AEGiS-BAR: SF: Condoms for pos tops with neg bottoms

Important note: Information in this article was accurate in 2000. The state of the art may have changed since the publication date.

SF: Condoms for pos tops with neg bottoms

The Bay Area Reporter - August 10, 2000
Terry Beswick

After nearly 20 years of making "condoms every time" the centerpiece of HIV prevention planning in San Francisco, and in light of controversial new estimates that HIV infections among gay men have increased at least 50 percent in the last three years, local health officials appear poised to finally embrace the realities of sex in the gay community, abandoning the time-worn message that gay men should use condoms 100 percent of the time.

Wednesday morning, the city released an "11 Point Action Plan" calling it an "opening salvo" of a still-undefined campaign to help curb the escalating rise in HIV infections, and refocus the city's current $16 million annual expenditure on HIV prevention programs.

"Our conclusion is that these programs work, but they're not working right now," stated Health Director Mitch Katz.

The centerpiece of the new plan embraces an idea long understood by gay men in San Francisco: that most HIV infections in the city occur when HIV-positive tops have unprotected anal sex with HIV-negative bottoms, referred to as barebacking.

"The model that was established in the early 1980s," said Mayor Willie Brown, at the City Hall news conference, "needs to be renewed, reinvigorated, and rededicated."

"In fact, if we could prevent unprotected anal intercourse between HIV-positive tops and HIV-negative bottoms, 95 percent of the epidemic would go away," said Katz, adding that he was now adopting the "top" and "bottom" vernacular when discussing HIV prevention.

The event was scheduled immediately before a hearing on the same subject called by Board of Supervisors president Tom Ammiano in the aftermath of leaks in late June around the new HIV infection estimates. At the hearing, Ammiano repeatedly asked Katz for an explanation for the higher incidence estimates, with Katz responding that "the experts sit around in a room and talk and decide" what is most likely the case.

In the face of two major factors -- an increase in the estimated number of gay and bisexual men living in San Francisco and a slew of studies indicating an increase in unprotected anal intercourse -- city health officials and colleagues at the University of California at San Francisco are now estimating that between 750 and 900 new HIV infections are likely occurring in the city this year, compared to 500 in 1997.

The higher number, 900, had been leaked to the media in June, leading to headlines around the world about the spike in unsafe sex among gay and bisexual men in San Francisco. On Wednesday, Katz repeated his perception that the subsequent criticism of the new estimate was directed at the unnamed leak, rather than at the lack of explanation of how DPH and UCSF had arrived at the number.

Key among the figures released Wednesday was an estimate that since 1997, the size of the gay and bisexual male population in San Francisco has increased from 43,100 to 52,000 today. These figures were juxtaposed with an estimate that the rate of new HIV infections in San Francisco among men who have sex with men -- the vast majority of cases here -- has increased from 1.1 percent in 1997 to a projected 1.7 percent in 2000. The latter estimate was derived from numerous "indicator" studies and epidemiological data.

The "11 Point Action Plan" appears to take a step toward a model of prevention called "harm reduction," and includes recommendations that could be directed at DPH itself and at community organizations. A few of the points are more philosophical rather than action items, such as "Reality Check: it remains a fundamental truth that it is better to remain HIV uninfected. If you are HIV-negative, stay that way!" The plan was reportedly presented on Tuesday to various community prevention organizations, and will be presented to the city HIV Prevention Planning Council today (Thursday, August 10).
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