Being Alive, Los Angeles; April 1998
Walt Senterfitt

New AIDS Cases and AIDS Deaths Are Down Nationwide and in L.A.

Dr. Kevin DeCock, chief of HIV/AIDS surveillance and reporting at the CDC (Centers for Disease Control and Prevention) in Atlanta, announced that 12% fewer AIDS cases had been reported nationwide in 1997 than in 1996. More dramatically, deaths due to AIDS were down 44% in the first six months of 1997 from the comparable period in 1996. This is the first time there has been such a decline in reported cases and deaths on a national basis since the epidemic began. The drops occurred in women as well as men, and in all racial and ethnic groups, though the decreases were highest in white men, especially gay and bisexual men.

The decreases for Los Angeles County are even more dramatic than for the nation as a whole. The HIV Epidemiology Program of L.A. County reported that, for all of 1997 compared to all of 1996, there was a 53% drop in deaths from AIDS. This drop was nearly uniform across all demographic categories-gender, race and ethnicity, sexual orientation, and exposure category. There was also overall a 31% drop in new AIDS cases reported in 1997 compared to 1996 (remember this includes those who had a T-cell count below 200 and/or an infection or cancer that qualifies as AIDS-defining according to the CDC definition). There were 3,550 new AIDS cases reported in 1996 but just 2,463 reported in 1997. (There is a delay between diagnosis of a new case and the report to the health department, but these delays are similar for the two reporting years compared here.)

In new cases, however, the drop was not uniform across populations as it was for deaths. Cases in white men dropped 44% vs. 22% in Asian/Pacific Islander men, 20% in African-American men and 18% in Latino men. In other words, new cases in all groups dropped significantly, but the decrease of new cases in men of color was only half of what it was among white men. Among women, there were 33% fewer cases in white women and Asian women, 17% fewer among Latinas and 15% fewer in African-American women. The proportion of the total cases that were in women as compared to men increased slightly, from 9.6% to 11.1%.

Implications

The evidence is that these reductions were mostly due to the beneficial effects of combination therapies and the increased availability of these new therapies in late 1996 and 1997. The vast majority of people who got these new therapies had some benefit, either in living longer if already diagnosed with AIDS or perhaps not progressing to an AIDS diagnosis if living with an earlier stage of HIV infection. The number of new HIV infections is in all likelihood not dropping at the same rate (though it is much harder for us to know about this than about AIDS cases).

The reductions in both deaths and new AIDS cases mean that the number of people living with HIV infection is increasing. More than 12,000 people in Los Angeles County alone are known to be living with an AIDS diagnosis, and another 20-30,000 are estimated to be living with HIV. The need for services, knowledge and support will likely continue to increase, even as the general public may think that the epidemic is rapidly declining.

The Newest HIV Infections In Los Angeles County

To try to learn more about who is becoming infected with HIV currently in L.A., my colleagues and I in community organizations and the health department started Project Open Window in late 1996. I was asked to present some data about our preliminary findings as a poster at the Chicago conference.

Project Open Window is so named because it attempts to open the "window period," the time very soon after HIV exposure, when one may be infected with HIV but not yet show up positive on a standard antibody test. By recognizing flu-like symptoms occurring within a month of a possible exposure to HIV, and by using specialized tests, we can in fact tell within a few days after exposure whether someone has gotten HIV.

By treating early, or at least starting to have one's T-cells and viral load monitored from the beginning, it is quite possible that we can permanently slow down the pace of HIV infection, perhaps keeping folks from ever getting sick.

We also interview people in the study about their potentially risky behaviors around the time they were probably infected, and the contexts in which their risks took place. We believe that talking to people when this is still fresh in their minds is likelier to give much more complete and accurate information than the standard studies of HIV infection, where participants must try to describe what they did years earlier.

In Chicago, we presented data on the first 44 enrollees, all of whom had become infected with HIV within the preceding 12 months or less. There are 37 men and seven women so far. Though the group is small, it is fairly representative demographically of the new AIDS cases reported in 1997, and came from 22 different testing sites or clinics. We used a combination of questionnaire data, an open-ended interview and some laboratory data to classify each person as to the probable route of infection. The results were interesting.

