Volume 3, Number 16
April 10, 2002

In this edition:

• HIV Prevention Messages Failing to Convince Gays; Condom-free Anal Sex Keeps Virus on Increase
• San Francisco Health Department Giving Out Free Passes to Sex Clubs
• Sharing Drug Injection Equipment, Not Just Syringes, Raises Risk of Hepatitis C Infection
• Despite Existing Needle Exchange, Fresno County Experiencing Hepatitis C Outbreak
• Antibiotics for Sex Partners Tried in Chlamydia Fight
• Syphilis Outbreak Alarms Southwestern Pennsylvania
• Novel Public Health Programs Screen, Treat Inmates for STDs
• STD Rates Jump Again in Clark County, Nevada
• Abstinence Programs Appearing in More Louisiana Schools

HIV Prevention Messages Failing to Convince Gays; Condom-free Anal Sex Keeps Virus on Increase

A small but worrisome proportion of gay men in the San Francisco area are engaging in unprotected anal intercourse, knowingly putting themselves at risk for AIDS, a groundbreaking health study shows. The study demonstrates that despite years of programs promoting the use of condoms as a means of HIV prevention, some gay men are nonetheless actively seeking out partners who will have unprotected sex with them, elevating concerns about rising HIV infection rates. Authors of the study said it underscored the need for a new approach to prevention.

"What it says is that, in this group, other needs supersede prevention of HIV transmission," said Gordon Mansergh, lead author of the study and a behavioral scientist with the Centers for Disease Control and Prevention in Atlanta. "Our conclusion was that we need to develop new prevention interventions differently. People are decidedly not using a condom. The old way is not working."

The study by researchers at the CDC and San Francisco's Department of Public Health is the first serious analysis of the practice of "barebacking," in which men who have sex with men intentionally engage in sex without a condom with someone other than their primary partner.Seventy percent of the 554 gay men contacted for the survey said they were familiar with barebacking, and of those, 14 percent said they had engaged in the practice within the past two years. Twenty-two percent of HIV-positive men had done so, compared with 10 percent of HIV-negative men. The primary reasons the men cited for engaging in barebacking was greater physical stimulation and "emotional connection." Participants in the survey were recruited at bars, dance clubs and community organizations in San Francisco and Oakland, and the study was conducted between July 2000 and February 2001.

The practice of barebacking has grown at the same time that rates of HIV infection have begun to rebound in San Francisco. City health experts estimate that there will be 700 to 800 new HIV infections in San Francisco this year, numbers rivaling the early years of the AIDS epidemic.

Some community activists have been calling for expanded public health outreach efforts to look at the totality of gay men's health, from fitness and cancer to mental health and substance abuse. Eric Rofes, professor of education at Humboldt State University, said the study's conclusion recommends just that. The study authors "seem to be understanding we need to work with gay men on broader health and wellness issues, instead of focusing solely on HIV," Rofes said. "In doing that, it will help us reduce the number of HIV infections."

The barebacking phenomenon is occurring with increasing frequency through connections made on gay Web sites and chat rooms, gym steam rooms, commercial sex clubs and bars, said Keith Folger, who heads the Prevention for Positives program at the Stop AIDS Project. Folger, who is HIV-positive, has admitted to engaging in barebacking himself.

Half of the men in the study who said they engaged in barebacking did so while they were on drugs or alcohol. Men also cited improved treatments for HIV disease as reasons for having more unprotected sex.

"(Barebacking) comes up at every event we have," Folger said. "In addition to figuring out how men should disclose their (HIV-positive) status, they want to know how they can go home and have sex without a condom." Folger has talked to other HIV-positive men who have abandoned condoms to avoid the hassles and negative guys who go latex-free just for the feel.

"We've failed in prevention by not asking the 25-year-old gay or bisexual men, 'What is it about HIV that you're not afraid of?'" Folger said. "There's a psychosocial illness in San Francisco. Despite how hard we've been hit by AIDS in this city, there's a silence around HIV. It's no longer in people's faces, yet people are still dying."

Study co-author Grant Colfax, director of HIV prevention studies at the Department of Public Health, said the study highlighted "shifting social norms" in the gay community. "This is the hard-core group, but they're having an influence on those who might not identify as being part of the barebacking phenomenon," Colfax said. "We need to begin talking about negotiated safety, not using drugs while engaging in unprotected sex, appeal to HIV-positive men's altruism to not spread the disease and drive home the message that AIDS isn't cured. You can still get HIV."

[The San Francisco Chronicle, 4/4/02]

San Francisco Health Department Giving Out Free Passes to Sex Clubs

Attention Castro guys! Get a sexually transmitted disease test and your next visit to a local sex club will be free. That is the message the Department of Public Health is sending with its "Castroguys Spring Cleaning" program, which began last Friday and continues through April. The DPH is working with sex clubs to promote STD testing among sexually-active gay and bisexual men in the Castro and South of Market. Local sex clubs are offering free admission to men who get tested as part of the program's community rewards incentives.

