May 24, 2002

This is the fourth in a series of articles about HIV, STD and gay and bisexual men. So far this year, I've written about Shigella, a bacterial disease of the intestines which causes diarrhea, abdominal cramps, and fever. Shigella can be acquired from having sex with other infected persons and has increased among gay and bisexual men (G/BM), starting last year. In February, I wrote about my own health with HIV infection, the considerable hassles of being HIV-infected and having to strictly adhere to medicines, and noted that the medicines themselves have caused me big problems. The third article focused on the very high rates of sexually transmitted diseases (STD) in gay men and some of the reasons offered for why we have so many partners which put us at risk.

This article describes local responses to the upswing in STD in G/BM in more detail, reasons being offered for why STD have been rising again to pre-AIDS levels in G/BM, and includes findings from a local rapid survey done last spring by anthropologists from the US Centers for Disease Control and Prevention (CDC).

Public Health Responses to Resurgent STD in G/BM, 1997 - present

STD in G/BM started to rise again in 1997. Initially, we thought that this might just be a transient rise that would cease, returning the rates to their prior relatively low levels. Nevertheless, at the close of the year in December, 1997, Public Health decided to announce via the general media that STD rates had increased in G/BM, and we took steps within the public health STD program to intensify services.

By late 1998, however, it seemed clear that the STD increases were being sustained, and so Public Health started to pursue additional steps to reduce these rates. We wrote articles for the King County Medical Society and CDC's Morbidity and Mortality Weekly Report, alerting public health and private providers (locally and nationally) to these rising rates. In addition, a "Bath House Coalition", which had been meeting since 1996 for HIV prevention work, decided to take action. This group included people from Public Health, Lifelong AIDS Alliance (LAA), Gay City, the UW HIV Net, and bath owners and managers. This coalition:

• Worked with the Public Health HIV counseling & testing staff to get us to add routine STD screening to the HIV testing efforts we had already begun in the baths. (It was becoming clear that many of the G/BM with STD also carried HIV infection, and that a sizeable share of STD transmission was occurring in bathhouse settings.)
• Developed alerts on the increasing rates of syphilis and developed signs for the baths to increase sexual safety.
• Held a drug company supported dinner meeting in August of 1999 for HIV prevention advocates and major providers of care to people with HIV/AIDS. The dinner brought together about 80 persons to review the problem of increasing STD in G/BM and to identify possible solutions.

Other community-based agencies also took action:

• An April, 1999 Gay City Forum on the topic of bare-backing provided an opportunity to hear from a large number of gay community members and to survey those present about increasing risk behavior.
• LAA created a new "STD in Wonderland" brochure to help educate people about these diseases and alert them to increasing disease rates.
• STD trainings for HIV prevention outreach workers were set up in early 2001.

These efforts resulted in additional articles in the general media (e.g., in the Seattle Times on 9/10/99, 5/10/00, 3/15/01, and 4/13/01).

An MSM-STD Summit Meeting, December 1, 2000

In mid-2000, as this problem wasn't going away and syphilis rates were back at pre-AIDS levels, Dr. Alonzo Plough, Director of Public Health - Seattle & King County requested that a community meeting be held. To assess this idea and build support, I then began a series of meetings with key G/BM and HIV/AIDS community leaders during the summer, and by the fall a planning group had come together to fashion a larger "Summit" meeting, scheduled for World AIDS Day (December 1st) 2000. Everyone at this point felt that for us to succeed in reducing STD rates back to the levels achieved in the mid-80s, there would need to be clear understanding of the problem and some innovative community-driven (not just public health) solutions. At the same time, we recognized that the G/BM community was not a single, cohesive whole, but instead composed of many segments which should each be represented. The planning group tried to identify key segments, the possible leaders of each, and determined the agenda for the day-long Summit meeting.

Some 70 persons ultimately attended, including people from key HIV/AIDS community-based organizations, gay businesses and media, bath owners/managers, grassroots leaders, Parents & Friends of Lesbians and Gays, and local and state STD & HIV researchers and prevention leaders. The goals of the Summit were to get community-based organizations to revitalize their prevention efforts, to create agendas designed to address the epidemics of HIV and the re-emerging STD, and to provide to public health community input on using staff and fiscal resources in the most effective ways possible.

After a morning of data presentations, participants broke into five smaller workgroups organized by topics. Below are the five group topic areas and the resulting recommendations (bulleted) that participants reviewed at the end of the day. In italics I also provide an update on the progress to-date on each of these recommendations: (For readers interested in more details, the final summary of this conference is available on the HIV/AIDS Program website at www.metrokc.gov/health/apu.)

1. Are HIV & STD Services Adequate and Appropriate?

• Public Health should develop & disseminate clear STD screening guidelines to providers and to at-risk communities.
  In March 2001, Public Health issued new STD Screening Guidelines for gay & bisexual men, and distributed these to practically all care providers in Seattle & King County.
  
