Bay Area Reporter - June 1, 2001
David Fraser

Arriving at his Civic Center office on his bicycle, the director of San Francisco's Department of Public Health allowed that the ride to work downhill from Twin Peaks was smooth enough. Going up again, he said with a smile, can be a struggle.

Dressed in jeans, short sleeves, and bike helmet, Katz said with a grin that he changes his clothes when heading "over there" across the street to City Hall.

In a May 22 interview with the Bay Area Reporter, Katz talked with clarity and tears about how HIV, AIDS, promise, and loss have shaped his life and world over the 20 years since the disease - then a mystery - was first publicly identified by the Centers for Disease Control and Prevention on June 5, 1981.

AIDS over 20 years

Katz traced the history of AIDS: "People were infected in San Francisco as early as 1978. By 1981 there were documented cases at San Francisco General of these weird opportunistic cases that no one had ever seen before in healthy young men.

"By about 1982, there was an understanding on the street that there was this illness, that it was occurring in gay men, and the strong suspicion in the community itself that it was somehow related to sex.

"The earliest prevention messages, which were not very good, were: be sure that your partner was healthy, and limit the number of partners that you have.

"So the earliest bad advice was based on the findings that some people had outrageous numbers of partners - and I say that with some admiration - they were people who were enjoying a healthy sex life; there was no reason that they shouldn't have had thousands of partners, at that time."

Squeamish about anal sex

But, said Katz, as with any infectious disease, as HIV became more common, people started to realize in 1984-1985 that the number of partners didn't matter as much as the sexual acts: "Pretty early on, the analysis was showing that it was anal intercourse that was the strongest [factor], and every single study showed the same thing."

Even now, he sees a kind of squeamishness, especially among doctors, about using even clinical terms like insertive or receptive anal intercourse "that doesn't help prevention one bit."

"Every time I go to a prevention conference I try to say, and frankly I feel like I'm one of the few people who ever says it, that in San Francisco at this time, if you eliminate unprotected receptive anal intercourse by HIV-negative men when having sex with HIV-positive men, you would eliminate at least 95 percent of the seroconversions among men who have sex with men [MSMs], everything else being equal."

By 1985, the HIV antibody test had been developed and was being offered in San Francisco via the AIDS Health Project.

"It was then," noted Katz, "that people learned this amazing fact - that half of gay men in San Francisco living in the neighborhoods with the largest populations of gay men were infected. This was astounding."

The professional is public is personal

And so were the consequences. Katz turned personal.

"Almost all our friends and colleagues who found out they were infected, in the mid-1980s, got sick in the early 1990s. Certainly for me that was the worst time.

"Those years in the late 1980s and early 1990s were absolutely miserable, and I actually feel that, as a person, putting aside everything else, that time was so hard for me, that there was a part of me that closed down. There was so much sadness, so many people dying, what was strange for me, looking back on the closed-down part, is I really didn't get closed down in the sense that I was unable to experience the sadness. It was that I was unable to really experience any joy. And I sort of feel like, it's only recently that my own ability to enjoy life has returned."

In what way, he was asked, has the personal sadness affected Katz's public life?

"I never saw being a doctor and a public health official as separate. With me, it was one life, always, à a lot of people in San Francisco cared and were working in public health and doing great things around HIV, I had to note that I was one of the few openly gay men during that time. There were a few others, [UCSF physician] Donald Abrams, but most of the people were straight doctors. You know, that's fine with me, you don't have to be gay or anything to understand the illness.

"But the fundamental difference was that all of my friends were sick. And dying. And their friends [of straight doctors] were not. And they were themselves not at risk, while I felt myself very much to be at risk.

"So in those times I was making the same kinds of tradeoffs in my personal sexual life as everybody else was à I remember sort of profoundly feeling that if I became infected, or if I was infected, that I would die of AIDS, which is very different from now.

"When the people closest to me were sick, or dying, my clinical practice was people who were sick and dying, my public health work was trying to come up with a coherent public health response to this unrelenting epidemic, which wasn't really very responsive in some ways to public health.

Community response

There was a crucial element that made a difference. Katz said, "The success of the HIV prevention model was very much a community response, and I don't think that public health [DPH] deserves too much credit. It was the community itself, people realized there was something awful going on, people started community-based agencies, they told each other to be careful about unsafe sex."

The DPH helped by feeding the data. But, Katz continued, "I really feel, if anything, that public health trailed the community. And the other success people talked about was the humanity in which gay men and lesbians responded to their own being sick. I think that's something for people to feel proud of, that the community itself said, 'We're a community that this affects, and we're going to take care of our own.'"

