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Suggestions to Curb Unsafe Sex to Prevent HIV Transmission & Drug Resistance
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Two articles in today's NY Times discuss the responses to the news on the case in NYC of a person who contracted HIV & with it drug resistance to 3 of the 4 classes of HIV drugs used to treat HIV: "How to Get Those at Risk to Avoid Risky Sex?" and "Gays Debate Radical Steps to Curb Unsafe Sex".
Gays Debate Radical Steps to Curb Unsafe Sex
NY Times
February 15, 2005
By ANDREW JACOBS
After all the thousands of AIDS deaths and all the years of "Safe Sex Is Hot Sex" prevention messages, it has come down to this: many gay men who know the rules of engagement in the age of AIDS are not using condoms. As news of a potentially virulent strain of H.I.V. settles in, gay activists and AIDS prevention workers say they are dismayed and angry that the 25-year-old battle against the disease might have to begin all over again.
While many are calling for a renewed commitment to prevention efforts and free condoms, some veterans of the war on AIDS are advocating an entirely new approach to the spread of unsafe sex, much of which is fueled by a surge in methamphetamine abuse. They want to track down those who knowingly engage in risky behavior and try to stop them before they can infect others.
It is a radical idea, born of desperation, that has been gaining ground in recent months as a growing number of gay men become infected despite warnings about unsafe sex.
Although gay advocates and health care workers are just beginning to talk about how this might be done, it could involve showing up at places where impromptu sex parties happen and confronting the participants. Or it might mean infiltrating Web sites that promote gay hookups and thwarting liaisons involving crystal meth.
Other ideas include collaborating with health officials in tracking down the partners of those newly infected with H.I.V. At the very least, these advocates say, gay men must start taking responsibility for their own, before a resurgent epidemic draws government officials who could use even more aggressive tactics.
"Gay men do not have the right to spread a debilitating and often fatal disease," said Charles Kaiser, a historian and author of "The Gay Metropolis." "A person who is H.I.V.-positive has no more right to unprotected intercourse than he has the right to put a bullet through another person's head," he said.
While not endorsing specific strategies, even mainstream organizations like the Gay Men's Health Crisis support the idea of trying methods that would have been anathema a few years ago. "It makes a community stronger when we take care of ourselves," said Ana Oliveira, the organization's executive director, "and if that means that we have to be much more present and intervene with people who are doing this to themselves and others, then so be it."
For many others, however, even talk of such steps provokes hand-wringing. "We don't want public health vigilantes going out and taking matters into their own hands, particularly if it means breaching the confidentially and civil rights of people with H.I.V.," said Jon Givner, the director of the H.I.V. Project at the Lambda Legal Defense and Education Fund. "Frankly, I find it pretty scary."
Whether such ideas gain acceptance, the fact that activists are even thinking about curbing gay sexual freedom is a huge shift.
In the early years of the AIDS epidemic, gay men protested attempts to close down bathhouses and strenuously opposed efforts by health officials to trace those infected with the virus. Until now, those advocates, driven by concerns about privacy and the stigma associated with the disease, have successfully fought off efforts to impose a traditional public-health model for tackling the spread of the virus.
"You have to remember that was the era when Jesse Helms and others were saying that gay people got what they deserved, and that the government shouldn't spend any money to help them," said David Evans, an H.I.V. treatment advocate who writes about prevention. "There was a time when people thought, 'Oh my god, they're going to put us in camps.' "
Such fears have faded in recent years, thanks in part to laws that protect people with AIDS against discrimination. Although the number of AIDS-related deaths has plummeted since the advent of a more potent class of drugs in the mid-90's, the rate of new infections has remained unchanged at about 40,000 cases a year, frustrating many advocates.
That frustration has been ratcheted up by the growing popularity of crystal meth in New York, which many say has led to an abrupt increase in unsafe behavior and a spate of infections. Although exact figures are difficult to determine, a recent survey of gay men found that 25 percent had tried crystal meth in the last few months.
Those frustrations were given voice in November by Larry Kramer, the playwright and activist who himself has AIDS, in a widely discussed speech at Cooper Union in which he criticized gay men for their behavior. "You are still murdering each other," he said then. "Please stop with all the generalizations and avoidance excuses gays have used since the beginning to ditch this responsibility for this fact."
