Expanded Coverage of AIDS/HIV in Underserved Special Communities: African Americans, Hispanics, Women, IVDUs

In recent days new data released from the CDC has highlighted that HIV is a growing problem in African-American and Hispanic men who have sex with men. But the surprising thing is that people are surprised about this. We've all been repeatedly apprised in recent years of the shift in disease incidence to communities of color, women and IVDUs from gay white men. Many of us have known and its obvious to assume that African-American and Hispanic men who have sex with men are at the greatest risk. The stigma attached to their lifestyle is great and greater apparently in their communities than in the white communities. These lifestyles and HIV are not discussed and accepted in their communities. Black and Hispanic political and church leaders have not adequately taken leadership. They are not vocal. Until the Congressional Black Caucaus initiatives from last year, leadership was lacking. we do not hear the likes og Jesse Jackson speaking on HIV. Leadership needs to account for these problems and their solutions. Below are the CDC press releases, CDC related articles, the NY Times article, and an article from NATAP Reports newsletter. Industry should support effective treatment education programs geared for these communities.

January 2000

Need for Sustained HIV Prevention for Gay and Bisexual Men: HIV Infections Continue at High Levels Among Men of All Raceswith Dramatic Impact Among Men of Color

Although gay men have made significant strides in reducing high-risk behavior and HIV infection rates in some communities, researchers estimate that men who have sex with men (MSM) still account for 40% of the overall 40,000 new HIV infections in the U.S. each year, and for 60% of all new HIV infections among men. Additionally, an increasingly diverse population of gay and bisexual men is impacted. The epidemic, which began primarily among white gay men, is now dramatically affecting gay and bisexual men of all races.

There are currently an estimated 325,000-475,000 gay and bisexual men living with HIV in the U.S. As of December 1998, 135,000 of these were living with AIDS. An estimated 356,000 AIDS cases have been diagnosed among MSM since the beginning of the epidemic through June 1999, and nearly 221,000 have died.

Due to the introduction of highly active antiretroviral therapies (HAART), AIDS incidence and deaths have been declining among all risk groups, including gay and bisexual men, since 1996. Declines in disease and death are encouraging for those already living with HIV and AIDS, but have not been accompanied by recent declines in HIV infection of the same magnitude. As new infections continue to occur, and more infected people are living longer, healthier, and sexually active lives, the total number of HIV-infected individuals (HIV prevalence) continues to grow. The result: a greater need for HIV prevention and treatment services than ever before.

Latest Data on Disease and Death

{These figures include gay and bisexual men who were most likely infected with HIV through sex with another man. The figures do not include gay and bisexual men who also inject drugs, because it is not possible to determine the specific route of HIV transmission for these individuals.}

AIDS incidence reported among MSM declined 22% from 1996 to 1997 (from 26,068 cases to 20,464 cases). This decline slowed to an 12% decline from 1997 to 1998 (from 20,464 cases to 18,153 cases). HIV-related deaths among MSM declined 49% from 1996 to 1997 (from 16,436 deaths to 8,401 deaths), and also slowed with a 23% decline from 1997 to 1998 (from 8,401 deaths to 6,467 deaths). The slowing in the decline of AIDS incidence and deaths can most likely be attributed to a combination of factors, including: having already reached most individuals who know they are infected with HIV and are susceptible to treatment, in addition to treatment failure caused by difficulty with adherence to drug regimens.

January 13, 2000 


Men of color now account for a greater proportion of AIDS cases among men who have sex with men than do white men, according to a new report in the  January 14 th issue of CDCís Morbidity and Mortality Weekly Report. 

Based on an examination of U.S. AIDS cases over the past decade, the CDC study found that men of color represent an increasing proportion of AIDS  cases among gay and bisexual men, rising from 31% in 1989 to 52% in 1998.  African-American men comprised one-third of AIDS cases among gay and bisexual  men, while Latino men represented 18% of cases. While declining from 69% in  1989, white men continued to represent 48% of AIDS cases among gay and  bisexual men in 1998.

ěThe face of AIDS among gay and bisexual men is changing,î said Helene D. Gayle, MD, MPH, director of CDCís National Center for HIV, STD, and TB  Prevention. ěAfrican-American and Hispanic men must recognize that this is not a disease  that only affects white gay men ń gay and bisexual men of all races are affected.î The report examines the areas hardest hit by AIDS and finds that in recent  years (from January 1996 to December 1998), 85% of AIDS cases among gay and bisexual men of color were concentrated in cities with populations over 500,000. The  five cities with the highest proportion of cases were New York (12%), Los Angeles  (9%), Miami (5%), Washington, D.C. (4%), and Chicago (3%). Trends varied by race.

