Reply to "AIDS turns 20"

Confronted with reports of increasing sexually transmitted diseases and new HIV infections among gay and bisexual men, the federal Centers for Disease Control and Prevention is embarking on a campaign to reverse those trends.

"We want to make sure that these issues stay highly elevated, that issues related to HIV prevention continue to be discussed in a productive manner and not let people revert to the most simplistic explanation that HIV prevention doesn�t work,� said Dr. Ronald O. Valdisseri, deputy director of the CDC�s National Center for HIV, STD and TB Prevention.

Over the past three months the CDC has held four meetings with community groups, and state and local health agencies to talk about recent developments in the AIDS epidemic and HIV prevention for men. Valdisseri and Terry Hammond, a CDC media relations director, sat down with LGNY for an hour-long chat on December 11 as part of the effort to raise the profile of HIV prevention.

The CDC issued a bulletin earlier this year raising the alarm over what might be a resurgent HIV epidemic among gay men. The bulletin also detailed prevention efforts for men who have sex with men. The agency will issue a guidance to AIDS groups that is meant to help those agencies in delivering HIV prevention services to gay and bisexual men.
Researchers give a number of reasons for some gay men giving up safe sex practices. Drugs and alcohol can lead men to be unsafe or they may have grown tired of being safe. A desire for a feeling of greater intimacy makes some toss the condoms. New and effective treatments may make the disease seem less threatening.

�When people became infected in the '80s it was a death sentence,� Valdisseri said. �It isn�t anymore... That perhaps doesn�t give us the contextual oomph that we had earlier in the epidemic.�

At the same time, some in the gay community have said that the AIDS epidemic is over. Andrew Sullivan made that point in �When Plagues End: Notes on the Twilight of an Epidemic� for The New York Times Magazine article in 1996. One group, Act UP/San Francisco, has attacked researchers and journalists who have reported studies showing increasing STDs and HIV infections among gay men.

The gay men�s health movement wants to make AIDS no more important and no less important than any other health concern. Eric Rofes, a Californian who is a leading voice in that movement, has said that while AIDS remains a community concern it is no longer a crisis. Rofes has also objected to what he has termed the overly sensational coverage of recent studies on STD and HIV increases among gay men.

�There are certainly a few people who continue to try to discount it,� said Terry Hammond, a CDC media relations director. �Whether that is because they are misinformed or whether that is purposeful who knows, but I�ve seen no reasonable epidemiologist who looked at all of these data taken together who said �This is not a problem.��

�We�d like to see this stay on the agenda,� Hammond said. �I think that some of the more traditional gay community organizations have moved on to other issues.�

Burnout may have reached prevention professionals as well. In a recent interview with gay.com, Dr. Thomas Coates, the head of San Francisco�s Center for AIDS Prevention Studies, suggested that the community should surrender when asked how the gay community can stem the spread of HIV.

�Well, maybe we should just stop,� Coates said. �Maybe we should just make lots of condoms available... and just accept that every year there will be a certain percentage of people who will get HIV... AIDS just is not the dreaded disease it once was in the gay community, and, perhaps, people are taking risks because they have other priorities such as feeling loved, feeling desired, and getting laid.�

Coates did propose a second option that included analysis of who was getting infected today and focusing prevention efforts on those men.

�I�m not sure what Tom�s motives were, but I think that, in what he says, it gives anyone, the listener, the reader, a sense of how complicated this is,� Valdisseri said. �There are overriding emotional motives, there are other health concerns and those make it difficult.�

Additionally, the prevention push comes as the Bush administration is scrutinizing the CDC�s HIV prevention budget. Some rightwing groups and elected officials have called for those funds to be slashed.

�We are going to be entering an era where a lot of folks are going to be asking questions about HIV prevention,� Valdisseri said. �The way I look at it is that there are going to be a lot of questions being asked about what works and how can we make our programs more effective. I think if they ask those questions and they inform that discussion then that will be helpful for us.�

Indeed, as the AIDS epidemic enters its third decade there are more questions about the success of HIV prevention. New York City will spend $33.0 million on HIV prevention this year. The Big Apple is seeing a syphilis outbreak and increasing new HIV infections among gay and bisexual men.

City testing of 436 anonymous blood samples collected at STD clinics in 1999 from gay and bisexual men found that 8.4 percent of the gay men had been infected that year. The incidence rate, or the percent newly infected in a year, among bisexual men was 4.9 percent. Other studies have shown infection high rates among African-American and Latino men.

"This is an incidence rate in men who have sex with men that we have not seen since the late 1980s,� said Dr. Lucia V. Torian, director of AIDS research and HIV sero-surveys at the city health department, in March.

San Francisco will spend $16.0 million on HIV prevention this year yet that city found that incidence among men who have sex with men using HIV testing sites there climbed from 1.3 percent in 1997 to 2.6 percent in 1998 to 3.7 percent in 1999.

Valdisseri said he did not know enough about any city to comment on their HIV prevention efforts, but he did offer a general response.

�Despite the fact that we might say that, relatively speaking, San Francisco has a lot of resources, one hypothesis might be it is still not enough,� he said. �After all we do have more people living with HIV now than at any other time in the past and more and more diverse populations.�

It might also be that the programs are not right for the communities they are reaching, Valdisseri said. He noted that marketers in the private sector regularly change their messages in response to marketplace tastes.

�I don�t know that public health does that to the degree that it should,� Valdisseri said. �First of all, we don�t often have the resources to do that and, sometimes, we don�t have the expertise to do that.�

Despite the obstacles the CDC is forging ahead. The agency sounded the alarm earlier this year and it will continue.

�The whole picture was such that we thought that that information was adequate for action,� Valdisseri said. �I would still say it�s a very worthwhile investment of resources to prevent people from becoming infected with HIV.�

By DUNCAN OSBORNE
LGNY, January 3, 2002

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