Of the 37 men, 57% were probably infected through unprotected anal intercourse-no surprise. But 20% were likely infected through receptive oral sex (sucking off someone else) and another 13% through either oral sex or unprotected insertive anal sex (fucking someone else without a condom). Of the seven women, six were likely infected through unprotected receptive vaginal sex and one through either vaginal sex or a blood transfusion.

We also asked both women and men about contexts of their sexual activity that may have influenced either the direct transmission of HIV or the behaviors which led to transmission. Again we found some perhaps surprising results: 77% of the men had practiced unprotected sex in bath houses or sex clubs in the 12-month period that included time of infection. A majority of men and women (62%) had engaged in sex while high on drugs and/or alcohol. More than half (52%) had had sex while using crystal methamphetamine.

Implications

If these data bear up as larger numbers are interviewed, we all may need to regard oral sex and being the top in unprotected anal sex as carrying a higher risk of HIV transmission than is generally believed. Many questions remain (such as whether and how much oral transmission risk is affected by whether or not the partner ejaculates while being sucked), but these findings are consistent with other recent studies of new infections.

The sex club and bath house association points at least to the importance of these venues for aggressive prevention outreach activities. The strong association of risky behavior with drug and alcohol use, and with crystal meth in particular, underscores the need to always look at HIV, sexual behavior and substance use together, rather than as separate issues and needs.

Risk Factors for Unprotected Sex Among Men with AIDS in L.A. County

Dr. Paul Simon presented a study of 617 men with an AIDS diagnosis who were interviewed between June 1995 and July 1997. These interviews were part of a larger study called SHAS (Supplement to HIV/AIDS Surveillance), conducted in L.A. and several other locations by the CDC, to see what happens to people after they have been diagnosed with AIDS. One part of the study asks about their sexual and needle-sharing behaviors since being diagnosed.

The group comprised 57% (self-identified) gay men, 27% heterosexual men and 16% bisexual men. Forty-six percent were Latino, 33% Caucasian and 14% African-American. About 20% reported a history of drug injection and 20% a history of crack use. Thirty per cent had known of their HIV status for less than 12 months before interview, 70% for a year or more.

Of those who said they had had sex with another man in the 12 months before the interview (312 of the 617), 71% said they had fucked another man. Of these, 11% said they never used a condom while fucking and another 20% said they used one only sometimes. That meant 69% said they used a condom every time.

71% of this sample also reported being fucked within the last 12 months. Of these men, 15% said their partner(s) never used a condom, 22% said "sometimes" and 62% said "every time."

For those who had sex with women (131 of the 617) in the past 12 months, 99% said they had fucked a woman vaginally. Of this number, 28% said they never used a condom, 25% said "sometimes," and 46% said "always." Also, 26% of these heterosexually active men said they had fucked a woman anally. Of these 34 men, 50% said they never used a condom for anal fucking, 21% "sometimes" and only 29% "every time."

(If you are keeping track, that means a good chunk didn't have any sex in the previous year.)

When trying to analyze who it was that practiced unprotected fucking, some factors that other studies have found meaningful (race, education and heterosexual orientation) did not make much difference here in this L.A. study, at least once you controlled for everything else that such associations might be due to. What did stand out, even after all appropriate controls and adjustments of the data were taken into account, were three factors: being of young age, having a relatively recent awareness of one's HIV status, and having traded sex for money or drugs within the past five years.

The strongest association was with age. Those under 30 were more than three times as likely to practice unprotected sex as those over 40. The in-between group (30-39) were almost twice as likely not to protect as were the over-40 men.

Knowing of one's HIV status for less than a year was associated with being two and a half times likelier not to use protection compared to those who had been aware for more than a year. Those who had exchanged sex for money or drugs were 1.6 times likelier not to use protection.

Implications

The data should be viewed with caution, because they are based only on self-reports and because they do not take into account the serostatus of the sex partners. Nevertheless, this report is evidence that a significant number of positive men in our area are engaging in unprotected sex with both men and women.

Prevention interventions should be designed which help positive men to more consistently protect their partners. The longer one knows of one's status, the more consistently one practices protection. This finding supports a public health argument for increasing efforts to detect HIV earlier. One will live probably longer and better if one knows of one's HIV infection sooner rather than later!

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