September 27, 2002

This sixth article for 2002 summarizes the responses to my last article, in which I provided a set of recommendations to gay and bisexual men that I called a "prescription" to the Seattle gay & bisexual "community", given my training as a physician and my (now 16 year-long) job as HIV/AIDS control officer for Public Health - Seattle & King County. While most people liked what I wrote, my recommendations were troublesome to some people. Here I write about the published and email responses to my prior article, and some other exhortations to gay and bisexual men that have occurred over the summer, and I describe my thoughts about those responses. I also want to re-frame our plight as gay men in terms of what's happening in Africa, because since I wrote the last article I attended the XIVth International HIV/AIDS Meeting in Barcelona where the situation in Africa was described in sad detail. I've come to realize that rates of HIV infection in gay men in Seattle, King County, and other large urban areas, are on average above the sub-Saharan Africa levels of infection.

My fifth "prescription" to the gay and bisexual male community to address the problem of increasing STD, and likely increasing HIV infections locally, consisted of the following recommendations (slightly restated):

• That we gay and bi men significantly reduce our number of sexual partners and work toward longer-term relationships. Long-term partnerships would permit us to have sex while reducing exposures to more people and more bugs.
• That we return to using condoms consistently and correctly with new partners.
• That we tell our partners whenever we know we carry an infection; most of us would want that for ourselves.
• That people who experience risk get tested for HIV and other STD regularly.
• That we work individually and collectively to reduce the amount of disease in our community to counter the image some have of us that we are full of infections; and
• That we help the larger community see that it cannot be truly healthy until our potential to be healthy is supported and achieved.

My "prescription" was published on gay pride week in the Seattle Gay News; it was also inserted into issues of The Stranger a week later in some areas of Seattle, and later reprinted in several other periodicals statewide. All of the articles I've written this year are available at www.metrokc.gov/health/apu on our website, for people who haven't seen them.

My article also coincided with two letters from the Governor's Advisory Council on HIV/AIDS, to which I contributed: 1) to gay men generally and 2) specifically to African-American men who have sex with other men. Both letters were also published in the Seattle Gay News and urged increased caution about sexual risk-taking. These publications occurred about the same time that a media campaign was released, consisting of bus posters, billboards, posters and bar coasters. These messages included: Your life; Your responsibility. Lesions Anyone? Get Tested. We're doing a good job -- of infecting ourselves. Who's getting fucked?

The campaign was developed by the MSM-STD Task Force, a group of community members and AIDS community-based agency staff, established in late 2001, in response to a World AIDS Day (December 1st) 2000 "MSM-STD Summit." In trying to decide on messages to deliver to the gay community, the Task Force decided that it primarily wanted to raise awareness and spark a reaction among gay and bisexual men, but it even wrestled with controversial messages like "AIDS Is a Hate-Crime". I've heard that others are working to create still other messages. All of these efforts have been designed to awaken gay men to the increased risks of STD since 1997 and the feared second wave of HIV transmission that appears poised to strike the community.

Responses to my "Prescription"

There were more responses to my "prescription" article than to anything else I've written to the community. In the 6/28 issue of the Seattle Gay News, letters were published from Kelly Furst, Paul Feldman, Fred Swanson, and Tony Smith - all dealing with the issue of increasing STDs in gay men, but not all specifically remarking about my "prescription". Kelly wondered why the increase in STDs was occurring around the time that a new gay organization seemed to be promising new solutions to HIV prevention. He also thought better work must have been done in earlier years of the epidemic because "the STD rates plummeted, so something worthwhile must have been going on."

Readers, if you will look more closely at one of the figures I presented about STD rates in my March, 2002 article, what you will see is that the STD rates fell considerably from 1981 to 1984, and that rates of STD in gay and bisexual men had already been cut in half by 1983, before any local, state or federal funds were applied to the effort and before many AIDS response organizations had had a chance to get underway. While lots of folks attribute these falls to the prevention work done by organizations, I don't think so.

Many of us have argued over the years that fear is not the best way to motivate safer behavior. Nevertheless, it appears to me that much of the changes that occurred were in fact driven by fear, as gay men learned from other gay men and from the media about this serious and frightening new disease and death in our midst. I don't doubt that AIDS organizational work and the eventual prevention funds helped considerably but their main impact may have been to reduce risks and STD more rapidly than might have happened without such efforts and resources. Recently, however, it appears the fears have largely abated with the arrival of highly active anti-retroviral treatment (HAART) and risk behavior is on the rise. Any organization which started up around the time new anti-retroviral cocktails came on the scene, especially if it promised solutions to the on-going epidemic, would have had to swim upstream against the rapidly increasing current of complacency, as AIDS and HIV became treatable.