New York City had the highest number of cases among African-American gay and bisexual men, followed by Washington D.C. and Atlanta. Los Angeles had the highest number of cases among Latino gay and bisexual men, followed by New York  and Miami. While Asian/Pacific Islanders and American Indian/Alaska Natives represent less than 2% of overall cases among gay and bisexual men, the cities with the highest number of cases among men of these races were Los Angeles and Phoenix, respectively.

Burden of Stigma in Communities of Color

Researchers outline possible factors contributing to the disproportionate  toll of HIV and AIDS among gay and bisexual men of color. In addition to economic  factors, such as high rates of poverty, unemployment, and lack of access to health  care, cultural factors, such as the stigma of homosexuality, may be playing a role. The study reports the results of a multi-site CDC survey of 8,780 HIV-positive men who have sex with men. Of those surveyed, 24% of African-American and 15%  of Latino men who have sex with men identified themselves as being heterosexual.  By contrast, only 6% of white men who have sex with men identified themselves as  being heterosexual.

Researchers believe the stigma of homosexuality in communities of color may  inhibit men of color from identifying themselves as gay or bisexual, despite having sex with other men. According to Gayle, this may prevent men of color from seeking or receiving the HIV prevention and treatment services they need.

Additionally, by not identifying as gay or bisexual, these men may not accept their own risk for HIV, and therefore, may unintentionally put their female partners and children at risk. HIV infection has increased significantly in women of color over the last decade.

ěThis is a very real and sensitive issue requiring increased dialogue and attention from leaders in communities of color,î Gayle said. ěThe stigma associated with homosexuality in African-American and Latino communities only compounds the traditional factors associated with high rates of disease in our communities. To truly win the battle against HIV, we must be willing to acknowledge and wrestle with the difficult issues.î

Gay Men of Color May be More Likely to Contract HIV at Young Age

The CDC study also points to the need to reach African-American and Latino men with HIV prevention programs and messages at an early age. Because AIDS cases alone are no longer indicative of new HIV infections, CDC also examined data collected from 1996-1998 in 25 states that report HIV diagnoses in addition to cases of full-blown AIDS. Data on HIV diagnoses among men in the youngest age group (13-24) provide the best indication of recent trends in infection in these states.

Among gay and bisexual men diagnosed with HIV during this period, 16% of African Americans and 13% of Latinos were age 13-24, compared with 9% of white men. Although data are not national, they can point to possible trends. ěThese data suggest that African American and Hispanic gay and bisexual men are being infected at younger ages than white men,î said CDC study author,  Janet Blair, Ph.D., M.P.H., ěMen of color must be reached early with comprehensive HIV prevention programs, especially in high risk communities.î

According to Blair, in addition to expanding prevention programs for men of color, locally based community efforts must also address the need for early  HIV testing, diagnosis, and treatment to reduce new infections and improve  survival. Since powerful new drug treatments became available in 1996, annual AIDS cases (AIDS incidence) and deaths have declined among all gay men. However, declines have not been as steep among gay and bisexual men of color, as among white  gay and bisexual men. Between 1996 and 1998, AIDS incidence among gay and bisexual men dropped 23% among African Americans, 26% among Latinos, and 39% among whites. AIDS deaths among gay and bisexual men dropped 53% among African Americans, 60% among Latinos, and 65% among whites.

Expanded Prevention Urgently Needed

CDCís prevention initiatives to address the growing epidemic among gay men of color include, expanded surveillance to better track the path of local epidemics, increased efforts to reach individuals with HIV counseling and testing linked to prevention and treatment services, and continued expansion of community-based prevention programs. One important element of prevention efforts for gay and bisexual men is the provision of anonymous HIV testing sites. Access to anonymous testing may help ensure that stigma and fear do not prevent individuals from seeking HIV testing. CDC has been working with organizations throughout the country to implement locally designed, targeted prevention programs specifically for men of color who have sex with men, including several designed to reach men who donít identify as gay. To expand these efforts in 1999, CDC awarded an additional $7 million in grants for HIV prevention services specifically targeted to gay and bisexual men of color.

ěWe must continue to combat complacency about HIV infection, ě said Gayle, ěHIV remains a serious, lifelong and incurable diseaseóa disease that can and must be prevented.î

The above mentioned $7million is part of a larger initiative. Since October 1998, HHS has been working in a partnership with the Congressional Black Caucus toaddress the severe and ongoing crisis of HIV/AIDS in communities of color, given the disproportionate impact of the disease in racial and ethnic communities. As part of this effort, HHS spent an additional $156 million in fiscal year 1999 to attack HIV/AIDS in racial and ethnic minority communities. The partnership also includes the deploymentof special Crisis Response Teams of HHS experts to work alongside local officials, public health personnel and minority community-based organizations in highly affected communities to help them address their communities of color HIV/AIDS crisis.

