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In a high-profile presentation to the most important annual aids science meetingthe 7th conference on retroviruses and opportunistic infectionsCDC epidemiologist Paul Denning described nationwide increases in unsafe sex and, more ominously, sexually transmitted diseases such as syphilis and gonorrhea.
Because such STDs can be spread by the same practices as HIV, they are considered an early warning sign.
But New York provides a ray of hope, because although rectal gonorrheaa marker for unprotected anal intercoursehas risen recently, city health officials told the Voice that other key indicators show HIV may not be on the rise among gay men here.
While the mainstream media widely reported new research from the conference indicating that oral sex accounts for as much as 8 percent of HIV transmissions among "men who have sex with men," the bigger newsthat the country may face a resurging gay epidemic was barely covered. Also sparsely reported was the heartbreaking study of an infected Canadian man. After more than eight years of living with the virus without symptoms, he was reinfected by his boyfriend with a second, drug-resistant strain of the virus that sent him hurtling toward full-blown AIDS.
The media and the gay community may be fatigued from previous warnings. "We've cried wolf before," says Tom Coates, director of San Francisco's Center for AIDS Prevention Studies. In the mid 1990s, experts warned of a "second wave" of HIV, especially in San Francisco. But new HIV infections didn't actually rise there until this year. A new blood test that tells whether an infection is less than six months old has enabled San Francisco researchers to study stored blood samples and people coming to testing and counseling centers. Willi McFarland, director of HIV seroepidemiology for the San Francisco Department of Public Health, says the rate of new infections among gay men attending such centers hit a low in 1997, but by 1999 it had soared more than two-and-a-half-fold.
At the retrovirus conference, Denning attributed some of the increase in risky sex to the belief that AIDS is now a manageable disease. But while people with HIV in wealthy countries are certainly living longer, one large study shows that infected people are almost nine times as likely to die as are uninfected people. What's more, medication side effects, such as bone damage, continue to emerge, adding to the distressingly long list that already includes bizarre changes in body shape, chronic diarrhea, nerve deterioration, and damage to the heart and liver.
But Denning made it clear that misplaced faith in AIDS medications was not the only reason for the distressing new trend, tracing the rise in STDs back before effective AIDS therapy became available. For example, a CDC program monitors gonorrhea in 28 localities across the nation, and between 1988 and 1992, the proportion of such cases among men who have sex with men held steady at about 4 percent. But then it started to rise, nearly tripling by 1998.
Particularly worrisome is that many such cases are among men infected with HIV, who, of course, can pass on the virus. In a national study of HIV-positive people, new cases of gonorrhea had been falling until 1994. But from that point through 1998, said Denning, the rate of new gonorrhea cases rose by about 250 percent. Yet another national study found that between 1995-96 and 1997-98, the proportion of HIV-positive gay men who had unprotected anal intercourse soared by more than 40 percent. That same research found that those with the most sexual partnersfive or more over the last yearwere also the most likely to have unprotected anal intercourse. Almost half of these infected men didn't rubber up.
Such research underscores an emerging consensus: Prevention needs to focus on HIV-positive men. But Larry Abrams, acting director of prevention for New York's Gay Men's Health Crisis, cautions, "We have to be careful not to stigmatize men who are positive." Coates, who has the virus, believes encouraging infected men to take responsibility is worth that risk. "People worry that we will be labeled vectors of transmission, but we are, Blanche, we are. There are no immaculate infections."
Targeting positive men is also crucial because they are at risk themselves. Until last week, no one had proven that humans could be "superinfected," the scientific term for contracting a second strain on top of an established HIV infection. But Canadian researchers reported that in late 1997 "Patient A," who had been living symptom-free for almost a decade, suddenly saw the amount of virus in his blood shoot up and his immune system deteriorate. His doctor placed him on anti-HIV drugs, but they had almost no effect. That is almost unheard-of for someone like Patient A, who had never taken such medications and whose virus therefore should not have been drug resistant. Curious, the doctor discovered that the patient had recently entered into a relationship with "Patient B," who had taken many different HIV drugs, making his virus resistant to most of them. Patient B happened to go to the same clinic, so researchers compared their viruses. Before the relationship, Patient A's virus was genetically very distinct, but after the relationship it was strikingly similar, including shared mutations for drug resistance.
While this case is troubling, the larger public-health concern remains brand-new HIV infections. The New York City health department lacks historical data on the numbers of gay and bisexual men who have acquired ordinary STDs. But the proportion of homosexually active men who test HIV-positive at city STD clinics has fallen from 47 percent in 1990 to 19 percent in 1998, with strong drops among all racial groups, a hopeful sign. Still, health department officials warn against complacency, noting that, in a local study of more than 500 young gay men, more than a third acknowledged having unprotected anal intercourse over the previous six months. That proportion did not vary much by race.
Denning did not break down his figures by race, a fact Abrams calls "surprising" and "unfortunate" because "all indicators show that something different is going on among black and Latino men." Just last month, the CDC reported that blacks and Latinos account for more than half of all AIDS cases among men who have sex with men.
Preventing a national resurgence of HIV among gay men will cost money, but Abrams points out that Congress, in a bill sponsored by Jesse Helms and passed years ago, bars federal funding for "explicit" safer-sex messages aimed at gay men. So, he says, "We're in a quandary. On one hand, the CDC does a tremendous job of getting the info out, but we can't get money to pay for the work that needs to be done."
Research intern: Elinore Longobardi
Additional articles on AIDs by Mark Schoofs.