Box Turtle Bulletin

“Over 28 times more likely to get anal cancer”

When traveling this year, consider the following:

• The second largest weather killer in the United States is a lightning strike.
• You are over 100 times more likely to be hit by lightning in Florida than California.

Makes ya think, doesn’t it? Perhaps vacation should be at Disneyland rather than Disney World.

But would it help you put things in perspective if you knew that the odds of getting struck by lightning in the US are about 1 in 500,000 and that only 40 to 50 people per year are killed here by a lightning strike? When you know the facts, then all of the above ceases to give you concern and instead you feel manipulated.

Keeping that in mind, look at the following condom awareness psa being aired by New York City:

When you get HIV, it’s never just HIV. You’re at a higher risk to get dozens of diseases, even if you take medications. Like osteoporosis, a disease that dissolves your bones; and dementia, a condition that causes permanent memory loss; and you’re over 28 times more likely to get anal cancer. It’s never just HIV. Stay HIV free. Always use a condom.

Scary!!

But is it true? And, as importantly, is it in perspective?

Osteoporosis is directly related to bone mineral density (BMD) and it is the measurement of BMD that is used to identify and – more or less – define who has or does not have osteoporosis and likely future fractures. And it is, indeed, true that HIV positive persons have higher rates of both osteoporosis and osteopenia (a similar but less sever condition). The reasons are, at present, undetermined.

So, yes it is fair and accurate to warn that HIV can, on average, increase one’s likelihood of osteoporosis (as can being a short white woman). And this condition is common enough that an increase in incidence is material and worthy of discussion.

But it’s not quite all of the story. The handsome young man whose bones were dissolving before our eyes is rather unlikely to have osteoporosis for decades, if ever. Osteoporosis (which primarily effects those over 50) is fairly easy to both treat and forestall, so this young man may need to take extra precautions (e.g. adequate calcium and vitamin D) but he is not going to wake up one morning and find that his skeleton has dissolved to soup.

Dementia is more common in people with HIV than without. Indeed, before HAART, dementia was a common consequence of HIV infection and was often the first qualification for an AIDS diagnosis. Currently it is less common, but still a major concern, especially as HIV infected persons age. (caregiver.org)

Before the arrival of highly active anti-retroviral therapy (HAART) in the second half of the 1990s, estimates of the percentage of people with AIDS who would develop HAD ranged as high as two-thirds. Many specialists, however, believed that the true figure was closer to 20 to 30 percent. More recently, experts have estimated that less than 10 percent of people on HAART develop HAD. However, because people with HIV are living longer than ever before, a greater number could ultimately develop the disorder, perhaps in its milder forms.

So far, I don’t necessarily quibble with accuracy of the psa, though the imagery suggests that these possible consequences are likely to be onset in early life, a false implication. But now let’s turn to one of my pet peeves, the ooky-spooky (and mostly bogus) anal cancer scare.

Yes, anal cancer exists. And yes it has higher rates in gay men than straight and even higher in HIV positive men. But the inclusion of anal cancer as a “higher risk” and the “28 times more likely” language tells me that this psa has no credibility whatsoever. It is not designed to inform, but to frighten.

The anal cancer scare is a favorite tactic of anti-gay activists. And it is irresponsible and immoral behavior when they seek to demonize gay men by claims that “”homosexuality is by its very nature dangerous to those who practice it.” It is no less irresponsible and immoral to use this scare tactic in the advance of a noble cause like encouraging condom use.

Anal cancer is very rare. In the US, about 5,260 people per year get this disease, of which about 40% are men (so, as you can see, women are 50% more likely to get anal cancer. Beware!!). About 720 patients die. Anal cancer is highly associated with HPV infection (though the vast majority of those infected with the HPV virus never develop anal cancer) and a vaccine is available which eliminates this risk factor.

Gay men, who are more likely to have become infected with HPV in their anus than are heterosexuals, experience anal cancer incidence of about 35 in 100,000. HIV infected persons, as are other persons with a suppressed immune system, are more likely to develop this cancer, but we still are talking tiny tiny numbers, maybe around one tenth of one percent.

Yes, HIV seroconversion is a life-changing experience. While most HIV positive people live relatively the same life as HIV negative people, there are more risks, rules, and precautions. Drug regimens must be adhered to, lifestyle choices have to be made, and health complications of some sort are almost unavoidable.

There are, indeed, many many good reasons to avoid infection with HIV. But fear of anal cancer is not one of them.

