More Harm Reduction, Less Abstinence-Only in COVID Messaging, Experts Say

More attention to harm reduction -- rather than totally abstaining from risky behaviors -- would improve messaging on the COVID-19 pandemic, Amesh Adalja, MD, a senior scholar at the Johns Hopkins Center for Health Security, said Wednesday.

"A lot of COVID-19 was abstinence-only" when it came to behavior, Adalja said during an online briefing sponsored by the Alliance for Health Policy on lessons to be learned from the HIV epidemic. "And it's not surprising that it failed. It's not surprising that most people lied about their activities. Because we know that abstinence-only doesn't work in any situation."

"For so long during the COVID-19 pandemic, that's what the actual official government policy was, even though many of us were saying, 'Harm reduction. Risk calculation. Just give people tools and they'll actually modify their behavior,' and I think that would have avoided some of the politicization that happened," he said. "If we would have had a harm reduction approach rather than the shaming and all of that that went on ... It all [involves] some COVID risk and that was just something that got ignored and hopefully now we're getting to that point."

"Always have the subject matter experts leading this," added Adalja. "When you have politicians involved, it's going to become political, just by definition, because when they view a public health emergency as a way to get a 'one up' on the other party, or they think about the rate of boosters or the low rate of boosters as a win or a loss for them rather than actually thinking about the infectious disease issue."

Both parties are "completely guilty" of politicizing these issues, and "for two different administrations during COVID-19, they don't actually think about what's going on on the ground," he continued. "What's the public health emergency? What do we need to fix here? They think, 'this is going to be good for my polling,' or 'this is my vision.' They shouldn't even be asking polling questions about disease because that's not something that should be in their purview."

Public health agencies, including the CDC, should be somewhat separate from government because "there just needs to be some insulation so that it's not sucked into the vortex of the day-to-day getting a 'one up' on your political opponent," he said.

Caring for HIV patients has become a non-partisan issue, but it didn't start out that way, according to Lindsey Dawson, MPP, associate director of HIV policy at the Kaiser Family Foundation. "HIV is still stigmatized, but there was a time of even deeper stigma. We had a sitting president that didn't mention HIV/AIDS until 1985," she said, referring to former President Reagan. "And that bipartisanship took a lot of coalition-building. It wasn't a given, and advocates made inroads in the agencies. So advocates were deeply involved in evolving policy at the FDA, changing regulatory pathways, and at NIH, having conversations about what clinical trials should look like. And similar conversations were happening on [Capitol] Hill. And so that bipartisanship was fought for."

Dawson said she agreed with Adalja that public health needed to be de-politicized. "We need to have a de-politicized, science-based approach to these conversations with leadership, and that's because the second you say something that is partisan or based in politics, there's going to be fear associated with it. And it's hard to do something when you're coming from a place of fear and threat. But if you're coming from a place of knowledge base and a science base, it might be easier to make political decisions. And I realize that that's easier said than done."

Another thing to consider in terms of distrusting public health messages is the mistrust in the medical community by people of color "based on the harm that has been done" to those communities by medical professionals, said Antoinette Jones, national field organizer for the Positive Women's Network, a group for women diagnosed with HIV. "That feeling is so embedded in the DNA of Black and brown people that it probably would never go away," she said.

"So the way to engage people who are living with HIV is going to look different than people who are not living with HIV, because people who are living with HIV have had more of a hands-on and a witnessing approach to seeing the progression of the HIV virus. So of course they are going to be a lot more trusting and eager to receive the COVID-19 vaccine and even the monkeypox vaccine because we are very, very much closer to science than the rest of our community who is not living with the virus," she continued.

"In order to not see the same things happen that we have seen in an HIV epidemic, we want to definitely do a [harm reduction] approach, but increased hands-on community support is important," Jones said. "Providing resources and education is important, especially when it comes to research and sharing back the research to the community that they have been involved in. And then also access is really important -- making sure that folks are able to get to these testing locations or these vaccine sites in order to increase those numbers ... as well as prevent further cases."

With the development of tools to combat HIV such as pre-exposure prophylaxis (PrEP) and antiretroviral treatment, "I think that HIV kind of became a paradigm for how science can solve a problem, but how it won't go all the way without actual implementation of those tools," Adalja said.

"And I think when you look at COVID, think about the way that the HIV response evolved, the tools that were brought to bear, and how this became a much more manageable infection," he added. "And I think it only happened because there was a concerted effort to actually treat HIV as the big health security risk that it was."

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