Important note: Information in this article was accurate in October 2000. The state of the art may have changed since the publication date.Sidebar: Having the Nitty-gritty Discussion About Sex
Herminia Palacio's voice is tinged with regret and relief as she explains the intricacies of HIV prevention in the aftermath of highly active antiretroviral therapy (HAART). "In the mid- to late-1980s, the gay community was faced on a daily, horrifying basis with the realities of AIDS: constantly attending funerals and seeing people wasting. Thankfully, now we don't have as many of those stark, in-your-face reminders of the devastation this disease can cause," she says.
With the success of HAART in industrialized nations, the AIDS epidemic turned two corners. The obvious one is that effective combination therapy has allowed thousands of HIV-infected patients to live longer, more productive lives. The other is far more subtle. "Much of what the disease does to people now is a more private enterprise," says Palacio, a special policy adviser at the San Francisco Department of Public Health. "As they struggle with side effects [from HAART], the signs of having HIV have become more personal and less public."
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| Based on data from more than two dozen studies and surveys, researchers and public health officials in San Francisco released a report last August indicating that new HIV infections had risen among gay men there from 1997 to 2000. The report is available at http://www.caps.ucsf.edu. |
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| Data from the Ontario Ministry of Health, presented last July during the XIII International AIDS Conference in Durban, South Africa, show that the rate of new HIV infections among gay men in Ontario more than doubled from 1996 to 1999. Source: University of Toronto |
The result is that effective therapy has changed the perception of HIV. Once feared as a serial killer, the virus now is viewed in some quarters as more of a perilous mugger: the attack is serious but survivable. In San Francisco, a bellwether during much of the epidemic to date, that shift in perception has helped fuel an alarming increase in new HIV infections among gay men, a group in which HIV incidence had stabilized or decreased for several years. Now experts warn that the trend likely will spread to other communities worldwide.
"We would be naive to think that [San Francisco's] experience is going to be unique," says Peter Katsufrakis, an associate dean for student affairs at the University of Southern California's Keck School of Medicine who also has a limited medical practice in Los Angeles County. Tom Coates, director of the AIDS Research Institute at the University of California at San Francisco (UCSF) is far more blunt. "What we're experiencing here is going to be experienced by every jurisdiction, and ultimately it will be a problem for the developing world," he says.
Last August, the San Francisco Department of Public Health and UCSF's AIDS Research Institute released a report that explains how health officials determined that infections are increasing, and how prevention messages can be revitalized to target changing perceptions of HIV. Projections of HIV infections through 2000 are based on data from more than two dozen studies and surveys. They include population-based longitudinal studies, convenience samples, telephone surveys, HIV testing data, blinded serosurveys, and other methods. (The report is available at http://www.caps.ucsf.edu.)
According to the report, 27 percent of San Francisco's estimated 52,000 men who have sex with men (MSM) are living with HIV/AIDS. In this population, new infections have increased from 1.1 percent per year in 1997 to an estimated 1.7 percent in 2000. The report indicates that about 10 percent of San Francisco's MSM are injection drug users. In this group, HIV prevalence is approximately 40 percent, and new infections have increased from 2.0 percent per year in 1997 to an estimated 4.6 percent in 2000. In injection drug users in San Francisco who are not MSM, the rate of new HIV infections has decreased, from 1.0 percent in 1997 to a projected 0.6 percent in 2000. No increases have been reported in heterosexual or mother-to-child transmission.
"The epidemic in San Francisco is like a sub-Saharan Africa epidemic," in terms of prevalence and new infections among gay men, says Coates. "The difference is, we have treatment."