I support the dissemination of information that clarifies and warns about avoidable health risks. But I do not support bogus fear tactics that seek to deceive and manipulate, even if the goal is admirable. And this psa is one of the most deceptive manipulation tactics that I’ve seen.

And we cannot blithely suggest that the end justifies the means, when there are real victims of this false impression of HIV. This psa stigmatizes HIV positive persons in ways that are unnecessary and cruel. Viewers leave with the impression that HIV positive persons are about to fall over dead or go stark-raving mad.

And, in the mind of many, the ails of HIV positive people reflect on gay people as a whole. Psa’s that warn of dementia or anal cancer in HIV infected persons translate to many viewers that gay people are diseased and insane. We all, HIV positive and HIV negative alike suffer the consequences of such presentation.

And, besides, they are wrong. Yes, most people with the virus will also have other issues that result. But it is not true that “It’s never just HIV.” For some few, an HIV infection will not result in any medical consequences. I can’t say exactly how many, but it may be more than those who get anal cancer.

GLAAD and Gay Men’s Health Crisis have joined forces to ask the city to pull the ad. I wholeheartedly agree.

Anti-gay McHugh notes the same misreporting that I saw

Dr. Paul McHugh is not a friend of our community. Long an anti-trans activist, he wrote an amicus brief in support of the Proponents of Proposition 8 in which he claimed that homosexuality cannot be defined.

But McHugh wrote a letter to the editor of the Baltimore Sun in which he noted the same misreporting of a study on HIV prevalence that I discussed here last month.

Sexually transmitted diseases proliferate among men and women who have multiple sexual partners. If the recent measure of HIV infection among Baltimore’s gay men was restricted to those who frequent “gay” bars and clubs, then it will overestimate the prevalence of HIV in Baltimore because it will not include those gay men who are not seeking extra partners (“Baltimore leads in HIV infection in gay men,” Oct. 2). The prime public health message to the people in any community seeking to reduce STDs, including HIV, is and has ever been, “If you are sexually active, have few and preferably only one sexual partner.”

McHugh is correct both in his analysis of the numbers and in his recommendation for the best way to avoid contracting sexually transmitted infections. It’s a pity that his anti-marriage efforts are in direct contradiction to his observation.

Washington Post gets the HIV prevalence story wrong

Darryl Fears of the Washington Post starts off with

Study puts HIV rate among gay men at 1 in 5

One in five gay men in the United States has HIV, and almost half of those who carry the virus are unaware that they are infected, according to a new Centers for Disease Control and Prevention study.

The problem? That’s just flat false.

As we reported, the CDC study was of men in urban settings and not reflective of gay men on the whole. It was not even representative of gay urban men, just those who are living it up at the bars.

And there is a material difference.

As we have stated in the past, only about 12% of gay men are infected with HIV. But Fears doesn’t have to take our word for it, it’s right there in the study which he was reporting. And the CDC made a point of warning against reporting their study in a sensational way:

Finally, these findings are limited to men who frequented MSM-identified venues (most of which were bars [45%] and dance clubs [22%]) during the survey period in 21 [metropolitan statistical areas] with high AIDS prevalence; the results are not representative of all MSM. A lower HIV prevalence (11.8%) has been reported among MSM in the general U.S. population. [emphasis mine]

While it may take an extra few minutes to read the whole report, it can make the difference between providing news and spouting nonsense.

Of course the Post was not alone is their sloppy reporting. The AP was actually worse

One in five sexually active gay and bisexual men has the AIDS virus, and nearly half of those don’t know they are infected, a federal study of 21 U.S. cities shows.
…
“We don’t have a generalized epidemic in the United States. We have a concentrated epidemic among certain populations.”

Even gay magazine, Bay Windows, got in on the act with the headline, “CDC: One in five gay, bi men is HIV-positive”.

The alarmist and misleading new headlines about HIV transmission

The Centers for Disease Control has issued a “new look at disproportionate impact of HIV and syphilis among U.S. gay and bisexual men”. And this “new look” is quite alarming:

The data, presented at CDC’s 2010 National STD Prevention Conference, finds that the rate of new HIV diagnoses among men who have sex with men (MSM) is more than 44 times that of other men and more than 40 times that of women.