A steady rise in STD and HIV rates among gay and bisexual men prompted the effort, DPH community health specialist Larry Hanbrook said. Hanbrook said reported cases of syphilis increased from 41 cases in 1998 to a high of 190 in 2001. Local health officials estimate HIV cases doubled over the past few years, with 1,000 new cases in 2001. The campaign follows findings that 14 percent of gay men engage in sex without condoms, according to a report by the Centers for Disease Control and Prevention published in the March issue of the journal AIDS.

STD testing was more common in the gay community before the AIDS epidemic, Hanbrook said, but has taken a back seat to HIV testing. "If you've got something that makes you itch or drip but isn't going to kill you, it makes (STD testing) seem less important," said Holbrook.

Those with an STD are three to five more times more likely to be infected with HIV, and those who are already HIV-positive and have an STD can become more severely infected. Hanbrook has been working with local sex clubs and community organizations, such as the AIDS Health Project, local merchants and the wellness group Castroguys, to incorporate various reward incentives for those who go to get tested. Merchants like Castro's Books Inc. and South of Market leather community favorite, Mr. S. Leather, offer various discounts to those who show they have been tested. But nothing beats the free sex club admission, which could save club goers up to $15. That will have some Castro guys heartily singing the DPH campaign slogan: "I did it for the money."

[San Francisco Examiner, 4/4/2002]

Sharing Drug Injection Equipment, Not Just Syringes, Raises Risk of Hepatitis C Infection

Sharing injection equipment other than syringes can also raise injection drug users' risk of contracting hepatitis C, according to a study published in the April issue of the American Journal of Epidemiology, Reuters Health reports. Dr. Lorna Thorpe of the University of Illinois-Chicago and colleagues followed 702 injection drug users from 1997 to 1999. All of the participants were screened for hepatitis C at the beginning of the study, and those who tested negative were screened again at six-month intervals. About 25 percent of participants tested positive for HCV at the outset of the study and another 29 seroconverted during the course of the study.

After controlling for shared syringe use, the researchers determined that sharing drug "cookers" -- devices used to heat and dissolve drugs such as heroin and cocaine -- increased by four times the risk of HCV infection. Those who shared cotton filters to purify the drug more than doubled their risk of contracting HCV.

"This study provides... evidence that sharing of drug injection paraphernalia other than syringes may cause transmission of HCV among injection drug users," the researchers state, adding, "Prevention messages and campaigns should be revised to alert active injection drug users to the importance of reducing or eliminating all equipment-sharing practices."More than 60 percent of all new HCV cases in the United States are attributed to drug abuse. Untreated, HCV can lead to serious liver damage and can be fatal.

[Kaiser Daily HIV/AIDS Report, 4/4/02; Reuters Health, 4/2/02]

Despite Existing Needle Exchange, Fresno County Experiencing Hepatitis C Outbreak

While the number of AIDS patients in Fresno County, California, has remained fairly stable over the past few years, nearly 40 new cases of Hepatitis C have been reported weekly so far this year to the county health department, officials said. "The continuing scourge of AIDS, coupled with the growing epidemic of Hepatitis C in our community, constitutes a health crisis," said Dr. John Zweifler of University Medical Center.

Drug users in Fresno County can currently receive free needles through the San Joaquin Valley Exchange Works program, which distributes syringes on weekends. Yet, advocates are asking county officials to start another needle-exchange program, hoping it will halt a Hepatitis C epidemic.

Federal law prohibits counties from distributing drug paraphernalia. But in 1999, California passed a law that allows for needle exchanges if a governing body declares a health emergency.

Board of Supervisors Chairman Bob Waterston said he worried whether a program would be legal under federal law and the liability to the county if someone was stuck with a dirty needle. "If we did this and we handed out needles, then we become responsible if someone's little kid sits on one of these," he said.

[Associated Press, 4/10/02]

Antibiotics for Sex Partners Tried in Chlamydia Fight

Alarmed by chlamydia's high re-infection rate in Denver, doctors will allow people with this STD to bring home extra doses of antibiotics for sex partners who refuse to get tested. Twenty percent of those diagnosed with chlamydia in the city get it again, usually from the same partner. It infected more than 13,000 people last year in Colorado. Although doctors all over the country already unofficially give people extra antibiotics for their partners, Colorado would be the second state to officially endorse the somewhat controversial measure, federal and state experts said. Denver may also consider allowing people with gonorrhea to take home extra drugs."It's hard to know whether it will be a major improvement, but we clearly need other tools," said Dr. John Douglas, director of STD control for the Denver Public Health Department and Denver's leading proponent of partner drug-sharing. "We know it's hard for people to get their partners treated." The responsibility tends to fall on women because they feel symptoms of chlamydia more than men and are more likely to seek treatment. Women are also hurt more in the long run: untreated chlamydia can spur pelvic inflammatory infections and lead to infertility.

