Reply to "AIDS turns 20"

New generation of gay men at AIDS risk
Studies released at global meeting show high rates of HIV infection, low testing and prevention knowledge

Members of the AIDS activist group ACT UP took over the stage and jeered U.S. Secretary of Health & Human Services Tommy Thompson during his July 9 address to delegates of the XIV International AIDS conference in Barcelona.

Yonnathan Hernandez, 20, hadn't even been born in 1981, when the Centers for Disease Control & Prevention in Atlanta first documented the disease that would later become known as AIDS.

In the late '80s and early '90s, when AIDS decimated gay men around the country, Hernandez was in elementary school, learning spelling and multiplication tables, not safer sex.

Hernandez' family moved to the United States from Mexico when he was 13. When he acknowledged his sexual orientation four years later, he came out into a world of young gay people who had never known what it was like to be sexually active without the reality of AIDS.

Yet unlike many older gay men, Hernandez also has never had a friend die of the disease, and he said many young people he knows don't act concerned about HIV.

"I know some people who are really worried about it, but a lot of people don't care about it," he said. "They know, but they don't get tested."

And while Hernandez, who is HIV-negative, got his first HIV test last year, studies released at the XIV International AIDS Conference in Barcelona, Spain, this week show many other young gay men don't know their HIV status and aren't taking steps to keep from getting the virus.

"The problem is huge, unacceptable and raging," said Duncan MacKellar, a CDC epidemiologist presenting several studies of young gay men at the Barcelona conference. "We have to do more prevention, and we have to do it better."

MacKellar and his colleagues presented several reports at the July 7-12 conference that examined alarming results from a survey of young gay and bisexual men ages 15-29, conducted at gay venues in six cities: New York, Baltimore, Dallas, Los Angeles, Miami and Seattle.

"What the data tell us is that many young gay and bisexual men are infected with HIV, most do not test frequently, and as a consequence, most do not know they are infected," MacKellar said in an interview from Barcelona.

More disturbing, "of those with unrecognized infections, many do not think they are at risk for being infected and unknowingly engage in behaviors that can transmit HIV," he said.

Other news from the XIV International AIDS Conference

The scores of studies presented at the Barcelona conference covered topics from treatment to prevention, for populations ranging from gay men in the United States to AIDS orphans in Africa. Below is a sample of findings of key interest to gay men; for more information, visit the conference Web site at
Majority of HIV diagnoses in 25 states still gay men. In a CDC analysis of data from 25 states with longstanding HIV reporting -- not including Georgia, which tracks AIDS but not HIV cases -- researchers found rates had stabilized at about 16,000 new diagnoses each year. During the seven-year period from 1994 to 2000, 43 percent of diagnoses were among gay and bisexual men, 27 percent were people infected through heterosexual intercourse and 23 percent of infections came from injection drug use.

Gay men have nine times higher HIV rate. A study by CDC epidemiologist Laurie Linley examined blood samples from 40,000 people at sexually transmitted disease clinics in four cities -- Los Angeles, Denver, Miami and Newark -- from 1997 to 1999. Using a testing method that detects new infections, researchers found 4.8 percent of gay men were infected with HIV annually, compared 0.4 percent of heterosexual men and 0.5 percent of women.

Rural states need more money for gay outreach. The first "major study evaluating HIV prevention in rural states" looked at efforts targeting men who have sex with men, and found a huge need for more funding, according to author Victor Barnes of the CDC. Researchers interviewed 80 HIV experts in 13 rural states, including gay leaders, state AIDS directors and prevention workers, along with 200 community volunteers. Participants estimated they needed an average of $847,000 more per state -- including $500,000 for programs directed at gay and bisexual men -- for adequate prevention efforts.

Mental health problems increase gay HIV risk. A CDC study of 2,881 men who have sex with men in New York City, Chicago, Los Angeles and San Francisco found that those with "psychosocial" problems such as childhood sexual abuse, depression, multiple drug use and partner violence had higher rates of unsafe sex and HIV infection. Men who participated in risky sex jumped from 7.1 percent of those with none of those problems to 33.3 percent for those with all four. Only 13 percent of those with none of the problems had HIV, while 25 percent of those with all four problems were HIV-positive, the CDC reported.