That certainly sounds frightening. And it lends itself easily to anti-gay activist who argue that gay men and women do not deserve equal rights under the law because gay men are crawling with disease. (Iowa Independent)

Homosexual activity is “more dangerous for individuals who engage in it than is smoking,” and because of this, state lawmakers need to pass a constitutional amendment overturning last year’s Iowa Supreme Court decision legalizing same-sex marriage, according to Iowa Family Policy Center President Chuck Hurley.

Naturally, anti-gay activists like Hurley fail to distinguish between “individuals who engage in homosexual activity” and individuals who engage in unsafe sex. And, having only the vaguest of notions about those same-sex couples who marry, he leaps at a conclusion that is out of his reach.’

Unsafe sex significantly increases the odds of seroconverting. And considering that the CDC lumps all men who have sex with men (MSM) together regardless of their relationship status or sexual practices, single gay men who whoop it up sans condom with a stranger tonight have a FAR MORE than 44 times likelihood of becoming HIV positive than does a heterosexual dude that does the same. Which is one reason we should encourage relationships and responsible sex.

But setting aside the lunacy of opposing committed relationships so as to stop promiscuous behavior, let’s look at the numbers themselves. And let’s consider the responsibility of the CDC and those who use their statistics to report them in a way that is meaningful and useful rather than pointlessly frightening.

Yes, “44 times that of other men” is scary. But what does it mean?

For that we have to look at the following paragraphs.

The range was 522-989 cases of new HIV diagnoses per 100,000 MSM vs. 12 per 100,000 other men and 13 per 100,000 women.

The rate of primary and secondary syphilis among MSM is more than 46 times that of other men and more than 71 times that of women, the analysis says. The range was 91-173 cases per 100,000 MSM vs. 2 per 100,000 other men and 1 per 100,000 women.

Unpacking the medical language, this is what we find:

There were about 33,750 new cases of HIV infection in 2007. Assuming that gay/bi men make up about 4% of the population, this number is about three quarters of one percent (0.75%) of all gay/bi men.

For syphilis, the number is about 5,900 cases and an infection rate of about one tenth of one percent (0.13%).

Previous analysis suggests that about 12% of all gay/bi men are currently living with HIV. As syphilis is treatable, the total number of gay men living with syphilis is less easy to determine.

Further, if we wish to be credible, we have to recognize that the gay community is not homogeneous. HIV and syphilis infections impact certain demographics far more than others. Factors such as race, location, education, and self-worth can have almost as much a factor on one’s likelihood to contract HIV as sexual orientation.

Too often we can read alarming headlines and think, “why fight it, it’s inevitable.” This isn’t true. Most gay men don’t have HIV and never will. And while these frightening statistics can remind us to be careful, they should be taken in perspective.

When we hear “HIV diagnoses… 44 times that of other men” or “2000 times higher than repeat blood donors”, we have to remind ourselves to step back and take a better look at the numbers. We need to recall that the purpose of information of this sort is to fight the virus, not the people who are infected. And we need to understand that we each are individual and not a statistic.

CDC: “Down Low” Men Not Responsible For HIV Among Black Women

African-American women make up 61% of all new HIV cases among women in the U.S., and they are 18 times more likely to become infected than White women. Until now, it was believed that this exceptionally high infection rate was due to bisexual African-American men. But a new statement from the Centers for Disease Control and Prevention throws cold water on that theory:

Heterosexual black men with multiple sex partners — not bisexual men who secretly have sex with men — are responsible for high rates of HIV among black women, according to a senior CDC official.

“We have looked to see what proportion of infections is coming from male partners who are bisexual and found there are actually relatively few,” said Dr. Kevin Fenton, director of the National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention. “More are male partners who are having female partners and are injecting drugs or using drugs or have some other risks that may put those female partners at risk of acquiring HIV.”

…”What we\’re seeing is a concentration of the epidemic among the poor, among ethnic minorities and racial minorities in the United States,” Fenton said.

Among gay men, African-Americans are bearing a disproportionate brunt of HIV infections. In the most tragic example, Black teens make up only 13% of the nation’s teen population but they account for 69% of new HIV/AIDS cases for those among the 13-19 age group.

Infection rates in gay/bi men

Those leading the fight against AIDS and anti-gay activists sometimes have a common goal: portray the incidence of HIV in gay and bisexual men in the most frightening terms. This appears to me to be what is happening as the result of a presentation at the National HIV Prevention Conference (Southern Voice)

Gay and bisexual men account for half of the new HIV infections in the U.S. and have AIDS at a rate more than 50 times greater than other groups, according to Centers for Disease Control & Prevention data presented at the National HIV Prevention Conference this week in Atlanta.