But the practice of giving people drugs without a prescription draws some skepticism. If someone had an allergic reaction, for example, the doctor could be liable. Doctors also say that overusing antibiotics can spawn bigger bacterial infections that are resistant to typical treatment.A University of California-San Francisco study found that partner-sharing reduced re-infection rates by about 8 percent. California health officials have followed the practice for more than a year, but cannot say how many people have benefited from it. It also remains unclear whether most health plans would cover extra antibiotics for a partner.

[Denver Post, 4/4/02]

Syphilis Outbreak Alarms Southwestern Pennsylvania

A growing number of syphilis cases in Pennsylvania's Westmoreland County has public health officials sounding the alarm to try to slow the outbreak. According to Richard McGarvey, spokesman for the state Department of Health, 20 cases of the sexually transmitted disease have appeared there in the past six months. Before that, Westmoreland County hadn't had a syphilis case since 1985.

In Allegheny County, there were four syphilis cases in 2000 and 11 in 2001. Eight have been reported this year. "We're well on target to be almost double what we were last year," said county Health Director Dr. Bruce Dixon. He added that infected individuals came from places such as Natrona Heights, Tarentum and Harrison, which neighbor New Kensington, the hotspot in the Westmoreland outbreak.

Tracing, diagnosing and treating the contacts of an infected individual helps limit the spread of the disease.

Almost all of the cases involved prostitution or crack cocaine use, he added. Most patients, male and female, were in their 20s.

"We've been worried over the last couple of weeks because the numbers have continued to go up," McGarvey said. "The general public could be at risk."

The number of syphilis cases in the state declined from 123 in 1997 to 78 in 2000. Provisional figures indicate 98 cases last year. According to the Centers for Disease Control and Prevention, the national rate of the disease dropped to an all-time low of 2.2 per 100,000 people in 2000. However, some cities, such as Norfolk, Virginia, Detroit, and San Antonio, Texas, had rates that were much higher than the national average.

The bacteria that causes syphilis, Treponema pallidum, is spread through direct contact with infected sores, which typically occur on the genitals or in the vagina or rectum. They can also form on the lips and in the mouth. The bacteria can be passed from a pregnant women to her unborn child. According to the National Institute of Allergy and Infectious Diseases, symptoms generally appear two to six weeks after exposure. First, a painless round sore called a chancre develops where the bacteria entered the body. It can be internal and go unnoticed. The chancre heals on its own in three to six weeks.

A non-itchy rash of brown spots, which almost always involves the palms and soles, develops a few weeks after the chancre's appearance. The rash may be faint, or look different on other parts of the body. The infection can spread through direct contact, sexual or not, with these sores. The rash clears in weeks to months even without treatment. Patients in this stage of secondary syphilis may also have fever, swollen lymph nodes, weight loss and nonspecific symptoms.

Then the infection seems to disappear. It is no longer contagious. Many people won't have any other problems, even if they were never treated. But about one-third of patients who had secondary syphilis go on to develop late-stage infection, in which the bacteria damage internal organs. They may become blind, paralyzed or demented before they die.

A single injection of penicillin is often curative if the patient has been infected for less than a year. Other antibiotics are also effective. Larger doses may be needed when the illness has progressed, but organ damage cannot be reversed.

[Pittsburgh Post-Gazette, 4/6/02]

Novel Public Health Programs Screen, Treat Inmates for STDs

Local jails have historically lacked programs for routine STD screening of detainees. Yet arrestees are at high risk for STDs, and no matter how narrow the window of opportunity, experts are calling for increased efforts at screening and treating this population.

"In terms of case detection, [jails] are one of the higher yield sites," said Richard Kahn, MS, an epidemiologist at the CDC. "In juveniles [in 1997], the median percentage for chlamydia among women entering juvenile facilities was 15 percent positivity, with a range of 1.5 percent to 28 percent. Positivity was greater than 10 percent in 17 of the 24 facilities that reported."

Among 115 facilities reviewed in a study, researchers found that fewer than half had a policy of offering routine testing for chlamydia, gonorrhea or syphilis to arrestees. Even in jails with routine testing, fewer than half of arrestees were tested for the three infections, and most testing was conducted among arrestees who had symptoms.

A 1998 CDC report indicated that the prevalence of STDs among women entering jails and juvenile detention centers in Chicago, Baltimore and San Francisco was high: 35 percent had syphilis; 27 percent had chlamydia; and 8 percent had gonorrhea.

"I think that overall, [jail] detection screening is going to find some of your highest rates of STDs anywhere in your community," said Charlotte Kent, MPH, chief of the epidemiology unit for the San Francisco STD Control program of the city's Health Department.

