Sunday, October 25, 2015

HIV Risk, High Rates of HIV Infection, and Optimal Testing Frequency: Interview with Stephen Fallon, September 18, 2015

By Sean McShee

As part of my investigation into messaging about and perception of the best schedule for HIV testing for gay and bi men in Broward County, on September 18, 2015, this reporter interviewed Stephen Fallon, Ph.D.  He currently is Executive Director of Latinos Salud. He has consulted with the Centers for Disease Control (CDC), National Minority AIDS Coalition (MAC), Health Resources, and Services Administration (HRSA), U.S. Office of Minority Health Resource Center, the AIDS Institute, and many other agencies. The following has been edited for clarity. 

SM:     Could you define prevalence?

SF:      People sometimes define prevalence as the presence of a disease, or condition in a given group. Sometimes prevalence is defined as a one in X chance of encountering someone with that condition.

SM:     How would this affect your risk of infection?

SF:      Your chances of choosing a sex partner in South Florida who happened to be infected with HIV would be low, in the 1 in 100,000 range. If, however, you narrowed the hypothetical sexual partners down to the gay male community in South Florida your chances would greatly increase. In certain zip codes or subcultures, the chances could increase to a 1 in 3 chance that your partner tonight could be HIV positive.

SF:      There are a lot of bus placards telling gay and bi men that we’re in the eye of the storm. I don’t think gay or bi men necessarily do the math, but they do know in an intuitive sense, that hooking up in South Florida is riskier than hooking up in Kentucky.

SM:     Can you describe how high levels of back ground prevalence in any group could result in less room for “error”?

SF:      When we’re talking about background HIV prevalence, we’re talking about probability. If you have a slip up tonight with a sexual partner, what is the probability that your partner might be HIV positive. This type of information is useful for public health planning. It tells us how urgent the need is to educate a community in a given area.

SF:      But, if I’m HIV-negative, and I have sex without a condom or the condom breaks, and  I become HIV infected, it wouldn’t matter what the background HIV prevalence was in my neighborhood, because to me personally my risk was 100% in that encounter.

SF:      But prevalence is predictive. I don’t think everyone realizes just how dire the epidemic is down here in Miami-Dade and Broward County. 

SM:     Some groups, for example, hetero Whites, have low prevalence. They seem to be able to avoid the need for protection, while other groups, such as gay and bi men in general, and Black gay and bi men in particular, have high prevalence and can’t avoid the need for protection. Are these groups more at risk for infection than others are? Could you explain?

SF:      The eye of the storm has zeroed in on the Black gay male community. Some interesting research came out a few years ago. Two articles just came out recently. The one a couple of years ago found that, in general, members of the gay community are more open to dating outside the norms of heterosexual America, except when it came to dating African Americans. Gay white men were more likely to date Latinos, or Asians, to date outside of their age range, and to date outside of their socio-economic class than was the norm for heterosexuals in America. I think the research was done in San Francisco. But if Black gay men wanted to choose sexual partners from outside their race had far fewer options.

SF:      For whatever reason, the legacy of prejudice or personal erotic preference, many White, Asian, and Latino gay men do not date Black gay men. As a result, if a Black gay man becomes infected in a particular geographical area, other sexually active Black gay men in that same area are far more likely to be exposed to that recently infected Black gay man.

SF:      There is a mistaken belief in pop culture that the high rates of HIV infection in Black gay men proves that they’re taking more risks. That is definitely not true. Two recent articles were recently published. One of them pointed out, that people who have the least sex are more likely to place trust in a new partner and have condomless sex with this partner.

SF:      A study just came out, similar to some other studies from a few years back. These studies found that, on average, Black gay men have fewer sexual partners, and fewer condomless sexual acts than other racial groups. Yet, HIV infection rates among Black gay men in most urban areas are 2 to 5 times higher than those for White gay men, and 2 to 3 times higher than those of Latino gay men.

SM:     Some people have suggested a closed network of Black on Black gay and bi male sexual contact. Could this be related to the frequency of preferences for non-Black partners stated in Internet Profiles? Personal preferences can have social consequences. Any ideas on how to deal with this issue?

SF:      From a public health standpoint, the dating preference could be a legacy of racist assumptions that somehow certain people aren’t worthy. I can’t really relate to this, as my own first partner was African American, as was another long-term partner. 

SF:      From a public health standpoint, though in the cruel game of just epidemiology and counting numbers, if cross-racial dating increased, it wouldn’t mean fewer infections. It would just mean that new infections would be diluted over more populations.

SM:     How does high HIV prevalence influence the risk of Latino gay and bi men, and gay and bi male immigrants?

SF:      A study found extremely high rates of HIV infection after immigration among Latino men coming from Central or South America to Florida, or to the East Coast, urban areas. Something like 25 percent of them who came here, HIV uninfected became HIV infected within five years of hitting our shores. I need to look that citation up because I found it shocking. In that case, it comes down to those other variables besides high rates of HIV infection here. People are coming in from another county, and, maybe, it’s the first time they can express their gay identity, and it’s the kid in a candy store. Or maybe that “trusted friend” who is teaching them a little English or letting them crash on their couch. There’s a certain warmth there that feels like love, and maybe you sort of pay them back with sex. Or there’s the pressure to conform with drug use, which might not have been common in their homes, and they’re not as familiar with how it clouds their decision-making. There’s just all sorts of complexities in human relationships that can influence risk for HIV.