On to the other responses. Paul Feldman, whom I've known for a decade, wrote the SGN to get readers to continue to "reaffirm ourselves as sexual beings. It's not how many people you fuck, it's how you do it..." He didn't think my "prescription for us to be in committed relationships is helpful... And, come on, do you really think sportfucking is going away any time soon, no matter what you or anyone else says about it?" He then proceeded to present his five suggestions for HIV prevention (most of which gain my agreement).

Shame, Stigma, or Reality?

It's Paul's third issue - about dirt and shame - that I find problematic from the medical standpoint. Dirt is what we get on our hands or clothes and can often be washed out. I wish HIV, or herpes, or syphilis were simply dirt; but these infections can't be washed away. All require potentially toxic treatment lest they kill, and two of these three in particular are true lifetime stains, chronic infections that threaten those who have them and those with whom they are intimate. To me, it's certainly not an issue of dirt or of shame at all, any more than lung cancer or drug addiction is a shame; these conditions are medical facts that make some of us sicker than others. Chronic infections (some worse than others), like any chronic diseases, cause sickness (morbidity), and often early death. Sure, people can choose to take risks and get infected, to the extent society will permit it. But lifelong infections and the sickness that comes with them are not what healthy people want for themselves, or their community, or for the future of communities that they care about.

I hold that condoms, especially in a community brought up on multiple partners, will not be enough, especially since they fail from time to time and (more often) people fail to use them carefully and consistently. And with the change in strategy I suggest - to move away from high numbers of partnerships towards longerterm relationships - we could greatly reduce our risks and levels of disease. While there will certainly be holdouts to my proposed strategy for improving individual and community health, even people who are now seeking lots of partners may actually see advantages over time from a reduction from a healthier and more respected community. We didn't think we could change the smoking levels as successfully as we have. It will take time.

I agree with Paul that sexual freedom, and non-relationship sex have been important, even normative hallmarks of the gay community since at least Stonewall, but that doesn't mean that I think this standard has or will improve gay health or esteem. As my friend and mentor in the AIDS fight Jim Curran said at the Barcelona AIDS meetings, " In thousands of communities throughout the world at this moment....it is simply not safe to have sex without a condom." There's HIV, there's herpes (in Barcelona blamed for much HIV spread), there's hepatitis C virus which many of us with HIV have (and many more people have chronic hepatitis C infection in the US than HIV), and there's the new Kaposi's sarcoma virus prevalent in gay men, found in saliva, and probably transmitted by deep kissing.

More partners - even with good intentions to use condoms - means more exposure, means more disease, means more sickness, means earlier death. Shame, stigma, or reality? And, does sex with more people really make for more pleasure in life, like more cigarettes, or is there just some addiction thing going on here?

Some of the responses to my last article were long and complex, but one I got by email was short, fairly direct, and not signed. A "fag who can think for himself" was the first to write to me to say he though I was "so funny!" He wondered if it hadn't occurred to me that some "men who love men" [his quotes] don't want a "long-term relationship" and prefer to have sex with as many partners "as we like...we'd prefer to take out chances [with STDs and/or HIV] rather than be 'good little boys' like you'd prefer us to be and settle down for a boring, unfulfilling sex life (similar to what you must experience). So, here's your prescription: do us a favor and fuck off and die already!..."

My attempted response to this writer bounced back to me. I had tried to expand on my earlier comment that I had to make some assumptions in writing my "prescription". To make more specific recommendations for community segments (or individuals) within the gay community would require extensive meetings with such groups (or sufficient one-on-one counseling with individuals) to understand their goals and values, and identify possible solutions and a means for motivating them. I wondered whether the seeming anger in his response arose from his fears that my writing might reduce the willingness of partners in the sexual marketplace to place themselves at risk.

Another email comment came from a fellow who had "a problem with … [my] statements about single people [which] seem uninformed and insensitive." While he felt the information I presented was valid, I displayed "a bias and classism that can only make it more difficult for [me] and the County to address the problem of HIV prevention. He said, "Don't patronize your target group, and keep your sanctimonious middle-class judgments out of this please." I responded that while I'd urged people to form longer-term relationships, I hadn't said anything good or bad about single people. I tried to clarify that I had suggested increasing longer-term relationships as a way of remaining equally sexual while reducing the number of sexual partnerships, and that I was simply trying to give my best clinical advice. After I finally got my response to him he later responded that after re-reading my "prescription" he realized that I'd not been trying to shame the community and he now had fewer problems with what I'd written.

