AIDS Action Committee’s Blog

A Change Is Gonna Come!
By Lee F. Carson

World AIDS Day always inspires me to reflect on how I started doing HIV prevention work for Black gay men, which began officially, exactly 7 years ago today on December 1, 2000. I, at that time was thoroughly excited about landing a job with an organization in my hometown of Rochester, NY that provided services for Black men who have sex with men (MSM). I remember thinking, “Wow, how can an organization like this exist in a small city like Rochester?” But it did, and it still does, and it, like all of the organizations across the country serving Black MSM have more work to do than ever, because in spite of our best efforts with the limited resources the government has given us, we have fallen short of saving the lives of Black gay men from HIV/AIDS. A disease with a small name, but powerful punch, that has robbed our families and our communities of so many beautiful and talented Black gay men. However, I believe a change is gonna come!

(Read on …)

Well it seems the evangelicals have finally found a way to bring AIDS into their special fold of Christian charity—they skip the part about gay men. Apparently, if AIDS is contracted by drug use or unsafe sex between heterosexuals, or better still a transfusion or perhaps maternal-child transmission, God not only permits but encourages ministering to its victims. And, there’s the international waiver—if you’re outside the USA, preferably in some poor benighted African country, it doesn’t matter how you contract it. There’s room for all in the fold. But there still doesn’t seem to be any room at the inn for gay men in the United States.

Sadly, that seems to be a pretty accurate description of this administration’s position as well. Restrictions on proven interventions have essentially read the gay community out of prevention efforts and have resulted in–drum roll please–an increase of infections in gay men! Of course I’m sure that when the CDC does finally, officially, release its increased estimates of annual HIV infection we won’t hear anything about that—but I predict there will be much conversation about the refusal of gay men to abandon their “ways” and significant hand-wringing over their unwillingness to become heterosexuals. Unspoken, perhaps, will be the phrase “Serves them right,” but many of us will hear it nonetheless.

Word has quickly spread that (another) Phase III microbicide candidate has been taken off the shelf. Cellulose sulfate, an attachment inhibitor, may have been causing increased risk for HIV transmission in trials being done at several sites. As a result, these trials have been halted.
This news follows the closure of another phase III trial in August 2006. As Keith Alcorn wrote yesterday, that trial was showing “a lower than expected rate of HIV infections”. Though this is a less controversial reason for trial closure, both were cellulose sulfate and showed promise as contraceptive gels.
This is quite disheartening news for those of us working diligently to make microbicides a reality for the millions of women and men at risk for HIV through unprotected sex. Microbicides, a topical gel that could be used inside the vagina or anus during intercourse to reduce the likelihood of HIV transmission and possibly other STDs, would provide a non-barrier risk prevention option to the rather slim arsenal of HIV prevention options that currently exists.

Advocacy will now focus on the three products (all are not cellulose sulfate based) still in Phase III development, one of which is nearing completion and expected to have results by the end of this year. In the meantime, the microbicide advocacy community will continue to call for the necessary funding and support to meet the highest standards in HIV clinical trials and to put forth a greater inventory of promising candidate products.

Despite very little if any concrete epidemiological data to support the assertion that bug-chasing (people intentionally seeking to become HIV infected) really exists, this urban legend continues to surface. In today’s Boston Metro an article about the shameful statistics of homelessness among gay youth a throw-away comment about the phenomena was highlighted and pulled out in a special box in the article labeled “Contracting HIV.”

When pressed, the source for the article agreed that there is only anecdotal evidence that homeless queer youth claim to be seeking HIV in order to receive services, and that in fact, these claims are likely to be cries for help rather than actual plans of action. Adolescence is by its very nature a time for drama, and what’s not more dramatic than alleging suicidal intentions? I don’t doubt for a minute the desperate nature of being a homeless queer kid – I just don’t want us all to overreact and further marginalize and demonize homeless queer kids by taking everything they say too seriously. And, the truth about homeless queer kids is that an estimated one-quarter to one-third of them report engaging in survival sex during their time on the streets. That’s a horrifying enough reality without over blowing anecdotal cries for help.

