Bay Windows - June 16, 2005
Ethan Jacobs, ejacobs@baywindows.com.

At a June 15 press conference held during the conference, Phill Wilson, executive director of the L.A.-based Black AIDS Institute, reported the results of a CDC study showing that within the MSM population, African Americans are hit the hardest.

"Alarmingly, almost half of black MSM, 46 percent, in a five city study [including New York City, Baltimore, Miami, San Francisco, and Los Angeles] were HIV-positive, and two-thirds of these men did not realize they were infected prior to participation," said Wilson. By comparison, only 21 percent of whites and 17 percent of Hispanics were infected.

While the study only looked at five cities, Ronald Valdiserri, deputy director of the CDC's National Center for HIV, STD, and TB Prevention, said the findings match earlier studies and the sample was carefully targeted to be representative of the MSM community.

"We believe this to be a representative sample... I would say that there's a great deal for concern among African-American MSM," Valdiserri said during the press conference.

African-American youth in particular are at higher risk. A 25-state study found that HIV diagnoses increased by 47 percent among 20- to 24-year-old MSM from 1999-2003, and of those men 60 percent were black.

Other studies presented at the conference showed a number of factors undermining prevention efforts in the gay community, from misinformation about what kinds of sex are risky to increasing use of crystal methamphetamine. HIV prevention workers hope the research presented at the conference will serve as a wake-up call both for their colleagues and the federal government to place a renewed focus on targeting prevention efforts directly to the gay male community.

"We need to have targeted programs and services for gay men," said Steven Tierney, director of HIV prevention for the San Francisco Department of Public Health and a member of the executive committee for the Washington D.C.-based advocacy group AIDS Action. "We need to design programs for gay men, and federal dollars need to be part of that."

Two of the studies presented at the conference highlighted new research based out of Boston's Fenway Community Health Center, and the studies contain a mix of good and bad news for Bay Staters. On the plus side, after six years of rising diagnoses of syphilis and gonorrhea among MSM, the Fenway saw a significant 17 percent drop in new diagnoses of both STDs in 2004. The study was unable to draw any definitive conclusions about the reason for the drop, but Kenneth Mayer, Fenway's research medical director, said he believes it may be due in part to public health campaigns around syphilis and gonorrhea that were used in 2004.

The more worrisome news coming out of the Fenway is that while many HIV-positive men have altered their sexual practices to avoid infecting their partners, many of those men use harm reduction strategies other than condom use, and those methods still put their partners at significant risk for contracting the virus. Fenway surveyed 104 of their HIV-positive MSM clients, mostly white and mostly in their 30s and 40s, and they found that their strategies for protecting their partner were hardly foolproof: one third said since becoming infected they were more likely to be the receptive partner during anal sex, a similar number said they do not "top" during anal sex with HIV negative men, and 40 percent said they only have oral, rather than anal, sex with HIV-negative partners. According to Mayer, all of these strategies still leave their partners vulnerable to the virus.

Similarly, the study found that two-thirds of the men believed that their viral load affected the likelihood of transmitting the virus to their partner, and they were more willing to engage in unprotected sex if their viral load was low or undetectable. Yet Mayer said while an undetectable viral load may reduce the risk of transmission, there have been clearly documented cases of people with undetectable virus infecting their partners.

Fenway's findings were in line with a study presented at the conference by the San Francisco Department of Public Health and the CDC, which found that many MSM are using viral load tests to guide their sexual decision-making, particularly among men in serodiscordant relationships (where partners differ from each other in their HIV status).

Fenway's study found that some of the men using these potentially risky harm reduction strategies thought that they were risk-free. One in 10 participants believed that they could not transmit HIV if they were "bottoming." About three percent of the men thought it was impossible to pass the virus to a partner if their viral load was undetectable. Yet for many of the men, said Mayer, it may be less an issue of misinformation and more one of denial, with men rationalizing that they can avoid using condoms as long as they give up their riskiest sex practices.

"There's a certain amount of calculus that goes on in people's head. 'I can't top because it's risky, so I can bottom because it's less risky,'" said Mayer. He said prevention programs need to address the different beliefs gay and bi men have about what activities are risky and correct any misconceptions they might have.

Mayer also said the study pointed to a need to continue working to dispel the stigma around HIV-positive people in the gay community. The Fenway found that just over half of participants disclosed their serostatus to partners before sex, and only a third asked their partners to disclose their own status. One in five men said they hide their status from potential partners to increase their chances of having sex with them.

"I think it speaks to the fact that there's still a lot of stigma around HIV, and people are concerned that people will reject them if they disclose," said Mayer.

Many of the other studies presented at the conference from other parts of the country highlighted challenges to HIV prevention. Among the most alarming is news from Los Angeles, where the LA Gay and Lesbian Center found that among MSM clients coming in for HIV testing, crystal meth use nearly double from 2001 to 2004. Of the clients who tested positive for HIV, crystal meth use nearly tripled. Quentin O'Brien, the LA Center's director of health and mental health services, said the study does not show conclusively that meth use is driving an increasing number of new HIV infections, but it does show a strong association between the drug and the virus that adds credence to that theory.