That’s a pretty frightening statistic. But perhaps the raw numbers give it some perspective.

Dr. Amy Lansky of the CDC presented research at the Aug. 24 plenary in which the CDC estimated in the U.S. there were 692.2 new HIV cases in 2007 per 100,000 men who have sex with men (MSM).

In other words, the rate of new infections in the population of gay and bisexual men in 2007 was 0.69%. Or in 2007 one out of every 144 gay/bi men seroconverted.

That still is very high. And it is consistent with our calculations that about 12% of gay/bi men (or about 6% of all gay/bi people) are infected with HIV. (So play safe kids… or better yet, find someone to have and hold from this day forward.)

But, in those terms, perhaps it isn’t quite as scary as the somewhat meaningless announcement that “MSM are 50 times more likely to have AIDS than women and non-gay or bisexual men.” I think most of us already know that sexually active gay men, especially those unpartnered, are at a much higher risk of HIV than Grandpa Joe and Grandma Sally.

And I wonder at the wisdom of making announcements of such comparisons. Provided without context, this quote can seem counter-intuitive. A gay man with both gay and straight friends might think that such ratios do not reflect their observations. And using language that feels out of sync with the realities of the experiences of gay men will not encourage better behavior; rather it will cause the target audience to dismiss the information.

Further it may distract from the fact that HIV transmission is not homogeneous within the gay community; some age, ethnic, and geographic subgroups need and deserve much more attention and focus in our battle against HIV/AIDS. Making statement that sound as though “HIV is a gay disease” misses the picture and downplays the tragic way in which this virus has devastated some gay communities – especially minority and economically challenged subsets – far worse than the “Will and Grace” gay man.

Such declarations also run the risk of providing a false sense of security to others in the non-gay-male category who live in communities which are disproportionately impacted by this disease. And it may encourage those responsible for shepherding resources to overlook, for example, sexually-active single black women in specific urban settings.

So while I strongly support that accurate information be presented and disseminated as widely as possible, I’d caution those who make statements about this disease to consider that their words not only be factually correct but also convey messages that are not confusing or counter-productive.

CDC Reports Significant Declines In HIV Infection Rates

According to the Centers for Disease Control and Prevention, the number of people living with HIV and AIDS continues to rise as antiretroviral medication continues to prolong lives. In fact, we reported on a study last summer which showed that life-expectancy for those infected with HIV is now approaching normal. While nobody likes to see the number of people living with HIV/AIDS continue to increase, we also noted another CDC study which showed that the number of new HIV infections has remained relatively flat over the past ten years, a finding that is consistent with the fact that new AIDS cases has actually been declining slightly over the same period.

Now the CDC reports some more good news which sheds some light into how the number of HIV infections have remained so flat: The infection rate has been steadily declining since the 1980’s:

Researchers found that the HIV transmission rate has declined dramatically since the early days of the epidemic. In 1980, for example, when the disease was still undetected, the transmission rate was 92 percent, meaning there were 92 transmissions per 100 persons living with HIV at the time. After the identification of AIDS, and later HIV, and the implementation of HIV testing and other prevention efforts, transmission rates began to decline.

Since the peak level of new infections in the mid-1980s, just prior to the introduction of HIV testing, the transmission rate has declined by approximately 89 percent (from 44 transmissions per 100 persons living with HIV in 1984 to five transmissions per 100 persons living with HIV in 2006). Over the last decade, as prevention efforts have been expanded and improved treatments for HIV became available, the transmission rate has declined by 33 percent (from an estimated eight transmissions per 100 persons living with HIV in 1997 to five in 2006). Five transmissions per 100 persons living with HIV in 2006 means more than 95 percent of persons living with HIV did not transmit the infection that year.

The large fluctuations in the graph prior to 1980 are due to the relatively small numbers of persons living with HIV at that time and the limited surveillance structures that were in place.

The analysis, conducted by Drs. David R Holtgrave, H. Irene Hall, Philip H. Rhodes, and Richard J. Wolitski, will be published in an upcoming edition of the Journal of Acquired Immune Deficiency Syndrome.

[Hat tip: Michael Petrelis]

CDC and Journal of the American Medical Association Confirms New HIV Estimates

The big news this morning is that the CDC has confirmed its latest estimates of HIV incidence in the United States. Regular longtime readers at Box Turtle Bulletin may remember that these new figures were first discussed last November, with a follow-up in March.