HIV/AIDS Among African Americans

In the United States, the impact of HIV and AIDS in the African American community has been devastating. Through December 1998, CDC had received reports of 688,200 AIDS cases - of those, 251,408 cases occurred among African Americans. Representing only an estimated 12% of the total U.S. population, African Americans make up almost 37% of all AIDS cases reported in this country. 

Researchers estimate that 240,000-325,000 African Americans - about 1 in 50 African American men and 1 in 160 African American women - are infected with HIV. Of those infected with HIV, it is estimated that more than 106,000 African Americans are living with AIDS. 

In 1998, more African Americans were reported with AIDS than any other racial/ethnic group.

* 21,752 cases were reported among African Americans, representing nearly half (45%) of the 48,269 AIDS cases reported that year. 

* Almost two-thirds (62%) of all women reported with AIDS were African American. 

* African American children also represented almost two-thirds (62%) of all reported pediatric AIDS cases. 

* The 1998 rate of reported AIDS cases among African Americans was 66.4 per 100,000 population, more than 2 times greater than the rate for Hispanics and 8 times greater than the rate for whites. 

HIV data from a CDC study* comparing HIV andAIDS diagnoses in 25 states with integrated reporting systems show these trends are continuing. In these states, during the period from January 1994 through June 1997, African Americans represented a high proportion (45%) of all AIDS diagnoses, but an even greater proportion (57%) of all HIV diagnoses. And among young people (ages 13 to 24), 63% of the HIV diagnoses were among African Americans. 

Prevention Efforts Must Focus on High Risk Behaviors

Adult/Adolescent Men. Among African American men with AIDS, men who have sex with men (MSM) represent the largest proportion (38%) of reported cases since the epidemic began. The second most common exposure category for African American men is injection drug use (35%), and heterosexual exposure accounts for 7% of cumulative cases. 

Adult/Adolescent Women. Among African American women, injection drug use has accounted for 44% of all AIDS case reports since the epidemic began, with 37% due to heterosexual contact. 

Interrelated Prevention Challenges in African American Communities 

Looking at select seroprevalence studies among high-risk populations gives an even clearer picture of why the epidemic continues to spread in communities of color. The data suggest that three interrelated issues play a role -- the continued health disparities between economic classes, the challenges related to controlling substance abuse, and the intersection of substance abuse with the epidemic of HIV and other sexually transmitted diseases (STDs). 

* Substance abuse is fueling the sexual spread of HIV in the United States, especially in minority communities with high rates of STDs.Studies of HIV prevalence among patients in drug treatment centers and STD clinics find the rates of HIV infection among African Americans to be significantly higher than those among whites. Sharing needles and trading sex for drugs are two ways that substance abuse can lead to HIV and other STD transmission, putting sex partners and children of drug users at risk as well. Comprehensive programs for drug users must provide the information, skills, and support necessary to reduce both injection-related and sexual risks. At the same time, HIV prevention and treatment, substance abuse prevention, and sexually transmitted disease treatment and prevention services must be better integrated to take advantage of the multiple opportunities for intervention. 

* Prevention efforts must be improved and sustained for young gay men. In a sample of young men who have sex with men (ages 15-22) in six urban counties, researchers found that between 5% and 9% were infected with HIV. A significantly higher percentage of African American MSM (8-13%) than white MSM (4-6%) were infected. 

It is clear that the public sector alone cannot successfully combat HIV and AIDS in the African American community. Overcoming the current barriers to HIV prevention and treatment requires that local leaders acknowledge the severity of the continuing epidemic among African Americans and play an even greater role in combating HIV/AIDS in their own communities. Additionally, HIV prevention strategies known to be effective (both behavioral and biomedical) must be available and accessible for all populations at risk. 

Need for Sustained HIV Prevention Among Men who Have Sex with Men

In the United States, HIV-related illness and death historically have had a tremendous impact on men who have sex with men (MSM). Even though the toll of the epidemic among injection drug users (IDUs) and heterosexuals has increased during the last decade, MSM continue to account for the largest number of people reported with AIDS each year. In 1998 alone, 16,642 AIDS cases were reported among MSM, compared with 11,070 among IDUs and 6,735 among men and women who acquired HIV heterosexually. 

Overall, the number of MSM of all races and ethnicities who are living with AIDS has increased steadily since 1992, partly as a result of the 1993 expanded AIDS case definition and, more recently, improved survival. 