"I think it's something that we've increasingly been suspecting," said O'Brien. "Anecdotally a lot of the people doing the testing were saying almost 100 percent of the people testing positive have used crystal over the past couple of years."

Mayer said while the news from LA is alarming, there's no hard data in Boston linking crystal meth to a rise in HIV infection, although crystal meth use is on the rise. Less than ten percent of clients coming in to Fenway to get tested reported using crystal in the last 30 days.

"There's every indication that [crystal meth use is] increasing, but the level of increase or the implications is hard to say," said Mayer.

Another study from the Denver Department of Public Health showed some of the prevention challenges presented by online hook-ups. The study found that men searching for other men online were more likely to either ask their partner's serostatus or have their partner disclose their status than men meeting each other at bathhouses, public sex venues, and social venues. Yet men seeking sex online were also much more likely to have unprotected anal sex than men at any other venue, and they were more likely to have been diagnosed with gonorrhea at their last clinic visit. Researchers worry that men who use the 'net to engage in serosorting, or having sex only with people of the same serostatus, may still be putting themselves at risk: even if the men are honest about their status, HIV-positive men may be in danger of superinfection (infection with another strain of HIV), and of contracting other STDs.

The CDC presented a study that helped dispel some myths about the so-called "down low" or "DL," in which straight-identified African-American men with female partners live secret double lives by having sex with men on the side. In 2004, D.L. King's book On the Down Low prompted a flurry of magazine articles, books, and even an episode of Oprah devoted to the phenomenon. Much of this coverage blamed DL men for HIV infections among black women. A CDC study of 12 cities found that, contrary to the perception in the media, African-American MSM are not the only ones identifying themselves as on the DL. About one in four of the Hispanic men interviewed in the study and about seven percent of the white men described themselves as being on the DL. Also breaking the stereotypes about men on the DL, about one-third of DL men in the study identified as gay, and only about 13 percent had one main female sex partner.

The study also found that the prevention messages geared toward the gay community are reaching most of the men on the down low, although not to the degree that they reach non-DL gay men. The vast majority of men said that they had been tested for HIV at some point in their lives and that they had received information on HIV prevention in the past year.

Richard Wolitski, a CDC official who presented the study at the June 15 press conference, cautioned that the men interviewed did not necessarily constitute a representative sample of the entire MSM population, but their responses disproved some prevailing myths about DL men. He said the study highlighted the need to focus on people's behaviors rather than on labels.

"Our HIV prevention efforts should focus on reducing specific behaviors of both men and women and men who have both male and female partners rather than on labels like the down low, which may mean very different things to different people," said Wolitski.

Some of the numbers coming out of the CDC conference differ somewhat from the state of the epidemic in the Bay State, since the CDC's statistics on new diagnoses only surveyed the 32 states that have used name-based HIV/AIDS reporting for at least four years (Massachusetts tracks HIV diagnoses through anonymous codes rather than by reporting the names of those diagnosed). In Massachusetts, MSM make up 35 percent of new diagnoses, although that figure is on the rise.

Similarly, more than half of new diagnoses in the CDC study were among African Americans, while the latest numbers from the Massachusetts Department of Public Health show that whites still make up the largest group of new infections in the Bay State. Yet African Americans and Latinos in Massachusetts are being infected at about ten times the rate of whites based on their share of the population.

Advocates hope that the data coming out of the conference prompts the federal government to shift more resources towards prevention messages that specifically target gay men. Tierney of the San Francisco DPH and the AIDS Action executive committee said under the Bush administration there has been a shift in resources from gay-specific HIV prevention programs that address issues of homophobia and stigma towards programs directed at the general population that focus on HIV testing and partner notification.

"Under previous administrations there was much more looking at behavioral change, what puts people at risk and how do you change the motivations for that risk behavior. Under this admin in an effort to get away from that behavioral stuff that's controversial," said Tierney. "There's an effort to focus on more scientific and medical stuff."

Yet he credited the CDC with maintaining its commitment to dealing with the epidemic in the gay community, giving particular praise for the CDC's decision to hold a conference looking at crystal meth and gay men last March.

The CDC's Valdiserri said the organization has made tackling the issue of HIV in the gay community head on, particularly among high-risk populations like African American men. He said the CDC awards grants specifically to community-based organizations serving young MSM of color, and the organization is funding further research to better understand the factors that lead MSM in general to engage in high risk behavior. Valdiserri said the CDC is committed to working with HIV service organizations around the country to help develop prevention programs that effectively target MSM. While the data coming out of the conference point to a dire situation in the gay community, Valdiserri said they only confirm what many health officials already knew.

"The CDC has initiatives that have been under way for at least two or three years in response to this issue, because as you know, these data aren't new. The data we presented this week are new, but they are consistent with studies that came out from [previous studies]... There have been a number of steps that the agency has taken, and we'll continue to move forward to address this extremely serious problem," said Valdiserri.

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