SF:      There are a number of cultural norms among Latinos. But they differ among Latino communities by country of origin, social class, etc. One norm involves putting someone else’s needs above your own. The most important thing is to establish a simpatico relationship, a feeling of comfort with somebody and not to assert your own needs.

SF:      This norm becomes dangerous for someone living with HIV, because they may not be asserting themselves in the physician’s office, or asking the physician to clarify what they didn’t understand. Or maybe they’re not taking care of themselves properly because they’re taking care of their abuela (grandmother) or their hijo (son). Family matters first among Latinos.

SF:      For someone not infected with HIV, if cultural norms say build rapport first and then worry about your needs, it would probably be easier for someone to take advantage of them. They may not assert their desire for condoms, mutual HIV testing, PrEP, or some other means of protection.

SM:     Would high levels of background prevalence make “promiscuity” less of an issue than low levels, as it is much easier to encounter someone capable of infection in a high prevalence zone than a low prevalence zone?

SF:      In a saturation zone, where almost everyone is positive, even if you only have one partner, you have the same chance as if you had 100 partners. Chances are they all HIV-positive.

SF:      Statistically that’s true, but the risk depends on what am I doing with that partner. Am I protecting myself in some way, such as condoms, PrEP, or Treatment as Prevention? 

SF:      “Promiscuity” directly intersects with background prevalence, because if I’m a heterosexual non-intravenous drug using male living in Montana, I can be the biggest slut in the state. I can have sex with 15 women a week and I am probably not going to catch HIV because there’s no HIV for me to catch. I would not be able to get away with slip-ups like that in South Florida.

SF:      That’s also the reason we don’t promote an awareness of background HIV prevalence as the sole method of your safety. If we’re in a saturation zone (an area with extremely high rates of HIV infection), many people are becoming exposed to HIV and are in that window period for uncertainty. That’s the time after infection when you’d get a false HIV-negative test result because your immune system hasn’t had time yet to grow antibodies. During that window, the HIV test will not return an accurate result. People in that window are legitimately telling you that they are uninfected with HIV, but they’re not. 

SF:      If prevalence was low, then infections would be rare, and since I’m not going from partner to partner, if I am not promiscuous. I'm not likely to be in the window, when we have sex.

SM:     The Kaiser Family Foundation (KFF) estimated a national prevalence of 12-13% for gay and bi men. Would you agree with that estimate?

SF:      Yes, I do. When they said national they probably meant the gay urban areas.

SM:     They were using a nationally representative internet sample.

SF:      That would work out to a 1 in 8 or 1 in 9. When we did the studies here in Florida, back about 7 or 8 years ago, we were already finding a prevalence of 1 in 5 among African American gay men in South Florida, 1 in 11 among Latino gay men and 1 in 16 among white gay men.

SM:     The KFF and others have estimated an HIV prevalence rate for gay and bi men in major cities of a 20% or more  Can you estimate the background prevalence in South Florida generally and Broward in particular among gay and bi men?

SF:      I haven’t crunched the numbers for Broward County, but probably 20 percent higher than when we did those studies or about 1 in 4 among Black gay men, about  1 in 8 among Latino among gay men, and about 1 in 13 among white gay men.

SF:      Miami-Dade County is number one in the nation for new HIV diagnoses, and Broward County is number two. That’s out of about 3,000 counties that make up our country, so this is not a small distinction.

SF:      We used to have to coax people to come in for testing. When the CDC turned their model to prioritized testing, with behavioral HIV prevention seen as the follow up rather than the lead effort, frankly, I was a little skeptical. I have to admit they were pretty much right, though. As a community of HIV prevention service providers nationwide, we have largely normalized testing HIV testing in the gay community. We’re not just testing the “worried well” anymore. 

SF:      This may be specific to my agency, since we’re always out with the vans. Maybe It’s the self-actualized, health seeking type of clients who walk into the vans. We have found a large increase in the number of people willing to take an HIV test on their way into or out of a club. We are getting a lot of first time HIV-positive results. It’s almost frightening, but good also. 

SF:      It’s good because we can link them to care and people aware of their status reduce their risk for transmitting HIV. Our linkage to care program differs from some of the other linkage services. Some of them have to limit their care by mandate to a relatively few services.

SF:      Our model is whatever it takes. For some people, you can just give them some of the information. They can handle getting into care on their own. When we can call them up, they will tell us they’re in care. But many of our clients come from different backgrounds, linguistic and socio-economic. They certainly come from different countries and cultures. They benefit from the extra effort that our linkage staff gives them. I tell my staff, “Your job description is whatever it takes. Give somebody what they need, and get them into care”.

SF:      Now we know how much better current treatments are. The prevention and care community had thought we were doing so well in the early and mid-90s with the medications available then. But now, when we look backwards, we’re finding that we were only buying people an extra 3.2 months of life expectancy.