At the time, the CDC were emphatic that the higher number of HIV cases reported “do not represent an increase in the epidemic.” Instead, the higher numbers were due to an improved surveillance system and blood tests. The CDC also said they were awaiting a professional peer review in a major medical journal.

The Journal of the American Medical Association yesterday released the results of that peer review and validated the new estimate. Among the Journal’s findings:

An estimated 39,400 persons were diagnosed with HIV in 2006 in the 22 states. Of 6864 diagnostic specimens tested using the BED assay, 2133 (31%) were classified as recent infections. Based on extrapolations from these data, the estimated number of new infections for the United States in 2006 was 56,300 (95% confidence interval [CI], 48,200-64,500); the estimated incidence rate was 22.8 per 100,000 population (95% CI, 19.5-26.1). Forty-five percent of infections were among black individuals and 53% among men who have sex with men. The back-calculation (n = 1.230 million HIV/AIDS cases reported by the end of 2006) yielded an estimate of 55,400 (95% CI, 50 000-60 800) new infections per year for 2003-2006 and indicated that HIV incidence increased in the mid-1990s, then slightly declined after 1999 and has been stable thereafter.

The CDC emphasizes again:

It should be noted that the new incidence estimate does not represent an actual increase in the numbers of HIV infections. Rather, a separate CDC historical trend analysis published as part of this study suggests that the annual number of new infections was never as low as 40,000 and that it has been roughly stable since the late 1990s (with estimates ranging between 55,000 and 58,500 during the three most recent time periods analyzed).

This is important to remember. This is not a sudden increase in HIV infections, but it does mean that the problem was considerably larger than previously understood. HIV Infection is the precursor to AIDS itself, with the infection often occurring 6-12 years before the onset of AIDS. AID diagnoses have actually been falling slightly throughout the past decade, which is consistent with the CDC’s finding that HIV infections have been relatively steady since 1999.

AFA’s Misquoting of the CDC

We commented earlier on an article in AFA’s OneNewsNow in which Regina Griggs displayed astonishing ignorance about the HIV infection rates of gay youth. Now the editors at AFA have amended the article

Over 70 percent of young kids 13- to 24-years-old, men having sex with men, are now HIV-positive,” Griggs notes. (see editor’s note)

and the editor’s note reads

In June of 2007 the Centers for Disease Control stated that homosexual sex accounted for 71 percent of all HIV infections.

Well now that’s an interesting statistic (though entirely irrelevant to Grigg’s claim). But what do they mean?

Is AFA saying that homosexual sex accounted for 71 percent of recent infections? The CDC Report (pdf) states:

MSM (49%) and persons exposed through high-risk heterosexual contact (32%) accounted for 81% of all HIV/AIDS cases diagnosed in 2005. [the most recent year reported ; emphasis added]

Is AFA saying that homosexual sex accounted for 71 percent of total persons living with HIV/AIDS?

By sex, 73% of adults and adolescents living with HIV/AIDS were male.

Of the estimated 341,524 male adults and adolescents living with HIV/AIDS, 61% had been exposed through male-to-male sexual contact, 18% had been exposed through injection drug use, 13% had been exposed through high risk heterosexual contact, and 7% had been exposed through both male-to-male sexual contact and injection drug use. [In other words, half: (61% + 7%) * 73% = 50% ; emphasis added]

Although the report provides information by ethnicity, location, age at transmission, cumulative deaths, and much more, I was unable to find any statistic that could be interpreted to state that “homosexual sex accounted for 71 percent of all HIV infections”.

(hat tip to reader Neil H)

HIV/AIDS in the Gay Community

Anti-gays often seek to portray all gay persons as diseased. There is a presumption that HIV/AIDS is an automatic consequence of “homosexual behavior” and that all gay persons (gay men in particular) are contagious and dangerous.

Just this week, PFOX’s Regina Griggs made the outlandish claim that 70% of all gay youth aged 13 to 24 are now HIV-positive. And last month we spent considerable time trying to educate Insure.com’s Robert Bland that HIV has not reduced the average age at death of gay men by 20 years.

But in the process of responding to Bland’s homophobic claim, I found that there did not appear to be an easily accessed answer as to just how many gay people are infected with the Human Immunodeficiency Virus. So I set out to make some calculations of my own.

