Box Turtle Bulletin

CDC Gets Behind PrEP

The New York Times reports that the CDC is now advocating the drug regimen commonly known as PrEP:

Federal health officials recommended Wednesday that hundreds of thousands of Americans at risk for AIDS take a daily pill that has been shown to prevent infection with the virus that causes it.

If broadly followed, the advice could transform AIDS prevention in the United States — from reliance on condoms, which are effective but unpopular with many men, to a regimen that relies on an antiretroviral drug.

It would mean a 50-fold increase in the number of prescriptions for the drug, Truvada — to 500,000 a year from fewer than 10,000. The drug costs $13,000 a year, and most insurers already cover it.

Aaron Hicklin of Out picked up the thread, summarizing some of the thinking behind the CDC’s new stance:

Although doctors advise patients to take the PrEP pill, Truvada, in conjunction with condoms, the move is an acknowledgement that after decades of public health education, condom use is in sharp decline among gay men. A C.D.C survey last November showed that the number of gay men reporting unprotected sex had risen nearly 20 percent from 2005 to 2011. Given the stigma around admitting to unprotected sex, that figure is probably much higher. Now, the hope is that by encouraging gay men who have unprotected sex to take Truvada, the number of new infections will continue to fall as scientists continue to hunt for a cure.

Even though PrEP as a regimen is not exactly new, Tim Murphy’s piece in Out last September rekindled what’s now a vigorous debate among gay men about whether or not PrEP should be offered more widely. Box Turtle’s last post about PrEP, here, is now at a healthy 69 comments (yup) with two main threads emerging. One side, now joined by the CDC, essentially says that the status quo focusing on condoms isn’t working and a new model which recommends both PrEP and condoms is needed. The opposing view, shared by Michael Weinstein of the AIDS Healthcare Foundation, worries that advocating that gay men get on PrEP will not only lead to an explosion of other STDs but also to higher rates of HIV because gay men won’t take the pill as directed and will use it instead as an excuse for unprotected sex:

“If something comes along that’s better than condoms, I’m all for it, but Truvada is not that,” said Michael Weinstein, president of the AIDS Healthcare Foundation. “Let’s be honest: It’s a party drug.”

Some of the concerns have been more directly pragmatic – many assume PrEP is too expensive and, also, many clinicians either haven’t been on board or haven’t been well-informed. Back to today’s story in the NY Times:

Advocates said there were several reasons there had been little clamor for the drug regimen. First, while many doctors prescribe statins as prophylaxis against heart attacks, for example, only AIDS specialists are likely to prescribe AIDS drugs as prophylaxis. But uninfected gay men have no reason to see AIDS specialists, and usually see general practitioners if they see doctors at all.

Also, Truvada is expensive. However, private insurers and state Medicaid programs have thus far generally covered such prescriptions, and Gilead has a program covering co-pays and giving Truvada to the uninsured.

While many in the gay community still share Weinstein’s fears, the CDC’s new position is getting a lot of heavy-hitting support – today, 69  HIV/AIDS groups cheered the CDC’s new guidelines calling them “a powerful additional tool in the AIDS response.”

Fact Checking the Family “Research” Council Straw Man Argument

In response to a Washington Post article about the economic benefits of same-sex marriage in DC, the Family Research Council (FRC) provides a classic example of how right-wing organizations manipulate data and statistics to suit their anti-LGBT positions.

Here’s the quote:

When same-sex weddings kicked off in D.C. yesterday, the city wasn’t seeing anything but dollar signs. In an absurd article in today’s Washington Post, reporters tried to argue that counterfeit marriage could be the economic salvation of the city’s economy. In a region with 12% unemployment, local officials claim that redefining marriage “will create 700 jobs and contribute $52.2 million over three years to the local economy.”

