An overview of presentations presented by New York researchers at Durban
Few Americans who attended the Durban AIDS meeting left without a profound of sense of transformation. AIDS activists marched through the streets of Durban, and the country's newspapers and televisions were dominated by AIDS coverage. The American advocates who attended the meeting spoke of feeling energy similar to the beginning of AIDS activism here, but in a wholly different context and with a wholly different set of challenges. Many left with broadened notions of what is possible in the fight against the global AIDS pandemic.
Unfortunately (and shamefully), many prominent American researchers simply did not go, depriving the conference attendees of their scientific expertise and depriving themselves of an experience of profound importance in the global fight against this disease. Most notable among the no-shows were Dr. Robert Schooley, chairman of the US-funded AIDS clinical Trials Group, the $70 million network that develops new treatments for AIDS and its related conditions, and Dr. Constance Benson, chair of the ACTG's scientific agenda committee.
The lack of high-level scientific participation was evident in the scientific proceedings. The abstracts from the conference are notably light, with most HIV science having shifted to the annual retrovirus meeting held early each year in the United States. Nevertheless, the conference proceedings did contain much behavioral data, and many presentations by researchers from developing countries that discuss the problems and opportunities they face.
Writing about the science at a meeting where context was more important than content required a new approach. To make some sense of the proceedings, this article provides an overview of presentations by New Yorkers who attended the Durban meeting, and has a particular focus on research related to New York's gay male communities.
New York in Durban
Researchers at Columbia University submitted 48 abstracts to the Durban meeting, more than any other institution in New York. The abstracts included several studies of zidovudine use in children born to HIV-infected mothers, and a large number of behavioral studies conducted in an HIV-infected population in the Rakai district of Uganda. Physicians at Harlem Hospital, which is affiliated with Columbia University, reported on a peer support program at their hospital for antiretroviral drug adherence. (Abstract WePeD4577.) The hospital trained 14 HIV-infected peer educators to serve as role models and liaisons with other HIV-infected patients at the hospital. The hospital staff report that, after 14 months, the program has assisted 52 patients, and has been a success.
The New York State AIDS Institute submitted eight abstracts to the conference. One abstract (Abstract ThPeB4982) reported on the progress of a treatment adherence demonstration project that enrolled over 600 HIV-infected patients with advanced immune-suppression. One abstract (Abstract ThPeC5326) described the current epidemiology of perinatal HIV infection in New York, and another abstract (Abstract MoPeC2359) reported on the success of further reducing perinatal HIV transmission in New York, but pointed to a lack of universal prenatal care for all pregnant women as a crucial barrier to further success.
Other abstracts submitted by the state health department looked at the design of HIV prevention programs for older adults (Abstract TuPpD1255) and described prevention projects for transgendered people (Abstract WePeE4927). One abstract looked at HIV RNA viral load levels over time in cohort of 1,284 HIV-infected women (Abstract MoPeB2182). This study found low CD4 levels were associated with the development of AIDS-related conditions, and high viral RNA levels were correlated with faster progression to AIDS. "These findings may help guide HIV treatment strategies" the authors conclude. Another abstract reported on the decline of HIV prevalence among intravenous drug users in New York, and credits this, in part, to syringe exchange programs (abstract MoPpD1124.) The health commissioner of New York reported (Abstract MoPeB2161) on the importance of maintaining confidentiality of state-collected HIV surveillance data.
The New York City Health Department submitted seven abstracts to the conference, two of which (on successes in perinatal prevention and needle exchange) were submitted jointly with the state health department. The city health department presented information on a community-based prevention program for transgendered people (Abstract ThPeD5682.) The city also reported on trends in HIV prevalence among gay men, which is reported below.
The city health department reported a study of foreign-born HIV-infected people in New York City (Abstract MoPeC2360). This is an issue of some considerable importance in New York City, where about 40% of the population is foreign-born. The study found that HIV-infected people who are foreign-born present for medical care at a far more advanced stage of immune suppression. The city health department also reported on the growing number of perinatally HIV-infected children who are living into adolescence (Abstract TuPeC3351). With improved treatments, more than 7,000 HIV-infected children are likely to enter adolescence over the next five years, according to the study.
The city health department reported on trends in AIDS mortality in New York from 1990 to 1998 (Abstract TuPeC3385). During this period, deaths from AIDS declined by 88%, from 406 per 1000 persons to 44 per 1,000 persons, the city health department reported. Deaths from all non-AIDS-defining causes among reported AIDS cases declined by 82% from 74 per 1,000 in 1990 to 13 per 1,000 in 1998, with the largest declines for pneumonia/influenza (92%), infectious/parasitic diseases (89%), malignancy (85%) and cardiovascular diseases (79%). In 1998, mortality from AIDS was higher among females than males, higher among blacks and Hispanics than whites, higher among male heterosexuals than female, and higher among intravenous drug users than men who have sex with men.
New York's Gay Men in Durban
Most observers agree the scientific reports at the Durban conference were light, emphasizing behavioral research over new drug development and basic science. Perhaps that makes all the more surprising the dearth at the conference of behavioral information about the HIV epidemics ravaging New York's gay male communities. Few populations in the industrialized world have HIV prevalence rivaling those of gay men in New York. But this was not evident from reading the scientific reports at Durban. Of 4,958 abstracts submitted for the conference proceedings, only 24 mentioned gay men in New York at all (0.004%), and most of these did so only to say New York's gay men had been receiving too much attention.
