February 11, 2003
Why is it that inner cities seem to be the epicenters of the U.S.' HIV epidemic? Our nation's prison system may be a key piece to the puzzle. The problem is not that unsafe sex is rampant within the system, according to David Wohl, M.D., assistant professor of medicine at the University of North Carolina-Chapel Hill, and colleagues. Rather, it's the unsafe sex that occurs immediately after prisoners are released back into society that is cause for concern. Tragically, he notes, there's a tremendous amount we can -- but don't -- do to lessen the health risks that ex-prisoners pose to those around them.
Wohl's study1 focused on a group of 80 HIV-positive inmates in North Carolina prisons. The prisoners -- 87 percent of whom were non-white, and more than half of whom were women -- were incarcerated for one-to-two-year periods, typically for drug-related crimes. (Eighty-four percent reported crack-cocaine use before going to prison; 29 percent had used injection drugs.) The researchers provided the prisoners with intensive case management and care referrals while they were jailed, and followed up with phone interviews after their release. The interviews took place, on average, five weeks post-release.
Not surprisingly, the investigators found that when these prisoners were released, they almost immediately sought out sex -- sometimes within the first few hours. About half of the former prisoners in the study reported having sex. Their average wait? Six days. Disturbingly, almost a quarter of the releasees said the sex they had was unprotected.
Just as alarming, 64 percent of the releasees said that their main sex partner was HIV negative or of unknown HIV status. Thirty-one percent of respondents admitted that it was very or somewhat likely they'd infect their partner with HIV.
The ramifications, Wohl notes, stretch far beyond this narrow population of former prisoners. "Persons with HIV infection who have been released from prison fuel the HIV epidemic in the communities to which they return," he said -- in the case of this study, a group of fairly metropolitan, heavily minority areas in North Carolina. When sex partners are reunited after being broken up by a prison sentence, Wohl says frankly, sex is going to happen. This study suggests that sex is often going to be high-risk as well.
Wohl reported that surprisingly few prisoners -- only three, in fact -- had sex while they were in prison. They remained, for all intents and purposes, faithful to their partners who were waiting outside the prison walls. (Whether those partners were themselves faithful is another matter open for debate, and one beyond the scope of this study.) When the former prisoners were then reunited with their partners -- it's worth noting that 81 percent of these releasees were heterosexual -- sex was bound to happen, and it was frequently unprotected. The risks of HIV passing between partners is significant, as are the risks of HIV then being passed on to additional partners in the future. What Wohl describes is essentially a spiral of risk that can easily consume an entire inner-city community.
Imprisonment "disrupts the social and sexual networks within the communities," Wohl says. "There are communities that are just blighted by incarceration -- and they happen to also be communities that are blighted by HIV. We don't think it's an accident."
The upshot, Wohl concludes, is that prevention efforts need to target not only HIV-positive prisoners, but also their partners in the community at large. "You have people that are coming in [to the prisons], who are spending time, they are by definition a captive audience," Wohl said. "We should be using that time productively to try to instill prevention messages." To do any less, he implies, would be to drive the HIV epidemic even deeper into urban communities.
Another large HIV risk group, of course, is men who have sex with men (MSM). Despite initial reports of success with HIV and STD prevention programs in this population, recent government statistics indicate that incidence rates are once again increasing in the U.S., suggesting a failure of current prevention efforts. What has received little clinical attention, though, has been the ability of the Internet to bring high-risk MSM together -- as well as its potential for use as a new method of HIV prevention.
During the summer of 2002, S. Hirschfield2 and colleagues in New York conducted an online survey of approximately 6,000 individuals who visited gay.com, an extremely popular Web site for gay men. The researchers found that gay.com was being used as a dating vehicle -- no shock there. What was alarming, though, was the finding that a huge proportion of the adult users in the survey had unprotected anal sex, often with people they had met through the site.
Of the nearly 3,000 users whose surveys were deemed usable (many were incomplete, clearly fake or answered by minors), the researchers found that 84 percent had met sex partners online. Those who met their partners online were 6 percent more likely to have unprotected anal sex than those who met their partners offline. Four out of every five HIV-positive men answering the survey said they had an HIV-negative partner, and HIV-positive men who had met their partners online reported having more unprotected anal sex than their HIV-negative counterparts.
Perhaps most interesting about this population was that it comprised a much more educated and economically advantaged community than the prisoners and their partners investigated in Wohl's study. Of the 2,934 men whose survey responses were usable, 85 percent were white, 87 percent had at least some college education, and 39 percent reported annual salaries of $40,000 or more. This was also a very young population: Nearly half of the respondents were adults under 30. Most of the rest where 30 to 49, with a small percentage 50 or older. Yet, it seems from this survey that at least in the MSM community, high socioeconomic status isn't much of a mitigating factor in HIV risk. More than half of all respondents reported having unprotected anal sex, with the highest proportion occurring among HIV-positive men, 61 percent of whom said they'd barebacked.
Other HIV risk factors included drug and alcohol use: 43 percent reported using some type of illegal drugs (marijuana and poppers were the most popular), and 34 percent said they got drunk at least once a week.
Despite the alarming numbers -- and the clear implication that HIV prevention efforts have utterly failed within the gay.com community -- there is one upside to this study, Hirschfield says. The high degree of interest the site's users exhibited in participating in the survey showed that gay.com, and other sites like it, could still potentially play a pivotal role in spreading HIV prevention messages.
If there's any way to paint a ray of sunshine on the darkening HIV situation here in the U.S., J. McConnell, M.D. and colleagues may have found it3. Although there's an awful lot of barebacking going on in San Francisco, he reports, much of it seems to be between people who already have HIV.
McConnell and colleagues analyzed data from 43 HIV-positive men participating in the Positive Partners study, a prospective study of HIV superinfection in San Francisco. The researchers' interest was piqued by data indicating that the number of reported rectal gonorrhea and syphilis infections in the area were skyrocketing, but that there's been no sign of a commensurate increase in HIV infections. Hoping to find out why, the researchers conducted this study.
What they found suggests that although gay men with HIV in the Bay Area are having a good deal of unprotected anal sex, they're also going out of their way to avoid infecting HIV-negative people. Although sex was frequent between serodiscordant partners, barebacking in which the receptive partner was HIV negative occurred only 7 percent of the time (which, though significant, isn't as high as the investigators thought it would be). When HIV-positive men in the study had unprotected anal sex with HIV-negative men or men of unknown status, the HIV-positive men tended to be the receptive partner, which presents a lower risk of infection for the HIV-negative partner.
The riskiest sex was generally saved for partners with known HIV-positive status: When both of the men involved were HIV-positive, barebacking occurred an astonishing 91 percent of the time. When the partner of an HIV-positive man was of unknown status, he was only slightly more likely to be on the receiving end of unprotected anal sex.
These findings offer a plausible explanation for why syphilis and rectal gonorrhea numbers have risen so much in San Francisco while HIV numbers have not. Unprotected sex (and thus transmission of sexually transmitted diseases) is still happening just as much as ever, if not more so. However, people with HIV are going out of their way not to increase the population of the HIV-positive community.
That's a great sign; the only problem is that syphilis and rectal gonorrhea aren't exactly a walk in the park to have either. The investigators pointed out that prevention efforts must be stepped up to keep sexually transmitted disease numbers down and ensure that HIV does not continue to spread.