AIDS Action Committee’s Blog

A year later, a response deferred: CDC’s “heightened national response” to HIV/AIDS in African-American community is chaotic, underfunded, and far from its goals.

As CDC quietly releases figures revealing an 80% boost in HIV in Black gay youth, advocates are calling for a national AIDS strategy, adequate funding, and political leadership. Launched with much fanfare in March 2007, the Centers for Disease Control & Prevention’s (CDC) A Heightened National Response to the HIV/AIDS Crisis Among African-Americans called for “expanding the reach of prevention services; increasing opportunities for diagnosing and treating HIV; developing new, effective prevention interventions, and; mobilizing broader community action.”

One year later, the Heightened National Response (HNR) effort has been marked by shifting leadership, lack of communication to local leaders and community organizations, and no new funding for any initiatives that are not restricted to HIV testing. It is now widely believed that Madeline Sutton, MD, MPH, CDC Acting Director of Partnerships in the Department of HIV/AIDS Prevention, the latest in a series of individuals responsible for HNR, will once again restructure the initiative in an attempt to address its significant shortfalls.

Read more at LifeLube. 

Increased awareness of HIV status prevented an estimated 6,000 new infections in the U.S. between 2002 and 2004, according to a report in this month’s Journal of Acquired Immune Deficiency Syndromes. This is, of course, very good news – and is one indication of the value of HIV testing and prevention efforts. To put this number in perspective, I’ll briefly summarize the study and what I think are some of its most important points.

To estimate the number of prevented infections, the researchers relied on information from the Centers for Disease Control and Prevention (CDC). According to CDC, the proportion of HIV-infected persons in the U.S. who were aware of their HIV status increased from about 70.5% in 2001 to 74.2% in 2004.

This increased awareness of HIV status is important, because HIV-infected persons who are aware of their status are more likely to take steps to prevent transmission than HIV-infected persons who are unaware of their status. In addition, when HIV-infected persons know their status, they can seek the medical care needed to maintain or improve their health and quality of life.

Another important number that the researchers used for their calculation was CDC’s estimate of the number of new HIV infections per year. That estimate is 40,000 infections per year – or a total of 120,000 infections between 2002 and 2004. (It’s worth noting here that CDC is expected to issue a revised – and many expect higher – estimate of new infections in the near future.)

Using a mathematical model, the researchers then calculated the number of new infections that were prevented by increased awareness of HIV status. They came up with a best estimate of about 6,000 prevented infections – although the actual number might be as low as 4,000 or as high as 8,700. They also calculated that these prevented infections would save more than $5 billion by avoiding HIV-related medical costs and allowing people to continue working.

These are impressive benefits from a relatively small (3.7%) increase in awareness of HIV status. Unfortunately, the reason for this increased awareness is not known. The researchers speculated, however, that “Overall increases in testing rates and increased use of testing services by at-risk subgroups may have contributed to the reported increase.” They also noted that “other prevention initiatives likely helped as well” in preventing a rise in new HIV infections, despite the fact that the total number of people living with HIV increased by about 90,000 between 2002 and 2004.

At the end of their paper, the researchers make several insightful comments. They write: “One can argue that the incidence of HIV in the United States remains unacceptably high and that this indicates a failure of HIV prevention.” They then acknowledge that the first assertion – that infection rates remain unacceptably high – may be true. But they note that the second assertion – that HIV prevention has failed – goes against the facts. According to their calculations, if there had been no change in awareness of HIV status, the number of new infections per year would have risen from 40,000 in 2001 to more than 43,000 in 2004.

They conclude: “Although additional prevention activities are needed to reduce HIV incidence to lower than current levels, the success of past prevention efforts should not be overlooked.”

Advocates for a new HIV prevention that would provide men and women with an alternative to condoms are reveling in our moment. The results of the first ever completed – not closed – microbicide trial of the product Carraguard are absorbing the trial’s results released today. The short answer is this study showed Carraguard, a microbicide derived from carrageenan which is more popularly known for it’s use in thickening food products, was safe to use and not harmful to women, but not effective in preventing HIV.