Despite all this, a few studies about New York's gay male epidemics were presented. One of the most interesting abstracts on New York's gay male population came from Ron Stall at the University of California at San Francisco. (Abstract ThOrC716.) His team has developed a new method of measuring HIV prevalence and HIV risk factors in gay males using validated telephone survey techniques. Dr. Stall conducted the first household-based sample of gay residents in four cities with a known density of gay men greater than 1.6%, including New York. The researchers use a random dial phone methodology, and a validated interview technique, to determine if the residents reached on the phone are men who have sex with men. The researchers asked about sexual and drug using practices, and also HIV testing and infection. The survey methods have been validated by in-person HIV testing using oral testing techniques in a subset of the sample.
The survey found an overall HIV prevalence of 18% in the complete sample of 2,881 men. Validation by oral HIV testing techniques found these self-reported results to be 100% specific and 98% sensitive. HIV prevalence was significantly higher among men with a history of injection drug use, men who reported at least weekly non-intravenous drug use, less closeted men, men with lower educational levels, African American men, men of middle age or older, and homosexually identified men.
The New York City Health Department reported on HIV seroprevalence trends in men who have sex with men who sought treatment at city-funded sexually transmitted disease clinics from 1990 to 1998 (Abstract WePeC4374). During this period, 3,640 men who have sex with men attended a city STD clinic, 42% of whom were black, 16% Hispanic, 30% white, and 10% of other or mixed race/ethnicity. Two-thirds were over 30 years old, and 19% were over 40. Overall HIV prevalence declined from 47% in 1990 to 19% in 1998, matching the seroprevalence level found in Stall's telephone survey.
Among racial groups, HIV prevalence declined from 34% in 1990 to 10% in 1998 among white men, 47% to 13% among Hispanic men, 56% to 32% in African American men, and 44% to 23% in bisexual men. Men with gonorrhea or syphilis had stable HIV prevalence over the study period, at 40% to 50%. HIV prevalence in men with all other STDs declined from 44% to 15%. HIV prevalence in men with no STD dropped from 48% to 10%. In the study, HIV infection was most heavily associated with black race/ethnicity, age under 25 years, and a diagnosis of gonorrhea or syphilis. Men with gonorrhea or syphilis were less likely to accept HIV testing than men with other diagnoses, gonorrhea was diagnosed four times more frequently in seropositive than seronegative men, and syphilis was diagnosed twice as often in seropositives as seronegatives. The city health department concludes that HIV prevalence in these men has declined significantly during the study period, but wide racial disparities were observed. The health department advises the use of gonorrhea and syphilis as sentinel markers for HIV risk.
Gay and lesbian youth in New York City remain at high risk for HIV, because of their sexual and drug-taking behaviors, concludes Joyce Hunter of the Center for HIV Clinical and Behavioral Studies at Columbia University, who interviewed 72 gay male adolescents and 52 lesbian adolescents. (Abstract TuPeC3485.) The youth, who were recruited through youth services agencies, were asked about their sexual and drug-taking behaviors in the previous six months. The interviews found three-quarters of the young men surveyed had multiple sex partners in the previous six months, and one-quarter had had unprotected anal sex. Among the young women interviewed, one-quarter had had unsafe intercourse with a male partner in the previous six months. Virtually all the youth surveyed (95%) had used drugs or alcohol in the previous six months.
Most gay and lesbian youth in New York who are at risk for HIV infection do not discuss HIV with their sex partners, nor do they disclose their HIV status or enquire about their partner's, concludes Ron Klitzman, another researcher at Columbia's Center for HIV Clinical and Behavioral Studies, who questioned 144 gay and lesbian adolescents (Abstract WePeD4655.) About 60% of the young men and women do not discuss HIV with their same-sex sex partners, and about three-quarters do not discuss HIV with opposite-sex sex partners. One-third of the adolescents usually do not use condoms during anal or vaginal sex, and about one-half use condoms inconsistently. Factors associated with increased discussion and disclosure of HIV among the adolescents was "high self esteem," previous HIV testing history, and discussions with a parent about HIV. The study found no gender differences, except that young males were somewhat more likely to have been tested for HIV.
Young Latino men who have sex with men in New York feel more connected to their ethnic community than to the gay community, and are relatively open with their friends and mothers, but not their fathers, about their sexual practices, concludes A. San Doval, of the Educational Development Center, who surveyed a random sample of 528 young men in New York City. (Abstract ThPeD5602.) The men were recruited at gay venues outside the "central gay-identified area of lower Manhattan." One-third of the men were under age 21, and almost half had been foreign-born. Almost 60% of the young men said most of their friends knew they had sex with men, and 53% said their mothers knew. About one-third felt a strong connection to the organized gay community, and another one-third felt no connection at all. Two-thirds said they felt very connected to their ethnic community. The author concludes ethnic affiliations are strong, pointing to the need to take advantage of these community ties in targeting HIV prevention services.
Gay identity among young Latino men who have sex with men in New York does not promote safer sexual behavior, according to another analysis of the same survey population by the Educational Development Center (Abstract WePeD4749.) Over half of the sample had a high school education or less, most (70%) identified as gay, 21% identified as bisexual, and the rest were unsure. Unsafe sex was very common. Three-quarters of the men had unsafe anal sex with another man within three months of the survey period. No differences in behavior were found between gay-identified and bisexual men in this survey.
This article was provided by Gay Men's Health Crisis. It is a part of the publication GMHC Treatment Issues. Visit GMHC's website to find out more about their activities, publications and services.