August 6, 2008
Hi. My name is David Malebranche. I'm an assistant professor with Emory University's Department of Medicine in Atlanta, Ga. I work predominantly at Grady Memorial Hospital doing clinical work with HIV, as well as research, particularly with black communities and black MSM [men who have sex with men].
What do you think was the most interesting part of the XVII International AIDS Conference?
It wasn't necessarily all the clinical stuff. For me, the timing of the International AIDS Conference this year was particularly appropriate, given the president's reauthorization and expansion of the PEPFAR [The U.S. President's Emergency Plan for AIDS Relief] program, as well as the recent AIDS statistics that showed that there was an incidence in 2006 of 56,300 new HIV infections.1
David Malebranche, M.D.
What do you think of all the MSM-related research being presented and the attention on MSM?
I saw some MSM stuff, but I didn't really see a lot that was noteworthy for me. I saw some stuff from other countries that reiterated a lot of things we already know: There's a lot of homophobia; there is a lot of bisexual behavior, and a lot of it has to do with culturalization, masculine socialization and things like that. However, I didn't see a lot of stuff relating that to risk.
What I see a lot of times with these presentations about bisexuality and about MSM is talk about the potential risk. But then when one looks at the data, there's a difference between whether someone is bisexual and uses condoms; whether you disclose who your sexual partners are -- men, women or both -- and whether you use condoms. I think sorting through that and fine-tuning that discussion need to be done, because a lot of people just lump the two together. They say, "Well, they're bisexuals, and they're having sex with both men and women, so they're probably the bridge from MSM to heterosexuals," instead of saying, "Well, they could be the bridge from heterosexuals to homosexuals, as well, if there's a large prevalence of HIV among heterosexual women."
I don't see that discussion taking place too much, nor do I see the discussion of condom use really happening that often. It's usually just by default: "Since you're bisexual, you're probably running around, willy-nilly, not using condoms, and being careless about who your sexual partners are."
I thought it was timely, particularly at the International AIDS Conference. What it did for me, and probably for a lot of other people, was to really bring home the epidemic in the United States.
We can congratulate President Bush and Congress for doing such a wonderful job with PEPFAR and promoting these treatment and prevention initiatives internationally in countries that need them, as far as getting the infrastructure together. But I think in the setting of that congratulatory foundation, we realize that it's exposed us, because we don't have this kind of foundation, we don't have this kind of infrastructure, and we don't have this kind of framework within the United States.
Given the fact that there were incidence estimates that were previously around 40,000, and now they're saying it's about 20% higher -- it's 56,300 -- that's a huge jump, and that's a huge miscalculation, even though the methods that they were using to estimate those numbers in previous years were probably a little bit archaic.
It highlights, or exposes, the U.S. Are you going to put out burning bushes throughout the world, or are you going to take care of your fire at home? That's one of the things we have to address, coming home from this conference.
So I think the CDC releasing those statistics and that JAMA [Journal of the American Medical Association] special issue3 on HIV/AIDS were particularly timely in the context of the International AIDS Conference.
Yes, young black MSM, in particular. But we have known this for years. It's been close to a decade that we have been talking about MSM -- young black MSM, middle-aged black MSM, and so on and so forth. I'd say 13-year-olds through probably 44-year-olds are getting hit the hardest. There seems to be a focus on the heterosexual epidemic whereas, still, we're looking at two thirds of these incidence estimates in the United States occurring among men who have sex with men. Maybe one quarter of them were among heterosexual women.
It really, again, exposes what we need to look at here.
One of the arguments that starts to come out of it, and one of the discussions that needs to come out of it, is this whole issue of the "HIV guilty" and the "HIV innocent." We used to talk about that back in the day, and I think we need to revisit that conversation because at this point, what's happening is that you see money flooding from federal institutions into academic institutions, faith-based organizations and community-based organizations, so that people can travel overseas, particularly to Africa, to do HIV prevention work and treatment work. Meanwhile, these same people who are traveling to Africa will basically step over the homeless person living with AIDS right outside their organization's door so that they can get in their limo and drive to the airport to fly to Africa, which is a really strange dynamic to me.
The only conclusion I can come to is that at the end of the day, when you look at the estimates in Africa and in several of the countries in Africa where they have done surveillance about what the specific risk behavior is, it's usually heterosexual transmission,5 which may be referring more so to women than men.
The only explanation I can come up with is that, at this point, MSM, bisexuals and IV drug users are still being pathologized -- and even heterosexuals are being pathologized here -- as if they're dirty, as if they're wrong; and no one wants to help folks here. Yet we'll travel thousands of miles overseas to help out people in other countries, and then pat ourselves on the back while the epidemic is brewing here, and continually getting worse -- which is very, very strange, and shows us this whole mix of morality, religion, judgment, discrimination and stigma that we have in this country that we're afraid to talk about.
Could you tell me a little bit about the population of patients you treat?
I work at the Ponce de Leon Center in Atlanta, Ga., which is a clinic that specifically deals with folks who have a clinical diagnosis of AIDS, either by an AIDS-defining illness or a T-cell count of less than 200 cells/mm3. The population is predominantly African American, and predominantly uninsured.