This is far from the end for microbicides, or HIV prevention research in general. We’re just making history. Carraguard was the first new microbicide candidate to enter clinical trials (in 1996) and the first to complete a Phase 3 trial. Other Phase 3 trials were stopped early for various reasons. These large-scale trials rely on participants to use the product consistently over a long period of time. Over 6,000 women participated in the Carraguard trial for up to two years, proving that such trials can be done with scientific rigor and ethical integrity.

More will be learned from this trial beyond Carraguard’s (lack of) efficacy as a gel that would allow women say in protecting themselves against HIV. What happened in these three South African sites where over 6,000 women volunteered their bodies and their sex lives for the greater good was a glimpse into their bedroom behaviors and the role research plays in the health of a community. Findings that may be considered ancillary to the research’s aim are perhaps the groundbreakers for advocates working with communities at risk, including those in South Africa: condom use by trial participants DOUBLED during the trial and STI rates decreased.

Add this to the reality that the presence of research infrastructure in these communities means increased access to health services for the trial volunteers, their partners and those who get screened but are not involved in the trial (over 9,000 people were screened in connection to this trial).

Opponents of research based on ethical concerns should have no issue with the Carraguard trial. The efforts by the researchers, by the advocates who relentless push for truly informed consent and access to care (think “No Woman Left Behind”) related to these trials, and by the women from the communities where the trial happened who fight stigma, sexual violence, and a lack of power in their primary relationships, all demonstrate how research can be the catalyst for a bigger intervention just awaiting the resources needed to make it happen.

Microbicide advocates have not run out of things to do. Three more candidate products are now in late clinical trials that will produce results soon. Developing new tools to prevent HIV– particularly among women – is an urgent priority. According to UNAIDS, approximately 3,500 women are becoming infected with HIV each day. Microbicide advocates have been actively, visibly and vocally involved in the process of microbicide research and development from the very beginning. Our involvement will continue until the goal in achieved – and safe, effective, accessible and affordable microbicides are in the hands of all who need them.

As the U.S. recognizes the 8th National Black HIV/AIDS Awareness Day today, we herald this year’s theme, “Prevention is Power” and take to heart the call for and challenges in the day’s annual reminder for people to Get Educated; Get Tested; Get Involved; Get Treated.

Annual recognitions such as this, and this one in particular, remind us to mark our location in our battle to end AIDS in America, demand bold and calculated action and seize special opportunities that get us closer to stopping new infections and ending HIV/AIDS in the African-American community and throughout the U.S.

Where are we in America? AIDS is still a leading cause of death for African-Americans and the leading cause of death for African-American women aged 24-34. Half of new HIV infections each year are among young people, and 56 percent of them are African-American. The President’s FY2009 budget is shameful in its recommended funding reductions. We still have no National AIDS Strategy although we require countries that receive U.S. funds for HIV/AIDS to have national plans. Infection rates of HIV are ramping up among African-American people, especially African-American gay and bisexual men and in some cities including New York and D.C., young African-American gay men.

What can we do in America? In this election year, we call for the next President to create a National AIDS Strategy with measurable outcomes, a specific timeline and adequate funding to address HIV/AIDS as a domestic priority. And we call for head-on action to address stigma, discrimination and denial that inhibit enacting the most effective interventions to deal directly with HIV prevention, education, testing, treatment, care and research, especially to curb the devastating effect of this disease on people in Black communities.

How can we seize special opportunities in America? Both of the Democratic and one of the three leading Republican Presidential candidates have committed to creating a National AIDS Strategy. Visit www.NationalAIDSstrategy.org to learn what you can do to help. Also, on National Black HIV/AIDS Awareness Day, more than 800 communities across the country are hosting informative and inspiring events to honor this day. Find one near you and support it. For example, in Los Angeles tonight, Black AIDS Institute hosts an event recognizing honorees as part of “Heroes in the Struggle,” a photographic tribute to African-Americans who have made outstanding contributions in the fight against HIV/AIDS. Established on World AIDS Day, Dec. 1, 2001, the traveling exhibit has raised awareness, challenged people and communities to be involved and recommit to ending HIV/AIDS in the U.S., and it has inspired needed dialogue about HIV testing and treatment. Visit www.BlackAIDSday.org to find an event near you.