Continuing Risk Among Young MSM 

Abundant evidence shows a need to sustain prevention efforts for each generation of young gay and bisexual men. We cannot assume that the positive attitudinal and behavioral change seen among older men also applies to younger men. Recent data on HIV prevalence and risk behaviors suggest that young gay and bisexual men continue to place themselves at considerable risk for infection with HIV and other sexually transmitted diseases (STDs).

* Ongoing studies show that both HIV prevalence (the proportion of people living with HIV in a population) and risk behaviors remain high among young MSM. In a sample of MSM 15-22 years old in six urban counties, CDC researchers found that, overall, between 5% and 8% already were infected with HIV. Higher percentages of African Americans (8-14%) and Hispanics (2-11%) were infected than were whites (2-6%). 

* A little more than half of U.S. states conduct HIV surveillance, but in these states, data show that substantial numbers of MSM still are being infected, especially younger men. In 1998, 52% of reported HIV infections among adolescent males aged 13-19 and 50% of cases among men aged 20-24 were attributed to male-to-male sexual contact. 

* Research among gay and bisexual men suggests that some individuals are now less concerned about becoming infected than in the past and may be inclined to take more risks. This is backed up by reported increases in gonorrhea among gay men in several large U.S. cities between 1993 and 1996. Despite medical advances, HIV remains a serious, usually fatal disease that requires complex, costly, and difficult treatment regimens that do not work for everyone. As better treatment options are developed, we must not lose sight of the fact that preventing HIV infection in the first place precludes the need for people to undergo these difficult and expensive therapies. 

These data highlight the need to design more effective prevention efforts for gay and bisexual men of color. The involvement of community and opinion leaders in prevention efforts will be critical for overcoming cultural barriers to prevention, including homophobia. For example, there remains a tremendous stigma to acknowledging gay and bisexual activity in African American and Hispanic communities. 

Need to Combat Other STDs

Studies among MSM who are treated in STD clinics have shown consistently high rates of HIV infection, ranging from nearly 4% in Seattle to a high of almost 36% in Atlanta. (See CDCís National HIV Prevalence Surveys, 1997 Summary, Table 1.) Scientists know that the likelihood of both acquiring and spreading HIV is 2-5 times greater in people with STDs, and that aggressively treating STDs in a community can help to reduce the rate of new HIV infections. Along with prompt attention to and treatment of STDs, efforts to reduce the behaviors that spread STDs are critical. 

Prevention Services Must Reach Both Uninfected and Infected

Research has shown that high-risk behavior is continuing in some populations of MSM, including those who are infected with HIV. As the number of gay and bisexual men living with HIV increases, greater efforts must be made to reach them with behavioral interventions that can help them protect their own health and prevent transmission to others. 

HIV/AIDS Among Hispanics in the United States

The United States has a large and growing Hispanic population that is heavily affected by the HIV/AIDS epidemics. In 1998, Hispanics represented 13% of the U.S. population (including residents of Puerto Rico), but accounted for 20% of the total number of new U.S. AIDS cases reported that year (9,650 of 48,269 cases). The AIDS incidence rate (the number of new cases of a disease that occur during a specific time period) among Hispanics in 1998 was 28.1 per 100,000 population, almost 4 times the rate for whites (8.2 per 100,000) but lower than the rate for African Americans (66.4 per 100,000). 

Hispanics in the United States include a diverse mixture of ethnic groups and cultures. As shown in the chart at left, HIV exposure risks for U.S.-born Hispanics and Hispanics born in other countries vary greatly1, indicating a need for specifically targeted prevention efforts. 

A recent CDC study2 examining data from the 25 states that had integrated HIV and AIDS surveillance from January 1994 through June 1997 found that HIV diagnoses increased 10% among Hispanics between 1995 and 1996. However, the number of cases reported among Hispanics was relatively small, since many states with large Hispanic populations have not HIV reporting and were not included in the study. 

Historical Trends in AIDS Cases Among U.S. Hispanics 

Between 1992 and 1997, the number of persons living with AIDS increased in all groups, as a result of the 1993 expanded AIDS case definition and, more recently, improved survival among those who have benefited from the new combination drug therapies. During that 5-year period, the characteristics of persons living with AIDS were changing, reflecting shifts in the populations affected by the epidemic. In 1992, 17% of those estimated to be living with AIDS were Hispanic, while in 1997, 19% were Hispanic. In comparison, non-Hispanic whites represented 49% of people estimated to be living with AIDS in 1992, but only 40% in 1997. 

