Washington Blade - August 1, 2003
Ryan Lee

The conference, held July 27-30 in Atlanta, also saw a groundswell of protests against the CDC's recent announcement that it is shifting its prevention efforts toward those already infected with the virus that causes AIDS.

The presence of Claude Allen, deputy secretary for the U.S. Department of Health & Human Services, as keynote speaker for the conference's closing ceremonies drew some of the strongest outcry.

Nearly half of the 2,000 people attending the July 30 closing ceremonies held signs reading "Stop the war on HIV prevention" in quiet protest as Allen delivered his keynote speech, which focused on what he called the ABCs of HIV prevention: abstinence, being faithful and condom use.

"I think the frustration over the process [of developing CDC's new initiative], and some real concerns about the way it appears to being implemented, really came to a head at this conference," said Gene Copello, executive director of Florida AIDS Action and co-chair of the Southern AIDS Coalition. "Certainly the closing ceremonies is where many folks wanted to express that in an explicit, but orderly way."

Terje Anderson, executive director of the National Association of People with AIDS, accused CDC officials of trying to keep Allen's appearance a secret - by not placing his name anywhere on the conference's program - to avoid organized protests.

But a few organizations got wind of Allen's presence and developed the demonstration.

"We wanted to deliver a message to him and to the administration that we're not happy with their record on HIV prevention," Anderson said. "Claude Allen and many of these ideological approaches to prevention are contrary to the kind of public health science that was being talked about at this important conference."

CDC officials said their focus remains on preventing the spread of HIV.

"One of our greatest priorities is providing adequate prevention support to the 850,000 to 950,000 Americans now living with HIV," said Ron Valdiserri, deputy director of the National Center for HIV, STD & TB Prevention at CDC, and the conference's co-chair. "Efforts to link HIV-infected individuals to testing, treatment and prevention services is critical for reducing new infections."

Yet many at the conference objected to the new CDC guidelines, aimed at encouraging doctors to take a more aggressive approach to delivering prevention messages to their patients infected with HIV and AIDS.

"I think the planners of this conference saw this as a chance for them to unveil their new baby and walk off in applause," said Shana Krochmal, communications director for Stop AIDS, a San Fransisco-based health organization for gay and bisexual men. "They were sadly mistaken."

Prevention for positives

Announced April 1, the CDC's new guidelines call for primary health care providers to screen HIV-positive patients - via questionnaires and interviews - about their sexual behavior. Doctors are also expected to provide prevention methods and counseling to these patients and their partners.

"We found that there is considerable opportunity to prevent HIV transmission in clinical care settings," said Stephen Morin from the University of California at San Francisco. "We also found that there are considerable missed opportunities for HIV prevention in clinical care settings."

In one study, 680 HIV-infected patients in nine states were interviewed by researchers as they exited clinics. Two-thirds of those surveyed said they were sexually active, of which 20 percent said they were concerned they may have infected someone else in the past six months.

Only six percent of all respondents said they had any discussions with their doctors about their sexual behavior, Morin said.

"Effective prevention with people living with HIV requires both providers and their patients to overcome their discomfort and unease in confronting sexual risk behavior," Morin said.

Another study from the University of Colorado revealed that "HIV care providers who received only one day of training reported feeling more comfortable discussing HIV risks with their patients," Morin said.

The initiative has been widely lauded by HIV activists, but many of those same people fear the CDC's new focus on prevention for HIV-positive people will result in a reduction in funds for community-based organizations.

"Many of the basic tenets of the initiative make a lot of sense, and there are elements that we think are very good," said NAPWA's Anderson. "Promoting knowledge of [HIV] status, working with positive people - those are good things that should happen."

But "a huge part of this initiative has been about moving resources that currently go to largely minority organizations that receive funding from the government to do prevention for negative people," Anderson said.

The CDC is asking community-based organizations - which were never guaranteed continued funding - to put a stronger emphasis on encouraging people to get tested and in contact with their doctors, Valdiserri said Monday.

"In terms of the initiative, some of the dollars that have gone into supporting the initiative were made available by projects and other activities coming to an end and then being redirected into the initiative," Valdiserri said. "We are not taking money away from community-based organizations, but it is a competitive process."

