.”

Wright was forced to marry her son’s father, and the relationship became abusive. She turned to crack cocaine to cope and became hooked. “You wanted to do the right thing because you’re a mom and you got this damn job you have to get to,” she said. “But you didn’t have any control. You wanted it all the damn time.”

She lost her job and became homeless.

She began to get sick. Even though she knew something was seriously wrong, she was either too high or too scared to go the hospital. She decided to get clean in 1989 for her children. A few years later, she found out that she had HIV.

She was recruited into one of the earliest treatment programs for people living with HIV. She was the only woman when she enrolled. Most of the other participants who began the program with her, mainly gay men, have since died.

Wright’s experience was transformative. “If it wasn’t for them I may not have accepted this situation,” she stated. “They just did everything that I expected everyone to do all my life – take care of me.”

She also credits her faith in God for getting her here. “He allowed me to know that this is just a journey,” she stated. “That is what keeps me.”

‘Real life stories of pain’

Stories of African-American women aging with HIV: 'My life wasn’t what I hoped it to be'
Toya Tolson gave birth to a son who died in her arms moments later. She started selling drugs, saying she was her own best customer. Aamir Khuller, CC BY-NC-SA

“I have a lot of stories,” said Toya Tolson. “They are real-life stories of pain.”

She became pregnant when she was in 10th grade. Her son was born prematurely, and he died right after his birth. She remembers holding him. “I have his birth and his death certificates,” she said between tears.

She coped by turning to drugs, mainly marijuana and love boat, a street drug made of marijuana dipped in a toxic chemical like formaldehyde, PCP, or both. It can cause severe brain damage and even death. She didn’t care. “I was getting high,” she said. “I was selling. I was my best customer.”

Eventually she became homeless. Alone on the streets, she became numb to feelings. “I put myself in a lot of dangerous situations,” she said. “It was just about survival.”

She was involved with a lot of strangers. “They weren’t relationships. They were sexual activities when I was out in the streets. I was in a confused state of mind. Where I probably encountered AIDS.”

What she really wanted was affection and attention, things that she felt like were always missing from her life. “I wanted to be loved. I wanted just to be around and thought they were my friends. But they wasn’t. They was using me. I didn’t comprehend until it was too late.”

Things hit bottom when she fell into a coma. No one expected her to survive. She spent months in rehabilitation, until she was sent home in 2005. That’s when she found out that she had HIV.

Today, she is thankful for being alive. “Every morning I wake up, I’m more than a moment. It’s a gratefulness. I’m still here. I have a second, an hour, another day.”

‘I thought I’d rather die’

Stories of African-American women aging with HIV: 'My life wasn’t what I hoped it to be'
Deborah Dyson’s parents were alcoholics, and she became addicted to crack. She wants others to know that there is life after HIV. Aamir Khuller, CC BY-NC-SA

“My life wasn’t what I hoped it to be,” Deborah Dyson said.

Both of Dyson’s parents were alcoholics. Raised by her godmother, her life took a turn for the worse when she moved back in with her biological family. A relative began to rape her when she was 12. Out of fear, she didn’t tell anyone. She turned to alcohol and drugs, both readily available in her home.

Things soon spun out of control. She dropped out of high school. A sister introduced her to crack.

She remembers the first time she smoked it. “That’s when you first figure out how crack works,” she recalled. “Because drinking was a thing I knew how to do, so I just needed to add the drinking to the crack to make that high. When you first drink, you get that good little buzz, so you’re always trying to find it again. That’s what I was doing, trying to find that feeling again.”

Soon, she turned to heroin. She used for 17 years, often out on the street.

Early in 1989, she became increasingly sick. Her friends urged her to get tested for HIV.

“I didn’t know anything about HIV,” she said. “I had friends dying of it but I didn’t know anything. I started taking AZT. I hated it. I got sick of it. I got mad. One day I took the whole bottle of pills and threw them up on the roof. I thought I’d rather die than take this.”

