Bay Windows - National News, September 8, 1999
Peter Cassels, Bay Windows staff

Improvements in AIDS treatments are giving gay men a false sense of security, with potentially dire consequences. The more confidence they have that the drugs can prolong the lives of people with AIDS and prevent transmission of the HIV virus, the less likely they are to use a condom during anal sex or abstain from other risky behavior, according to one recent study. HIV researchers and educators are examining new ways to convey the message that AIDS remains a major problem and gay men should continue safeguards.

A paper presented Aug. 31 at the National HIV Prevention Conference in Atlanta detailed the study, among the first to support anecdotal evidence that improvements in AIDS treatments may contribute to increasingly complacent attitudes among those at high risk for contracting the disease.

University of Southern California researchers surveyed 410 gay men in West Hollywood who said they were aware of protease inhibitors, the life-prolonging drugs which, when taken with a "cocktail" of two other AIDS medications, can reduce the level of the virus in the blood so low it can't be measured. Of 346 who were HIV-negative, those who were more confident about the ability of the cocktail to control AIDS said they used condoms during anal sex 74 percent of the time. Less confident individuals indicated they used condoms 85 percent of the time.

While scientists at the conference said the study was too limited to draw general conclusions about how treatment advancements may affect risky sex behavior, they acknowledge that there's an increasing indifference to HIV in the gay community.

"People think the epidemic is more manageable now," Dr. Kenneth Mayer, one of the nation's leading AIDS researchers who attended, told Bay Windows. "Being HIV-positive is not as serious as it used to be, because drugs make people less infectious," added Mayer, research director at the Fenway Community Health Center (FCHC) in Boston and director of Brown University's AIDS program. The result, he reports, is that there's some battle fatigue. "People are saying it's too much to try to be safe all the time."

Just because the drug cocktail frequently makes the virus undetectable in blood doesn't mean it's not elsewhere in the body, Mayer emphasizes. FCHC and Harvard University researchers have detected evidence of persistent HIV in semen DNA of four out of 20 men after six months on protease inhibitors. "What we found was the latent ù but still traceable ù form of the virus," he explains.

That and other factors are raising red flags. HIV experts are re-examining how to warn people at risk that AIDS is still a life-threatening disease and gay men still need to factor it into the equation of existing, developing and future sexual relationships.

"To say the epidemic is as bad as it was 10 years ago would be a lie," Mayer acknowledges. "The death rate dropped significantly starting in 1996, but in the last year it has plateaued. There's been less of a mortality rate improvement. That shows we may be running out of drug options for some people."

The risk is particularly serious among some young gay men, those in their late teens and early twenties, who didn't experience the ravages of the epidemic at its peak in the 1980s. Studies conducted by Project ACHIEVE, a nationwide program funded by the National Institutes of Health, show increasing rates of HIV infection, although not exclusively among that age group. Older gay men also are increasing unsafe sex practices, Mayer points out. In New England, the project is being conducted by the FCHC in collaboration with Brown University. Studies are under way at the FCHC's Boston facility and two Brown teaching hospitals in Rhode Island: Memorial in Pawtucket and Miriam in Providence.

Strides in treatment may be only one reason why gay men seem to be complacent about unsafe sex, according to Brian Byrnes, education director at Boston's AIDS Action Committee. "Another reason is that the epidemic is aging and has become normalized in people's lives," he told Bay Windows. "Our job is to maintain a critical consciousness. We want to enhance people's knowledge about why they're taking risks. That's hard to do these days."

Byrnes believes the message HIV educators need to convey is about keeping the community healthy: "I think this breather in the epidemic allows gay men to look at a broader range of health issues. They need to understand the connections between HIV and other health dangers they face ù Hepatitis B and C, for instance."

Gays are making more sophisticated risk reduction decisions in their relationships, he points out. "We know couples may decide to push the risk limits if one is negative and the other is positive, but with a very low or undetectable viral load."

The HIV educator says gays fall into three categories of safe sex behavior. One is those concerned about their health and that of their sex partners. Another is those who practice safe sex consistently throughout their lives. The third is the large group in between who plays safe depending on circumstances.