The relations between gay men and lesbians have often been close, often discordant, he said, but those years brought them together.

"You know, the women in our community, I think, were some of the hardest working, because in general they were healthy à it was in some ways the closest time in San Francisco."

Katz's voice went flat, and slowed.

"By the early 1990s, there was so much fatigue, some of the greatest leaders were dead. I called a close friend of mine who had never discussed his health with me, to find out that he was on leave from his job, and subsequently he died.

"Many people didn't want to talk about it, didn't want people to know they were sick, they just à you know à died. It was the years that I used to have conversations all the time with my own patients about how à how they could essentially kill themselves, when the time cameà

"It was horrible. It was horrible."

Turning point: 1992

Mostly, Katz said, "1992 was the peak of AIDS deaths because it was the peak of HIV seroconversions 10 years earlier. When you think about what happened, the earliest seroconversions were 1978-79, but in order to get a lot of cases, you need a lot of people infected.

"Even if no protease inhibitors had ever been developed, San Francisco would have experienced the peak and fall around 1992, because infection rates went from around 8,000 in the early 1980s to about 1,000 a year. That's both gay and straight, though in the early years it was almost all gay.

"That was the peak. What has happened is that through treatment people really are living longer, that's a different effect."

Uphill and down

Before becoming the city's health director in 1998, Katz was director of the DPH AIDS Office, a post to which he was named in 1992. Commenting on his job running the AIDS Office, he said, "I don't think it's a coincidence [that] myself and the previous director of health [Dr. Sandra Hernandez] were both directors in the AIDS Office.

"HIV turned out to be the greatest health challenge facing this Health Department. The people who sort of learned in the crucible of conflict of epidemics how to survive and build programs, have the skills people wanted in the area of running the department.

"There's no question in my mind that it was more difficult to be director of the AIDS Office in those years than it is to be Director of Health now.

"It's also true that I draw on those years all the time, as a model of how to respond to other epidemics and other social problems, hepatitis C, the housing crisis in San Francisco.

"For good or for bad, my staff always comments on how calm I am. Part of why I attribute it is à after you've been through so much death, to be upset by a vote at the Board of Supervisors, or a change in policy, or someone who's angry at you, just seems to be sort of pointless, so unimportant to me relative to what it was like for people I loved to be dying and for me to be unable to do anything about it."

Lessons learned What overall lessons has he learned?

"It does provide a very different perspective on what in life matters," Katz says. "For what I think I've lost from HIV in terms of enjoying my 30s, maybe, I think the gain has been a perspective in my 40s that I don't know I'd have otherwise had on what matters, what is truly a life and death issue, what is politics and squabbling.

"And in the job I do, through all the controversies that come up, I try to ask myself, what really does matter, when I think about what I've done as director, I think, gee, it really does matter that I've helped Marc Trotz to open up four hotels for people who are homeless, the Camelot, the Windsor. à And the gay and lesbian transitional housing [program], I think that's really a good thing.

"You know, I think the point of my job is really to be around to do the things that really matter, building housing for people or proper medical care, and the rest - the intrigue, the squabbling, the protests - they don't really matter, they're not really important."

And, he added, "It's only been in the last couple of years that I've found myself saying, the point of life can't only be to work à there should be some other way to enjoy myself, and to have fun."

Declining optimism

Life after protease inhibitors were made available in 1996, Katz said, has shifted things for better and worse.

"I do feel like the success of protease inhibitors has made a fundamental difference. There's no question they don't work for everybody, that the side effects are awful, but anyone who has lived through those middle years, that I know, has an astounding appreciation à you know, someone very close to me was, from my point of view, snatched from the hands of God.

"And it just made such a huge difference à people who were preparing to die, writing their wills, suddenly came back.

"I remember feeling this tremendous sense of optimism not only about people who were sick, but that this would burn out the epidemic, and I really didn't anticipate - although I should have - the degree to which HIV no longer being a death sentence, would affect people's behaviors.

"And I say that because I know myself, because in those [early] years, I felt that if I had unsafe sex, I would die à and I don't think it would be rational to think about it that way anymore, I don't think that's true.

"A person who becomes infected today, and is willing to take combination therapy with three drugs, will live out their normal life span à it will be inconvenient for them, it will be expensive, they will have side effects that they don't want, they may have changes in body habitus, but they will live out, I believe, their normal life span. That's very different."

Behavior and immunity

And that, said Katz, has changed the tune and the mores of sexual behavior.