It is very difficult to say with certainty exactly what percentage of gay persons are living with HIV/AIDS for a number of reasons:

• Difficulty in estimating the gay population
• Difficulty in estimating the total number of persons infected with HIV
• Difficulty in estimating those infected with HIV that are gay or bisexual

However, I’ve taken the best source information I could find and made some assumptions. Wherever possible I’ve erred on the side of caution and my estimations propably understate the total number of gay persons and overstate the extent to which gay persons are infected.

Here is what I’ve found:

• There are at least 5.3 million gay and bisexual men and 5.5 million gay and bisexual women over the age of 15 living in the United States today, for a cumulative GLB Community of at least 10.8 million people.
• Around 12.3% of gay and bisexual men – 6.0% of the Gay Community – are living with HIV/AIDS.

For detail about by assumptions and the sources for my calculations, see our new page:

The Prevalence of HIV in the Gay Community

Life Expectancy With HIV Closer To Normal

New research published this week in the Journal of the American Medical Association demonstrates that the life expectancy of people with HIV is now approaching those who are not infected.

A team of British researchers lead by Kholoud Porter constructed a database consisting of 16,534 individuals whose date of HIV infection is known with different degrees of accuracy assigned. Researchers discovered that mortality due to HIV/AIDS is now 94% lower than it was before 1996. That was the year in which the multi-drug Highly Active Anti-Retroviral Therapy (HAART, or the “AIDS Cocktail”) became available.

Excluding those who are infected due to injected drug use, people today who are under 45 years of age when infected with HIV experience an excess mortality rate of less than 1% during the first five years after infection. That excess mortality rate rises to approximately 2.4% to 7% fifteen years after infection.

The results are not as good for those who are above the age of 45 when infected. People in that age group experience a 1.5% greater mortality rate than the overall population during the first five years after infection. That morality rate rises to 11.9% at the fifteen year mark.

Porter commented to Reuters on the study’s results:

“This is looking really good that life expectancies are becoming close to the uninfected population,” said Porter, an epidemiologist. “It also underscores the importance that people are identified and treated early.”

Anti-gay activists often try to claim that being gay shaves 20 years off the life of a gay man. Nazi apologist Paul Cameron has been claiming that for years, returning to that theme again just last year in a move that earned him condemnation from the president of the Eastern Psychological Association. This study doesn’t try to assess the lifespan of the overall gay male population. It should however lay to rest the urban myth that gay men die at 40. It won’t probably, but it should.

HIV Infections Actually Remained Flat Between 2005 and 2006

We’ve already mentioned that the so-called fifty percent “spike” in HIV Infections between 2005 and 2006 was the result of more states reporting HIV infections to the CDC, not because there was an actual increase in infections in one short year. In fact, we’ve reported on the CDC’s new reporting requirements back last November. Once we remove the new states from the CDC’s count of HIV Infections, we find that there truly wasn’t an increase. HIV infections appeared to have remained approximately flat:

The Centers for Disease Control and Prevention’s (CDC) newly published 2006 HIV/AIDS Surveillance Report estimates that there were 52,878 new cases of HIV in 2006. This is a 49 percent increase over the 35,537 cases estimated for 2005, however, the increase is largely due to the fact that the CDC used data from seven additional states in 2006 compared with 2005. If you remove the states not included in the 2005 estimates from the 2006 estimates, the number of HIV cases drops to 34,878, a 2 percent decrease between 2005 and 2006.

I wonder how long it will be before someone ignores all the caveats from the CDC and jumps on the “spike” bandwagon.  Start your stopwatches… now.

Did HIV Infections Really Increase 50% From 2005?

News reports are breaking that the Centers for Disease Control and Prevention’s 2006 HIV/AIDS Surveillance Report (PDF: 2.6 MB/55 pages) shows a whopping 50% increase in the number of those who are infected with the HIV virus from the previous year. (This figure includes those who are infected with HIV, but who are not yet diagnosed with AIDS.) Regular readers of Box Turtle Bulletin may remember that we reported last November that the CDC had changed how they determined this statistic, and that this new methodology is resulting in a higher estimate than before. We reported:

Before the new regulations took effect, the CDC’s methods for estimating the HIV infection rate was based on actual AIDS diagnoses. But HIV infection and AIDS are two different things: HIV is the virus which leads to an AIDS diagnosis some ten years after infection on average. What the CDC used to do to estimate the rate of HIV infections was to take the actual count of AIDS diagnosis and work backwards from there to arrive at an estimate of HIV infections.