Studies promising on new AIDS drug. A new drug that attacks the AIDS virus in an entirely different way could dramatically restore the health of HIV patients whose infections have outfoxed all existing medicines, research indicates. Studies presented July 8 in Barcelona found that patients for whom current drugs had stopped working were twice as likely to have virus concentrations decrease below detectable levels if they added the new medicine, known as enfuvirtide, or T-20, to their cocktail. Experts said the drug, expected to be on the market next year, could save the lives of people who have exhausted treatment options. Current HIV drugs block either of two substances the virus uses to make new copies of itself once it is inside a blood cell. T-20 is the most advanced experimental drug in a new class of AIDS medicines, called entry inhibitors, which attack the virus by preventing it from getting into the blood cells it kills.

New guidelines suggest treatment can wait. New treatment guidelines suggest symptom-free HIV patients can wait longer than previously recommended to begin taking AIDS drugs. "The threshold for initiation of therapy has shifted to a later time in the course of HIV disease'' because of increased awareness of the effectiveness of AIDS drugs and their toxic side effects, an International AIDS Society-USA panel concluded. The panel recommends starting drug treatment when levels of disease-fighting CD4 white blood cells drop to between 200 and 350 per cubic millimeter. The group two years ago suggested treatment with CD4 levels of about 350. A U.S. Health & Human Services group of experts issued similar guidelines in January 2001.

VaxGen president expects aids vaccine within three years. At a July 8 press conference in Barcelona, Donald Francis -- president of VaxGen, a company working to develop an AIDS vaccine -- suggested that he expects a vaccine to be on the market by 2004 or 2005, according to the conference news service. VaxGen's vaccine is currently in stage III of clinical trials. Francis said a vaccine likely won't be 100 percent effective, but any protection could make a huge difference in the global AIDS fight.
The Associated Press contributed to this report

Bleak picture

The 17,000 researchers, activists, government officials and other participants at the six-day XIV International AIDS Conference focused on seven tracks: basic science, clinical science, prevention science, social science, epidemiology, intervention and program implementation and advocacy and politics.

But while the conference focuses on the theme "Knowledge and commitment for action," some of the highest profile action has taken place outside of the official agenda, as protesters targeted U.S. officials over a perceived lack of support for the global AIDS fight.

Jeering activists crashed a press conference Tuesday and drowned out U.S. Health & Human Services Secretary Tommy Thompson's speech to the Global Fund to Fight AIDS, saying the U.S. has not contributed enough money to the worldwide fight against AIDS.

Thompson's speech could not be heard over shouts of "Shame!" by activists who said they wanted to "blow the whistle on Tommy Thomson and President George Bush for crimes against people with AIDS," the conference news service reported.

As protests raged outside, inside the conference, little news could be perceived as positive, especially in terms of gay and bisexual men in the U.S.

The research conducted by MacKellar and his colleagues at the CDC offered bleak statistics that drew quick -- and horrified -- reaction from HIV activists, especially those focusing on young African-American men, the group the studies show is hardest hit by the epidemic.

"In some cities, the HIV infection among black gay men is equal to or greater than the HIV infection rates of developing nations," said Steven Walker, a representative of National Advocates for Black Gay Health.

Meanwhile, in San Francisco, the original epicenter of the epidemic among gay men, a separate five-year study presented in Barcelona suggested a rise in a drug-resistant strain of HIV.

And although overall cases of full-blown AIDS in the U.S. appear to have remained stable from June 1998 to June 2001, at roughly 40,000 cases diagnosed each year, even that isn't good news, CDC officials stressed at a July 7 press briefing as the conference opened.

Prior to 1998, cases of full-blown AIDS were declining, said Dr. Ronald Valdiserri, deputy director of the CDC's National Center for HIV, STD & TB Prevention.

The new appearance of stability -- likely caused in part by people who don't know their HIV status or aren't receiving treatment -- may be masking an increase among gay and bisexual men and some heterosexuals, the CDC reported.