  
• Public Health should identify & select appropriate clinic services and best delivery sites based on data pertaining to the number of STD and HIV cases found, and clients' preferences.
  In the fall of 2001, the HIV/AIDS Program's Clinical Services staff (primarily providing HIV counseling & testing) were consolidated with similar staff in the STD Program, and moved to the Harborview STD Clinic site. Based on STD and HIV case-finding data, bathhouse services have been substantially increased.
  
  
• Public Health should implement new approaches to service delivery with input from at-risk communities. For example, since the former partner notification and outreach services are not working well to identify new cases, Public Health should explore new ways to find exposed and high-risk persons.
  In 2001, the STD Clinic implemented a peer recruitment model to recruit high risk person for screening.

2. How can emotional and substance abuse issues be better addressed?

• Using community driven approaches, with Public Health as a catalyst, develop new and revamp current programs to emphasize G/BM emotional health, and to highlight depression and substance use as co-factors for risk-taking.
  
  
• Identify collaborative partners, such as alcohol companies, to fund programs.
  
  
• Convene a community coalition to better integrate emotional health and substance use into HIV/STD prevention.
  In July, 2001, Public Health asked for agency proposals to help us facilitate an "MSM-STD Task Force". Lifelong AIDS Alliance, the only applicant, was funded to work with Jim Jorgenson, the HIV/AIDS Planning Council's Facilitator, to promote the work of this group which got started in October, 2001. The Task Force has three subcommittees: the first focusing on the development and dissemination of new prevention messages, a second on coordinating Task Force efforts with community-based STD/HIV prevention providers, and the third on identifying leadership within the various constituencies of the MSM population so as to rally their support and involvement in prevention efforts.
  
  Readers interested in participating in this important Task Force are invited to contact: David Richart, Director of Prevention Education, Lifelong AIDS Foundation, 206-957-1700.

3. How can we better address risks in bathhouses and other sex environments?

• Expand the bathhouse coalition to include other venues and bar owners.
  
  
• A community coalition (see above) should develop a prevention agenda and recommend specific HIV prevention efforts for implementation.
  
  
• Prevention services in bath settings should expand and have increased resources.
  Staff has been re-deployed; see the second bullet under the first group's recommendations.

4. How best to use the media and community leaders?

• Target HIV-positive and HIV-negative G/BM with messages around the importance of disclosing one's HIV status to potential partners.
  
  
• Coordinate HIV/STD prevention messages between agencies.
  
  
• Acknowledge that community norms have shifted, universal condom use is not now the norm, and that G/BM use a "risk calculus" to make decisions about risk behaviors.
  All three of these recommendations are being considered by the new MSM-STD Task Force.

5. How can we increase resources to address HIV/STD prevention?

• Protect and maintain current HIV/AIDS funding; review & realign current programs with evidence-based practices.
  This recommendation prompted efforts this last legislative session to get the Legislature to resist Governor Locke's proposed $1 million cut to AIDS Omnibus resources; it received the attention of the state Department of Health's Omnibus Study Committee in 2001; and drove action by Lifelong AIDS Alliance, Public Health, and other agencies and individuals to resist cuts. Additionally, the HIV/AIDS Planning Council work continues to prioritize resources for HIV prevention, based on best evidence.
  
  
• Convene broad based coalition to develop funding proposals. This recommendation was forwarded to the MSM-STD Task Force.
  
  
• Work to assure use of HIV care resources to target positive men with prevention messages.
  This recommendation helped spark work done by the HIV/AIDS Planning Council, including dissemination of a "Collaborative Needs Assessment" to local care providers who are now being offered additional educational opportunities to learn about prevention and its incorporation into on-going care for people with HIV.

Local Explanations for Resurgent STD/HIV

This section summarizes the reasons given for resurgent STD and HIV in G/BM, including local evidence presented at the December 1st, 2000 Summit. We generated these data and hypotheses through various local studies. Readers who would like additional detail on the studies and details should contact me directly. Here are some of the findings:

• HIV-positive G/BM report engaging in more risky behaviors than G/BM who are not infected with HIV.
• Drug use (especially use of crystal and poppers) is strongly associated with risk-taking and STD.
• HIV-positive individuals may engage in their most risky behavior with other HIV-positives, suggesting that while STD have increased in recent years, the risk for new HIV transmission may not be as great as we fear; however,
• HIV-positive G/BM are not just having sex with other positives, but also report sex with other men who are either HIV-negative or whose HIV status is unknown.

In addition to the findings of these studies, other researchers and community leaders have offered additional thoughts for this widespread problem of increasing and unprotected sex:

It may be that people infected with HIV who formerly were not feeling very well or sexual are now much better on the new anti-retroviral drugs - more able and eager to have sex.

