A New Strategy For Preventing AIDS
The Obama administration recently announced new strategy designed to cut the number of new HIV infections in the U.S. by 25% over the next five years. Even though AIDS has fallen off the national radar, something does need to be done.
According to the July 2010 CDC-HIV/AIDS Fact Sheet, over one million Americans are infected with the AIDS virus and 21% of those infected don’t know it. 576,000 people have died and the majority of these are men who have sex with men (MSM). After peaking in the mid 1980’s, the number of new infections each year has stabilized at an estimated 56,300, however, while the number of newly infected in other categories continues to decrease, the number of MSM newly infected increases each year. Currently 57% of the newly infected are MSM.
Because AIDS in the U.S. has from the beginning been a disease spread by MSM to MSM, gay activists demanded and received the right to direct prevention efforts. From the very beginning gay AIDS activists rejected standard public health strategies for the prevention of sexually transmitted diseases (STDs) and focused instead on protecting the sexual freedom and privacy of MSM and pushing a pro-gay agenda in public schools. They assured the public that education and condoms were sufficient to stop new infections.
At the beginning of the epidemic there was hope that, in the face of this always fatal disease, changes in behavior would prevent new infections, but it soon became clear that these changes were not sufficient. In 1988, Ron Stall and associates, experts in the field, wrote: “The efficacy of health education interventions in reducing the sexual risk for HIV infection has not been consistently demonstrated. More education, over longer periods of time, cannot be assumed to be effective in inducing behavior changes among the chronically high-risk men.”
Since then, drug therapies have transformed infection with HIV from a near certain death sentence into a chronic disease. Optimism concerning treatment has increased high-risk behavior and infections among MSM. According to Dr. Philip Alcabes, an epidemiologist at Hunter College: “[I]t looks like prevention campaigns make even less difference than anyone thought…HIV incidence did not decline as much from the 1980s to the 1990s as we believed despite the dramatic increase in condom promotion and so-called prevention education.”
An article in the prestigious British journal The Lancet was blunt: “US efforts to prevent HIV have failed miserably.”
While the gay AIDS activists refuse to admit their strategy failed and continue to push for more money for education, particularly in schools, there is no evidence that the thousands of MSM, who become HIV-positive each year, have not heard of AIDS, do not know how it is spread, and do not know how to prevent infection. It is time to agree with The Lancet; the gay AIDS activists’ strategy has failed miserably.
A study of 28,530 MSM who attended STD clinics in England reveals precisely why. Between 1999 and 2002, MSM who came to the clinics for treatment of other STDs were anonymously tested for HIV. Of these 3,593 (12.9%) were HIV positive. 2,520 of these had been previously diagnosed. This alone should be of concern, since infection with another STD is a sign that these HIV-positive men or their partners were having sex with other partners. Not only could these encounters spread HIV, but infection with a new STDs could complicate treatment for HIV.
Of the remaining 25,910, 11,655 (45 %) refused voluntary counseling and HIV testing (VCT) even though the fact that they were infected with another STD meant that they were engaging in sex with multiple partners and at high risk for HIV infection. Of those who refused VCT, the anonymous testing revealed that 737 were HIV positive. These HIV positive men went back into the community, untreated, and purposefully ignorant of the risk they posed to others. It is not surprising that, given this pattern of behavior, new infections among MSM continue to increase.
HIV infections heavily burden the health care system, since as a chronic disease it requires years of expensive medications, paid for by health insurance or Medicaid. Political considerations should not prevent public health officials from using the most effective methods available to prevent the spread of infectious disease. Routine testing, reporting the names of those infected, contact tracing, and partner notification are the standard strategies for the control of other STDs. At the beginning of the AIDS epidemic, gay AIDS activists argued that these should not be employed in the case of HIV because there was no cure and because AIDS patients and MSM would suffer stigmatization and discrimination. However, one of the main reasons the experts in STDs did not push mandatory contact tracing and partner notification was that MSM had so many partners (and so many anonymous contacts) that the task was seen as impossible.
If we really want to prevent new HIV infections, efforts should focus primarily on those who engage in anal intercourse (AI) because this is the highest risk activity– particularly for MSM who are infected with other STDs. According to an article in a British medical journal:
…transmission rates are higher for AI than for vaginal sex… A gay man can be easily infected through unprotected receptive sex, and then infect someone else through insertive sex. Gay men are therefore more susceptible to the spread of the virus.
Since we know which behavior carries the highest risk, those persons engaging in that behavior should be the primary focus of prevention efforts. It is clear that relying on MSM to moderate their own behavior and accept VCT has failed to prevent new infections; therefore a new strategy should be adopted:
• Anyone who engages in anal intercourse (AI) should be required to be able to produce the names and contact information for all his partners should he become HIV-positive or infected with another STD. The responsibility for providing accurate information about sexual partners should be placed on those engaging in high risk behavior. When one thinks about it, it is not unreasonable to require that, in the midst of raging epidemic, MSM ask the name and address, phone number or email of the persons with whom they engage in AI.
• Everyone diagnosed with any other STD should be tested for HIV and informed of the results.
• Public health authorities shall contact and test everyone who has engaged in AI with a person diagnosed as HIV positive. Such contacts shall be done discreetly.
• Anyone who has been diagnosed as HIV-positive has a legal obligation to inform all sexual partners before engaging in sexual activity. Lying about one HIV status should be considered a crime.
• Everyone who engages in AI with multiple partners has an obligation to be tested regularly for HIV.
• Correctional facilities should test all incoming male inmates for HIV, and segregate those who are HIV positive to prevent the spread of infection to other prisoners, protect those HIV positive from abuse, and facilitate treatment.
• Internet sites, such as Manhunt, which allow MSM to contact those interested in engaging in sexual activity, including AI, should provide a way for those using the service to serosort. Serosorting is the practice by which HIV positive men have AI only with other HIV positive men and HIV negative men only with other HIV negative men. Likewise, venues (such as Circuit Parties) which cater to MSM shall either prohibit AI or provide methods of serosorting.
No one has the right to infect another person with a serious disease, even if that person expresses a desire to be infected or insists that he doesn’t care. Such behavior adds to healthcare costs for all. There have been rumors about Bug Chasers, men who purposely seek to become HIV-positive and HIV-positive men called Gift Givers who oblige them. Advertising for this activity should be prohibited.
The call for routine testing and contact tracing is not new. Almost since the beginning of the epidemic, some have questioned why standard public health measures have not been applied in the case of the HIV. In 1997 in an article in The Atlantic Monthly entitled “The AIDS Exception,” Chandler Burr, a gay man, laid out the case for applying traditional strategies for addressing the AIDS epidemic. He wrote:
Does an absence of routine testing, reporting, and notification mean that a host of undiscovered AIDS and HIV cases are festering in the larger society? Yes.
Do the disease-containment and disease-prevention measures of traditional public health–the measures from whose full-force AIDS has been significantly shielded–work? The answer given to this question by AIDS exceptionalists as well as traditionalists seems is yes. According to Ralph Frerichs, a prominent UCLA epidemiologist:
Given that we have not pushed for aggressive testing, reporting, and partner notification, it appears that our society is willing to accept a high amount of HIV infection to avoid interfering with the rights of HIV-infected people.
The failure to employ standard, sensible public health strategies to the HIV/AIDS epidemic kills approximately 9,000 gay men every year. Why don’t their friends care?