Across the pond earlier this week, in the pages of the Guardian, journalist and epidemiologist Elizabeth Pisani provoked a debate about an emerging theory to test and treat our way out of the AIDS pandemic. One passage captured my attention, and sent me searching for recent HIV stats.
Let's go over a few key sentences. Pisani wrote:
A few years after antiretrovirals became widely available, new infections among gay men in the UK began to rise.
The slide below, from Britain's Health Protection Agency, shows there indeed has been a troubling rise in new gay HIV diagnoses, which peaked in 2007 and appear to be on the decline.
However, look at the dark purple line, which represents the number of straight people from abroad and their HIV diagnoses. Their stats are much larger than those for gays, but Pisani omits this info. She also exclude mention of the rise in domestic straight diagnoses, seen in the yellow line.
And UK straight HIV figures, unlike the gay or straight foreigners HIV numbers, seem to be on the rise.
More from Pisani:
We've seen the same [rise in gay HIV infections] in Australia, the United States and practically everywhere else we have data.
Here's a recent chart from a collective of Australian public health and private advocacy organizations issued for World AIDS Day:
Looks to me like HIV infections in Australia peaked in the 1987, with a slight increase starting in 2001, and maybe going down in 2007. Yet Pisani says not a thing about the highest figures showing up two decades ago.
And what about the United States and its HIV transmission rate, where gay men comprise the majority of HIV infections? The chart below is from the Centers for Disease Control and shows a serious drop in transmissions, which the CDC heralded thus -- Dramatic Declines Indicate Success in U.S. HIV Prevention.
Here's the good news from the CDC that accompanied the chart:
Since the peak level of new infections in the mid-1980s, just prior to the introduction of HIV testing, the transmission rate has declined by approximately 89 percent [...] Over the last decade, as prevention efforts have been expanded and improved treatments for HIV became available, the transmission rate has declined by 33 percent [...]
I am troubled that Pisani singled out gay HIV stats in the UK, while totally ignoring the larger stats for straight foreigners and the surge in stats for domestic native-born straights. Why isolate out only the gay numbers?
And why does Pisani not report that for Australia and the U.S., overall HIV infections and transmissions, of which gay men make up the bulk of the caseload, hit a high long ago?
Troubling as her presentation of selective stats is, it is also problematic what she says here:
One reason for [increases in HIV] is that gay men use condoms less now than they did when HIV = Aids = a horrible death. Now, though, HIV = a pill every day. Boring, but not the end of the world, unless you're the taxpayer picking up the tab for it or the epidemiologist worrying that drug-resistant strains of HIV will reignite Aids.
Sorry, but I can't detect an ounce of any happiness that gay are not dying quickly and horribly as in the days before AIDS cocktails. A great medical advance, deflecting opportunistic infections and prolonging life, for Pisani, boils down to a big bore.
Maybe she's implying that for gay men living with AIDS, who are staying alive and leading productive lives, that it's boring for us. Or that we don't give a damn about taxpayers, which, in case she hasn't heard includes gays and people with AIDS, paying for our healthcare needs.
Does Pisani bemoan taxpayers footing the bill for diabetics who need insulin or people at-risk of heart attacks getting government funded cholesterol lowering drugs?
Sure, I'll cut Pisani a bit of slack here and offer up that perhaps she's really not expressing nostalgia for the bad old "fags dying like flies" days before protease inhibitors. She doesn't want a return to daily funerals for gay men dead of AIDS.
But what I hear in her words regarding a lot fewer quick and horrible deaths, is something I've heard too often from public health and AIDS Inc folks in the US. And that is a none-too-subliminal desire for the old times, when fear stalked the sexually active gay male community, and effective treatments didn't exist.
I wish Pisani and others would stop blaming gay men for being human, with the same sexual desires as straights, and give us the credit we deserve to all the beneficial things the gay community has done to combat AIDS over nearly three decades.