Having the nitty-gritty discussion about sex |
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The question of why patients take obvious health risks is as old as the Hippocratic oath, and the answers are limited only by the bounds of the human psyche. As HIV infection increasingly becomes viewed as a chronic rather than fatal illness, physicians should be prepared to renew strategies in advising patients who may have lapsed into unsafe behaviors and those who may be encountering HIV information for the first time. "First and foremost, the physician's responsibility is to make it okay for patients to talk about these issues; make the physician-patient relationship a safe environment," says Herminia Palacio, a special policy adviser with the San Francisco Department of Public Health. Recent data indicating that HIV incidence has increased among San Francisco gay men have raised an old taboo for some physicians--explicit talk about sex. "Sex is so much a part of our popular culture, but in that context it is fantasized and idealized. It is not the nitty-gritty discussion about using condoms and lubrication; that's not fantasy," notes Peter Katsufrakis of the University of Southern California's Keck School of Medicine. Katsufrakis says physicians should introduce discussions of sexuality and lapses in safe behavior in routine, non-judgmental ways. In his limited Los Angeles County medical practice, Katsufrakis says he has seen patients who insist they always used condoms but then eventually seek treatment for urethral discharge, a symptom of gonorrhea. In those cases, he says, it is the physician's responsibility to help the patient make the connection between unsafe sex and whatever is prompting it--alcohol use, drug use, or psychological or emotional factors. Tom Coates of the AIDS Research Institute at the University of California at San Francisco offers some specifics. "HIV care is very complicated, but the message physicians need to give out is that if their patients want to be on top, to use a condom, and to never let anyone top them without a condom. Physicians have got to use clear, frank language." Coates also advises regular sexual health check-ups that include screening for syphilis, gonorrhea and chlamydia for patients with more than one sexual partner per year. Patients who are not HIV-infected and have multiple sex partners should be HIV-tested every six months as part of routine care, he notes. Asking patients if they practice safer sex, and having patient information on safer sex practices in waiting rooms and examination rooms helps to reinforce the message, Coates adds. "Be tuned in," he notes. Drug use is a driving force behind HIV transmission; methamphetamine use has been clearly linked with high-risk sex. Patients who use Viagra should be informed of the drug's risk-reduction powers. "When patients can maintain an erection, it's easier to use a condom," Coates says. The effectiveness of highly active antiretroviral therapy (HAART) has caused patients to view HIV as a chronic, manageable illness. But many patients aren't aware of the realities of HAART. Physicians should inform uninfected patients that HAART "requires a minimum of four pills per day to up to 20 pills a day," says physician Tom Barrett of the Howard Brown Health Center in Chicago. "There are also adverse effects and we need to do blood draws every three to four months, and that's if it all works well. If not, it gets intensified," he adds. "And for several patients in our practice right now, things are not going well." --Rebecca Voelker |
Have these numbers come as a surprise? Yes and no, he says. For the last two or three years, health officials and researchers in San Francisco have watched rising rates of rectal gonorrhea and other sexually transmitted diseases (STDs) that are indicators of HIV infection. Obviously, high-risk behavior was on the rise.
"We saw a doubling of STDs in people diagnosed with AIDS," he says. "But what we didn't know was whether treatment--this is a heavily treated population--would reduce [HIV infectiousness] enough that we would not see a rise in new infections. The shoe fell when we learned through these data that an increase in risk behavior does translate into an increase in new infections."
Public health officials and HIV-treating physicians may have wanted to believe that reductions in viral load would lead to reduced transmission, but evidence does not support that hypothesis. A recent study of serodiscordant couples in Rakai, Uganda, showed that even though 37 percent of transmissions occurred at the highest levels of viral load--50,000 or more copies of HIV-1 RNA per milliliter--transmission still occurred when viral load was as low as 1500 copies.1
For resource-limited countries that still clamor for antiretroviral therapy, San Francisco's trends may seem meaningless. But Coates says they contain an important message.
"Whenever treatments are being introduced--and they're being introduced to a greater extent in the developing world--and whenever vaccines are introduced and they're imperfect, people are going to want to give up on other means of prevention," he says. "When treatment is less than perfect in preventing transmission, and when vaccines are less than perfect in preventing transmission, and people give up on other means of prevention, the net result may be an increase in HIV transmission. That's what we're experiencing in San Francisco."
To date, a documented increase in HIV incidence among gay men in the United States may be confined to San Francisco. The New York City Department of Health reports that HIV incidence there is steady or declining, but health officials say they are watching the figures carefully. Says Marty Algaze, manager of communications at Gay Men's Health Crisis in New York: "Our experts here think we need to wait a bit longer and see if this is a trend or a fluke that has happened in [San Francisco] the last few months."
At the Howard Brown Health Center, which specializes in gay and lesbian healthcare in Chicago, physician Tom Barrett says an increase in syphilis has been observed. "We can't correlate that with new HIV infections, but instinctively it makes sense" that HIV incidence may be rising, says Barrett.
