Important note: Information in this article was accurate in October 2000. The state of the art may have changed since the publication date.The gay press in California and around the country have spent a lot of ink debating some numbers released just before the Durban International AIDS Conference and an accompanying speculation by San Francisco's chief HIV epidemiologist that "rates of new HIV infections in some parts of San Francisco's gay population have increased to sub-Saharan levels." This news was greeted with loud echoes of everything from "Can't be! It's the health department cooking numbers in a plot to justify more restrictions on gay sex," to "The AIDS crisis is over! This is another detraction from the health needs of the large number of HIV negative gay men and lesbians," to "It's highly suspect! Bogus! A San Francisco plot to keep their unfair share of federal AIDS funding," to "We are not surprised, given the lessening fear of HIV with the advent of HAART and the barebacking craze."
Each of these and most other reactions is at best one-tenth true, but the controversy has been valuable. Its context is the hard-to-dispute fact that HIV prevention has not kept pace with the changes in the epidemic.
It is important to remember that there is no way to count new HIV infections and therefore no way to prove beyond a doubt whether rates of infection are increasing, decreasing or level. New HIV infections are not yet reportable to public health departments in California and even if they were, there is usually no way to tell if a positive test is a new infection or an old one in someone who has not been tested or reported before. Most of all, there is no way of knowing how many new infections occur anew or exist already among people who haven't been tested at all. Thus, the best we can do, and we are getting better at it, is to estimate based on several different kinds of data. The estimates will always be approximate at best, but if we use the same or better methods every year, we can get a pretty good picture of the trends.
San Francisco is better than anywhere else in the US at estimating infections (some might say, aided by all that money, its small size and the high visibility of the gay community). There are more studies and surveillance systems to base estimates on and more experts to analyze them. The San Francisco Department of Public Health (DPH) periodically convenes a panel of these experts and a group of community people living with or working with HIV on the front lines, to develop for planning purposes consensus estimates of people living with HIV/AIDS and the annual rate of new infections. The latest such consensus panel met in May 2000.
One new tool to help determine HIV incidence is what's called the "detuned Elisa assay." This takes advantage of the improvement in HIV testing over the years, the improvement that has shrunk the so-called window period (when one might be HIV+ but not yet show up it on an antibody test) from six months to six weeks. The detuned assay tests a person's blood with both the old, less sensitive test and the new, more sensitive one. If one is negative on the old test and positive on the new one, we can conclude that person is within the old "window period" of a new infection. By doing this double test on thousands of specimens, the CDC has concluded that someone can be identified with this system as being within the first four months of infection. So in a high volume testing center, STD clinic or medical care system, one can estimate how many infections are new. By combining these data with other information about the population that uses the testing system, one can estimate the percentage of negative people in the population who are seroconverting each year.
The San Francisco consensus panel estimated that the proportion of gay and bisexual men becoming HIV infected rose from 1.1% a year in 1997 (the time of the last consensus panel) to 1.7% a year in 2000. Among the much smaller number of gay and bisexual men who are also injection drugs users (IDUs) the rate and the increase were much greater: from 2.0% seroconverting every year in 1997 to 4.6% a year in 2000. Among heterosexual IDUs the rate declined somewhat from 1.0% a year in 1997 to 0.6 % a year in 2000. Among non-IDU heterosexuals, the estimates are tiny and stable: 1/100th of a percent per year in both years.
These estimates from HIV testing sites were bolstered by findings from other sources. There is increased incidence of HIV in a cohort study of young gay men, increased cases of rectal gonorrhea, increased frequency of bacterial sexually transmitted diseases (STDs) among gay men living with AIDS, increased total numbers of people with AIDS and HIV (of whom a big chunk are sexually active), increased self-reports of multiple partners and unprotected anal sex among gay and bi men, increased self-reports of unprotected anal sex among partners of different or unknown HIV status, and decreased consistent condom use overall.