At my clinic, I see predominantly males. I have white males, Hispanic males, males of Asian descent -- a whole mix of ethnicities, but I'd say that about 85% to 95% are men of African descent, whether from native Africa, from the Caribbean or African American. A large proportion of them are MSM. And some are heterosexual, some are bisexual and some are IV drug users, but the vast majority of them reflect the epidemic in the nation, where MSM are being predominantly impacted.
Are you finding that your patients are getting enough support? That there are enough prevention or treatment services to accommodate them?
Yes. I think it's difficult, and there are a lot of hoops to go through. We're sponsored by Ryan White CARE Act funds. At Grady Memorial Hospital, we will also accept private insurance. I have some patients who are on private insurance, but then they have to go out to get their labs drawn someplace else instead of at our building, because they contract with different lab services. That makes things difficult.
The main thing I've noticed, over the past seven years that I've worked there, is that patients have a particularly difficult time jumping through the hoops to get on treatment. Once they get on treatment, the services are there. They can kind of coast, but there are so many hoops to jump through, so much paperwork to fill out, so many people to see and so much traveling back and forth to do.
You're talking about a population that may not have cars, and that may be dealing with substance abuse, mental illness, stigma and discrimination from being homosexual, and all kinds of other issues. And yet you're asking them to do all these things just to get their medications.
A lot of people get turned off and turn away, but the ones who stick to it -- if they have good support from the social workers, the providers, the staff at our clinic, which is very supportive -- once they get over that hurdle and they get plugged in, they usually do fine. It's just a matter of getting over that hurdle of getting treatment if you're uninsured, and then getting on with your life after that.
Are there transportation vouchers and other services?
Yes. We do all of that. We'll give them services for the trains or the bus, and tokens or Breeze Cards for the MARTA system in Atlanta. We do all these things in Atlanta, Ga., but it's a matter of getting it together. You have to prove that you're at a certain level below the poverty line, and you're not making enough money and can qualify for these services.
In some respects it's a catch-22, because the main concern for someone who's diagnosed with AIDS is, basically, "Can I live through the next few months? Am I going to be alive in the next few months? Am I going to live to see the next year?" Once you get them over that hump, then you say, "Now you can live your life. What did you want to do before? Did you want to go to school? Did you want to work this job? What did you want to do with your life before HIV hit you?"
Then all of a sudden they reach this crossroads, where it's like, "If I go to school and if I get a good job, then I'm going to be making too much money to qualify for the services that I had before, and then I'm going to have to work harder. It's going to make it more difficult. I'm going to have to pay more out-of-pocket for my medications" ... and so on and so forth.
In some ways, it's almost an incentive for people not to work, not to pursue their jobs, and to just stay uninsured and not making enough money. A lot of times it gets a little bit difficult for patients to grapple with that, once they want to get going. I've seen a lot of success stories with it, so I know it can be done. But it's a very difficult thing to have to choose in your life: "Do I pursue my dreams and become successful like I wanted to, and risk losing my insurance temporarily, or losing my benefits temporarily and risk getting off meds, even though now my viral load is undetectable and my T cells are in the 500 range, whereas they were 10 before?"
It's very, very difficult to negotiate that. There's no how-to book. There's no Dr. Spock book to explain that to you. But there needs to be more information out there. If you don't have a supportive clinic, a supportive family, a supportive community and supportive providers, it's going to be a lot more difficult. It's like you almost have to be out there on your own.
I know you are not staying for the late-breakers, but do you know a little bit about some of the studies that will be presented? Could you talk about the abacavir [ABC, Ziagen] data6,7,8 a little bit?
Not in great detail. I went to a review of some of the clinical data previously. Back in January of this year, Epzicom [abacavir/lamivudine, ABC/3TC, Kivexa] was actually listed as one of the preferred initial regimens for treatment-naive patients to start on, along with Truvada [tenofovir/emtricitabine, TDF/FTC] plus Sustiva [efavirenz, Stocrin] or a PI [protease inhibitor].9 Some studies started to come out after that that showed that if your viral load is over 100,000 copies/mL, you may have worse outcomes with Epzicom, as opposed to with Truvada.6 Also, there was a large cohort -- multi-country, multi-city -- that showed an increased risk of MIs [myocardial infarctions] among people who were on Epzicom, as opposed to Truvada.10
I think that's interesting data, given yesterday's discussions about the hypersensitivity reaction to abacavir and how, if people are positive on the HLA-B*5701 test, it's more predictive of whether they will have that hypersensitivity reaction.11 When you look at a lot of these studies, the question you have to ask yourself, as a provider, is, "Does it apply to my individual patients?"
For me, working at a predominantly African-American clinic, where there is a high co-prevalence of other chronic diseases like hypertension,12 renal insufficiency13 and diabetes,14 Truvada may not always be the best option because of the tendency of tenofovir [TDF, Viread] to sometimes irritate the kidneys.15
So a lot of times, you really have to look at the data and synthesize it, and see what the population was that they were studying. Then, with each individual patient that comes up, you need to see what's going on with them and see if they are actually a candidate for this.
