Newsday - August 29, 1999
Laurie Garrett - Staff Correspondent

As several cities report disturbing outbreaks of syphilis and gonorrhea among gay men, the CDC on Sunday will convene in Atlanta its first ever National HIV Prevention Conference, which is expected to draw public health officials from across the nation.

There, CDC officials are expected to unveil a new "STARHS Strategy" for combatting HIV that combines use of a new testing technique that allows technicians to distinguish old infections from those acquired within the previous 120 days with an effort to trace people's intravenous-drug and sexual contacts.

Because people can live symptom-free with HIV for a decade, there was no way previously to tell when they might have become infected. But the new technology changes that: While it's hard for many sexually active people to recall the names and addresses of all their partners, spanning years of activity, it is typically a simple matter to conjure a list for the past four months.

Armed with this new information, public health authorities feel they can track down individuals who appear to be spreading HIV, and - for the firsttime - interrupt the chain of transmission on a large-scale basis.

The idea behind STARHS - which is a somewhat tortured acronym for "Serologic Testing Algorithm for determining Recent HIV Seroconversion" - is to do for HIV what has long been done for syphilis and gonorrhea. While the CDC hasn't the legal power to impose any such policy on local public health agencies, it can set suggested guidelines.

Typically, if the CDC creates enough of a splash, an idea is adopted by most states. That's what happened, for example, six years ago when the CDC suggested that the nation adoptthe "Directly Observed Therapy," or DOTs, approach for stopping the spread of drug-resistant tuberculosis that had been successful in New York City.

"With this testing strategy," the CDC will suggest, "we can begin to know which populations are becoming HIV-infected today . . . and stop the further spread of HIV before it's too late."

But sociologists and many AIDS activists say the policy will face controversy because many recently infected individuals may well be unwilling to give up the names of their sexual and IV drug-use partners.

New York State passed a law last year requiring that HIV test sites and physicians ask infected individuals the names of their sexual or IV drug needle-sharing contacts. But even though Health Department officials hope to have the program under way by the fall, details of how it will be implemented and how the information will be used have yet to be hammered out.

The New York City Department of Health hopes that use of the new test being championed by the CDC - known as the detuned ELISA - will resolve many questions that have been thorns in the side of HIV researchers since the epidemic began.

"We are poised to begin detuning," said Dr. Mary Ann Chiasson, the city's assistant commissioner of Health. "We will do both retrospective and prospective studies. For us, the pressing issue is to determine where the infections are occurring right now."

Standard ELISA blood tests for HIV measure the presence of antibodies against the virus. Highly tuned ELISA tests can pick up even minute numbers of antibodies present in the first days of infection, before the immune system has mounted a full response to the virus.

A detuned ELISA does the reverse. It detects only the presence of large antibodies that typically appear three to five months after infection. By administering both the standard and detuned ELISA tests at the same time, technicians can tell an individual's precise stage of infection.

"It's brilliantly simple," said Dr. Willi McFarland of the San Francisco Department of Public Health. "When we heard about this we were ecstatic because this opens up the possibility of answering questions we never could address before."

Right now, San Francisco is the only city in the world that is routinely using detuned ELISA tests. And after about nine months of detuning thousands of northern Californians, McFarland and his colleagues are convinced of its utility as a research tool, and stunned by the surprising windows it has opened on California's gay community.

"We found that about 20 percent of our clients are in that early phase [OF INFECTION], which was quite astonishing to us," McFarland said. "So it's saying that 20 percent sought testing within less than four months of getting infected. We estimate that about 500 San Franciscans get infected per year, and that's been a pretty stagnant number for the last 10 years, we think.

"Now, though, we're not really sure what it is now, and we're worried that it's going up. It looks like about 2.5 percent of the city's gay men convert to HIV-positive per year," he said.

Nationwide, thousands of people undergo HIV tests annually, and most turn out to be "worried well," studies have shown. In most of the country, the biggest testing centers are run by local public health agencies, offering enormous pools of blood samples for study under the STARHS system.

About 9,000 San Franciscans get an HIV test in a city clinic yearly, and McFarland's colleagues in neighboring Alameda, Marin and San Mateo Counties have also recently been administering limited numbers of detuned ELISAs in cooperative studies.