The increase in estimated rates translated to increases in estimated numbers, especially when the rates were applied to upwardly revised estimates of the total number of gay and bi men in San Francisco, derived from studies with stronger methods. The panel estimated that there will be 573 new infections in gay men in 2000 compared to 283 in 1997; 143 in gay/bi IDUs, up from 53 in 1997; and declines in heterosexual IDUs from 117 to 68 and in non-IDU heterosexuals from 45 to 6.
Though some writers in the San Francisco gay press and some community leaders have quibbled with this or that component of the estimates, no one has introduced credible evidence or argument that the basic trend depicted is false. Readers may find a complete presentation of the data as well as the recommendations below on the University of California San Francisco (UCSF) HIV Web Site: http://HIVinsite.ucsf.edu/ari/HIVEstimatesReport8900.html
A community panel examining the estimates remarked that while the numbers have evinced alarm, sadness and a great deal of anger, almost no one was surprised. The increase is based in their view on several realities.
For one thing, and this has been confirmed in studies in West Hollywood and Los Angeles, the perception of AIDS as a death sentence is largely gone among gay men, as a result of the partial reality and the widespread hype surrounding highly active antiretroviral therapy (HAART) and the change of HIV/AIDS to a "chronic, manageable disease." When AIDS were still seen as a death sentence, and people had seen hundreds of their community waste away and die, people made certain choices about risk that became less common when that perception changed. It is not only HAART, but new generations coming of age without the visible swaths of the scythe of the Grim Reaper.
The perception of HIV on the streets has changed, and most HIV efforts have not caught up with that change. Studies indicate that high-risk sexual behavior is on the rise in San Francisco (and most likely in WeHo, Long Beach and LA).
The San Francisco community analysts divided gay men's communities into three distinct groups, all with real but different prevention needs. The first group comprises people who have eliminated high-risk behavior from their lives (whether they are HIV positive or negative). They have a thorough knowledge of HIV transmission and risk reduction techniques, and have chosen to eliminate risk based on personal decisions about their risk and need.
A second group has engaged in high-risk behavior throughout the epidemic, despite years of exposure to risk reduction in media and community prevention efforts. This has not changed. For these men, "decisions about perceived risk are outweighed by their needs for identity, intimacy, pleasure or other considerations. They know about risk, have made choices, and engage in behavior at the level of risk they believe to be appropriate."
A third group of gay and bi men has changed its behavior recently. "This group makes situational decisions about risk behavior. These decisions are based on their knowledge and understanding of HIV transmission, the perceived risk of the behavior in question, and the stated or presumed HIV status of their partners."
HIV prevention and education have been based on many theories for the past 20 years. Most of these theories have assumed that reasoning things out can lead to safer behavior. While that is certainly partly true, reason isn't the only thing that guides our behavior in the heat of the moment. Most gay men make decisions on sex at a level far more basic and urgent than one naturally including complex reasoning analysis. The San Franciscans noted, "A brochure can be informative on Tuesday morning; in a moment of passion on Friday night, a different analysis occurs." (Do I hear you say "duh"?)
Substance use before and during sex is also a factor. For some individuals, chronic loneliness, isolation and alienation may lead to remedies that include high-risk behavior. So can pursuit of pleasure in a society where discrimination can make life painful.
Finally, prevention has until now largely excluded the needs of HIV+ people. Nearly every positive person wished HIV to stop with him or her, but there has been precious little support for doing that, in the context of a sex-and intimacy-positive full, rounded life.
In a nutshell, the realities of new HIV infections are complex, and prevention needs to change. (I acknowledge that I am limiting this analysis largely to gay and bisexual men who overwhelmingly predominate in the epidemic on the West Coast. There are different but analogous stories to be told about women, hetero-and bisexual communities of color, IDUs and different regions of the country.)
The San Francisco DPH and its community planning bodies have issued an "11 Point Action Plan" as an opening salvo in a dynamic process of "dialogue, programmatic renovation and community norm building among gay men." The plan is not deemed either exhaustive or complete, but a foundation of assumptions being made to begin to both revitalize HIV prevention in San Francisco and to revitalize the San Francisco gay community's ownership of its own longevity.
I present these points here in their original form. I believe that they are worthy of intensive discussion in Los Angeles and elsewhere around the nation.
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