San Francisco notes HIV rise in MSM population

About two MSM a day will be newly infected in SF

It wasn’t entirely a surprise given the steep rise in male rectal gonorrhea in recent years, but the numbers still are frightening: San Francisco’s population of men who have sex with men (MSM) is becoming infected with HIV at a much higher rate now than four years ago, according to public health data. In 1997, data showed that 1.04% of MSM became newly infected with HIV within one year; the most recent data put that figure at 2.2%. (See chart on HIV prevalence in San Francisco.)

Source: Draft document by the San Francisco Department of Public Health AIDS Office; Jan. 30, 2001

San Francisco’s total population of gay men is estimated to be 46,800. Of these, 12,786 or 27.3% are HIV-positive. By contrast, the national prevalence of HIV infection is estimated at 0.3%. The city’s 2001 HIV Consensus Panel issued a draft paper on the topic Jan. 30, but has refrained from commenting on what the cause of the sharp increase might be. What the panel will say is that this high rate of new infection will continue unless some major changes are made. For instance, the panel predicts that this year there will be 748 new cases of HIV among San Francisco MSM. Injection drug users will add 144 new HIV cases to the total.

"We know what will happen in 2001 if we don’t do anything different," says Mike Shriver, advisor on AIDS and HIV policy to Mayor Willie L. Brown, Jr. "We’ve been visited by the ghost of Christmas yet to come, and it’s deeply troubling."

Targeted prevention efforts lacking

Shriver points out that the increase in new HIV infection rates does not mean prevention efforts have failed; it only means that not enough national effort has been put into prevention efforts targeting MSM populations, especially directed toward changing behavior among men who already are HIV-positive. "We have put almost nothing into HIV prevention for gay men in this country," Shriver says. "We don’t have incidence rates higher than this because communities have done the best they could with the limited resources they have available, and it’s almost pennies compared to what it should be."

The panel’s data are a conservative estimate that mirrors what many people working on the front lines of the epidemic have seen among their MSM populations, says Brian Byrnes, MPhil, director of prevention services for the San Francisco AIDS Foundation. "We still have a long way to go to fully understand the why’ behind this trend," Byrnes says.

The foundation, which researches the epidemic and provides education to at-risk populations, has collected some data suggesting possible causes for the resurgence in new infections. Despite the general public opinion that gay men don’t care about HIV anymore, this is not the case, Byrnes says. "They care deeply about HIV, but sexual decision-making is becoming increasingly complex as the epidemic changes."

At-risk men have incomplete info about HIV

But they sometimes will attempt to protect themselves through methods they’ve invented based on incomplete information, he explains. For example, a man may decide it’s safe to not use a condom with a man who appears to be in good health. The man may assume that even if his partner is positive, the partner is on antiretroviral therapy, which should make him less infectious. "Men develop their own science and their own facts based on little bits of information they pick up, and it’s usually a science that justifies their desires," Byrnes says. "They create that science in the absence of information, and we need to make information much more available to the men."

In educating men who have sex with men, it’s important to address the myths and spell out details, Byrnes says. For instance, educational materials should discuss pre-seminal fluid and its potential to be infectious. Just as heterosexual men might use the withdrawal method to prevent impregnating their partners, so do homosexual men use the withdrawal method to prevent infecting their partners.

The San Francisco AIDS Foundation began its own campaign on Feb. 1 to attack the myths often held about HIV infection. The campaign includes billboards and posters displayed in areas frequented by gay men. One advertisement will show a picture of two attractive men in an embrace. The picture shows thought bubbles above their heads. One man is thinking, "He’d tell me if he was negative," and the other man is thinking, "He’d tell me if he was positive." Then beneath the picture there is a question: "How do you know what you know?"

Using the medicine-cabinet test

Another assumption men who have sex with men often make is that someone’s HIV status can be guessed by paying attention to certain clues, Byrnes says. A man might say, "I looked in his medicine cabinet and didn’t see any medicine, so he must be negative," Byrnes says. Or an HIV-positive man might say, "Well, I left POZ magazine on my coffee table, so he should know I’m HIV-positive."

While communication skills and assertiveness techniques would appear to be important issues, these skills are not always easy to provide to this population, Byrnes says. "Skills building only works for people who are willing to participate in skills-building exercises."

One of the big hurdles in prevention work is reaching the core at-risk group of MSM who are not interested in learning about HIV or preventing HIV because they are unaware of how their own sexual decisions are placing them at risk, Byrnes says. "So the onus falls back on us to develop fresh and new interventions and go back to our populations and ask what they want from us so we get a better understanding of what they need in order to build better programs," he says. "That’s what this data in San Francisco means to me: We need to learn how to reach those men who are most likely to be one of the 748 new HIV infections this year."

Here are some statistics and details about San Francisco’s HIV epidemic, reported in the city’s draft paper:

♦ MSM and who use injection drugs have an incidence rate of seroconversion that is about twice as high as the seroconversion rate for MSM in general, at 4.6% a year.

♦ Statistics on the transgendered population, representing men who became women, were included for the first time. The new HIV seroconversion rate was an alarming 7.8%, and the total incidence rate was estimated to be 35%. Shriver cautions that these statistics are from one study and therefore may not be confirmed in later data collection.

♦ The number of MSM reporting that they always used condoms during anal intercourse during the last six months has been steadily declining since 1994. (See table.)

100% Condom Use Among MSM
Year 

Number of men interviewed

Number reporting 100% condom use with anal sex

Percent


1994

3556

2474

69.6


1995

3526

2393

67.9


1996

3276

2131

65.0


1997

2544

1546

60.8


1998

2813

1634

58.1


1999

2179

1180

54.2


Source: Data reported in the 2001 HIV Consensus Panel draft paper.

♦ The number of cases of male rectal gonorrhea have more than doubled since 1994, steadily rising each year, beginning with 72 in 1994 and peaking at nearly 200 in 2000.

♦ Another trend that points to the lack of safe sex practices among MSM who already have AIDS shows that the STD incidence rate has nearly doubled from 0.69% in 1995 to 1.37% in 1998, the last reported year.