HIV increase, risky Internet sex highlighted

According to data collected from 25 states from 2001-2002, HIV diagnoses among gay and bisexual men increased for the third year in a row. In 2002, diagnoses rose 7.1 percent, and they have climbed 17.7 percent since the lowest point in 1999.

"Many behavioral studies reporting increases in unsafe behavior among [men who have sex with men] are very concerning," Valdiserri said. "We continue to sound this warning note to communities that we need to redouble our prevention efforts."

No other group has seen noticeable increases in the same time span, Valdiserri said.

But cases of full-blown AIDS cases around the country did rise 2.2 percent in the last year, from 41,227 in 2001 to 42,136 in 2002, the CDC reported at the conference.

While the percentage increase is slight, the figures raised concerns because AIDS cases had been declining for the last decade.

"The lack of progress in reducing AIDS diagnoses is likely due to several factors," the CDC reported, "including treatment failure, difficulty adhering to complex regimens, and late HIV diagnoses delaying initiation of treatment."

Internet a hot topic

The role the Internet plays in gay and bisexual men's sexual behavior was also a pillar issue of the conference.

The Internet has overtaken bathhouses, bars and sex clubs as the main venue for anonymous hook-ups, according to a syphilis study by the California Department of Health Services.

"In 2002, 28 percent of our men who have sex with men syphilis cases reported meeting partners over the Internet," Terrence Lo, one of the study's authors, said Tuesday. "The Internet included chat rooms, online personals ads and sex parties posted online."

The number of gay and bisexual men who reported meeting on the Internet for sex increased from 12 percent in the first six months of 2001 to 40 percent in that same time period of 2003.

"This clearly indicates the necessity to develop appropriate strategies and interventions online," Lo said.

Just as the Web may facilitate risky sexual behavior, it has also shown promise as a new way to deliver STD prevention messages to hard-to-reach individuals, said Gregory Rebchook of the University of California at San Francisco.

"Men in our study spent an average of 20 hours a week online for personal purposes, and said they were willing to participate in online HIV prevention efforts," said Rebchook, noting that 58 percent of respondents in one of his surveys reported having unprotected sex in the past two months.

Activists said the rise in HIV diagnoses among gay and bisexual men merits careful analysis.

"The prevention funds from the federal government has been relatively flat for the past few years and that may have an impact," Copello said. "It is troubling, but it may be related to increased testing and better reporting."

For Krochmal, the new data simply underscores the need to maintain focus on high-risk groups.

"If we're able to determine infections continue to rise in [gay and bisexual men], why is the response not to allocate more resources?" she said.

Widespread dissent

The HIV Prevention Conference came on the heels of the CDC's increased scrutiny of sexually explicit HIV prevention programs at San Francisco's Stop AIDS Project, sparked by complaints from conservative Congress members.

Many activists present at the conference expressed concern that the federal health agency would let politics, rather than science, guide its efforts.

The CDC may be preparing to throw out prevention methods that have been proven to work over the past 20 years, and community-based organizations will inevitably suffer from a shift of funds, said Michael Cover, director of communications for the Whitman-Walker Clinic in Washington D.C.

Even HIV-positive people have been excluded from the process, Anderson charged.

"They've never talked to positive people about what we want for services - they just picked a bunch of them," he said. The CDC's guidelines suggest narrow prevention efforts for HIV-positive people, focusing mainly on individual contact between doctors and patients, he said.

The initiative's language - which shifts funds as opposed to adding new funds - also places too much pressure on HIV-positive people to curb the spread of the disease and maligns them as "vectors of infection," Anderson said.

"If we're going to put all the responsibility for transmission of HIV, and prevention of transmission of HIV, on the shoulders of people living with HIV and AIDS, that sends the wrong message," he said. "We believe negative people need prevention services and negative people have shared responsibility in preventing new infections."

CDC officials said the question of additional funds is best answered by Congress. "Congress provides CDC with its budget," Valdiserri said. "There will always be [community based organizations] that won't receive the money they desire."

Instead of asking legislators for more money, the CDC should ensure proven prevention programs are funded, Stop AIDS' Krochmal said.

" I don't think we can expect Congress to give CDC more money when they won't be accountable to the communities they serve," Krochmal said.

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