San Francisco Examiner - June 1, 2001
Fred Dodsworth

Fred Dodsworth: We're now entering our second decade of the AIDS epidemic. Dr. Mitch Katz: HIV has dominated all of my adult life. I'm a physician and I've cared for people with HIV since the very beginning.

And I'm a health administrator who has created programs for people with HIV-AIDS.

And I'm an openly gay man, sexually active in San Francisco during this whole time.

Q: Why didn't AIDS decimate the straight community as it has the gay community?

A: HIV is not an easily transmittable virus. That's one of the few good things about it -- which is just a fluke of biology. HIV tends to be a particularly mean virus in every way except one, and that's the contagiousness. Because HIV is not easily transmittable, even through sex, even in the highest risk paths, like receptive anal intercourse without a condom, the risk of sero-conversion (becoming HIV positive) is one in 25. That's probably why it never became as much a crossover into the heterosexual community.

Q: Where is AIDS today?

A: From a treatment point of view, things have never been better.

When I care for patients in my clinic who are newly infected, I tell them there's no reason they shouldn't live out their normal life span. They'll have to take medications. Medications will have some bothersome side effects. But I'll be able to come up with a regimen that will work for them, will not cause too much in the way of bothersome effects. And they'll live however long God intended them to live. Whether they're going to go out and get hit by a truck, or live to be 95, I can't answer but I truly believe that they won't die of HIV anymore.

The problem has been that the success of treatment has brought a failure of prevention that I don't think anybody fully anticipated. I know I didn't.

In retrospect, I should've seen it. I should've remembered the feeling I had throughout the '80s and '90s -- if I were to sero-convert, I would die. That -- certain death -- is a very powerful motivation to stay safe.

It's not rational to feel that way anymore. It's not certain death to become infected.

And we all know how motivating sex can be. Sex is deeply pleasurable and it also invokes issues of intimacy, of love, trust.

So people have become a whole lot less safe. And the rate of sero-conversion has about doubled among men who have sex with men. It's gone from being around 1 percent a year -- in other words, if you have 100 men, in a year you'd expect one to become infected -- to a point where now, depending upon on the data sets you look at, it's probably more like two to three out of the 100.

Q: That's a horrific increase.

A: Exactly. Some public health officials take this, "Well HOW can they be doing that? After all the people we've buried. After all the money we've put into this" attitude. But it's very natural. I don't find it surprising. The better question is, what do we do about it?

Q: What can we do about it?

A: We've been pushing the HIV-positive community to take greater responsibility to not infect people. The major message around HIV has always been: Use a condom every time -- "anyone can be positive, use a condom with anyone." And there's also: "Use it with all sexual practices."

But, in fact, people are not doing that and in San Francisco, among men having sex with men, 95 percent of the sero-conversions are occurring because of an HIV-positive top having intercourse with an HIV-negative bottom. If we could eliminate unprotected sex between HIV-positive tops and HIV-negative bottoms, 95 percent of the new sero-conversions would go away.

There has been tremendous reluctance to talk about that because that involves saying something about positive guys, which people don't want to say and it requires using those words, and doctors don't like to use those words.

Q: Are there any examples of sero-conversion in oral sex?

A: There are case reports. The most ... hummmm ... rigorous analytic study found none. But there are case reports. It doesn't happen very often.

Doctors tend to be absolutists. "We can't talk to our patients about that because they CAN become infected through oral sex." People say, "Well I'm not going to use a condom with oral sex. It doesn't taste good. That's ridiculous. I'm not going to do that." So then it weakens the advice. You said use it with oral sex and yet it goes counter to their experience.

Public health has always been about targeting messages. The most effective messages in public health are always narrow messages. My job as a public health expert is to eliminate unprotected, receptive, anal intercourse between positive tops and negative bottoms. If I could do that, I could drive the epidemic away -- everything else continuing as is.

Q: Our culture is uncomfortable talking about sex.

A: People are more uncomfortable talking about gay sex. But it is impeding our ability to prevent the disease. We need to talk about it.

Q: Does being a medical doctor aid you in your role as health director?

A: The origins of public health are not in medicine. The origins of public health, which with the movement that started in about the 1880s, 1890s, was around sanitation, around teaching people good practices.

I say this as a practicing clinician -- medical stuff has overshadowed public health. Because doctors are more important than public health people in our world. But public health, I think, is a better way of dealing with epidemics like HIV's than medicines -- because public health has a better appreciation of empowerment models.

If we want people to not become infected, then we have to increase self-esteem.

We have to make people feel that they are part of the community. That they are wanted, needed. That they have a reason to live, to be. It raises what are in fact very existential questions about what is the meaning of life, and how people look at it. What I know in talking with people who've sero-converted, is that it's that sense of not caring that much that results in the sero-conversions.

E-mail Fred Dodsworth fdodsworth@sfexaminer.com

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