In my work in AIDS Action’s Health Library, I’m often asked this question.
Last week, a group of Swiss HIV experts issued a statement basically saying: “No, condom use isn’t necessary – provided that certain other conditions are met.” [Emphasis mine]

Before going into more detail, I think it’s important to note that some other expert groups have disagreed with the Swiss group’s conclusions. The U.S. Centers for Disease Control and Prevention (CDC) issued a brief statement, saying that the CDC “underscores its recommendation that people living with HIV who are sexually active use condoms consistently and correctly with all sex partners.” Likewise, UNAIDS and the World Health Organization stated that, to prevent transmission of HIV, they “strongly recommend a comprehensive package of HIV prevention approaches, including correct and consistent use of condoms.”

So, what exactly did the Swiss experts say? And why is it controversial?

In brief: Based on their review of several medical studies, the Swiss group concluded that an HIV-infected person who is on HIV treatment and has a consistently undetectable viral load “is not sexually infectious, that is, cannot transmit HIV through sexual contact.”

However, according to their statement, the following conditions must also be met:

The Swiss group also acknowledges that “medical and biologic data available today do not permit proof that HIV infection during effective antiretroviral therapy is impossible,” but they believe that the risk is “negligibly small.”

Critics of the Swiss statement have emphasized that research on HIV transmission and viral load has focused on heterosexual couples and vaginal intercourse – and does not necessarily apply to anal intercourse.

A number of people have also pointed out that, even if the Swiss experts are right, their conclusions about unprotected sex would apply to only a small number of HIV-infected persons: people who have excellent adherence to their HIV regimen, a consistently undetectable viral load, and no other STIs.

Practically speaking, the “no STIs” restriction could probably be met only within a monogamous relationship in which both partners were tested for STIs before stopping condom use. STI testing would be essential, because many people with STIs have no symptoms.

The bottom line for me:
Several studies have shown that reducing a person’s HIV viral load tends to reduce their risk of transmitting the virus. This is very heartening, but it does not mean that people with undetectable viral loads have no risk of transmitting the virus.

(Read on …)

A new public service announcement by porn director Chi Chi La Rue urges gay adult video consumers to consider the implications of condomless, so called “bareback” porn, for performers and audiences alike. La Rue’s Internet Movie Database listing for direction credits includes an astounding 239 titles in hetero-, bisexual- and gay-themed erotica, beginning with 1989’s “Who Shaved Cassi Nova?” and topping off, as it were, with last year’s “Restless Youth.” So it’s clear La Rue is an insider who is well-versed on the ins and outs of the business, so to speak.

In 2006, La Rue opted to terminate a lucrative contract with Vivid Video, a major production company for heterosexual erotic movies. After releasing three years’ worth of La Rue-directed straight videos with condom-clad performers, Vivid decided to make condoms optional for its performers. Finding this arrangement incompatible with the La Rue philosophy, Chi Chi left Vivid and has since focused on gay condom-mandatory productions.

Presumably, a rise in the number of bareback titles available to gay video consumers motivated La Rue to create the public service announcement, featured prominently on a new website. What’s particularly notable about the PSA is how many different issues it touches upon, from testing to the blurry lines between fantasy and reality (especially when the fantasies star real live people) to the place of consumers in the “food chain” of bareback video production.

There’s a case to be made that sex without condoms is often a very pleasurable experience, and La Rue doesn’t take on that aspect of the discussion. But what’s remarkable at this stage of the game is that somebody is talking about the issue at all, when folklore is telling us that people are “over” talking about safe sex.