Not so fast, says FRC. The last census counted 3,678 same-sex partner homes in D.C. Assuming that number has stayed roughly the same, then the 150 who applied for marriage licenses yesterday would amount to a whopping four percent of the local homosexual population–hardly the stuff of economic recovery. For the Post’s $52.2 million projection to come true, all 3,678 of those D.C. couples would have to get married and spend over $14,000 per wedding. (I don’t know about you, but my wife and I spent a LOT less!) These “marriages” (which have yet to meet financial expectations in other states) may make a fast buck in the short term, but they will do nothing but drain the economy down the road. Consider the massive health care expenses incurred by taxpayers every year to cope with the diseases spread by homosexual behavior. According to the Kaiser Foundation, federal funding grew to more than $18 billion in 2004 to deal with the HIV/AIDS epidemic. Over half of all U.S. infections are in men having sex with men! That means taxpayers spend roughly $10 billion a year treating the diseases caused by a behavior celebrated in same-sex “marriage.” So much for economic development!

Not so fast FRC.

Yes, according to the Washington, DC Census Snapshot published by the Williams Institute, there are an estimated 3,678 same-sex couple households in the district, and the Associate Press did report that 150 same-sex couples applied for licenses on the first day same-sex marriage became legal there. This is about all that is factually correct in FRC’s statement.

FRC’s claim that the 150 couples represent “four percent of the local homosexual population” is a classic manipulation used by the religious right and discredited “researchers” like Paul Cameron. They take an estimate of one portion of a minority population and pretend that it is generalizeable to the population as a whole. In this case, the number of same-sex couple households willing to self-identify in the Census is not equivalent to the total population of lesbian, gay, or bisexual DC residents, which according to the Williams Institute is approximately 33,000.

Even more importantly, it is laughable for FRC to base its argument on the number of couples who applied for licenses on the first day. The Washington Post article references another Williams Institute report, which estimates that 2,000 same-sex couple in DC would marry over the next three years. In addition, another 12,500 couples are expected to come from out of state to get married. This is a more complete picture of the estimates used to create the projection of 700 new jobs and $52.2 million in revenue, but FRC simply ignores this information.

Where to begin with FRC’s last argument about same-sex marriage being a long-term drain on the economy because of “diseases spread by homosexual behavior?”

We could cite CDC data on transmission rates caused by “heterosexual behavior.” We could also estimate federal funding spent on prevention efforts that address the damage caused by social, and familial environments created by FRC. As they say, so much for economic development!

However, it would be a waste of time to feed into FRC’s “straw man” arguments.

They have no interest in examining real facts. Nor do they see the folly in their position against allowing same-sex couples access to an institution that fosters monogamy as well as mutual caring and support. As so many articles and special reports on Box Turtle Bulletin have illustrated, there is no place for scientifically supported facts in the anti-gay playbook.

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.

Lack of Clarity in Reporting on HIV and Circumcision of Gay Males

Several studies have shown that in African and Asian nations heavily impacted by HIV, circumcision can reduce infection rates in males by 50 – 60%. Now a CDC doctor has announced that while circumcision is effective in reducing female to male transmission during vaginal sex, it does not assist in resisting infection between gay males during anal sex. (U.S. News & World Report)

Circumcision “is not considered beneficial” for gay men concerned about lowering their risk of becoming infected with HIV, Dr. Peter Kilmarx of the CDC told the Associated Press. He released the study findings at a conference on Tuesday.

The finding are at odds with some studies conducted in Africa, which have suggested that circumcised males may be less prone to HIV infection during heterosexual sex. But circumcision may not offer the same protection when it comes to anal sex, Kilmarx said.

In the study, the CDC team tracked the HIV infection rate of nearly 4,900 men who had anal sex with an HIV-infected partner. The researchers found an HIV infection rate of 3.5 percent — whether the men were circumcised or not.

While this may appear informative to a heterosexual, this reporting leaves more questions than it answers.

• Were these 4,900 tops who engage in insertive sex only? Because if not, how could the circumcision of a bottom (passive partner) possibly impact HIV transmission?
• Does the 3.5% infection rate reflect a bottom to top transmission? Was this 3.5% in a year, a decade, when?
• Were these “partners” in relationships or just sex-partners?
• Or did they just say, “Here are some cut men and here are some uncut men. Let’s see to what extent they seroconvert”?

This story is but another illustration of why it is important that gay men and women are included in reporting stories that effect our lives. It would be interesting to know the extent to which bottom to top HIV transmissions occur and whether circumcision of the top could impact this transmission. But reporting like this tells us nothing of much use at all.