Cumulatively, males account for the largest proportion (82%) of AIDS cases reported among Hispanics in the United States, although the proportion of cases among women is rising. Women represent 18% of cumulative AIDS cases among Hispanics, but account for 21% of cases reported in 1998 alone. U.S.-born Hispanics account for the largest number of AIDS cases reported among Hispanics in this country. Among U.S. Hispanics whose place of birth was outside of the United States, individuals born in Puerto Rico account for the majority (58%) of AIDS cases. 

>From the beginning of the epidemic through December 1998, 100,950 Hispanic men have been reported with AIDS in the United States. Of these cases, men who have sex with men (MSM) represent 43%, injection drug users (IDUs) account for 36%, and 5% of cases were due to heterosexual contact. About 7% of cases were among Hispanic men who both had sex with men and injected drugs. Among men born in Puerto Rico, however, injection drug use accounts for a significantly higher proportion of cases than male-male sex. 

For adult and adolescent Hispanic women, heterosexual contact accounts for the largest proportion (47%) of cumulative AIDS cases, most of which are linked to sex with an injection drug user. Female IDUs account for an additional 41% of AIDS cases among U.S. Hispanic women. 

Building Better Prevention Programs for Hispanics

While race and ethnicity alone are not risk factors for HIV infection, underlying social and economic conditions (such as language or cultural diversity, higher rates of poverty and substance abuse, or limited access to health care) may increase the risk for infection in some Hispanic American communities. 

* Transmission related to substance abuse continues to be a significant problem among Hispanics living in the United States, especially among those of Puerto Rican origin. Studies of HIV prevalence among patients in drug treatment center find the rates of HIV infection among Hispanics to be significantly higher in some regions of the country, particularly the Northeast and Midwest. Comprehensive programs for drug users must provide the information, skills, and support necessary to reduce both injection-related and sexual risks. In addition, HIV prevention and treatment, substance abuse prevention, and sexually transmitted disease treatment and prevention services must be better integrated to take advantage of the multiple opportunities for intervention. 

* Prevention messages must be tailored to the affected communities.Hispanic populations need interventions that (1) are consistent with their values and beliefs and (2) include skills-building activities to facilitate changes in sexual behavior. Further, because the HIV/AIDS epidemic among U.S. Hispanics reflects to a large extent the exposure modes and cultural modes of the individualsíbirthplaces, an understanding of these behaviors and differences is important in targeting prevention efforts. For example, some high-risk behaviors associated with drug abuse (such as use of shooting galleries) may be more predominant among Puerto Rico-born Hispanics than among other Hispanics. Therefore, for these populations, prevention strategies should emphasize (1) preventing and treating substance abuse and (2) decreasing needle-sharing and the use of shooting galleries. For Hispanics born in Mexico, Cuba, and Central and South America, CDC data indicate that male-male sex is the primary mode of HIV transmission. Messages targeted to these populations must be based on an understanding of their cultural attitudes toward homosexuality and bisexuality, which may be different from those of other populations at high risk for infection. 

To improve prevention programs in Hispanic communities across the United States, in addition to addressing underlying social and economic conditions, we must apply the lessons we have already learned about the design of culturally appropriate HIV prevention efforts for each Hispanic population. 
MSM of Color Surpass White MSM in AIDS Incidence: May be Infected at Earlier Ages

In the January 14, 2000, issue of the Morbidity and Mortality Weekly Report, CDC reported that the number of annual AIDS cases among MSM of color has surpassed the number among white MSM. Of MSM reported with AIDS in 1989 (24,444), men of color represented only 31%. By 1998, men of color accounted for 52% of the 18,153 cases of AIDS reported among MSM. While declining from 69% of cases in 1989, white men continued to represent 48% of AIDS cases among MSM in 1998.

Percentages of Annual AIDS Cases Among MSM by:













Asian Pacific Islander  



American Indian/Alaska Native 



Because AIDS cases alone are no longer indicative of new HIV infections, CDC also examined data collected from 1996-1998 in the 25 states that reported HIV diagnoses in addition to diagnoses of full blown AIDS during that period. Data on HIV diagnoses among men in the youngest age group (13-24) provide the best indication of recent trends in infection in these states. Among MSM initially diagnosed with HIV during this period, 16% of African Americans and 13% of Latinos were age 13-24, compared with 9% of white men. While the total number of cases was much smaller in other --

(MSM of color is defined as non-Hispanic black, Hispanic, American Indian/Alaska Native, and Asian Pacific Islander men >13 years of age who have sex with men.)

--racial/ethnic groups, a similar trend was identified among Asian Pacific Islanders and American Indians/Alaska Natives, with 15% of HIV diagnoses among MSM in both groups occurring among 13- to 24-year-olds. These data suggest that in these states, MSM of color are becoming infected with HIV at younger ages and must be reached early with prevention efforts. Although data are not national, they can point to possible trends elsewhere.

