June 21, 2002

Overview

In January of this year, I began a series of articles about some growing and serious health problems threatening gay, bisexual and other men who have sex with men (MSM) locally and in other parts of the world. In these articles, I've noted an upswing of sexually transmitted diseases (STD) and evidence of complacency among MSM regarding sexual behavior that puts them individually, and our community, at sustained high risk for HIV and STD infections. I wrote readers to caution them that life with HIV, even with the treatments now available, is no "piece of cake" in my view, as someone "lucky" enough to have lived for nearly 20 years with HIV.

In May, I summarized some of the steps that have been taken by public health and local community agencies in response to increasing STD rates and risk behaviors among MSM. Since then I've acquired still more evidence that risk behavior, and perhaps HIV infection, is rising again among MSM. I've presented the evidence to Seattle City Council staffers, to state Senator Pat Thibaudeau, and I'm making plans to take this show on the road, because I think it's a scary problem.

While a rising tide of new risky behavior among MSM is not the only problem confronting our community, it is the most important problem we face as men who love other men. This is far and away the biggest threat to our health, our esteem, our community and all the progress we've made together in my lifetime. It threatens to keep us at the current high levels of new HIV infection (50 times those in the straight community) such that AIDS will remain our major cause of reduced longevity and diminished health. And it isn't just an enormous threat to us: it also threatens the well-being of the broader society, since every segment of society impacts and is impacted by every other segment.

My Perspective

I was hired by Public Health in 1986 as a physician involved in patient care, teaching, research and community activism. I had helped start a group of nearly 100 Seattle gay, lesbian, and transgendered physicians, was a volunteer with gay mental health and STD agencies and became intimately involved early on in Seattle's response to AIDS. I believe that my job, then and now, was to be a doctor not just to individuals, but to the community as a whole - to diagnose the problems we face, to recommend strategies to address our problems, to "prescribe" a course to improved community health.

While most physicians have problems brought to them by individual patients, my public health role has been to assess the health and "diagnose" the ills of our community, and to use all possible political, governmental, and social processes to reduce any possible harm. In my career prior to AIDS, I took the patient's history (listened and asked questions, information which turned out to be the most useful in patient care), did a physical examination, and ordered lab tests to gather further evidence to specify the problem. Now, as King County's HIV/AIDS Control Officer, I'm challenged to care for several types of "patients": Individuals who might newly acquire (or who just acquired) HIV, those persons' intimate communities (their networks of sex and/or drug-using companions, who may be exposed and at-risk), those persons' circles of respected and considered peers who influence their behaviors and ultimately all people within the local, state, and federal region.

For this article, I focus on the male gay and bisexual "community" as though it was my patient, a single entity, which of course it is not. There are young "queers" and old gays, urban, suburban and rural men, black and Hispanic gays, "straights" who have sex with other men, Native American and Asian men who are sexual together, leather men, and persons who adopt the dress of, or choose to be, another gender - to name but a few of the varieties of community members. I identify this problem in the larger group of men who have sex with other men, no matter how they identify themselves, because I think this is where there is a clear and present danger.

Evaluating the "Patient"

Let me briefly review the MSM community patient's history here:

• Since 1998 many more MSM are telling us that they have the drip, sores, or a rash; when we (increasingly) diagnose syphilis, three-quarters of those men tell us that they are infected with HIV, too.
• MSM coming in for HIV counseling and testing tell us that they have increased their risk taking:
  • They have increased (by 60%!) their numbers of partners since 1994-5.
    
  • Those who have anal sex have increased (by over 20%) the proportion of their encounters unprotected by condoms since 1994-5
• A specific survey to investigate why STD rates were rising in MSM shows that:
  • MSM with HIV are having unprotected sex with HIV negative as well as positive partners, and with persons of unknown HIV status.
    
  • Much of the increased risk occurs when people are high on drugs.
• Other surveys tell us that many MSM:
  • are tired of harm reduction strategies (like condoms, and safe-sex messages)
    
  • no longer feel HIV is the threat it used to be, and that they don't even know anyone who has HIV.
• And as for the "patient's" physical exam findings:
• STD rates among MSM have risen from a low achieved in the late 1980s and early 90s back to new and much higher levels.
  • While rates of syphilis are less than 1 per 100,000 among persons in the general community, rates among MSM are 160-180, and among MSM with HIV, these rates exceed 1,000 per 100,000 (over 1%).
  • MSM gonorrhea rates are also many times those in straight men.
  • Syphilis is back at the levels seen before AIDS, almost all of it is occurring in MSM, and 75% of these men also carry HIV.
  • The average age of syphilis cases is 35; so, these are not all young MSM. Nevertheless...
• % of young MSM (16-24), and 2% of those aged 25-34, have been getting HIV-infected each of the recent years in King County, according to our local HIV incidence study. These rates of new infection alarm me very greatly.
• Of MSM overall, about 14% (1 in 7) are infected with HIV; but the rate is much higher (over 40%, nearly 1 in 2) in MSM who also inject drugs.
• Surveys of patients at the Harborview STD Clinic show that the rates of HIV infection have doubled since their lowest level in 1996-7. Some of these persons appear not to be aware of their HIV.
• Finally, the number of people living with HIV has been rising about 5% each year since the mid-1990s when highly effective treatments became available, slowing the rate of decline and death among those with the virus. Now, fewer persons with HIV die annually, while an estimated 400 new infections (or more, given the new STD rates) occur each year in Seattle-King County.