A friend recommended that she switch doctors and clinics, and this change made a huge difference.“ They showed me that I could live. They gave me good medical treatment,” she said.

Being around others with HIV and becoming a grandmother has also helped Dyson be less fearful of death and HIV. “I don’t let anything scare me because I know at the end of the day God has my back,” she said. “I’m not perfect, but I don’t allow a disease to tell me what I can and cannot do.”

How old is too old to drive?

When Britain’s Prince Philip crashed his Land Rover into another vehicle on Jan. 17, 2019, many people were surprised that he was still driving at age 97. Many thought that surely someone – the queen perhaps? – would have persuaded him to give it up, or would have “taken away” the keys.

Older unsafe drivers are a growing problem, thanks to the baby boom generation. In the U.S., 42 million adults 65 and older were licensed to drive in 2016, an increase of 15 million from 20 years ago.

Yet who wants to stop driving? It is not only a major symbol of independence but also a needed activity for older people to be able to shop, go to the doctor and maintain social connections.

I’m a geriatrics specialist physician, a daughter of parents who had to stop driving. I live in Florida, where 29 percent of our drivers are older adults, which everywhere else in the U.S. will experience about 10 years from now. I also serve as editorial board chair of the Clinician’s Guide to Assessing and Counseling Older Drivers, a collaborative project between the American Geriatrics Society and the National Highway Traffic Safety Administration, or NHTSA. I have spent a great deal of time training clinicians how to detect and treat factors leading to the loss of driving skills early enough to prevent crashes and the loss of independent mobility.

Older drivers by the numbers

How old is too old to drive?
Older drivers are typically good drivers, but they can have impairments they may not recognize. Photobac/Shutterstock.com

By 2030, NHTSA estimates that 1 of out of every 4 drivers will be an older adult.

About 7,400 adults ages 65 and older were killed, and more than 290,000 were treated for motor vehicle crash injuries in 2016 alone.

Males 85 years and older and 20-24 years of age have the highest crash rates. Age and experience may be a factor here, but far and away the greatest number of vehicular deaths are still from substance abuse-related crashes, accounting for 23,611 out of a total 37,133 deaths in 2017.

According to Centers for Disease Control and Prevention data, most older drivers have good driving habits. The CDC reports that many self-restrict their driving to conditions where they feel safe and confident, such as avoiding high-speed roads, nighttime driving, bad weather or high-congestion times of day.

Know the stop signs

How old is too old to drive?
Good driving skills, such as having good vision and range of motion, are more important than age. Nikolai Kazakov/Shutterstock.com

Prince Philip announced on Feb. 9, 2019 that he would give up his driver’s license, but only after he and others had suffered serious consequences.

So how can others know when it’s time to get help or stop driving, for ourselves or for our parents, friends and neighbors?

It is all about the skills, not the age.

Key warning signs that it may be time to stop include getting lost, failing to obey traffic signals, reacting slowly to emergencies, using poor judgment, or forgetting to use common safety strategies, such as checking for blind spots.

Vision, cognition and the physical ability to manage the controls to the vehicle are critical functions that we must be able to perform, whether we are young or old in order to drive safely and effectively. Vision is well-recognized as the single most important source of information we use when navigating and making judgments.

Having difficulty with daytime sun glare, as was reported in Prince Philip’s crash, or nighttime headlights, brushing into objects on one side, or having to brake suddenly may be signs that something is impairing our ability to perceive road hazards accurately. Regular vision checkups are important to assure that we keep optimal vision for driving.

Cognition is essential to processing all the information we receive, ignoring distractions, remembering our route, responding to traffic signals and making good decisions. Medications and medical conditions such as sleep apnea, Parkinson’s disease or dementia can stop us from being able to think and respond well enough to keep ourselves or others safe while driving. Getting a good evaluation from your health care provider can help to minimize these risks and flag situations.