I hear all about how guys my age are letting their guard down. I enjoy getting fingered as much as the next guy, but enough already. The following passages are not in any way meant to remove the ownership my generation should claim. I know it is my health, my choice and ultimately my life. I aim instead to add more to the myriad of reasons why infection rates are increasing in guy my age and slightly younger.

AIDS left us with a gap and injured as a community. As older men lost friends, brothers, lovers, and roommates, guys my age lost countless mentors. We, the younger generation, were left to fend for ourselves. The oral traditions, all puns intended, of our community all but completely stopped. There is an age bracket that was completely devastated. Those men should have helped out guys my age. Most guys my age didn’t get a hand in traversing the sticky mess that is the gay terrain. We, the younger generation, are left navigating for ourselves in a world that gets increasingly more complex.

I have been blessed to have been taken on by a wonderful group of men. One in particular refers to himself as my Auntie. They brought me under their wing and helped me navigate through what was an extremely overwhelming world. The big city homosexual can be a lot to handle. This city can feel so isolating and alienating. If it weren’t for those men I can say with all certainty that I would not be who I am today. My life, undoubtedly, would resemble an after school special. I ran around from bar to club six nights a week until someone who was caring enough to call me on what I was doing did just that. It was the voice of an older friend who watched so many go that route before me, who refused to watch another guy be taken in by those trappings.

A few of the bravest of these men have shared with me what it was like in the time back then, the time we don’t speak of. Some of them are positive some of them are not. They spoke candidly about the fears of not knowing. They didn’t know how it was transmitted. They didn’t know who would be next. They were never really sure what happened to those familiar faces across the bar they stopped seeing. Did he move out of town or did he get it too? Some people watched helplessly as their friend, disowned by his family, wasted away to nothing in the living room, stripped of dignity and pride, a skeleton on the couch.

That was not my life experience. I was born a few years before HIV was named. There is no time in my memory without the shadow of AIDS. AIDS wasn’t a gay disease to me. It was what killed the sweet boy Ryan from TV. He had hemophilia just like my best friend.

(Read on …)

Hello, New York Times… HIV isn’t making an alarming comeback; it has never gone away. It never stopped infecting and affecting our communities. It never stopped taking our friends and loved ones. What happened is that HIV has moved from the front pages of our newspapers, from the screens of our televisions, and from the forefront of many minds, and ultimately from the pens of funders. As the Director of The MALE Center, I cannot tell you how many times that I hear the question, “HIV is still around?” when I explain what I do.

The silence has been forced over many years. The muzzles of the CDC, federal and state material review panels, and the mandate from funders that agencies must utilize “boxed” interventions have stifled effective and grass roots HIV prevention and treatment in this country. Agencies had to throw away prevention materials and interventions because they were “too explicit” or “too racy” to be used in the community or because the agency lacked the funds to prove them effective. We have been mandated to tone down our language or face censure from our funders. Boxed effective interventions that have been created and tested in the early 80’s, often in populations unlike ours, are what we are required and forced to utilize in the new millennium.

The structure of our funders and their inability to work together has failed to mitigate the changing epidemic of HIV and has failed to coordinate local prevention efforts. We know that HIV is a complex issue. To address HIV, one must utilize a multifaceted approach to health. HIV prevention cannot occur in a vacuum. It occurs with the complexities of substance use, mental health, STDs, homelessness, violence, racism, homophobia, stigma, employment, socioeconomic status, and fear, just to name a few. Linear funding streams inhibit coordinated, comprehensive, and synergistic programming.
Bureaucratic indoctrination to doing nothing beyond what has been “proven” has led to limited funds for innovation and creativity. It has effectively gagged the true voices of HIV prevention. The “proven” has also led to increased infection, decreased concern, and a malaise of apathy. Gay men have been at the forefront of this epidemic. We are a resilient community. We have no less need to band together now than 25 years ago. Our voices are not silent, but our messages are not unified. This is the call to action! Find your voice and in doing so help create ours!

The MALE Center provides the opportunity to mobilize, empower, embrace and promote our community. Contact us to get involved!