Other Studies Confirm Dramatic and Continued Impact Among Gay Men
Abundant evidence points to the need for sustained prevention efforts for gay men of all races, especially young men of color. Several recent studies have pointed to high levels of risk behavior, HIV infection, and other STDs. STDs are markers of high-risk sexual behavior and may be early warning signs of a possible increase in new HIV infections among MSM. Additionally, an individual is five times more likely to acquire HIV from an infected partner if an STD infection is present in either one of them.

… In a six-city study of HIV incidence among over 96,000 clients of STD clinics between 1991 and 1997, researchers found that approximately 8% of gay and bisexual men were infected per year ń a level 17 times higher than that found among heterosexuals seen in the same clinics. The study found the highest level of new infections among African Americans (11% per year), when compared to Hispanics (7.7%) and whites (6.5%).

… A seven-city survey of 15- to 22-year-old MSM sampled at public venues showed alarming levels of HIV infection among young gay men. The Young Menís Survey found that an average of 7% of young men in the study were infected with HIV (HIV prevalence), with 3% becoming newly infected each year (HIV incidence). Both HIV prevalence and incidence were highest among young African-American men (14% prevalence, 4% incidence), young men of mixed race (13% prevalence, 5% incidence), and young Hispanic men (7% prevalence, 3% incidence). HIV incidence increased with age, rising from 2% among adolescent men becoming infected annually, to 4% among young men in their twenties. Additionally, 41% of young gay men in the study had engaged in unprotected anal intercourse in the past six months.

… One 28-city study, the Gonococcal Isolate Surveillance Project, reported  that from 1994 to 1998, the proportion of gonorrhea cases among MSM doubled from 6% to 12%.

… Researchers from Seattle-King County reported marked increases in both gonorrhea and syphilis cases among MSM. Most notably, while the county had no cases of early syphilis in 1996, 88 cases were reported between 1998 and the first half of 1999, 85% of which were in gay men. These men reported having multiple partners and frequently engaging in unprotected anal intercourse.

… In Portland, Ore., gonorrhea among MSM increased 45% between 1994 and 1996. Fifty-four percent of MSM diagnosed with gonorrhea were also infected with HIV.

… An STD clinic in the District of Columbia serving a large number of gay and bisexual men reported that gonorrhea cases increased 93% from 1993 to 1996, with 82% of these cases among MSM.

… In San Francisco, the incidence of rectal gonorrhea in males increased from 21 cases per 100,000 adult men in 1994 to 38 cases per 100,000 in 1997. San Francisco also experienced an outbreak of syphilis among MSM in the summer of 1999. This outbreak, which was subsequently linked to contacts made in an Internet chat room, has involved seven people to date, five of whom are HIV-positive.

Together, these seven people reported having a total of 99 sex partners in the three-month period prior to the interview.

Optimism Contributing to Complacency About HIV Prevention
These data suggest there may be a resurgence of unsafe sex among gay and bisexual men in the U.S. The impact of treatment advances on the attitudes and sexual practices of gay and bisexual men is one factor that may be contributing to this increase. A 1999 study of 416 gay men from West Hollywood, Ca., found that the more optimistic men were about the new treatments, the less likely they were to use condoms during anal sex, abstain from anal sex, or limit their number of sex partners.

In this study, HIV-positive men who were optimistic about the ability of AIDS treatments to prevent the transmission of HIV and improve the quality of life only used condoms 66% of the time, compared to 80% of the time for HIV-positive respondents who were not optimistic about new treatments. Among HIV-negative respondents, the optimists used condoms 74% of the time, versus 85% of the time for those who were less optimistic.

This and other studies indicate that high-risk populations may be becoming complacent about the need for HIV prevention and lulled into a false sense of security by the availability of powerful new AIDS treatments. HIV prevention programs must be designed to reach both HIV-infected and uninfected individuals with the information, effectively reached, and a great deal remains to be done. It is critical that HIV prevention efforts are sustained among white gay and bisexual men so that progress to date is not lost. Additionally, it is also imperative that we work to expand these efforts to gay and bisexual men of color and to young men at risk, reaching them with prevention programs proven to work.skills, and support needed to overcome complacency and maintain safer sex behaviors.

Need to Expand Access to Effective Prevention Programs:
Throughout the past two decades, a great deal has been learned about how to effectively change sexual- and drug-related behaviors and reduce the risk of HIV infection among gay and bisexual men. However, not all groups of gay men have been
AIDS Surges in Black and Hispanic Men 

By LAWRENCE K. ALTMAN, NY Times, Jan 13, 2000

For the first time since AIDS was discovered nearly 20 years ago, AIDS was diagnosed in more black and Hispanic gay men than in white gays in 1998, Federal health officials reported yesterday. 

