-Caveat Lector-
Is the Rate of New HIV Infections Rising?: The San Francisco
Controversy and Its Lessons for Los Angeles and the US
Walt Senterfitt
Being Alive - October, 2000
-------------------------------------------------
The gay press in California and around the country have spent a
lot of ink debating some numbers released just before the Durban
International AIDS Conference and an accompanying speculation by
San Francisco's chief HIV epidemiologist that "rates of new HIV
infections in some parts of San Francisco's gay population have
increased to sub-Saharan levels." This news was greeted with loud
echoes of everything from "Can't be! It's the health department
cooking numbers in a plot to justify more restrictions on gay
sex," to "The AIDS crisis is over! This is another detraction
from the health needs of the large number of HIV negative gay men
and lesbians," to "It's highly suspect! Bogus! A San Francisco
plot to keep their unfair share of federal AIDS funding," to "We
are not surprised, given the lessening fear of HIV with the
advent of HAART and the barebacking craze."
Each of these and most other reactions is at best one-tenth true,
but the controversy has been valuable. Its context is the
hard-to-dispute fact that HIV prevention has not kept pace with
the changes in the epidemic.
What Are the Facts In San Francisco?
It is important to remember that there is no way to count new HIV
infections and therefore no way to prove beyond a doubt whether
rates of infection are increasing, decreasing or level. New HIV
infections are not yet reportable to public health departments in
California and even if they were, there is usually no way to tell
if a positive test is a new infection or an old one in someone
who has not been tested or reported before. Most of all, there is
no way of knowing how many new infections occur anew or exist
already among people who haven't been tested at all. Thus, the
best we can do, and we are getting better at it, is to estimate
based on several different kinds of data. The estimates will
always be approximate at best, but if we use the same or better
methods every year, we can get a pretty good picture of the
trends.
San Francisco is better than anywhere else in the US at
estimating infections (some might say, aided by all that money,
its small size and the high visibility of the gay community).
There are more studies and surveillance systems to base estimates
on and more experts to analyze them. The San Francisco Department
of Public Health (DPH) periodically convenes a panel of these
experts and a group of community people living with or working
with HIV on the front lines, to develop for planning purposes
consensus estimates of people living with HIV/AIDS and the annual
rate of new infections. The latest such consensus panel met in
May 2000.
One new tool to help determine HIV incidence is what's called the
"detuned Elisa assay." This takes advantage of the improvement in
HIV testing over the years, the improvement that has shrunk the
so-called window period (when one might be HIV+ but not yet show
up it on an antibody test) from six months to six weeks. The
detuned assay tests a person's blood with both the old, less
sensitive test and the new, more sensitive one. If one is
negative on the old test and positive on the new one, we can
conclude that person is within the old "window period" of a new
infection. By doing this double test on thousands of specimens,
the CDC has concluded that someone can be identified with this
system as being within the first four months of infection. So in
a high volume testing center, STD clinic or medical care system,
one can estimate how many infections are new. By combining these
data with other information about the population that uses the
testing system, one can estimate the percentage of negative
people in the population who are seroconverting each year.
The San Francisco consensus panel estimated that the proportion
of gay and bisexual men becoming HIV infected rose from 1.1% a
year in 1997 (the time of the last consensus panel) to 1.7% a
year in 2000. Among the much smaller number of gay and bisexual
men who are also injection drugs users (IDUs) the rate and the
increase were much greater: from 2.0% seroconverting every year
in 1997 to 4.6% a year in 2000. Among heterosexual IDUs the rate
declined somewhat from 1.0% a year in 1997 to 0.6 % a year in
2000. Among non-IDU heterosexuals, the estimates are tiny and
stable: 1/100th of a percent per year in both years.
These estimates from HIV testing sites were bolstered by findings
from other sources. There is increased incidence of HIV in a
cohort study of young gay men, increased cases of rectal
gonorrhea, increased frequency of bacterial sexually transmitted
diseases (STDs) among gay men living with AIDS, increased total
numbers of people with AIDS and HIV (of whom a big chunk are
sexually active), increased self-reports of multiple partners and
unprotected anal sex among gay and bi men, increased self-reports
of unprotected anal sex among partners of different or unknown
HIV status, and decreased consistent condom use overall.
The increase in estimated rates translated to increases in
estimated numbers, especially when the rates were applied to
upwardly revised estimates of the total number of gay and bi men
in San Francisco, derived from studies with stronger methods. The
panel estimated that there will be 573 new infections in gay men
in 2000 compared to 283 in 1997; 143 in gay/bi IDUs, up from 53
in 1997; and declines in heterosexual IDUs from 117 to 68 and in
non-IDU heterosexuals from 45 to 6.
Though some writers in the San Francisco gay press and some
community leaders have quibbled with this or that component of
the estimates, no one has introduced credible evidence or
argument that the basic trend depicted is false. Readers may find
a complete presentation of the data as well as the
recommendations below on the University of California San
Francisco (UCSF) HIV Web Site:
http://HIVinsite.ucsf.edu/ari/HIVEstimatesReport8900.html
<http://HIVinsite.ucsf.edu/ari/HIVEstimatesReport8900.html>
Why Are Infections Increasing? What's Going On?