No increases in new HIV infections have been documented in Boston, but HIV-treating physicians are concerned. "Anecdotally, we're seeing a few recent seroconverters," says Cal Cohen, research director of Community Research Initiative of New England, a Boston nonprofit group that focuses on HIV research and treatment. "But there certainly has been a blip [upward] in terms of STDs."
The US Centers for Disease Control and Prevention (CDC, Atlanta) report that nationally, the rate of new HIV infections is stable at 40,000 per year.
In Ontario, Canada, HIV incidence among gay men had been declining for several years. Yet researchers at the University of Toronto have compiled data showing that new HIV infections among MSM more than doubled from 1996 to 1999. Their data, taken from the Ontario Ministry of Health's HIV testing database, included 27,838 person years of observation among MSM. In 1996, the rate of new infections was 0.87 per 100 person years; it rose to 2.07 in 1999.
"We were hoping it was a statistical aberration of some sort," says Liviana Calzavara, principal investigator of the study and associate professor of public health sciences at the University of Toronto. "We had been hearing stories anecdotally about people putting themselves at increased risk. So, this was not unexpected, but we did not think [the increase] would be as dramatic as it is."
Increased rates of STDs among gay men have become common in some urban centers of Europe. "Clearly there has been a change in sexual practice," says Christine Katlama, head of the HIV clinic at Hopitalier Pitie-Salpetriere in Paris. Even though HIV infections are not reported to public health departments in France--only AIDS cases are reported--Katlama nonetheless fears that an increase in HIV incidence among gay men could unleash a backlash. "People will say, 'If you become HIV-positive, it is because of risky behavior.' It might increase the phobia for some people."
Drug-resistant strains of virus also have raised the stakes in preventing new HIV infections, Cohen notes. "In Boston, 16 percent of the people coming through our door have resistant virus." He adds that at the recent Interscience Conference on Antimicrobial Agents and Chemotherapy in Toronto, researchers in Spain reported rates of drug-resistant HIV as high as 25 percent.
The major question now is how to re-package prevention programs that, for some high-risk groups at least, appear to have become obsolete. In Amsterdam, the Netherlands, public health officials went to gay bar owners to discuss the possibility of distributing free condoms after they realized that from 1998 to 1999, rectal gonorrhea cases reported at the city's STD clinic had doubled and syphilis cases had nearly quadrupled.
"Another possibility here is to do more prevention counseling around people who are HIV-positive," says Roel Coutinho, director of Amsterdam's Municipal Health Service. "But we know this from the 1980s: there is a saturation point [in repeating safer sex messages] where you can do no more."
Ronald Valdiserri, deputy director of CDC's National Center for HIV, STD & TB Prevention, disagrees. He says prevention should be viewed in a similar vein as marketing. "No successful manufacturer would keep the same advertising program year after year--they anticipate new tastes and trends. Even if it's the same product, it's packaged in different ways. Prevention is the same," he notes.
New programs, says Palacio, must acknowledge how difficult it is to sustain low-risk behavior over time. "Sex, relationships, and intimacy are fundamental human needs," she notes. After 20 years of being instructed to use a condom during every sexual encounter, Palacio and others say many gay men have succumbed to prevention burnout.
"This is not about ignorance; it's battle fatigue," Cohen observes.
"Older men who saw the first wave of the epidemic and lost their friends are tired of the whole thing," notes Algaze. The other side of the spectrum is that younger men haven't witnessed the death march of the 1980s and early '90s. "They think the epidemic is over," Algaze adds. "If you get infected, you can start to take the pills."
Coates emphasizes instilling a sense of community responsibility and acknowledging the conflict patients feel when the desire for sexual freedom comes up against HIV prevention.
"Gay liberation is about sexual freedom and HIV prevention is about restraint," says Coates. "Until HIV is eradicated in our community, gay liberation cannot reach its potential. HIV will sap the longevity of the community. We need to ask, 'Does the community as a whole want this to happen?'"
1. Quinn TC, Wawer MJ, Sewankambo N, Serwadda D, Li C, Wabwire-Mangen F, Meehan MO, Lutalo T, Gray RH. Viral Load and Heterosexual Transmission of Human Immunodeficiency Virus Type 1. N Engl J Med 2000 Mar 30;342(13):921-9.
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