A total of 18,153 AIDS cases were diagnosed among gay men in 1998, the most recent year for which figures were available, 9,182 of them, or 51 percent of the cases, among black and Hispanic men, the Centers for Disease Control and Prevention said yesterday in a weekly report. 

This compares with 8,678 cases, or 48 percent, for white gay men. Black gay men made up one-third of the AIDS cases among gay men in 1998, Hispanic men 18 percent and Asian and Pacific Islanders 1 percent, the centers said. 

Since the AIDS epidemic began, most of the cases have occurred among gay men, and white gay men have made up the largest subgroup. But through the years the percentages have steadily risen for black and Hispanic gay men as those for white gay men decreased. 

For example, in the decade from 1989 to 1998, the percentage of AIDS cases among black and Hispanic gay men rose to 51 from 30, and for white gay men it dropped to 48 from 69. 

The centers officials said the new figures were the strongest evidence yet of the magnitude of the epidemic among black and Hispanic gay men, and they said the shift had been the result of several factors. One was that white gay men organized to educate themselves about the use of condoms and other prevention measures, while minorities largely ignored the issue of infection with H.I.V., the AIDS virus, the officials said. 

Stigma about homosexuality seems to be playing a major role in the spread of infection with H.I.V., and the stigma may be even greater among blacks and Hispanics than it is among whites, said Dr. Helene Gayle, who heads the H.I.V. program at the centers.

Also, a centers' survey of 8,780 men found that many black and Hispanic gay men who said they became infected with H.I.V. from sex with other men did not identify themselves as homosexual or bisexual. Of those surveyed, 24 percent of black and 15 percent of Hispanic men who said they had had sex with men identified themselves as being heterosexual compared with 6 percent among a similar group of white men. 

By not considering themselves at high risk for AIDS, black and Hispanic gay men may not seek or receive the H.I.V. prevention and treatment services they need and may unintentionally put their male and female sex partners and children at risk, Dr. Gayle said in a news conference. 

The Centers for Disease Control and Prevention, the Federal agency in Atlanta charged with tracking and preventing the spread of AIDS in the United States, also found that gay and bisexual black and Hispanic men become infected at an earlier age than white gay men. 

The findings underscore the need for intensifying prevention efforts among blacks and Hispanics, particularly those who may be poor and lack access to health care, centers officials said. 

The news ''will surprise many people across the nation who think the gay AIDS epidemic is a totally white one,'' Dr. Gayle said. 

But, she added, ''the surprise is that people are surprised'' because ''people have ignored this'' trend. 

Phil Wilson of the African-American AIDS Policy and Training Institute at the University of Southern California, said, ''It did not need to happen.'' 

Mr. Wilson said more black churches, fraternities, sororities and organizations like the National Association for the Advancement of Colored People needed to speak out on AIDS. Mr. Wilson said he was ''shocked that there is so little about this issue in black media.'' 

Dr. Rafael Campo of Beth Israel Deaconness Hospital in Boston, said, ''Today's shocking data are merely a harbinger of worse news to come.'' 

Dr. Campo said that when the Harvard AIDS Institute invited prominent Hispanic sports, entertainment and health leaders and elected officials to a summit meeting on AIDS, similar to one held by blacks, ''quite sadly'' only one came. 

''It was quite astonishing to see the silence in action when we were trying to develop initiatives in the face of these incredibly shocking statistics,'' Dr. Campo said. ''Some of the Congressmen we invited represent districts that have among the highest AIDS rates in nation and none of them came.'' 

The new findings come from the continuing analyses of AIDS cases reported to the centers from all states and territories for the decade from 1989 through 1998. 

Since powerful new drug treatments became available in 1996, the number of AIDS cases and deaths have declined among all gay men. But declines have not been as steep among black and Hispanic gay and bisexual men when compared with white gay and bisexual men, suggesting possible differences in access to care. 

