New S.F. HIV stats released; leveling off reported

July 8, 2002

Dear friends:

Two years ago the San Francisco Chronicle generated tremendous global news coverage about the city's newest HIV/AIDS estimates. What fueled many of the stories was a quote from a San Francisco department of public health researcher who alleged the estimate of new HIV infections for 2000 were "sub-Saharan levels of transmission." This quote conjured up images of caskets for the AIDS dead lining Castro Street.

But now, according to the latest annual HIV/AIDS epidemiology report from the DPH, gay and bisexual men's HIV transmission rates may not have been increasing at an alarming level.

"Data from 2000 (available for January to September only) suggest that HIV incidence may have leveled off from that observed in 1999. However, the estimate, 3.9% per year, is still significantly higher than 1996 to 1998. Findings remain to be confirmed with complete data for 2000 and 2001."
(Source: Chapter 9, HIV/AIDS among Men Who Have Sex with Men)

How can the DPH come along, after planting the notion that HIV among gay in San Francisco was rising, and present limited evidence that suggests rates may have actually leveled in 2000? Sure, the department has data from only three quarters under scrutiny in this passage, but I don't expect the final quarter for 2000 will show a wild upsurge in HIV for gays. Plus, just mentioning now that there may have been stable HIV rates two years ago is a subconscious admission from DPH that their claims back then may have been hype, unproved by hard facts and epidemiology.

I've gone over the new report since it was released on June 25 at a news conference and have excerpted the sections that most interest me. After the excerpts, I've commented on the information presented. Unfortunately, the DPH has not yet posted the report on their web site, but copies of the report can be obtained from the epidemiology department of the DPH's AIDS Office. Contact information is available at: http://www.dph.sf.ca.us/Reports/HlthAssess.htm.

I hope the skeptical writers who looked at the alarming sub-Saharan allegations of two years ago re-visit the story. C'mon Paul Varnell, Patricia Nell Warren, Peter Cassells, Andrew Sullivan, Bob Roehr. There's a story or a column waiting for you in the new San Francisco HIV/AIDS Epidemiology Annual Report.

In closing, I think it speaks volumes about the lazy approach the NY Times, the SF Chronicle and other news outlets have toward AIDS reporting. Two years ago, these papers fell over themselves to write scarier-than-thou stories about Botswanan winds of AIDS devastation sweeping down Castro Street. Now, silence about the new HIV report for the city. When will we get the follow up stories regarding the claims of 2000 by DPH?

--Michael Petrelis
San Francisco, CA

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All citations in quotes are from the San Francisco HIV/AIDS Epidemiology Annual Report
2001


"While it is extremely beneficial to increase the life expectancy and quality of life for person with HIV infection and AIDS, an effect of the improved survival has been that HIV infection is not frightening to most people as it was prior to the improved therapies. Thus, uninfected persons may be less fearful of acquiring HIV infection and therefore more likely to engage in high-risk behaviors. Recent evidence points to continued increases in sexual risk behavior in the population most severely burdened by AIDS in San Francisco -- men who have sex with men (MSM). Consider the indicators from diverse sources in aggregate: male rectal gonorrhea continues to increase; syphilis is exponentially expanding among MSM; sexually transmitted diseases among MSM living with AIDS are increasing; the frequency of anal sex; unprotected anal sex, and unprotected anal sex with partners of unknown HIV serostatus are increasing; and HIV seroconversions among MSM are increasing or remaining high."
(Source: Executive Summary)

[The DPH is disappointed people with AIDS aren't dying like they used to, because then the DPH could use the dead and dying in its HIV prevention programs. It is so offensive and pathetic that the downside to people with AIDS staying alive is how it hinders DPH HIV efforts. In a sense, DPH is saying why doesn't someone like Wall Street Journal reporter Michael Waldholz die of AIDS so the DPH can use his death to make AIDS frightening again to gays. The DPH wants more dead AIDS patients so uninfected people will be fearful. These researchers are sometimes so twisted in their illogic, as this excerpt shows, in my opinion. --MP]


"Table 1.3 presents estimated sizes of populations at risk for HIV, the number of persons living with HIV and the projected number acquiring HIV in the year 2001 in San Francisco. The table is identical to that included in our 2000 Annual Report as a summary of the work of a panel of experts meeting in 2000 and 2001. Estimates are not updated every year, but rather every few years when substantially new data become available."