"You know," he said, "when you're in the heat of the moment, certain death is very different from the inconvenience and potential side effects of taking a lot of pills. I think it's resulted in a lot more unsafe sex, it's changed the mores à what I remember in those years as a sexually active gay man was a certain joint sense of responsibility, not only was I safe, but other people felt it was important to be safe.

"It was sort of like herd immunity; even if someone didn't want to use a condom themselves, the other person would have said, 'Oh, you know, we have to use condoms.' I feel like that's mostly lost.

"I feel talking to my patients, friends, acquaintances, people have essentially started having a lot of unsafe sex, and that the rules have changed.

"I find it sad because I really thought the epidemic was going to burn out, that the number of infections was going to drop because of the viral load drops à and it makes me very sad that isn't how it's worked out."

Prevention and funding

Amid public debates over spending, the question arises of where to target money.

Katz pointed out: "There's another study just out that shows HIV prevention as cost-saving, not just cost-effective. PAP smears and mammograms are not cost-saving but they are cost-effective. HIV prevention is actually cost-saving."

He added that some prevention methods are truly effective, citing needle exchange for intravenous drug users, and small group counseling and support sessions.

But, he said, while attending such sessions has been shown to decrease individual risk behavior, "it doesn't begin to address it as a population."

Moreover, he said, "No one has ever shown that a media campaign mattered, which doesn't mean that it doesn't, but à"

There are also "a couple of studies [that] show that if you can build opinion leaders around HIV prevention, then that matters."

Ambivalence over sex

Overall, in his view, there remains a deep ambivalence about sex: "In some ways I think it's gotten worse. In the earlier years, the prevention people, who - let's face it - are not generally people at risk, could feel that what they were doing was informing people à you hear often, 'If only we could get out the message.' I'm only talking about MSMs, because they're what really fuels the epidemic in San Francisco.

"People know how HIV is transmitted; if you had a forced test among gay men in San Francisco, they would score like 98 percent à it isn't about knowledge. I think there's a deep ambivalence from federal and state policy makers about funding something where they feel people are making a conscious decision about their behavior.

"All the things we do around harm reduction get a lot of flak, right? People say you're just condoning behavior à policy makers are deeply ambivalent, and I think that more than anything has prevented people from funding prevention in the way they should."

HIV/AIDS: Looking ahead

While Katz feels the future treatment of HIV looks bright due to better medicines and adherence to regimens, he is not nearly as optimistic about prevention's outlook.

"I feel sex is a highly motivating behavior," he said. "It raises all kinds of issues, of intimacy, family, lust, and those are not issues easily translatable into a public health intervention. You can't address someone's desire to be loved, to feel a part of something, with the very best of media campaigns, the most widely distributed condoms, the best peer leaders.

"Mind you, you should do all those things, but I guess I feel a certain pessimism that those things will fully be effective. They certainly work, they stem the epidemic, more should be done, but I think there are more fundamental challenges, and some of my own prognostication for the future would be that more attention needs to be paid to wellness models, this a more general lesson of HIV."

That lesson "has a lot of applicability to substance abuse, homelessness, that would have to move from the health education to true empowerment type models that enable people to take control of their own health, that encourage them to be responsible for their own health by giving them information and tools, and focusing less on diseases and more on self-esteem, self-awareness, building communities, getting a dog, having family, addressing painful relationships."

Gay people need a strong overall community framework that they're often denied nationwide, he said.

"Donald Abrams said, and I agree with him: What a mixed message! Prevention experts talk about how people should have monogamy, and yet there's no gay marriage - such hypocrisy. How can you be at one time complaining about gay men having all these multiple sexual partners and at the same time saying you don't believe in gay marriage; shouldn't it have to be one or the other, can you really be opposed to both?

"That's because he's asking for logic, thoughtful thinking. But this remains a country with deep prejudices against gay people à you leave San Francisco, New York, you go most anywhere else, the prejudice is so deep."
010601
BR010605

AEGiS presents published material, reprinted with permission and neither endorses nor opposes any material. All information contained on this website, including information relating to health conditions, products, and treatments, is for informational purposes only. It is often presented in summary or aggregate form. It is not meant to be a substitute for the advice provided by your own physician or other medical professionals. Always discuss treatment options with a doctor who specializes in treating HIV.

Copyright ©1980, 2003. AEGiS. All materials appearing on AEGiS are protected by copyright as a collective work or compilation under U.S. copyright and other laws and are the property of AEGiS, or the party credited as the provider of the content. .