Immune Reconstitution is Occurring But Not As Much For African-Americans, and Individuals Contracting HIV through Heterosexual Contact or IV Drug Use

The following text excerpted from NATAP Reports newsletter dated April 1999:

Several research efforts were reported at Retrovirus showing that HIV hinders a person's immune system from responding to opportunistic infections, but increases in CD4s and low viral loads due to HAART can restore the ability of the immune system to respond to these infections in many individuals. Constance Benson reported that the results from ACTG study 320 showed the greater the rise in CD4s after starting HAART the less likely a person is to get opportunistic infections, and individuals with no CD4 increase regardless of their viral load have a higher risk of developing infections. For individuals without CD4 increase following HAART, IL-2 treatment can be considered. It is important to remember that despite CD4 increases and viral load reduced to low levels, opportunistic infections can still occur but often at reduced and low rates. It was reported from a study of 323 individuals with <5,000 copies/ml that 7 persons experienced an opportunistic infection. One study at Retrovirus reported a 15% decline in AIDS defining events during 1996-97 and a 45% decline in AIDS deaths in the USA. However, it was reported at Retrovirus from a large study (n=1416) conducted at Johns Hopkins by John Bartlett and others that use of HAART was higher for homosexual males (70%) compared to injecting drug users (50%), individuals contracting HIV through heterosexual contact (56%), and African-Americans (55%). They reported an 81% decline in the incidence of opportunistic infections or death from 1995 to 1998 in homosexual males, but there was only a 60% decline in patients who contracted HIV through heterosexual contact. They reported that viral load was more likely to be undetectable at 1 year after starting HAART (38%) for homosexual men than for those contracting HIV from IV drug use (21%) and through heterosexual contact (31%).

AIDS Deaths Declines Overall in NYC and the USA, But Improvements Are Less for African-Americans, Women, Hispanics and Injection Drug Users

The following article is reprinted from NATAP Reports newsletter dated May '98:

Overall declines in AIDS deaths and the incidence of AIDS were reported at the Retrovirus Conference. However, the real story is the disparity in the numbers between minorities (African-Americans, Hispanics, and women) and non-minority populations. Also, there is a wide gap between exposure categories of men who have sex with men compared to injecting drug users and heterosexual contact.

Dr Kevin DeCock, of the Center for Disease Control and Prevention, reported that there was an overall 44% decline in deaths and a 12% decline in AIDS incidence in the first 6 months of 1997 compared to the first 6 months of 1996. During 1996, AIDS incidence declined overall 6% and AIDS deaths 23%, compared to 1995 statistics.

However, DeCock reported that from 1995 to 1996, AIDS incidence continued to increase among non-Hispanic black men by 19% and among non-Hispanic black women by 12% from heterosexual exposures. While the overall AIDS deaths decreased among whites by 32% from 1995 to 1996, African Americans only decreased 13% and Hispanics decreased by 20%. The decrease for male and female injection drug users is 17% and 10%, respectively. For males and females contracting HIV through heterosexual contact, the decrease is 8% for both. The figures for AIDS incidence reflect similar patterns with whites decreasing by 13%, while African-Americans had no decline at all and Hispanics had a decline of only 5%. These numbers may mean that minorities, injection drug users, women, and heterosexuals have more limited or inadequate access to treatment, treatment education, and/or adherence initiatives.

M Chaisson from the NYC Dept of Health reported similar patterns. She reported a 33% overall decline in AIDS deaths for the first half of 1997 compared to the second half of 1996. Again, there is a disparity. There was a decline of 41% for white men, compared to a 29% decline for black men, a 30% decline for black women, 34% decline for Hispanic men and 37% decline for Hispanic women. Deaths for men having sex with men fell by 40% but for injection drug users by 30%, Encouragingly, the 30% decline for black women followed a 16% decline for black women in the 2nd half of '96 compared to the first half of '96.

The improvements in the AIDS incidence rates overall are probably due to several factors, including improved treatments for OIs, improved access to care and treatment, improved therapies, and improved treatment education. However, the improvements are not equitably shared by all. THE NYC, NYS and Federal and other local govts need to address these inequitable patterns with improved outreach for treatment education. Since these populations comprise an increasingly larger percentage of overall AIDS and infection numbers, the improved rates of declines may take a reversal if changes are not instituted. In their press release of April 23, 1998, the CDC said, "This (AIDS incidence) data will tell us about where and how many new infections are occurring--information critical for addressing the need for prevention and treatment.


The CDC reported recent trends regarding new infections in the 25 states that have integrated HIV and AIDS reporting systems. Taking a closer lok at the impact of HIV among young people in these states, the majority of newly diagnosed and reported HIV infections were among African Americans and women. Of the 7200 cases of HIV reported among 13-24 year olds from January 1994 to June 1997, 44% were female, 63% were African American, 5% were Hispanic. At least 26% were heterosexually acquired, 31% comprised men who have sex with men, and 6% comprised IVDUs. The HIV diagnosis in this age group remained relatively stable during the 4 year period, but the groups infected are changing.

The CDC also said, "With treatment advances, the total number of people living with HIV and AIDS is increasing, resulting in an increasing need for treatment and prevention services. These services should be targeted towards the groups "with the greatest needs with a primary focus on young African Americans and Hispanic men and women at risk through sex and drug related behaviors."