Another explanation is that people with HIV who are benefiting from the new drug cocktails (as shown by consistently low viral load levels in their blood) might feel that they are less of a danger to others and therefore don't need to worry as much about sex which might transmit infection. Even though public health has cautioned that drugs which control HIV in the blood do not always work to control HIV in semen and other body fluids; nevertheless, there is gradually accumulating evidence that effective treatment can reduce HIV transmission generally.

Many people think that both HIV-infected and HIV-uninfected G/BM are burned out on HIV/STD prevention. They argue that this epidemic has now gone on over two decades - long past it's projected end - and that G/BM just can't restrict their need to have sex, and unprotected (more natural) sex any longer.

Finally, some believe the continued messages to promote sexual safety from public health and many community agencies have lost their poignancy after all these years and that entirely new approaches are needed.

Anthropologists Assess the Community: What do WE think is
going on?

Finally I'd like to summarize the findings and recommendations from a recent study of the STD situation here in Seattle G/BM. At the request of Public Health - Seattle & King County and the Washington State Department of Health, CDC anthropologists came to Seattle in March, 2001 to ask the community about STDs. The anthropologists interviewed 40 community members and key public health and community agency leaders. Their purpose was to identify and explore factors influencing the higher rates of STD here in G/BM and to recommend ways to improve STD and HIV control. Their findings addressed a number of factors:

1. Seattle's Gay Community is "comfortable but clicquish".
   That is, G/BM here felt relatively strong support from the general community, but we were seen as existing in a lot of often poorly connected groups, including club boys, leather men, bears, punks, MSM of color, etc. This left some G/BM feeling isolated and depressed.
   
   
2. Sexual behavior and STD spread are fostered by placing responsibility for disclosure about HIV testing and status on the other person, by fears about a loss of privacy, and by lack of consistent condom use. Perceptions about what's acceptable sexually seemed to include reduced concern about STD and condom use, including less use of condoms than in earlier years of AIDS, increasing sex and lack of protection by those with HIV, perceptions of HIV & AIDS as a less threatening disease now, and the constantly changing membership of our G/BM communities, as people newly arrive while others move away to other cities and regions.
   
   
3. HIV/AIDS Fatigue & Complacency. G/BM reported being tired of prevention messages, and although still concerned about HIV/AIDS they appeared to have much less concern and understanding about STD. Although some G/BM don't care as much about HIV/AIDS (which some now see as only a minor problem), G/BM didn't like being called "complacent", and thought instead it was the prevention and care systems which had become complacent.
   
   
4. HIV Prevention & Care Changes. GBM said that prevention programs are less visible in recent years, and that there were many more sources of care for G/BM than in earlier years. However, care providers rarely ask about sexual safety, the need for STD screening, or about how partners are being protected.
   
   
5. Public Health Access Issues. GBM noted that there are barriers to HIV and STD services, including the sometimes long wait for counseling and care, limited clinic hours, the lack of clinic staff who are also persons of color, the fear of being scolded for risk behaviors, and the need to meet eligibility requirements in order to receive services.
   
   
6. STD Knowledge & Awareness. Many G/BM and their service providers know little about many of the STD and about the recently increased risks for STD. Persons also mentioned high levels of stigma people feel about many of these conditions, especially syphilis.
   
   
7. Internet and Travel. More and more G/BM are finding partners via the Internet, as rapid ways to hook-up. While this might increase risk taking opportunities, chats also offer chances for people to discuss disease status and desired protections.

Where Do We Go From Here?

The purpose of this 2002 series of articles has been to demonstrate the existence of a very serious problem facing our gay and bisexual men, locally and indeed globally. STDs have risen to levels that are again very high, syphilis levels are what they were prior to the state of the AIDS epidemic, and about three-quarters of the G/BM with syphilis tell us they're also infected with HIV. Reported numbers of sexual partners have risen, and condom use has declined.

Several North American cities have presented convincing evidence that a second wave of HIV infection is spreading among G/BM, and the San Francisco estimate of the number of new HIV infections expected this year is double (800) what they projected some years ago (400). Our data suggest the likelihood of a second wave of HIV here as well. This is tragic on top of an estimate that about 1 in 7 G/BM (~14%) are already HIV-infected.

I have begun this series to stimulate discussion in our G/BM communities, and would welcome readers to respond to the Seattle Gay News or to me directly (email me at bob.wood@kingcounty.gov; snail-mail address: HIV/AIDS Program, 400 Yesler Way, Suite #300, Seattle, WA. 98104.) For the fifth, and last, article in this 2002 series it is my intention to make some "prescriptions" for G/BM and our communities. Expect to see the next article in this series around the time of our celebration of Gay Pride.