[Oh? Are we now living in a resource deficient region of the world? Why can't DPH update its Table 1.3 annually? Not enough money and researchers? They could at least update the estimates in this important table consistently, say every two years. Something more solid than "every few years." --MP]



"Unfortunately, recent data on sexual behavior and sexually transmitted diseases show continuing increases in risk for HIV among MSM in San Francisco. In particular, male rectal gonorrhea and primary and secondary syphilis among MSM continue to increase into 2002. the weight of evidence suggest that the projected number of new infections among MSM in 2002 will not decrease over those estimated for 2001 and may actually be higher."
(Source: Chapter 1, Overview of HIV/AIDS in San Francisco)


[I will shout it loud and proud until I am hoarse: male rectal gonorrhea is up due to increased testing. The DPH and news reporters conveniently overlook this fact. All one need due to check this fact is read the annual STD reports issued by the DPH. Look at the section on rectal gonorrhea. Here is some of what you'll find. "http://www.dph.sf.ca.us/Reports/STD/SF%20STD%20Annual%20Summary%202000.pdf

San Francisco Sexually Transmitted Disease Annual Summary, 2000

Section J
Rectal gonorrhea
Page 70

[snip]
The majority of these cases are reported from City Clinic: the proportion of cases seen at the clinic increased from 67 percent in 1996 to 74 percent in 1999. In response to the city-wide increases seen in 1995, we began testing more MSM seen at City Clinic for rectal gonorrhea (since infections may be asymptomatic): the number of tests increased from 542 in 1995 to 1285 in 1999 while the number of male visits per year remained approximately 11,000. This increase in screening could be expected to increase the number of reported cases. The number of cases with symptoms did not change between 1996 and 1999, which indicates that the increase in cases may be due to the increased number of tests. Since men with proctits would most likely seek medical care, the trend in proctitis cases may be a better marker for trends in unprotected anal intercourse among MSM." --MP]




"The proportion of deaths in which HIV/AIDS was listed as an underlying cause of death decreased from 87% of AIDS deaths occurring between 1993 and 1995 to 71% in 1999. (Table 4.2). The other frequently cited underlying causes of death in 1999 include non-AIDS cancers, 6.2%; drug overdose, 3.7%; heart disease, 3.2%; liver disease, 2.5%, and suicide, 2.2%. The proportions of person with AIDS died of these non-HIV/AIDS related conditions increased over time. Although infrequent, cardiomyopathy was listed as a cause of death in 1.5% of deaths in 1999 compared to less than 0.5% of deaths in earlier years this may reflect an increase in deaths from HAART-related cardiomyopathy."

"Table 4.3 summarizes multiple causes of death among persons with AIDS including both underlying and contributory causes of death. Although persons with AIDS predominantly died of HIV/AIDS-raeleated causes, the increasing proportion of deaths due to non-HIV/AIDS-related causes suggests that certain high prevalent risk behaviors in this population are playing an important role in mortality trends. Co-infection with HIV and hepatitis viruses may be related to deaths associated with lung cancer, obstructive lung disease, and coronary disease."
(Source: Chapter 4, Trends in AIDS Mortality)


[It appears as though the side effects of the anti-AIDS drugs are an underlying reason behind some increases in AIDS mortality. --MP]


"The majority of persons with AIDS in San Francisco have received antiretroviral therapy and the proportion of persons with AIDS on therapy has been increasing since 1996. Between 1996 and 2001, the use of highly active antiretroviral therapy (HAART) increased substantially (Figure 6.1). By the end of 2001, 87% of persons living with AIDS had received some form of antiretroviral therapy and 71% were noted to have received HAART.
(Source: Chapter 6, Use of HAART among Persons Living with AIDS)


HIV prevalence and incidence data;
Anonymous Counseling and Testing Data

"Data originate from persons seeking voluntary HIV counseling and testing at anonymous sites in San Francisco. The data may therefore not be representative of the wide MSM community as a whole. HIV prevalence is measured as the number of MSM testing HIV antibody positive divided by the total number of MSM testing and presented as the percent living with HIV each year. HIV incidence is estimated using STARHS (see Technical Notes) and is presented as percent acquiring HIV per year."