On a personal note, let me say I like Pisani and spent a short amount of time with her when she passed through San Francisco in 2008, promoting her book "The Wisdom of Whores." What impressed me was her grasp of many HIV and gay issues specific to this city. For a smarty-pants who doesn't live here, she sure had a lot of knowledge about local stats, programs and some of the key players.
I don't believe she is homophobic, but she may suffer from the public health officials' syndrome that doesn't allow for any praise of good efforts made by gays to control HIV. Over the years, I've heard from too many experts who only know how to wag a finger of shame at gays and others at-risk of HIV, while never being able to offer a pat on the back.
Would it kill Pisani and her colleagues to once in a while find reason to praise gay men and our contributions to battling AIDS across the planet? We might listen more to what she and colleagues have to say, if they were more balanced in praising and, when necessary, offering up constructive criticism.
this note was emailed from longtime DC-based HIV reporter bob roehr:
All of the statistics of DIAGNOSES, particularly the ones prior to about 2000 are laden with LOTS of social factors. For instance, the early peaks of both HIV and AIDS diagnoses are strongly influenced by the availability of tests (and standard vs rapid); a reason to get tested (if you can't do anything about it, why get tested); and the availability of treatment.
The backlog of infections accounts for the early peak of HIV diagnoses. The availability of HAART accounts for the decline from peak of the AIDS diagnoses.
What really matters are new/recent infections and only the last chart addresses that. Much of the decline from peak is explained by gay men practicing safer sex, long before the availability of a test or treatment.
This post isn't very fair. I've read Pisani's book and she repeatedly praised the efforts of gay men in fighting HIV/AIDS in developed countries. She also argued that HIV in other parts of the world can't always be addressed by empowering the gay community. In a countries where drug use or prostitution or the sexual habits of heterosexuals are the leading cause of HIV, basing prevention on what has worked in developed countries doesn't make a whole lot of sense. Also see:
Insinuating that she somehow is "expressing nostalgia for the bad old 'fags dying like flies' days before protease inhibitors" is contrary to everything of hers that I have read.
Michael, you have misinterpreted the Australian data somewhat. The number of HIV diagnoses in Australia peaked in 1987, but this is not the same as new infections.
The HIV test became widely available in Australia at the end of 1986, which explains the spike in diagnoses in 1987. Many (probably most) of these cases would have been infected for several years prior to diagnosis.
More recent Australian surveillance data includes the date of last negative test, date of presumed HIV acquisition and we also collect separate data on 'newly acquired HIV infections' as well as HIV diagnoses.
As in the UK, HIV infections fell dramatically over the first 15 years of the epidemic, and here they reached their lowest point in 1999. Since then, the number of new infections has slowly risen, from a low of 718 (in 1999) to 995 (in 2008). That's a 38% increase in the ten-year period.
I think you're wrong to compare the low level of infections achieved after 15 years of safe sex advocacy to the high level that occurred before safe sex was commonplace. And I think Pisani is right to point out that in western countries (especially those, like the UK and Australia, that have publicly-funded universal healthcare programs) that AIDS is over.
Here in Oz we have almost 20,000 people living with HIV, and last year we recoded about 200 deaths, of which fewer than 40 were due to AIDS-related causes. I didn't read in Pisani's article any 'nostalgia for the bad old days' – I think that's an offensive observation to make.
The truth is that we need a new engagement with HIV prevention that acknowledges and celebrates the reality that an HIV infection is no longer likely to be a death sentence, and moves on from the 'use a condom or you'll die' messages that are still disturbingly prevalent.
Something to keep in mind is that HIV transmission rates in the U.S. are very close to the averaged failure rate of condoms. And the brand with the largest market share in the U.S., has higher than average failure rate (and was much worse in the early 80's).
Since studies have indicated that HIV+ people who are on the antivirals and have suppressed viral loads (<50) are essentially noninfectious, the focus on gay men is a mistake.
The focus needs to be, as it always should have been, on people of any demographic who engage in unprotected sex. It means that the plethora of birth control pills marketed to heterosexual women are irresponsible at the very least.
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