But with the average ten year latency period between infection and AIDS, along with the fact that Highly Active Anti-Retroviral Therapy (HAART) has lengthened this latency period for many people with HIV infection, the estimate has become grossly inaccurate. So now that states are required to report HIV infections as well as AIDS diagnosis, the CDC is getting a much better look at the actual rate of HIV infection.

…

So far, the CDC doesn’t believe these new numbers represent a significant increase in actual HIV infections.

Page 9 of the 2006 report shows that 52,878 people are reported to have HIV (not AIDS) in 2006. The 2005 report pegged that number at 35,537. However, several large states (California and Illinois, for example) are participating in the names-based reporting system for HIV (not AIDS) diagnoses for the first time. The CDC acknowledges that much of the increase is due to the dramatic rise in the number of states participating in the surveillance program:

CDC officials were emphatic that the higher number of HIV cases reported “do not represent an increase in the epidemic.”

“Instead, it’s more about our surveillance system than any increase,” CDC spokesperson Jennifer Ruth said Friday.

The CDC only recently tied HIV reporting to the amount of money states receive to fight HIV, meaning new numbers are beginning to come in as more states report HIV cases in compliance with CDC standards. In 2005, the CDC’s HIV/AIDS surveillance report included data from 38 states and territories, compared to the 50 states and areas that contributed data to the 2006 surveillance report.

Georgia, which was one of the last states to conform to CDC’s confidential name-based system for reporting HIV cases, ranked eighth in the number of HIV cases reported in 2006, according to the surveillance report.

Data from these new states were not included in the 2005 report.

Other data, specifically the number of actual AIDS diagnoses by year, seems to suggest that the actual prevalence of HIV is not rising nearly so dramatically, if at all. The number AIDS diagnoses has held relatively steady or even slightly downward for the past eight years even as the overall population continues to grow.

There are two ways to interpret this. First, more effective HIV medication may be forestalling the progression of HIV infection to full blown AIDS. But it also suggests that the number of HIV infections leading to those diagnoses may have been fairly stable through the 1990’s. If the number of yearly AIDS diagnoses continues to hold relatively steady over the next several years, then that should validate the belief that there has not been an actual spike in HIV infections.

See also:
HIV Infections Actually Remained Flat Between 2005 and 2006

CDC’s HIV Stats Higher Than Previously Thought

We mentioned that UNAIDS revised their estimates downward for the number of people worldwide infected with HIV. The US Centers for Disease Control and Prevention (CDC) is grappling with the opposite problem. The Washington Blade reports that the CDC is trying to figure out how to break the news that the annual number of new HIV infections in America are as much as fifty percent higher than the 40,000 or so per year they had previously estimated:

According to AIDS advocacy groups familiar with the CDC, middle level officials at the disease prevention agency have quietly confided in colleagues in professional and scientific circles that the number of new HIV infections now appears to be as high as 58,000 to 63,000 cases in the most recent 12-month period.

…CDC officials have told leaders of AIDS advocacy groups that the new figures are being withheld while they are subjected to a rigorous peer review process by an unidentified scientific journal, which is expected to publish the findings within the next few months.

Others familiar with the CDC have said CDC would likely publish the new data in its own journal, Morbidity and Mortality Weekly Report.

As of this morning, the CDC’s web site still cites the 40,000 figure for HIV infections. This tracks the actual number of AIDS diagnoses that the CDC counts each year.

Part of what the CDC is trying to grapple with is the political dimension of HIV/AIDS. Headlines screaming about a fifty percent spike in HIV infections are sure to provide a bonanza for anti-gay extremists. With that crowd, this news will be like winning the lottery.

But according to the Blade, the CDC’s experts believe that the dramatic increase doesn’t reflect an actual increase in HIV infections, but are the result of new requirements that states accurately track and report HIV test results. There has been mandatory reporting of AIDS diagnoses since the mid-1980’s, but requirements for mandatory reporting of HIV infections didn’t begin until more recently.

Before the new regulations took effect, the CDC’s methods for estimating the HIV infection rate was based on actual AIDS diagnoses. But HIV infection and AIDS are two different things: HIV is the virus which leads to an AIDS diagnosis some ten years after infection on average. What the CDC used to do to estimate the rate of HIV infections was to take the actual count of AIDS diagnosis and work backwards from there to arrive at an estimate of HIV infections.

But with the average ten year latency period between infection and AIDS, along with the fact that Highly Active Anti-Retroviral Therapy (HAART) has lengthened this latency period for many people with HIV infection, the estimate has become grossly inaccurate. So now that states are required to report HIV infections as well as AIDS diagnosis, the CDC is getting a much better look at the actual rate of HIV infection.