"These data point to the urgent need to stem the spread of HIV among gay and bisexual men and heterosexuals in many areas of the country, especially in those African-American communities most dramatically impacted," Valdiserri said.

In the dark about HIV

The CDC's six-city study of young gay and bisexual men -- one of the largest ever conducted, according to MacKellar -- found high rates of HIV and low rates of testing and risk reduction behavior.

The agency began releasing statistics from the study last year, immediately setting off alarms for HIV activists: Of men ages 23-29 in the study, 30 percent of young gay African-Americans had already been infected with HIV, compared to only three percent of Asians, 15 percent of Hispanics and seven percent of whites.

News released this week at the Barcelona conference offered little more hope: Of the total study sample of 5,719 gay and bisexual men ages 15-29, 10 percent tested positive for HIV. Out of those, a staggering 77 percent were unaware of their status.

Broken down by race, the numbers showed significant disparities in testing behaviors: 91 percent of African-Americans with HIV didn't know their status, compared to 70 percent of Hispanics and 60 percent of whites.

Almost 60 percent of young gay men of all racial groups with undiagnosed HIV thought they were at low or very low risk of contracting the virus, and in the six months before their diagnosis, 49 percent had three or more sex partners and 51 percent had unprotected anal intercourse.

"We asked those who didn't test why they hadn't and the two main reasons were they thought they were at low risk and they were scared to learn the result," said MacKellar, the study's lead author.

"But many of those who thought they were at low risk had engaged in high risk behaviors, and many were actually infected," he said. "So clearly, our prevention efforts need to make sure we clarify perceived risk."

While MacKellar said it is "hard to say" if the results of his six-city study could be extrapolated around the rest of the country, "it's amazing how consistent the findings were across the cities in terms of HIV prevention, risk behaviors and testing rates," he said.

"I wouldn't be surprised if you found similar rates in other metro areas," MacKellar said.

AIDS activists and gay young people said they wouldn't be surprised either.

Hernandez said he initially was afraid to be tested for HIV because he wondered if he would be positive, and the leader of HIV programs at the Atlanta gay youth group where Hernandez gets tested said he frequently hears similar fears.

"We have to do education and convincing to let people know how truly important testing is," said Damian Denson, men's program manager for African-American HIV prevention at YouthPride, a gay youth center in the Atlanta suburb of Decatur. "We see a lot of fear, which is normal. Each time I get tested, I'm just as nervous as the previous time."

At 24, Denson, who is African-American, is technically a youth himself. But with a master's degree in public health, he said he is "frustrated" and "disappointed" to learn so many gay young men -- especially black gay men -- still aren't being tested.

"For the African-American community, it goes into so many social constructs as far as racism and homophobia, which creates this level of risky behavior that erupts in a large number of infections," Denson said. "It shows us how so much more work needs to be done."

In August, YouthPride will expand its free HIV testing from the first and third Wednesday of each month to every Wednesday from 5:30 p.m. to 7:30 p.m., Denson said.

New fears in San Francisco

While CDC studies showed an increase in HIV in young gay men, a new study released in Barcelona showed an increase of drug-resistant strains of HIV among San Francisco's newly infected gay men.

Those infected with HIV strains resistant to at least two different classes of drugs rose from 2.5 percent in 1996 to 13 percent in 2000, according to a study by the University of California, San Francisco.

"Some people are becoming infected with a virus that is much more difficult to treat,'' said Dr. Frederick Hecht, the study's co-author and a San Francisco General Hospital AIDS specialist.

The results are particularly noteworthy, Hecht said, because the evolution of the HIV epidemic around the country often follows the pattern of San Francisco.

Resistance to the latest class of AIDS drugs developed quickly, and resistant strains are being transmitted even by those undergoing treatment, the study reported.

XIV International AIDS Conference

But the study may not mean HIV is becoming more dangerous, Hecht said. Differences in blood cell counts were relatively small, and some people with the new virus strains showed more disease-fighting white blood cells than those with the nonmutant virus.

Still, resistant HIV strains are harder to treat because physicians must start with "salvage regimes," usually only prescribed when other treatments have failed, Hecht said.

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