"In general, there has been an increase in HIV prevalence and incidence among MSM seeking anonymous HIV testing in recent years (Figure 9.3). This increases is corroborated by recent rises in sexual risk behavior and sexually transmitted diseases in the city. Data from 2000 (available for January to September only) suggest that HIV incidence may have leveled off from the that observed in 1999. However, the estimate, 3.9% per year, is still statistically significantly higher than 1996 to 1998. Findings remain to be confirmed with complete data for 2000 and 2001."


[What the hell has happened to the claims of sub-Saharan levels of new HIV infections? Seen any follow up stories in the NY Times or the SF Chronicle about what HIV reports now show for 2000, when the papers were heralding the dawn of sub-Saharan rates of HIV in San Francisco? For the DPH to somewhat casually mention that HIV rates for gays may have leveled off is a backing off from the alarms of 2000. If the DPH can't locate evidence two years later to back up the alarm, questions must be raised about estimated HIV rates two years ago and today in San Francisco. --MP]



The Asian Counseling and Testing Survey

"In 2000 and 2001, a survey of approximately 500 Asian/Pacific Islander (API) MSM aged 18 to 29 years was conducted by recruiting persons at randomly selected community venues (gay-identified, bars, gyms, bookstores, etc.) and on streets in gay neighborhoods at randomly selected time periods. The survey is the largest of its kind conducted in the US to date."

"HIV prevalence was 3.1% among API MSM age 22 to 25 years and 2.9% among API MSM age 26 to 29 years (Figure 9.6). No HIV infection was detected in the youngest group of API MSM, age 18 to 21 years."


[No HIV infection was detected among young Asian gays? Sound like good news to me. And I thought young gays in general, and young gays of color, in particular, were getting HIV at alarming rates. Maybe they aren't, if we apply this glimmer of hope to apply to a larger pool of young gay Asians across the county. --MP]


Sexual risk behavior data

"Trends in sexual risk behavior are tracked through data collected by the Stop AIDS Project, a community-based organization providing HIV prevention education to MSM. Two indicators of sexual risk behavior among MSM are presented: the percent of respondents reporting unprotected anal sex in the last six months (Figure 9.8) and the percent of respondents reporting unprotected anal sex with multiple partners; that is, two or more partners in the last six months (Figure 9.9). As illustrated, both measures of risk for HIV have increased from 1998 to 2001. (Of note, figures differ from those presented in the 2000 Annual Report because the denominator includes all respondents; data presented in the 2000 Annual Report included only first time survey respondents and only persons who reported any anal sex. Overall trends remain consistently upward regardless of sub-analysis.)"


[Oh, puh-leeze Louise! Do not come by peddling your Stop AIDS Project "research" into the sexual risks of gays without acknowledging that the agency's own workers, along with DPH prevention workers, freely and publicly declare themselves engaging in sex without condoms, with multiple partners. It is obscene the DPH and Stop AIDS Project "study" high risk sex among gays and then present the findings to the public, without a whisper about their own employees doing the same thing!
--MP]


(Source: Chapter 9, HIV/AIDS among Men Who Have Sex with Men)


HIV prevalence and incidence data;
Anonymous Counseling and Testing Data

"HIV incidence has been 0% per year from 1996 to 2000; that is, no recent HIV infections have been detected among non-MSM IDU seeking anonymous HIV testing."

(Source: Chapter 10, HIV/AIDS among Injection Drug Users)

HIV prevalence and incidence data;
Anonymous Counseling and Testing Data

"HIV incidence has been 0% per year from 1996 to 2000; that is, no recent HIV infections have been detected among heterosexuals seeking anonymous HIV testing."

(Source: Chapter 11, HIV/AIDS among Heterosexuals)

HIV prevalence and incidence data;
Anonymous Counseling and Testing Data

"HIV incidence has been 0% per year for most years."

(Source: Chapter 12, HIV/AIDS among Women)


[All those zero percents forces me to wonder: whatever happened to the claims of sub-Saharan rates of new HIV infections in San Francisco? How do you have an epidemic of apocalyptic proportions with so many zeros, a report of a leveling off of HIV, and rectal gonorrhea rates have increased due to more tests for it performed? --MP]