The Problem & My Diagnosis

Many MSM (who account for 85% of our cases of HIV & AIDS in King County and who have highest rates of new infection) appear to have become complacent about HIV and other STD. Some are having sex with huge numbers of partners, and whether HIV infected or not, they're taking big risks for themselves and endangering our community. Increasing STD rates make HIV that much more transmissible. In the face of the largest pool of people with HIV and AIDS that we've ever had locally, more and more men are becoming complacent about sexual safety, and that's a train wreck that's happening already. Particularly scary is that we are the people who pushed broader community and governmental responses in the early years of AIDS, and are now turning our back on the problem.

Dr. Mitch Katz, director of Public Health in San Francisco, a city which has identified similar trends in its MSM communities, recently said that while the risk per contact might have fallen in recent years (as a result of anti-retroviral treatments bringing high viral loads of HIV under control), this effect is entirely offset by increasing numbers of sexual partners and the decreasing use of condoms among MSM. San Francisco has now doubled its estimate of the number of new HIV infections happening among their MSM.

Assumptions in My Approach

Before I can identify recommendations to address and reduce this problem (this super-high risk for HIV & STD, and the enormous toll these new infections will take on our community), I must describe the medical model I'm using a bit more. In an ideal clinical situation, one-on-one between a provider and patient, after a problem is identified, the doctor provides his or her technical expertise, practical experience, and prognosis, and begins to investigate the patient's goals. (The patient should have the right to make the final choice unless society is likely to be intolerably affected.) Here I'm trying to develop recommendations for the MSM community as "the patient", which is tougher than treating one patient. We're more than just a bunch of individuals, and most of us have different goals, priorities and needs.

In lieu of knowing the definitive goals of our MSM "Community" I have decided to simply assume that what we want is the best possible balance of a number of elements, including:

• The best health achievable, including a long and full life, physical stamina, self-esteem, attractiveness, and freedom from chronic disease and the need for incessant and toxic treatments.
• Fulfillment of human intimacy needs, including sex (including for those with HIV), and the ability to have long-term relationship(s) with significant others which are respected and recognized by society.
• Security in basic human rights and against discrimination.
• Prosperity and the ability to contribute meaningfully to and be respected by society.

My Prescription

My most important recommendation, and certainly the most urgent one, is that we must significantly reduce our number of sexual partners, and to work toward longer-term relationships, which I think most of us will ultimately find more fulfilling. That way, the goals of intimacy that I'm assuming above - sex and long-term abilities to provide and get mutual support - can be met, and exposures will be reduced.

My recommendation for those who will have trouble limiting their sex partners (and lots of partners pose a particular risk to young men, those newly "out", and to older singles, since sex can be addictive) is that we must return to consistent and correct condom use to limit exposures within our community. This will not just protect MSM until there's a vaccine for HIV, but it will reduce exposures to all those other diseases which may not yet be known, eradicable, and which may be particularly dangerous.

To persons who know that they carry infections - incurable life-long ones like HIV, herpes, genital/anal warts, chronic hepatitis, and the new virus that causes Kaposi's sarcoma and the curable STD like gonorrhea or chlamydia, you have a clear and crucially important responsibility to make your partners aware of what you know you carry. You must let them know! Envision being thanked by future brothers and the whole of society for keeping your infections to yourselves, no matter how much a partner might beg to be bare-backed, or say he's not concerned about getting an infection. I am personally taking my HIV (and no doubt several other diseases) down with me when the time comes.

And, to people who have engaged in risk, especially with high-risk persons (other gay men, or injectors), if you don't know whether or not you have become infected, I strongly urge you find out. Get tested regularly for HIV, for herpes, for syphilis or whatever. In addition to helping protect your partners, and our community, you need to know whether you are infected in order to get treatment to prevent worsening disease.

To all my brothers who celebrate sex and intimacy with other men, I recommend that we cannot allow ourselves to be put at risk of forever being seen as cesspools in the eyes of the world, and that we strongly reject treating ourselves, our partners, and our communities as just a bunch of nameless objects with no value except for sex. If we don't value ourselves, our brothers and our community, who else will?

Finally, to society at large, I recommend that you recognize the fact that men who love men have been around and will be around forever, and I challenge you to help us to realize our potential to be educated, skilled, productive, and prosperous members of a diverse society. You should want us to be in long-term well-supported relationships, to be happy, and to be healthy. Until you help assure our equal health and happiness, your own health and happiness are in jeopardy. This isn't a threat; almost no one intends to harm other persons. But, we all live in an increasingly interdependent world, and your health depends partly on our comfort in and acceptance by society. No communicable disease, including HIV and all other STD, impacts only one segment of our world. As the global AIDS epidemic has sadly proven, we are all in this together.