Here are some of the surprising findings:

Out of several thousand tested not one single woman has come up positive for recently acquired infection in the Bay Area.

One individual, found in an allied clinic in Los Angeles, has come up positive even though his only sexual activity was oral. And the researchers have confirmed he acquired his HIV orally.

None of the Bay Area's IV-drug users have turned up positive for recent infection, except those who are gay. The researchers believe these men acquired HIV not from needles, but from sex.

All of the newly acquired HIV infections have been in gay men, mostly white, in their 30s. And a map of where those men live today matches - almost to the block - a 1984 map of San Francisco AIDs cases compiled by University of California in San Francisco epidemiologist Andrew Moss.

McFarland would like to learn more about those men - especially who their partners might be. But unlike New York and a dozen other states, California has no contact-tracing law for HIV. And any attempts to elicit partner information from the state's mostly gay male HIV population is greeted, McFarland says, with cries of, "sex police! It raises a lot of issues - political things - and the memory of Typhoid Mary. We were baffled by the tremendous resistance to naming names. Undermining our whole effort is community resistance."

Will the New York gay community, which is larger but less cohesive than San Francisco's, prove more open to naming names?

"I can't say what will happen in New York," said Joshua Lipsman, executive director of Gay Men's Health Crisis in Manhattan. "But the experience in other states is that on an individual level, when people get appropriate counseling, they're willing to take steps to slow community transmission of HIV."

A GMHC survey conducted last year in Manhattan questioned 7,000 gay men, finding that 80 percent had undergone an HIV test within the previous three years: 13 percent were HIV-positive. That infection rate was a far cry from the presumed 50-percent HIV-positive rate in the New York City gay community in 1980.

That was the good news. The bad news, Lipsman said, was that 39 percent of the respondents admitted to having had unprotected anal intercourse within the previous year. The reason?Because of the apparent success of protease inhibitor drug treatment of HIV infection, "the misimpression in the public is that you pop a pill and you're fine," he noted.

Five years ago the ravages of AIDS - and the signal danger about HIV - were visually obvious to even casual observers strolling through gay centers of Manhattan, such as the West Village and Chelsea. Since 1996, however, when widespread use of protease inhibitor cocktails began, the visual image of gay neighborhoods has completely transformed.

One result is "that the lessening of fear about death and AIDS has resulted in a decrease in fear about contracting HIV," said Dr. Mitchell Katz, director of the San Francisco Department of Public Health. Katz suggests "there is fatigue" within the gay community about the safe-sex message.

And it's understandable, Lipsman argues, because, "not only can no one maintain a sense of emergency forever, but even that sense of exhaustion and fatigue was accelerated by protease inhibitors."

GMHC has felt it in the form of donor fatigue, and the organization is struggling, regrouping. In 1996, just before widespread protease inhibitor use, GMHC operated on an annual budget of $30 million and had a staff of 310 people.

Today, with donations down, "the agency is trying to recover from a kind of free fall," and has just 190 employees and a budget of $24 million. AIDS organizations all over the United States say they are similarly strapped for funds.

And this drop in donor support comes when such indicators of unsafe sex as rectal gonorrhea and syphilis are rising in incidence, according to the CDC and local health departments.

Nationally, gonorrhea incidence in gay men rose 74 percent between 1993-96 in 26 surveyed cities. Seattle reports that the number of syphilis cases in gay men has increased in that city by 60 percent since 1996, and gonorrhea by 76 percent. Chicago saw syphilis, which had disappeared from its gay population, suddenly resurface last year in the North Side's homosexual neighborhood. And gonorrhea incidence among gay Chicagoans doubled last year.

According to the New York City Department of Health, local gonorrhea rates haven't risen. But syphilis has. Overall (in all population groups, gay and straight) there were about 80 active syphilis cases in New York City last year. This year cases are well ahead of 1998, and the department forecasts more than 100 for 1999.

San Francisco's troubling trends are more obvious, according to its Department of Public Health. In 1994 less than 1 percent of the gay men who were diagnosed with gonorrhea also had HIV. Last year 16 percent of the gay gonorrheal men were HIV-positive, meaning, McFarland said, that more HIV- positive and HIV-negative men in the city were having sex without protective condoms.