Incidentally, while I had recommended longer-term relationships to gay and bisexual men, I didn't write about how that could be achieved. I was grateful, therefore, to read in The Stranger an article by Dan Savage as part of their pride issue, entitled, "What I know now about LTRs" (long-term relationships). In ten very helpful points, Dan wrote about "everything gay men need to do to find everlasting gay love." I found Dan's article very insightful, but of course no short bit of writing from Dan, me, or anyone else will likely make it easy to start and maintain a longterm partnership. So, those were the responses and some of my thoughts.

Sub-Saharan Africa and The Emerald City

Are rates of HIV infection in Seattle gay and bisexual men really comparable to rates of HIV infection in sub-Saharan Africa? I first heard this description of the HIV situation in urban gay and bi men from Ron Stall, an openly gay Ph.D. anthropologist and public health epidemiologist now working at the Centers for Disease Control and Prevention in Atlanta, but formerly with the Center for AIDS Prevention Studies at the University of California, San Francisco. These words, "sub-Saharan levels of infection", got my attention, because I had just come from Barcelona where many of the presentations characterized the sorry state of HIV and AIDS in much of Africa, with very high rates of infection, millions dying each year for lack of affordable treatment, and millions of others, including staggering numbers of orphans, left behind. I decided to take another look at the numbers.

In Africa below the Sahara I discovered that there are a lot of countries, a little over 50 by my count, which contain over 4/5ths of a billion (around 822 million) people. The Barcelona meetings updated me on the latest UN AIDS estimates that this region held about 30 million of the world's 40 million people living with HIV/AIDS. A little simple arithmetic, therefore, yields a rate of HIV infection of about 3.6% (30 million divided by 822 million) in these countries overall. The worst rates, with above 20% of people infected, were noted to exist in seven of these countries, and several of these had HIV infection rates estimated to be in excess of 33% (one in three).

So, how do Seattle gay men compare with those sub-Saharan Africa rates? Our estimate is that about 14-15% (one of seven) of an estimated 40,000 gay and bisexual men locally are currently infected with HIV. Further, among the 2,000 or so gay and bisexual men who have the additional risk of injecting drugs, about 40-50% are HIV-infected. These rates of HIV infection in men who have sex with other men are similar to those seen in most other large urban areas in developed countries, and perhaps less in Seattle than in bigger and more gay cities like San Francisco, Los Angeles, and New York.

Clearly, gay and bi men in practically every urban area in the developed world do have some of the worst rates of infection anywhere on the globe. But of course, many of us here in America have the advantage of incomes, jobs with health insurance, or the benefit of huge government subsidies - all of which will permit us to access the life-saving treatment, in contrast to the people of Africa. We have our own little Africa right here in the Emerald City.

Closing Thoughts and Questions

I am deeply concerned about and committed to the health of men who have sex with men. Twenty years into this epidemic, I cannot accept that we gay and bisexual men, HIV negative or positive, in relationships or not, are going to sit back and watch rates of STD and HIV rise to earlier levels in our community and not be outraged. Today we know that HIV causes AIDS, we know how it is transmitted, we know how to avoid transmission, and enormous resources have been spent to establish HIV prevention organizations and to address these problems. Sure, more resources would be useful. But the STD situation has practically reverted to the situation that existed before all the deaths began. In my mind's eye, I can see the many patients and friends I have lost to this epidemic turning over in their graves wondering if we've all lost our minds and whether all the work they and the rest of us did was for naught.

So, yes, gay men locally and in other urban areas of the developed world do have Sub-Saharan infection levels, and this is truly alarming, and the situation appears to be getting worse. I still believe we can reduce infection levels, but to do so will take renewed efforts and time. And, I still encourage gay men to try out my prescriptions for a healthier community, which includes love and respect for ourselves, for each other and, yes, fewer one-night flings and more long-term relationships. And if these brief encounters are destined to continue at the same level, somehow we've got to begin caring as much about our anonymous partners as we do about people we've known for a longer time, using condoms, and disclosing our health situations.

What's your level of outrage, remembering that silence equals death? I remain eager to hear your thoughts.