In an interview, Mr. Kramer said on Sunday that the warning of a possibly aggressive new strain of H.I.V. confirmed his fears and filled him with a sense of hopelessness. "Even in the days of the worst infections, no amount of prevention seemed to work, and that's probably the scariest thing of all," he said.
Even if the warning turns out to be a false alarm, many AIDS experts say it is only a matter of time before a supervirus does emerge.
"You can't have a core group of people having sex with large numbers of people without amplifying any sexually transmitted disease that enters the system," said Gabriel Rotello, author of "Sexual Ecology: AIDS and the Destiny of Gay Men." "I don't have any doubt that a resurgent H.I.V. epidemic will hit the gay population in the near future," he said.
It is this fear of a drug-resistant virus that has driven some who track the spread of AIDS to suggest a more aggressive approach to prevention. Walter Armstrong, the editor in chief of Poz, a monthly magazine about AIDS and H.I.V., said the traditional fear-based approach to prevention was at best only a temporary solution, especially if no supervirus outbreak materializes. A more effective approach, he said, would involve gay organizations using traditional public health measures, such as more widespread screening and a partner-notification effort to track users of crystal meth who have been infected recently.
"Why would it not be possible to get them together to communicate to each other, and then to their sex partners, that lives are being put at risk by reckless behavior?" he asked. "I think there are ways to do interventions ethically, sensitively and compassionately. There's a huge window of opportunity between criminalization and empty prevention messages."
Still, others remain wary of such measures. Walt Odets, a clinical psychologist and the author of "In the Shadow of the Epidemic: Being HIV-Negative in the Age of AIDS," said he thought such intervention smacked of a witch hunt.
He and others said it would be more effective to try to identify the underlying causes of drug abuse and self-destructive behavior, including the difficulty of living in a society that rejects committed gay relationships while condemning homosexuals for having sex outside those relationships. Gay men, he said, are using methamphetamines as an anti-depressant.
Many health experts suggest a more vigorous return to conventional H.I.V. prevention. Isaac Weisfuse, the city's deputy commissioner of health, said his agency was planning to place information banners on gay Web sites and devote more money to hard-hitting ads about methamphetamine use.
And, he noted, the free condom has largely disappeared from public places. "Unfortunately, condom use has fallen off the radar screen," he said. "We need to do something we did well 20 years ago, which is to get condoms in every place people socialize or have sex."
Others, like Mr. Rotello, were less optimistic. Until people really believe an unstoppable virus is out there, he said, they will continue to indulge in unsafe sexual practices. "People are not going to modify their sexual habits in ways that are difficult or unpleasant until they see their friends dying again," he said. "And to me that's just an unbelievably depressing thought."
How to Get Those at Risk to Avoid Risky Sex?
NY Times
February 15, 2005
By BENEDICT CAREY and ANAHAD O'CONNOR
If nothing else, the AIDS case that alarmed health officials in New York last week illustrates the enormous difficulty of promoting and sustaining changes in sexual behavior, social scientists say.
The man at the center of the furor, who officials fear may carry a rare and possibly virulent strain of H.I.V., reportedly engaged in unprotected sex with hundreds of partners in recent months and took the drug crystal methamphetamine.
In cities across the country, there are many other people - gay, bisexual or heterosexual - who invite similar sexual risks.
Over the last decade, AIDS activists and health officials have mounted public awareness campaigns, distributed pamphlets at medical clinics and conducted large-scale studies aimed at increasing condom use and reducing anonymous sexual encounters. Almost every effort has fallen short in high risk groups, experts say: a result of social and political factors, the increasing prominence of Internet liaisons and drug use and dynamics of disease transmission that researchers have only begun to understand. New AIDS and H.I.V. cases increased 1 percent from 1999 to 2003, according to a Centers for Disease Control and Prevention survey of 33 cities in the United States.
"Prevention has always been the neglected stepchild in terms of funding, compared to biomedical research," said Dr. Anke A. Ehrhardt, director of the H.I.V. Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute. Dr. Ehrhardt said that even if this rare H.I.V. strain was an isolated case, "there will be others, and we will have another epidemic unless we put behavioral change front and center and do it better than we are doing it now."
Some researchers and AIDS advocates also cite as obstacles decreased federal financing for primary prevention efforts and pressures to stress abstinence over other methods of reducing sexual risk.