By J.T. Jacoby

I agree with Denise McWilliams to some extent of course; but from where I sit, party, play and relax…it’s much bigger than that.

Repatriating from Asia this summer and having lived in Europe, I’ve been part of gay culture, gay party culture, drag, ptown, going to church, “straight” stuff (I hate that term) - you name it. I’ve been all over Americana and the world - pick a global or US party city: been there done that. The culprit of the immense rise in HIV has been under out noses all of the time: American culture. Why is it that a Parisian or Madrileno does not think twice about a condom but an American is often almost afraid to “insult” by using one? I can assure you their libido is no different than ours. Ha! Try India or Brazil for some libido…and condoms (no public comment for me there…you’ll have to make a leap of playful faith).

It’s our “American culture” of fitting in, looking like this, numbing our minds to the many messages of keeping up with the Jones’. I’m too skinny, I’m too fat, I’m poor, my whatever is too small, I’m so ghetto. We are killing ourselves and the disintegration of the American male gay community is accelerating our own demise. #1 globally at 16% of GPD for healthcare? ($23B federal only for HIV/AIDS alone!) THAT IS HUGE! It’s not a healthcare issue. It’s not a political issue.

It’s cultural and we never caught this. Americans, specifically unlike other cultures (because we do know better), reject self preservation/respect in favor of acclimation. It’s no different than straight culture - we just happen to have an intimate disease that kills. The numbers are in and they don’t lie - they tell a terrifying truth. It’s time for us to come together again. I’ll host the first chat. Will you join me?

JT Jacoby is a member of the Board of Directors of the AIDS Action Committee and a Senior Director at Fidelity Investments. Having just returned to Boston recently from an overseas, multi-year assignment to India, JT served on the Board up to his departure to India. He spearheaded, along with his fellow AAC Board members, a three-part community project titled “Community Conversations,” which was the precursor to the formation of The MALE Center, a community and wellness center for gay, bi and trans men and a program of AIDS Action Committee.

Three things I know for sure after living half my life under the cloud of the HIV/AIDS epidemic is that life is complicated, sex is complicated, and HIV is complicated. There are almost-countless numbers of tributary issues that flow into the ocean we find ourselves navigating, metaphorically speaking, that it can sometimes feel as if we’re trapped in a perfect storm of relentless waves of watery doom.

But I’ll be damned if the New York Times editorial didn’t dash off more than half a dozen of them (and that’s just the tip of the iceberg, to belabor the high seas references) in a mere 403 words with a thorough veneer of judgment buoying the proceedings. There’s the “problem with these young whippersnappers of today” angle; the “people are irresponsibly letting their guard down” angle; the “what is the deal with young men of color?” angle; the “gasp! people drink and do drugs” angle; and the hope-undermining “nobody even knows how long these treatments are going to work, anyway” angle.

Each of these points needs a nuanced dissection and discussion of its own, but the most important thing to get at is the underlying nostalgia for the Good Old Bad Old Days that often tints the discussion of the AIDS epidemic now, particularly across the generations in communities of men who have sex with men. When the disease was new and terrifying, the Times informs us, the gay community helped change behavior by preaching loudly against taking sexual risks. Hold the phone. Are we really going to argue that if only we could go back to when we were all terrified, to a simpler time when AIDS was all but untreatable and we buried friends who died after being horribly ill that the complicated business of prevention would all but take care of itself?

I can’t believe that anybody who actually lived through those first waves of the epidemic could ever think it would be worth going back to that time, even for what they perceive as our own good. Instead, I would argue, that it’s more important than ever for us to look toward the future with cautious optimism by sharing our stories with each other, stories of our hopes and dreams and our successes and failures and our pleasures and our problems in all their messy complication. You know, to tell the stories of our real lives now and acknowledge the possibility of a better future. That was what was at the heart of early and mid-period HIV prevention efforts, and what lies there today, often encumbered by funding dollars with strings attached. That is the true power that needs to be unleashed again.