San Francisco Examiner - Aug. 09, 2000
Ulysses Torassa, Examiner Medical Writer

Political correctness and the fear of being accused of blaming the victim have kept health workers from focusing enough on stopping people with HIV from spreading the infection to others, according to Health Director Mitchell H. Katz. He also wants to redirect some of the money now spent on health campaigns into substance abuse treatment, since many new infections are related to drug and alcohol use.

"Any health department faced with these kind of numbers should be asking: How should prevention change?" said Katz, an AIDS doctor who formerly headed the department's office on HIV and AIDS. "What we are proposing is a controversial retooling of the prevention model."

New HIV infections in San Francisco have climbed from a low of 498 in 1997 to 790 this year, according to estimates based on an analysis of recent data by researchers at the Health Department and UC-San Francisco's AIDS Research Institute. The new figures are being presented Wednesday at a Board of Supervisors' Finance Committee meeting, along with a broad outline for combatting the trend.

All of the increase appears to be coming from gay men, where the number of new infections went from 283 in 1997 to an estimated 573 this year. New infections among heterosexuals who don't inject drugs are down to just six, from 45 in 1997.

The numbers are not a complete surprise to public health officials, who had already noted several early warning signs, including the emergence of so-called "barebacking" parties where men gathered to engage in unprotected sex. More HIV-positive men are also catching sexually transmitted diseases like syphilis and gonorrhea, a sign that they are having unsafe sex in greater numbers.

With the advent of anti-retroviral drugs, the number of people living with HIV has grown steadily. It is now estimated that a third of gay men in San Francisco are HIV-positive.

"We're facing a new generation of problems in HIV prevention," said Thomas Coates, who heads the UCSF AIDS Research Institute. "That is, how to do prevention when AIDS isn't so scary any more."

And Coates said the issue isn't peculiar to San Francisco. But with its large, concentrated population of gay men - estimated to be about 52,000 - it is the first place to reflect the trends.

"Other cities are now scrambling to find out if it is going on in their communities," Coates said. "Everybody believes it will be the case."

The Health Department has come up with an 11-point plan to address the trend. For one thing, Katz said it's clear that the blanket advice to use condoms at all times is losing its punch, as rates of condom use have begun to drop. Instead, he wants to narrow the focus of safe sex messages to situations of anal intercourse between an HIV-positive man and his HIV-negative male partner.

"If we could prevent unprotective anal intercourse between HIV-positive tops and HIV-negative bottoms, we could prevent 95 percent of the transmission in San Francisco," Katz said.

Katz said he wants to target more efforts at keeping people with HIV from spreading the infection. Until now, he said, "it's been that HIV prevention is for negatives and HIV services are for positives."

"No one wanted to be seen as being politically incorrect by suggesting that a negative person became infected because of a positive person," Katz said. "But that's the only way it happens."

Katz said he knows the new tactics will draw opposition from many quarters, including from local health groups that receive money from the department to carry out prevention campaigns. Among other things, he wants to redirect some of that money to drug treatment programs.

"We're not saying let's do more of the same," Katz said. "It will be difficult because it'll mean certain groups used to funding won't get funding anymore. People's jobs will change."

One of the largest recipients of HIV prevention funds is the San Francisco AIDS Foundation. Brian Byrnes, its director of prevention, said the agency agrees that new strategies need to be created to address the changing way gay men view HIV and AIDS.

But he said the foundation believes more effort needs to go into understanding just which gay men are engaging in risky sex, and why.

"Is the trend they've identified generalizable to all gay men, or is there a segment that is engaging in greater risk and therefore make up the lion's share of these new infections?" he said. "Much more needs to be known about the specific populations represented in the data in order for us to review and assess our current prevention programs and to tailor them to the needs of the specific populations."

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