A nationwide team of researchers and public health workers recently completed perhaps the most ambitious effort to reduce H.I.V. transmission rates among high-risk gay men. The Explore project, as it is known, followed 4,295 sexually active men in six American cities who were H.I.V. negative when the study started in 1999. Half the men received 10 sessions of one-on-one counseling, intended to drive home the dangers of risky sex and to provide practical strategies for avoiding it. The other half received two visits a year from a health clinic worker who discussed risk reduction.
The results, published last summer, fell short of expectations. After a year, the rate of new H.I.V. infections was 18 percent lower in the group who had counseling, and these men were about 20 percent less likely than the others to have had sex with a partner whose H.I.V. status was unknown. But after two years, the differences between the two groups vanished.
"We had a strong initial effect, but it just didn't last," said Dr. Thomas J. Coates, an infectious disease specialist at the University of California, Los Angeles and a lead author of the study.
Earlier studies were even less encouraging: one found that men who received behavioral counseling were more likely to catch a sexually transmitted disease than those who did not get the special therapy.
Researchers say that several factors outside their control have made such public health efforts harder than ever. The antiretroviral drugs that have extended the lives of so many people with AIDS have also tempered the dread of catching the virus, they say, especially among a younger generation of gay men who have not known the agony of watching friends die of the disease.
Many men now search for and find casual sex partners on the Internet, bypassing bars and other central meeting places where public health workers traditionally have reached people. And especially among gay men, the drug crystal methamphetamine has become associated with casual sex for some men. Some experts suspect that methamphetamine may also increase a person's susceptibility to infection by suppressing immune function.
"Crystal meth is all over the place now, and once you start using it, it becomes integrated in your mind with sex, and the idea of sober sex holds no interest," said Peter Staley, a former user who mounted an anti-methamphetamine campaign in Chelsea and is now working with health officials to reduce usage citywide. "If you're trying to get clean, you might go a month or two without sex at all, but you can only do that for so long."
In the Explore study, researchers also monitored drug use, and found that about 20 percent of the subjects reported using methamphetamine. Men who used this or other drugs like cocaine were significantly more likely to engage in unprotected sex with a partner whose H.I.V. status was unknown.
"This suggests that no level of use of these drugs should be considered safe from an H.I.V.-prevention perspective," the authors concluded.
On Internet sites like manhunt.net and in chat rooms on America Online, many men make it clear they want no part of the drug, by posting in their online profiles "no-PNP," or no party and play, shorthand for sex with drugs. Many men also make it plain that they will consider only safe sex, with condoms. But other men advertise their use of the drug, and recruit multiple sexual partners.
Another reason that behavioral change campaigns have not been as effective as hoped, some experts say, is that their messages have not been tailored specifically enough to reach those who most need to hear them.
The prevalence of unprotected sexual encounters, researchers have found, is a poor predictor of H.I.V. transmission rates.
In a study conducted from 1988 to 1993, for example, researchers at the El Paso County, Colo., health department tracked the activity of 595 heterosexual men and women in Colorado Springs who were at high risk for H.I.V. infection, because of prostitution, intravenous drug use and frequent sexual activity. The researchers traced the sexual links among these people and some 10,000 partners and found that transmission rates were not going up, despite widespread unprotected sex.
The reason, the researchers found, was that those who had the virus were on the periphery of the social network. In contrast, people who were more central to the group - sexually connected to many others, like spokes from a bicycle axle - did not have the virus, and so were not spreading it.
"This is one reason why you might know people who are doing all sorts of exotic things but are not infected, and someone else has just one encounter and gets it," said Dr. John J. Potterat, the lead researcher. "It's not fair, but it's a question of what the social networks look like."
A similar study of high-risk heterosexuals in the New York region found a different social network: in this case, the people who were central to the network and had the most sexual partners were infected with H.I.V. A small number of people were driving transmission rates up.
By first studying the social network in a given population, Dr. Potterat said, public health officials can begin to hone their efforts: a general message may be effective for most people, but health workers should focus much more intently on informing and advising the people at the network's center..
"We need to focus public health efforts on sabotaging these networks," Dr. Potterat said. But he added that so far, no one had done so.
Still another complication, experts say, is that many high-risk men who engage in unprotected sex with multiple partners have histories of drug use, childhood abuse and depression. As a result, prevention workers are not likely to succeed with a single strategy.
"Reaching this group is confounded by the fact they have a number of other issues," said Dr. Gail Bolan, chief of the sexually transmitted disease control branch for the California Department of Health Services. "The interventions that are most effective in the general population don't seem to work for them, and we haven't identified a magic bullet."
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