In San Francisco, males and females who come into youth detention are offered screening for chlamydia within 12 hours, Kent said. Gonorrhea screening is offered only to females, because prevalence of the disease in area males is low. If detainees are released before STD results are available, disease intervention specialists (DIS) follow up with them in the community and try to confirm they have been treated, either by a clinic or a private provider. The DIS also provide field-delivered therapy, meeting detainees who have been released and giving them antibiotics. "Between people being treated while they're still incarcerated and the work of our staff, we're able to get about 85 percent of the people who are positive treated," Kent said.

In December, the St. Louis Health Department started a pilot project, the St. Louis City Correctional Health Initiative (CHI), to establish a freestanding STD clinic within the city jail. According to Bill Dotson, chief of the Center on the Health of Specific Populations for the Health Department, the four key parts of CHI are:

• Medical evaluation and treatment at the time of arrest or detainment, plus referral to permanent health care providers.
• Court-mandated health assessment and treatment as a condition of release.
• Aggressive case management and follow-up with released prisoners to assure compliance with mandated health programs.
• Data collection and evaluation to better understand the burden of disease in the incarcerated population.

Dotson estimates the clinic may save up to $500,000 a year for the city by handling health problems on-site instead of transporting detainees to a hospital emergency room. In addition, "emergency room visits do not generally address such public health concerns as STDs, tuberculosis, and hepatitis, which occur at higher rates in this population," Dotson said. "If we can come in there and provide some basic medical screening at intake and medical follow-up, with care as needed in the holdover facility, then we can prevent [ER visits]."

In addition, a database was created to follow detainees and refer them to more permanent medical situations. The data assessment is being shared by the project, the city courts, and Glaxo SmithKline. Judge Jim Sullivan of the city's 22nd municipal district is also involved in the process, making referrals for health care a condition of review before sentencing. "Then that will be looked at favorably before the disposition of the sentence," said Dotson. "We're looking at that as a way to enhance compliance."

Judges may require health education and testing as a condition of release. Before the CHI, the city Health Department was already providing testing and education on STDs and HIV through its Health Education and Training (HEAT) program. As required by local ordinance, the department also provides STD testing for anyone arrested for prostitution. In addition to STD testing, Dotson said that two local AIDS services organizations-- Recruiting Blacks Against AIDS and the Effort for AIDS-- educate and counsel men arrested for prostitution and other sexual offenses. Dotson said he would like to see all detainees tested for HIV and other STDs, but as with many such programs, funding is an issue.

[STD Advisor, 3/02]

STD Rates Jump Again in Clark County, Nevada

Rates of gonorrhea and chlamydia have jumped for the second year in a row in Clark County, Nevada. Statistics from the Clark County Health District show rates for chlamydia have risen 40 percent, from 194 per 100,000 people in 2000 to 273 per 100,000 people in 2001. Rates for gonorrhea rose nearly 26 percent, from 97 per 100,000 in 2000 to 122 last year. The rise was mirrored nationwide and was caused in part by increased testing during the past two years, a lack of education and knowledge about the diseases, and a lack of condom use, especially among adolescents, health district officials said.

[Associated Press, 4/4/02]

Abstinence Programs Appearing in More Louisiana Schools

More and more seventh-graders around Louisiana will be taught that they should say no to sex before marriage as Governor Mike Foster's Program on Abstinence expands to include schools in 20 parishes. The governor's program began three years ago as a pilot in a few schools across the state. Beginning this fall, seventh graders in Lincoln Parish will be among those joining classmates around the state spending 12 hours in classes that focus on abstinence.

"It's pretty well integrated into the regular curriculum," said DeSoto Schools Superintendent Walter Lee. School boards in Bossier and Webster parishes are also considering adding the governor's abstinence program to their curricula. "It [the program] is growing this year. We have had acceptance from 90 percent of the school boards we've presented to," said Steve Casey, a program curriculum coordinator for north Louisiana.

Teaching abstinence as opposed to safe sex makes more sense, Casey said. "At the rate STDs are growing, safe sex is just not working. We feel if we can catch them early in middle school we can get them to say no by the time they're in high school," he said.

Once a school board adopts the curriculum, volunteers are asked to teach the 12-hour course, Casey said. "We feel that by getting volunteers to teach the curriculum, we take the added pressure off the teachers," he said. Volunteers must undergo background checks and be approved by the school board.

[Associated Press, 4/8/02]

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The HIV Update is a weekly report of articles, studies and other information related to HIV/AIDS, sexually transmitted diseases and related risk behaviors compiled from various news sources by the Children's AIDS Fund.

The Children's AIDS Fund is a non-profit, non-partisan organization dedicated to helping limit the suffering of HIV-impacted children through direct assistance and resources, as well as through technical assistance for their parents and care-givers. For additional information, call (703) 471-7350.