Physical abilities such as turning the steering wheel, neck flexibility and detecting where the pedals are correctly are important for operating the vehicle smoothly. Many of the same conditions associated with falls are also related to motor vehicle crashes.

Possible solutions

People can take brief self-assessments to get an idea of how they are doing, or ask a trusted individual to rate their driving using a tool validated by on-road testing, and discuss the results.

A driving rehabilitation specialist may be helpful in identifying problem areas, learning strategies for improvement and rehabilitating rusty or lost driving skills. You can find one using national databases on the America Occupational Therapy Association or the Association for Driver Rehabilitation Specialists websites.

It may be tempting to get a new vehicle featuring the latest safety features such as collision avoidance sensors, but these are not a substitute for a driver’s own skills. And, sometimes changing vehicles may even create mild confusion in a driver accustomed to a certain vehicle.

‘Mom, can I take away the keys?’

How old is too old to drive?
Taking away the car keys could be avoided with earlier discussions about safety and cognition. fatir29/Shutterstock.com

Adult children often want to protect their parents if they notice impairment. It’s important to have open, respectful communication to establish that maintaining mobility and finding alternative means of transportation are key to retiring from driving. These discussions should occur long before there’s a crisis.

Being willing and able to stop driving requires having a realistic mobility plan. National and local transportation resources can help people get around without driving, but it does take some effort to get used to planning activities well in advance. New skills may be needed, such as learning how to access ride-hailing services like Uber or Lyft, or someday, managing an autonomous vehicle.

Until then, following basic driving safety strategies and keeping as mentally and physically fit as possible is the best way to help us help ourselves to keep driving for longer.

To end the HIV epidemic, addressing poverty and inequities one of most important treatments


To end the HIV epidemic, addressing poverty and inequities one of most important treatments
Homelessness is a major driver of HIV/AIDS. Andrew Marcus/Shutterstock.com

In his State of the Union speech, President Trump called for ending the HIV epidemic in the United States within 10 years. Health and Human Services Secretary Alex Azar and senior public health officials stated that the government plans to focus on highly impacted areas and getting drugs to people at risk.

I am a social scientist with over 10 years of expertise in the area of health disparities. My research interests include understanding and addressing disparities in HIV and cancer outcomes, particularly among immigrant and minority populations, using a social determinants of health framework.

While remarkable progress has been made in the fight against HIV/AIDS, ending the epidemic will likely take longer than 10 years and will take more than drugs. That’s because the main driver of the disease has more to do with social inequity than with the virus alone.

The overall annual number of new HIV diagnoses has remained stable in recent years in the U.S., but this has not been the case for all groups. In fact, data from the Centers for Disease Control and Prevention reveal that major racial, ethnic, socioeconomic and even geographical inequities still exist. These inequities exist at every step in the HIV care continuum, from testing to mortality.

This means that there are gaps along the continuum and these individuals are being lost at each step, including HIV testing and diagnosis, linkage to appropriate HIV care, support while in care, access to antiretroviral treatment, and support while on treatment. These gaps exist due to barriers such as poor access to services, poverty, food insecurity and homelessness, and stigma and discrimination.

A HIV hot spot: The South

To end the HIV epidemic, addressing poverty and inequities one of most important treatments
A nurse pricks the finger of a young person to draw blood to test for HIV. Adam Jan Figel/Shutterstock.com

Among the CDC’s most distressing recent findings: More than half of new HIV diagnoses in the United States occur in the South. The heavy burden of HIV in the South is driven by factors such as concentrated poverty in cities, suburban areas and rural counties, high levels of unemployment, inadequate local health care infrastructure, and a lack of access to health insurance and quality health care services. Other important factors include increased stigma and discrimination toward those living with HIV. This can lead to people being afraid to get tested or seek treatment for fear that someone may find out they have HIV.