"Age is a significant factor in determining which group a man falls into," he points out. "Young people think they are immortal. Others think contracting HIV is inevitable, so they don't bother to avoid it, a conflict between invulnerability and inevitability."

Some young gay men make risk reduction decisions when beginning a new relationship, according to Byrnes: "Certain sexual behaviors take on huge meaning and significance. Sex is an incredibly intimate act. Where emotions are overwhelming, gay men of any age often have sex without knowing whether their partners are infected."

He urges sex partners to get tested before they have unprotected anal sex. "They should discuss their HIV status and determine what sexual rules they should have, for example, whether should they have sex outside the relationship."

It's all about communication. "What strikes me is many men come to our community looking for acceptance. We do incredible amounts of caretaking ù more of us are volunteer or professional caretakers than any other group. We develop strong relationships and friendships, yet if you ask gays about a sense of community, they say there is none. They live in fear of rejection. There's disconnection, alienation and a growing cynicism that their emotional and sexual needs cannot be met. We don't talk to each other about our fears, hopes and desires because we're afraid of rejection."

Byrnes believes gay men must take better care of one another. "The community needs to work on that. What it takes is for one gay man to make eye contact with another, connect, say hello and listen to his story. If we find it easier to talk about HIV and our sex lives, we'll be better able to disclose our HIV status to each other."

Encouraging open discussion about HIV status is just one way experts are attacking the issue. Mayer says researchers are excited about projects aimed at figuring out how HIV educators can craft more effective unsafe sex counseling programs and developing a true AIDS vaccine.

EXPLORE, a six-city study of gay men, is the biggest behavioral intervention program ever undertaken. Part of Project ACHIEVE, the program will enroll more than 5,000 sexually active gay men in Boston, New York, Chicago, Denver, Seattle and San Francisco. "Half will get standard counseling and testing," Mayer reports. "The other half will participate in an intensive program exploring things in their lives that would tend to make them susceptible to risky sex." The FCHC and coordinators in other cities began recruiting participants last spring and will continue doing so until early next year.

A study of AIDSVAX, a new anti-HIV vaccine manufactured by VaxGen, a subsidiary of Genentech, is the first major step towards developing a vaccine, according to Mayer. The biggest such study to date, it's being conducted at more than 60 sites nationwide. HIV-negative gay men are getting the vaccine, which does not contain the virus. The study explores understanding how the body reacts to HIV's outer structure. The vaccine tricks the body into making antibodies, thinking it's responding to the virus, and tries to prevent it from bonding to cells. The study began in 1998 and will conclude by early October. Participants will be tracked for about two years before researchers can report results.

The pharmaceutical industry is developing new drugs to control AIDS at a faster pace than trying to find a vaccine because of economics, Mayer says: "Big companies are avoiding vaccine research because they have to recruit huge numbers of people. If they get risky sex people who are negative, they have to spend lots of time counseling. The cost of following 5,000 people, providing testing, counseling and support is about $265 million a year. The whole HIV research and development effort takes hundreds of millions of dollars annually, so it's not insubstantial. Some companies are taking small steps forward in trying to produce a vaccine. VaxGen is the furthest along."

Strides are being made in helping people with AIDS who are running against a wall with protease inhibitors, to which the virus eventually builds up an immunity. "I'm optimistic that we have new drugs coming into the pipeline," Mayer says. T-20, an intravenous drug, inhibits the virus from binding to cells. "It's a different mechanism from protease inhibitors," he explains.

Some progress also is being made to prevent the virus from entering the body even if sex partners don't take precautions. Mayer presented a paper in Atlanta on a vaginal microbicide study under way in Rhode Island that works like a spermicide. "We're hoping to study a rectal microbicide as well, but the federal government is reluctant to provide funds," he reports. Researchers wanted to conduct such a study in Seattle, he added, but Sen. Jesse Helms, R-N.C., learned of it and leaked the information to the Washington Times.
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