A community panel examining the estimates remarked that while the
numbers have evinced alarm, sadness and a great deal of anger,
almost no one was surprised. The increase is based in their view
on several realities.
For one thing, and this has been confirmed in studies in West
Hollywood and Los Angeles, the perception of AIDS as a death
sentence is largely gone among gay men, as a result of the
partial reality and the widespread hype surrounding highly active
antiretroviral therapy (HAART) and the change of HIV/AIDS to a
"chronic, manageable disease." When AIDS were still seen as a
death sentence, and people had seen hundreds of their community
waste away and die, people made certain choices about risk that
became less common when that perception changed. It is not only
HAART, but new generations coming of age without the visible
swaths of the scythe of the Grim Reaper.
The perception of HIV on the streets has changed, and most HIV
efforts have not caught up with that change. Studies indicate
that high-risk sexual behavior is on the rise in San Francisco
(and most likely in WeHo, Long Beach and LA).
The San Francisco community analysts divided gay men's
communities into three distinct groups, all with real but
different prevention needs. The first group comprises people who
have eliminated high-risk behavior from their lives (whether they
are HIV positive or negative). They have a thorough knowledge of
HIV transmission and risk reduction techniques, and have chosen
to eliminate risk based on personal decisions about their risk
and need.
A second group has engaged in high-risk behavior throughout the
epidemic, despite years of exposure to risk reduction in media
and community prevention efforts. This has not changed. For these
men, "decisions about perceived risk are outweighed by their
needs for identity, intimacy, pleasure or other considerations.
They know about risk, have made choices, and engage in behavior
at the level of risk they believe to be appropriate."
A third group of gay and bi men has changed its behavior
recently. "This group makes situational decisions about risk
behavior. These decisions are based on their knowledge and
understanding of HIV transmission, the perceived risk of the
behavior in question, and the stated or presumed HIV status of
their partners."
The Gist of What's Wrong with Prevention
HIV prevention and education have been based on many theories for
the past 20 years. Most of these theories have assumed that
reasoning things out can lead to safer behavior. While that is
certainly partly true, reason isn't the only thing that guides
our behavior in the heat of the moment. Most gay men make
decisions on sex at a level far more basic and urgent than one
naturally including complex reasoning analysis. The San
Franciscans noted, "A brochure can be informative on Tuesday
morning; in a moment of passion on Friday night, a different
analysis occurs." (Do I hear you say "duh"?)
Substance use before and during sex is also a factor. For some
individuals, chronic loneliness, isolation and alienation may
lead to remedies that include high-risk behavior. So can pursuit
of pleasure in a society where discrimination can make life
painful.
Finally, prevention has until now largely excluded the needs of
HIV+ people. Nearly every positive person wished HIV to stop with
him or her, but there has been precious little support for doing
that, in the context of a sex-and intimacy-positive full, rounded
life.
In a nutshell, the realities of new HIV infections are complex,
and prevention needs to change. (I acknowledge that I am limiting
this analysis largely to gay and bisexual men who overwhelmingly
predominate in the epidemic on the West Coast. There are
different but analogous stories to be told about women,
hetero-and bisexual communities of color, IDUs and different
regions of the country.)
What Is To Be Done?
The San Francisco DPH and its community planning bodies have
issued an "11 Point Action Plan" as an opening salvo in a dynamic
process of "dialogue, programmatic renovation and community norm
building among gay men." The plan is not deemed either exhaustive
or complete, but a foundation of assumptions being made to begin
to both revitalize HIV prevention in San Francisco and to
revitalize the San Francisco gay community's ownership of its own
longevity.
I present these points here in their original form. I believe
that they are worthy of intensive discussion in Los Angeles and
elsewhere around the nation.
A Call to Action
* New HIV infections are going up among gay men in San Francisco.
* San Francisco needs a new prevention model-one which recognizes the
impact that successful HIV therapies have had on the gay community.
* The gay community needs to take the lead in developing a
community response.
The 11 Point Action Plan
1. Ownership-Take ownership of the epidemic, implementing
culturally-specific, community-driven responses. Prevention is
not done to a community, but by and with a community.
2. Condoms for HIV+ tops with HIV negative bottoms. Assume
responsibility.
3. Condoms for HIV negative bottoms with HIV+ tops. Assume
responsibility.
4. Know your current HIV status. Get HIV tested every six months
if you were last negative and have had risky sex or needle use.
Seek care and support if you're HIV+.
5. Prevention for positives. Develop and expand HIV prevention
programs that are designed by and for HIV+ individuals.
6. Eradicate bacterial STDs in gay men. Rectal gonorrhea,
syphilis, chlamydia.
7. Recovery. Expand drug treatment. Mature our substance abuse
services to address real life issues facing gay men such as the
relationship between speed use, Viagra, and unprotected sex.
8. Counsel. Rebuild and expand the network of services for
mental health and wellness.
9. Positive care. Get more HIV+ people into care and/or onto
appropriate antiviral treatments, provide better treatment
regimens, improve adherence and offer individually tailored
counseling and care.
10. Reality check. It remains a fundamental truth that it is
better to remain HIV uninfected. If you are HIV negative, stay
that way!
11. Gay men's health matters. It is important that HIV prevention
be nested within a broader health agenda for the community.
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