And as for the hullabaloo that there is a community of gay men out there seeking HIV, again, I think the evidence is incredibly limited. I’ll even agree with Andrew Sullivan for a moment in his brilliant piece on Salon.com refuting claims made in Rolling Stone Magazine in 2003.

There’s more than enough work to be done to support queer youth and support people at risk for HIV without making up scary stories.

Headlines
The recent headlines about the potential role of male circumcision in stopping the HIV epidemic have been dramatic. “Circumcision ‘helps to halt HIV” (BBC, July 26, 2006); “Study Says Circumcision Reduces AIDS Risk by 70%” (Wall Street Journal, July, 2006); “AIDS Conference to Debate HIV, Circumcision Link” (NPR August 17., 2006); and most recently, “Male Circumcision is ‘Real-World Equivalent’ to AIDS Vaccine, Opinion Piece Says” (New York Times, Jan 16, 2007).

Geographic Differences
Yet few of these pronouncements have really clarified that while male circumcision may indeed play a vital role in reducing HIV transmission in the developing world, its potential to stem the relentless tide of HIV infections in the US is, at best, limited.

It is critical to understand how different the HIV epidemic in the US continues to be from the epidemic in the rest of the world. Heterosexual transmission and commercial sex worker transmission makes up a much more significant proportion of how men become infected with HIV outside of the US. Only 15% of men infected with HIV in the US report high-risk heterosexual sex as their likely route of infection. And, most men in the US are already circumcised — somewhere around 60% of newborn baby boys in the US are circumcised. The studies cited in the articles above that showed the most dramatic results in circumcision reducing HIV transmission for men were discovered where male circumcision is, to a large part, previously nonexistent. It’s possible that any protective factor male circumcision offers is already at work here in the US.

More Questions
Not enough is yet known or studied about the role of circumcision in male-to-male HIV transmission to determine if increasing circumcision among American men would make a difference. And, all the studies on circumcision continue to point to the role in reducing infection for the men themselves – no evidence is given about potential protective effects for their female partners. Given that 80% of women infected with HIV in the US cite heterosexual sex as the likely route of their infection, this is critical question that remain to date unanswered. Navigating critical differences in the HIV/AIDS epidemic across the world remains one of our greatest challenges in 2007.

This article, from The New England Journal of Medicine draws attention to an important gap in U.S. HIV prevention efforts: the lack of effective harm reduction practices in our prison systems. This includes making condoms available, providing clean needles or access to bleach for injection drug users, and offering drug treatment and methadone maintenance programs.

Although public health advocates favor harm reduction, U.S. prison officials have rarely adopted it. Some argue that making condoms or clean needles available would send a “mixed message” to inmates condoning sex and drug use. A few even hold the punitive view that HIV and other infections are “just deserts” for breaking prison rules.

Whatever the rationale, policies that block harm reduction in prisons carry a heavy human cost – increased rates of HIV, viral hepatitis, and other infectious diseases both within prisons and in the communities outside.

Here are some sobering facts: The HIV infection rate among the 2 million prison inmates nationwide is more than four times that of the general population. In addition, about one out of every four HIV-infected persons passes through the correctional system in any given year. See this recent report on health disparities for more.

At the end of “Sex, Drug, Prisons, and HIV,” Columbia University’s Robert Fullilove observed:

Any reservoir of infection that is as large as a prison would warrant, by simple public health logic, that we do our best…to reduce the risk of transmission… The issue has never been, Do we understand what has to happen to reduce the risks?… It’s always been, Do we have the political will necessary to put what we know is effective into operation?

For more information, this audio interview with Theodore Hammett discusses HIV in prisons and the barriers to adopting harm reduction measures there.