Gay and bisexual men account for 66 percent (25,748) of all diagnoses and 82 percent of HIV diagnoses among males. And, although African-Americans represent 13 percent of the U.S. population, they account for 43 percent (16,694) of HIV diagnoses. Likewise, Latinos represent 18 percent of the population but account for 26 percent (9,908) of HIV diagnoses.Racial and ethnic minority women account for a disproportionate share of diagnoses of HIV infection among women.

An arsenal beyond the medicine chest

HIV interventions that focus narrowly on pharmaceutical or drug innovations alone or individual behavior change cannot effectively address the magnitude and complexity of the HIV epidemic, as I explain in my recently published article with co-researcher David R. Williams, Ph.D. at Harvard T.H. Chan School of Public Health, in Public Health Reports. What we need most urgently today is a new generation of rigorously evaluated, cost-effective HIV interventions focused on the fundamental contextual factors for disease. These factors include:

  • access to adequate housing
  • access to quality health care and health insurance
  • access to child care
  • education, employment status, gender equality and income.

These factors are known generally as the social determinants of health (SDH) and have been viewed as the drivers of health for decades by many public health experts.

To cite a few examples, in one scientific study, structural community factors, such as poverty and poor employment opportunities, limited access to health care resources among women in the Deep South. In addition, stigma, transportation challenges, and access to illicit substances impacted health-seeking behavior and decision-making, and the ability to engage in HIV care.

Similarly, another study found that homeless individuals were more likely to be uninsured and less likely to adhere to their HIV anti-retroviral medication, demonstrating that housing is an important mechanism for improving the health of this vulnerable group.

Moreover, racial/ethnic stereotypes are deeply embedded in American culture and, whether consciously or not, can adversely affect the care that providers give to their patients. Evidence indicates that interventions that address implicit racial bias among providers can improve the quality of care and reduce racial/ethnic disparities in HIV outcomes.

With this scientific evidence in mind, it is perhaps unsurprising then, that despite three decades of public education and clinical campaigns, more than half of all the new infections in the entire region of North America, Western Europe and Central Europe occur in the U.S.

Make things fair

To end the HIV epidemic, addressing poverty and inequities one of most important treatments
Tents for homeless people in San Francisco, Calif., where a lack of housing is a rising crisis. Gov. Gavin Newsom recently announced a plan to create new housing to provide homeless people with secure housing. Eric Risberg/AP Photo

So what will it take to end the epidemic in the U.S.?

Put simply, to fight HIV, we need to address poverty and social inequity. This approach is the vital game-changer needed to eradicate the HIV epidemic in the U.S. Whenever feasible, social determinants need to be incorporated into behavioral and biomedical strategies to increase their likelihood of success. A new generation of HIV interventions focused on the fundamental SDHs should be the centerpiece of efforts to address HIV-related disparities.

There is growing scientific evidence documenting that interventions that address poverty and inequities in social and living conditions can be effective in reducing risks of HIV infection. Numerous studies reveal that improving education and affordable housing can reduce incidence rates of HIV and AIDS, because low levels of education and unstable housing have been found to decrease social stability and increase HIV risk behaviors.

These studies reveal that interventions that strengthen women’s income, housing stability and gender empowerment are associated with improved psychological well-being, economic productivity and reduced HIV risk. Improving access to care and enhancing quality of care can also contribute to reducing disparities in the incidence of HIV.

It is time to recognize that every government action has the potential to affect health and health equity, including policies dealing with finance, education, housing, employment, transportation and health. Economic studies also support the fact that most rigorously evaluated interventions focused on SDHs have been shown to be cost-effective and save society money in the long run. It is therefore important to integrate this Health in All Policies approach to have the widest impact on the HIV epidemic.

I believe Americans must commit to making it clear to our leaders and to all Americans that all sectors of society gain when we invest in tackling inequities in the most vulnerable areas. HIV/AIDS is not a partisan issue. Political will – and good will toward our most vulnerable fellow citizens – can engender a national “culture of health” that shatters boundaries, equalizes access, and makes HIV/AIDS a fading spectre from the past.