Dr. Kimberly Page-Shafer of the University of California in San Franciso and Dan Wohlfeiler of the local Stop AIDS Project surveyed 21,857 gay men between 1994-97, finding a steady increase in the number that admitted to having sex without a condom, reaching a full third of the respondents in 1997. And as the curve of safe sex on Page-Shafer's chart declined over the three years, gonorrhea incidence rose from 20 per 100,000 San Francisco men (gay and straight, combined), to 38 per 100,000.

Another UC San Francisco study conducted by scientist Ron Stall showed that by the end of 1997 half of more than 500 men who were questioned repeatedly since 1993 were having unprotected intercourse.

"What is remarkable about this study is that for the first time in the history of the epidemic, we are seeing very large increases in unsafe sex," Stall explained. "This is new. And it's on the order of a 50-percent increase over the last two years. About half of the risk-taking is unprotected anal intercourse where the men either knew that their partner had a different HIV serostatus, or didn't know their partner's serostatus."

What most upset Stall and Katz - both of whom are prominent gay leaders in San Francisco - is that their community seems no longer to be listening to the primary message of 1990s public health: Always have sex using a condom.

"People were supposed to feel remorse about having unsafe sex," Katz said. "Now there's this small minority saying, 'Yes, I did, and I'm not sorry.' "

It's called "barebacking," UC San Francisco medical sociology graduate student Michael Scarce says, and its popularity is growing among gay men.

"It's very organized; it's very elaborate," Scarce said. "Gay men do it in a premeditated way, and fetish-ize the fact that condoms aren't being used.

"You even have this system of apartments that have emerged into private barebacking parties that operate like businesses. They take money at the door, and men check their clothes and come in around the clock . . . "

For his doctoral thesis, Scarce has interviewed 826 gay men nationwide who say they don't regularly use condoms. Most are white, averaging age 36.

He says they know everything that the CDC and groups like GMHC and Stop AIDS Project have to say about HIV. And they reject the prevention campaigns, calling public health officials and gay leaders, "safer sex police" and "condom police."

But even though they are "public health outlaws," Scarce insists their popularity is rapidly increasing.

"It probably never would have happened without the Internet," Scarce said. "It was through the anonymity of the Internet that gay men were able to be honest about what they wanted and connect with one another to get it."

Scarce has identified more than 150 list servers on the Internet dedicated to unsafe sex within the gay community and has observed barebacking parties in three different cities.

Two weeks ago, Dr. Jeffrey Klausner, director of City Clinic located in the Castro District in San Francisco, announced discovery of a cluster of syphilis cases among men - both HIV-positive and HIV-negative - who met in an America Online chat room. Though only seven cases have been confirmed, five of whom were HIV-positive, Klausner is still trying to track down all 99 chat room participants. So far, he's found and tested 33.

"It's a virtual epidemic," epidemiologist Moss said. And the virtual gay community poses a tremendous challenge for public health. Scarce says that both older gay leaders and public health officials have completely missed what's going on, remaining mired in old-fashioned concepts.

So, it seems, have the loudest, most brazen gay activists, as their major battle has been over reopening the gay bathhouses, closed in San Francisco since 1984 by order of the Department of Public Health and a local superior court judge.

Leading the charge is former New York City ACT UP member Michael Petrelis, an HIV-positive activist. Petrelis, who grew up in suburban New Jersey, is new to San Francisco, and wasn't there when the gay community debated the bathhouse issue 15 years ago, at the height of its epidemic.

But he's collecting signatures to put an initiative on the ballot this fall that would allow reopening of the bathhouses on the grounds that their continued closure constitutes anti-gay discrimination.

"An hysterical model for dealing with AIDs was created here in the 1980s," Petrelis says. "And I've been waging a campaign . . . to say there isn't a reason to be hysterical. The numbers [of HIV infections] are decreasing."

Petrelis, occasionally in alliance with ACT UP San Francisco, has loudly and sometimes in an atmosphere of clear intimidation, denounced the city's health officials and AIDS-prevention organizations. They've thrown kitty litter at people, barged past hired security to disrupt community meetings and left frightened people in their wake.