Although all the data may say that Epzicom is not as good as Truvada for certain particular patients, if they have chronic renal insufficiency, a viral load that is less than 100,000 copies/mL and their HLA-B*5701 is negative, I would put them on Epzicom instead of Truvada. You have to take the data and then apply it to each individual case.
Are you presenting data today about renal insufficiency?
I'm not. I do more behavioral research. I don't do clinical trials. I'm presenting some data we obtained with the Minority HIV/AIDS Research Initiative, which is a cooperative agreement with the CDC. It was a three-year study looking at the issue of gender role conflict, racial identification as black among black MSM, and sexual risk behavior along the road.16 We examined whether experiencing higher gender role conflict strain, or having a positive racial identity as being black, influenced their condom use practices.
And did it?
It was a little bit complicated. We had a sample size of about 480. What we found was that gender role conflict -- such as being more conflicted about being a man, about certain things, such as being successful or not being emotional, those kinds of things you get socialized to be as a man -- didn't necessarily predict unprotected anal intercourse with other men with this population.
But among the small subset that was bisexual -- we had about 75 men who reported having sex with both men and women in the past six months -- it did influence that.
What was interesting was that it may not be particularly relevant when it comes to your male sexual partners, but we need to actually do more work to find out exactly what's going on with the female sexual partners.
Looking at a lot of that research, and a lot of the behavioral research with black MSM and black bisexual men, and even white bisexual men, Latinos, Asians, and so on and so forth, what you realize is that people are choosing condoms and behaviors based on individual characteristics, gender characteristics, and then also situational characteristics.
What do you mean by that?
Individual characteristics could be: Do they trust the person? Is it a casual relationship, versus a long-term relationship? Are they married? Is this someone they have been with for five years? That may be more of a primary determinant, or predictor, of whether you use condoms or not rather than whether your partner is male or female.17
So if you really trust someone, if you're really in love, if you've been with somebody for four or five years -- and we've seen this with the heterosexual data, the homosexual data, the bisexual data -- then you are more likely to forego condoms, because you think, "Well, this is my boo; I've been with him for five years, so I know he isn't tipping out on me." [i.e., I know they aren't having sex with other people.] Whereas, with a casual partner, you'll say, "Well, I don't know where this person's been, so I need to strap up."
What's interesting is that we still need to tease out and look at the complexity, because it's not as simple as somebody being straight-identified or gay-identified, or whether they are a man or a woman. It has a lot more to do with more general human characteristics, life situations, and how you feel about that individual, being a determinant of whether you use condoms or not.
Interesting. What's your next step? Are you doing another similar study?
I'm working on a study right now. I'm working on a revision for a R01 [NIH Research Project] grant that I submitted. We're actually trying to look at a cohort of black men in the state of Georgia, and doing comparisons between those who are behaviorally heterosexual, bisexual and homosexual, as well as looking at rural versus urban areas, and different age groupings.
We're looking particularly at issues of mental health: Qualitatively, what are the facilitators of good mental health? What are the barriers to good mental health? Does that have an impact on sexual risk behavior and testing practices?
When looking at things like stress coping, we'll use measures like depression scales and perceived stress -- those kinds of things. It will be interesting; I don't think anyone has done a study with a large cohort of black men, just recruited. Are you over the age of 18? Do you identify as black or African American? And then let the behavioral categories from the demographic responses stratify them out into heterosexual, homosexual and bisexual.
Up to now, we've been asking: Why don't we do a study with homosexual men? Why don't we do a study with bisexuals? Why don't we do a study with heterosexuals?
What we have been finding in a lot of our research is that, regardless of who someone is having sex with, or how they sexually identify; there are common cultural threads and experiences about being a black man in America that I think we need to closely examine.
Until we examine those things, we'll be kind of running around, looking at risk groups based on how you sexually identify, or what the gender of your sexual partner is, and we still may be missing the boat about some of these general things, situational things like poverty, mental health and stress. Regardless of how you sexually identify, you're going to be subject to some of those social stresses.
How many of these International AIDS Conferences have you been to?
Two, including this one.
Do you think that these conferences make a difference, that they change anything? Or are they just a lot of talk?
No, because I've never been a proponent of the idea that talking is doing nothing. There are some people that will go to conferences and complain, "Oh, we're just doing a lot of talking and no one's coming up with solutions. I need to hear solutions with each session. You need to tell me what I need to do with my population."
I'm very clear that when we give sessions, when there's a workshop that I go to, I'm not looking at the presenter to give me the answers to how to care for my population; I'm looking to hear what they have to say. Then I'm going to take that and process it, and go from there.
I think people can get out of conferences what they want to. You can go to a conference, listen to some stuff, leave and never do anything with the information at all, whether you're a clinician or a service provider or a person living with HIV. But if you go to the conference wanting to make connections, wanting to learn, and then maybe incorporate some of the things that you see into your own community, or maybe they'll inspire you to do some work on your own, that's what I think you can get out of it.
So I think that talk is always good, and I don't think we talk enough about these things. I don't think they are a waste of time at all. It's only a waste of time if you decide it's going to be a waste of time, and you don't decide to do anything with the information you're given.
Great. Well, thank you very much.
This transcript has been edited for clarity.