Another factor which may be causing the HIV stats to rise could be the CDC’s latest recommendation that most adults in the US undergo an HIV test during routine doctor exams as well as hospital emergency room visits. This may be catching many people who either avoided HIV testing or who believed they weren’t at a significant risk for infection. So not only is the CDC now actually counting HIV infections instead of merely estimating them, their policies may have resulted in an increase in the number of people getting tested each year.

So far, the CDC doesn’t believe these new numbers represent a significant increase in actual HIV infections. Yearly AIDS diagnoses has held relatively steady for the past eight years, which suggests that the number of HIV infections leading to those diagnoses was probably fairly stable through the 1990’s. If the number of yearly AIDS diagnoses holds steady over the next several years, then that should validate the belief that there is no actual spike in HIV infections.

UNAIDS “Cures” 6.3 Million With HIV

This is something that happens all too often. Say you’re a medical professional trying to understand the spread of a particularly sexually transmitted disease. What better place to go to study it than the local STD clinic? Just run a survey of the people who show up, and if you’re lucky and the findings are interesting — either they confirm something that others have suspected or they show something new and different from what was believed to be true before — you get to write up a research report, publish it in one of literally hundreds of professional journals, and your small contribution adds to the enormous body of knowledge which continues to accumulate about that disease.

If you’re unlucky however, someone else — say, an anti-gay activist — will read your report and they will write another report which says that everyone behaves just like your sample from the local STD clinic. They do this even though your sample is in no way representative of the general population, or even necessarily representative of STD clinics in other cities. But that’s how we get such nonsense as the so-called “Dutch Study.” Anti-gay activists claim that it “proves” that gay relationships last only 18 months on average and that gay men have some eight additional partners each year while in that relationship. Of course, this is not what that “Dutch Study” demonstrated at all. But no matter. They have their shocking statistic which they use quite often.

So what does it say about the state of our knowledge of the worldwide AIDS epidemic when we discover that epidemiologists — those who are tasked with studying the transmission and control of epidemic diseases — do the same thing as these anti-gay activists?

This morning’s New York Times reported that the UN agency UNAIDS issued a report acknowledging that it had been overestimating the size of the worldwide AIDS epidemic (PDF: 144KB/3 pages) by more than 6 million people, and that the epidemic actually peaked in the late 1990’s. And how did this happen? According to the New York Times:

Until recently, most national estimates were made by giving anonymous blood tests to some young women who came into public health clinics because they were pregnant or feared they had a sexually transmitted disease; those results were expanded with statistical models.

But epidemiologists have realized that such a method — usually applied in big urban clinics because it was more efficient — oversampled prostitutes, drug abusers and people with multiple partners, and ignored rural women. Then the statistical extrapolations exaggerated those errors.

Recognizing this elementary flaw — one they should have recognized from the beginning — UNAIDS now estimates that there are currently 33.2 million people infected with HIV, down from its estimate of 39.5 million from a year ago. It’s as if 16% of the world’s HIV-positive population was cured overnight.

Of course, we know that there was no miraculous cure. It’s just faulty math. And unfortunately, epidemiologists — the very people who should know better — are too often prone to making exactly this kind of error.

Some suggest that there may be political motivations involved in inflating the numbers. After all, jurisdictions which can show that they have a severe problem with a given disease can more easily qualify for grants, discounts, loans and other aid to fund research, prevention and treatment programs. If that’s the case, then this implies that one jurisdiction’s exaggeration may draw badly needed funds from other jurisdictions which act professionally and play by the rules.

It’s hard to tell if that’s a major problem with the UNAIDS surveillance program. Several African countries are now implementing more rigorous surveillance programs, while India has switched to a more representative household survey. UNAIDS says that these two developments are largely responsible for their estimate’s dramatic decrease. But there’s no question that HIV/AIDS is heavily politicized the world over.

I’m glad there are now 6 million fewer people with HIV in the world. It should still concern all of us that there are still maybe 33.2 million, more or less, with HIV. That’s the bigger picture we need to focus on.

But at the risk of drawing too much attention away from that more important picture, I’d like to suggest that there’s another lesson to be learned here. People and statistics are two entirely different things. And sometimes, when you really look at where statistics come from, you may discover that they have surprisingly little to do with the people they purportedly represent. Just try to ask those 6.3 million who were “cured.”