By
Ethan Jacobs
In this age of crystal meth addiction, AIDS fatigue, and endless studies
showing rising rates of HIV infection among gay and bi men, the news in
the San Francisco Chronicle July 20 that city health officials
believe HIV infection rates may be decreasing was an unexpected piece of
good news.
Last February a New York Times story about a supposed HIV "superbug," a
story that was later debunked, had health officials and pundits
predicting a new dark age in the AIDS epidemic. In June a number of
studies released at the National HIV Prevention Conference in Atlanta
painted a grim picture for the gay and bi community, with one study
showing that men who have sex with men (MSM) make up half of all new
infections and another showing that in some cities nearly half of all
African American MSM are HIV positive. Yet that latter study,
ironically, was also cited by San Francisco health officials in the
Chronicle to show that the progress of the virus may be slowing in their
city. While prior estimates placed the rate of infection among gay men
at 2.2 percent per year, the CDC study instead found an infection rate
of 1.2 percent.
Dr. Steven Boswell, president and CEO of Fenway Community Health,
explained that the state mechanisms for tracking HIV infections in
Massachusetts are not precise enough to conclusively track the rate of
new infections each year. Officials from the state Department of Public
Health (DPH) were unavailable to comment for this story by press time
and the Boston Public Health Commission was unable to provide data by
presstime, but according to an October 2004 DPH fact sheet, new recorded
HIV infections have fallen from 1295 new cases in 1999 to 993 cases in
2002. Yet Boswell said those numbers are not an accurate measure of
yearly infections because people testing positive in a given year could
have been infected as much as several years before.
"Just reporting data from testing centers, those data don't give you the
information to say that the rate is increasing or decreasing," said
Boswell.
In contrast San Francisco health officials are basing their estimates on
falling HIV infection rates in part on a five-city study conducted by
the CDC and released June 24, which studied MSM in five cities: San
Francisco, New York, Los Angeles. Miami, and Baltimore. The study
recruited a few hundred men in each city, including 365 in San
Francisco, and surveyed them about their sexual behaviors, drug use, HIV
testing history and use of HIV prevention services. They then tested the
men using a specialized HIV test that measures recent infections and
found that San Francisco had the lowest rate of new infections, at 1.2
percent of MSM per year (in contrast, Baltimore had the highest at 8
percent per year). San Francisco health officials had previously
estimated the rate as being 2.2 percent.
The CDC study alone was not enough to prove that infections were
dropping, but Willi McFarland, the San Francisco Department of Public
Health's director of HIV/AIDS statistics and epidemiology, said it fits
with other recent studies suggesting a drop in new infections. Data from
the city's STD health clinics shows a decrease in the rate of new
infections since 2000. Another indicator comes from the Stop AIDS
Project, which found in recent surveys that men report less unprotected
anal sex with men of a different HIV status (serostatus) or with men
whose serostatus is unknown.
Within the month San Francisco health officials will convene a panel of
experts to look at the available data and estimate a new yearly
infection rate for the city.
While there are no conclusive explanations for the apparent decrease,
McFarland suspects a combination of factors. Prevention experts believe
when people know their status, they are more likely to take precautions
to protect their partners, and San Francisco has been aggressive at
urging people to get tested through public health campaigns.
"The efforts of promoting testing, knowing your own serostatus, seem to
be working," said McFarland.
Another factor is that San Francisco has worked to get more people with
HIV into treatment, and McFarland said people may be less infectious on
their medications when their viral load is low.
In 2000 San Francisco health officials had sounded the alarm that rates
of infection among MSM were climbing, with some health clinics reporting
tripling of new infections from 1997 to 1999. McFarland said that
warning combined with the above factors may have contributed to the
apparent decrease.
"Somewhere around 2000 and 2001 things began to turn around. From the
period of '95 up through 2001 we had noted a resurgence in HIV
transmission in the gay community," said McFarland. "Perhaps our ability
to detect that second wave and sound the alarm contributed to our
ability to turn it around."
Ben Perkins, director of AIDS Action's MALE Center, a wellness and
prevention center serving MSM, said the prevention strategies that
McFarland suspects led to the decrease are also major parts of the
prevention arsenal in Boston. Before opening the MALE Center in June,
Perkins visited San Francisco to study prevention efforts out there to
study similar programs to help design the center. Perkins also suspects
the advocacy in San Francisco around crystal methamphetamine may have
contributed to the decrease in infection rates, and he cited the efforts
of local prevention workers and health officials to attack meth
addiction here in Boston. Yet he cautioned against assuming that Boston
was due for a drop in new infections.
"One of the take-home messages is that prevention is art as well as
science, and while science can give us numbers, there are other things
it can't tell us," said Perkins, in particular the causes of the drop in
cases in San Francisco.
Boswell cautioned against premature optimism about local infection
rates. Syphilis rates among MSM have been on the rise since 2001, and
Boswell said while increased syphilis infection does not by itself
indicate increased HIV infection, it suggests that more men may be
having unprotected sex, and syphilis infection can make people more
susceptible to HIV infection.
"There are certainly what we call surrogates for HIV infection. Other
STDS are some of those, but they don't map HIV perfectly," said Boswell.
"Having said that, we still see very significant numbers of syphilis
cases here and haven't seen a tail-off of those cases."
It could take San Francisco several years to find conclusive evidence
behind the decline. Boswell said it is uncertain how permanent the
decrease will be.
"We've seen decreases in transmission over this epidemic, and we've also
seen increases in the rates of transmission, so this is a fluid
situation. It's something that can change readily," said Boswell.
Patrick Sullivan, chief of the behavioral and clinical surveillance
branch of the CDC's Division of HIV and AIDS Prevention, said that while
the San Francisco data is promising, he worries that the larger message
from the five-city CDC study will be lost. Among all of the men who took
part in the study, nearly half of those who tested positive were unaware
of their status prior to the study. About four out of five 18-24
year-olds who tested positive did not know they had HIV, and two-thirds
of the African- American men testing positive in the study were unaware
of their status. He said the news out of San Francisco should persuade
people to continue the drive to get people tested, not to ease off.
"Even in the face of success the fact is that we need an ongoing,
sustained, and comprehensive approach that reaches out to those men who
are at greatest risk and unaware of their infection," said Sullivan.
From http://www.baywindows.com/media/paper328/news/2005/07/28/News/San-Fran.Reports.Big.Drop.In.Hiv.Infections-964795.shtml |