Many officials interviewed by Newsday expressed frank fear of both Petrelis and ACT UP San Francisco, a well-financed group that operates a medical marijuana buyers' club that became legal last year as a result of a state ballot measure. When Klausner announced the syphilis AOL outbreak, the group barraged the City Clinic with a day of hate-filled phone calls and threats, he said.

Petrelis insists there is "no data" to show that bathhouses constitute centers of HIV transmission. And he insists that bathhouses are great places to hand out AIDS-prevention leaflets.

Wohlfeiler and Moss, meanwhile, agree that no good data exists linking bathhouses with HIV, but they argue that common sense should prevail.

In 1984 then-Department of Public Health director Dr. Mervyn Silverman was slow to close the bathhouses because he also then thought, as Petrelis today asserts, that they would serve as centers for AIDS education.

But eventually, Silverman said in a recent interview in his Haight-Ashbury home, "I saw that there was no question that people were having unsafe sex in the bathhouses. And no question that a lot of people in the gay community felt their friends were getting AIDS in the bathhouses.

"It was not hysterical reasoning," he said.

Two people were key to Silverman's decision in 1984, he says, suggesting that their comments then should keep bathhouses closed now, as well.

One was Dr. Donald Abrams, who in 1984 had the largest AIDS patient load of any doctor in the city. "I asked people in my clinic if they went to the bathhouses, and they all said 'Yes,' " Abrams recalled recently. "I said to Merv then that we knew enough to close the houses. There was sufficient evidence that they were contributing to the epidemic.

"And now, all these years later, with all the losses this community has suffered," he said, "it doesn't make any sense to me to turn around and reverse that decision."

The other key player was Moss, the epidemiologist, who was doing his best to provide data on the epidemic with surveys at a time when no ELISA tests existed. His surveys showed that about a third of the city's gay men had symptoms consistent with AIDS. When tests finally did become available, it would turn out that half the gay population was HIV-positive.

When Moss tried to sort out why some were infected, and others not, he found that it wasn't bathouses, per se, that were the issue. It was the number of sexual partners men had been with, a problem made worse by the bathhouses.

In 1984, 65 percent of men who say they had had sex with more than 800 other men within a year had AIDS symptoms. This compared with 25 percent of men with AIDS symptoms who said they had had sex with fewer than 600 partners.

A separate CDC study by Dr. William Darrow reached about the the same conclusion.

When Silverman's decision to close the bathhouses came before Superior Court Judge Roy Wonder, Moss said that while bathhouses were key to the problem, "at least two other aspects should be considered. One is to make it clear what the truly terrifying nature of the disease is, how grave and serious a disease it is," he said. "The second is to attempt to support what you might call serially monogamous lifestyles - that is, cutting down by changing from a lifestyle with a very large number of sexual partners to a lifestyle that is closer to serial monogamy."

But now, Stall of UC San Francisco says, "the one hundred thousand dollar question" is whether gay culture has entered a new paradigm that calls for a different approach to HIV prevention altogether. "The temptation to say the war's over and return to normal life is almost palpable in San Francisco," he says.

So how does the CDC's detuned ELISA contact-tracing plan figure in such a picture?

Many experts interviewed said they could not predict how the gay community would react to such a plan. Petrelis, fcor instance, says the idea makes him nervous, but he wants to give it more thought.

Scarce, who says he is writing a book about the "barebacking" phenomenom, is not optimistic. He predicts, "a war is coming between gay men and public health [officials] if they do contact tracing."

ILLUSTRATION/PHOTO: 1) Cover Photo by Rob Schoenbaum - Dr. Joshua Lipsman, executive director of the Gay Men's Health Crisis in Manhattan, says a sense of emergency is fadin in the New York gay community. (Queens Bulldog.) 2) Photo by Fred Mertz - Dr. Willi McFarland of San Francisco's Department of Public Health is convinced the detuned ELISA test is a great research tool. 3) Photo by Rob Schoenbaum - Joshua Lopsman of Manhattan's Gay Men's Health Crisis says people mistakenly feel that AIDS is over. 4) Photo by Paul Mueller - Dr. Mitchell Katz. 5) Photo by Fred Mertz - Michael Petrelis.

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