SF:      Now with today’s regimens, if someone is newly infected or treatment na├»ve, their life expectancy can almost approach that of someone uninfected with HIV, if, and this is a big if, they follow the steps properly, staying on their meds and seeing their doctor regularly. It’s very exciting.

SM:     I have not found any regularly published reports of HIV prevalence among gay and bi men in Broward. Do you know of any?

SF:      No. We do have regular updates to the HIV testing data, and that does stratify by demographic or behavioral group. But it doesn’t also calculate the prevalence within each population.

SM:     Every few years in San Francisco, Health Department Planners, Epidemiologists, and Providers estimated the prevalence of HIV in San Francisco. Would be useful here? Would it be helpful for HIV planning?

SF:      It would definitely useful for planning. I’m not sure how useful it would be for the layperson on the street or for a provider. Even if an agency had the numbers and found out the epidemic has changed incrementally from year before, the agency is probably not going to change its focus radically. Broward has many fine agencies. Each of them serves everyone, but they also each have their specialty populations Here at Latinos Salud, we serve Latino gay men, as well as, anyone who identifies as transgender, and anyone living with HIV whether Latino or not.

SF:      We can’t make certain statements about whole groups of people, but we do find some general skill sets allow us to help some people more effectively: the building of rapport, the familiarity of a face that looks like yours, or an accent that sounds like yours. None of that would change if they told me that in 2013 HIV prevalence was 1 in 16 among Hispanic gay men and in 2014, it rose to 1 in 14 Hispanic gay men. That wouldn’t change how we do our work. There’s still plenty of need either way.

SM:     For years, there have been reports that people were more infectious just after HIV -conversion before anti-bodies have developed than throughout the course of HIV infection. Could this lead to a sort of spiral effect, with each new infection leading to even more infections that are new?

SF:      We all know that if I become HIV infected and I run to the clinic tomorrow or even next week and I test. I am going to get a false re-assurance. I am going to get HIV-negative test result even though I’m infected. Many people don’t really know why that is. They haven’t learned the reasons why. Our immune system is like a castle with all the cannons aiming out. It doesn’t know to look inside itself where HIV is growing. It’s inside the castle. So, for a few weeks to a few months, the virus has a free reign and the population of the virus can become enormous, up to 2 million viral particles of HIV per milliliter of blood.

SF:      At some time after the initial infection, the immune system figures out that HIV is there. Then you start getting sick with HIV conversion-flu. That’s actually a wonderful thing. The immune system is dragging that population of HIV down. Now you’re in a tug of war. We do know that without medication you will lose that tug of war eventually. But, thank god, the immune system was there to take it to a tug of war rather than a rout. 
SF:      We know that if somebody has been recently infected, they honestly don’t know, and can’t know, that not only are they HIV-infected but they are highly infectious.  

SF:      If you were to have a slip up with somebody in the first two months after their infection, they are 12 to 20 times more contagious than they will be for the rest of their life. You would actually be safer going to a hospital where someone was horribly ill with opportunistic infections related to AIDS and having unprotected sex with them That would be safer than having unprotected sex with someone newly infected. I don’t think many people appreciate or know that. 

SF:      While the decade of your life does not predict the time of your diagnosis of infection with HIV, “older guys” are more likely to know their status or to have been infected at an earlier age. Many younger gay men think that all the HIV is in the population of older men. As a result they believe that as long as they don’t hook up with “an older guy”, they will be safe, but “older” gay men are the just the population who know they have HIV infection.

SF:      Now, younger people are naturally sexually active. It’s that age when you are experimenting and figuring out what you like. Unfortunately, this also makes their peers who believe that they are HIV uninfected, their greatest threat of HIV infection, as they are most likely to be recently infected.

SM:     Is that type of spiral effect occurring in Broward right now?

SF:      In discussing background prevalence, the term we use is core groups,  If there’s a lot of HIV infection in a one group (XYZ group), it may not be in another group of peers who are somehow slightly different (ABC  group). Suppose you’re in ABC group. Maybe you are all in your twenties and living in South Florida, but maybe XYZ group has much more HIV infection in it. If you’re picking your sexual partners from group XYZ rather than ABC group that will have an effect. If there’s no HIV to catch, you can do whatever you want, but of course, there might be other STDs. There’s no such thing as a truly free pass.

SF:      The more HIV there is in a group, the less likely you are to luck out, if you fail to have some type of protection. The more HIV infection there is in a group, the more necessary; it is to have some type of protection such as condoms, prep, etc.

SF:      The more newly infected people in the group, the more highly contagious that group is.

SF:      Latinos Salud is doing the fourth generation HIV test. That means we’re testing for antigens rather than just anti-bodies. In general, the antigens present 15 and half days earlier than anti-bodies do. If someone comes in, and they’re in the window of uncertainty, even a little ways into it, we’re likely to catch their infection and help them to know their status. 

SF:      When most people become aware of their HIV-positive status, they significantly reduce their risk taking with partners who are either HIV-negative or unknown status. Most gay men, like all humans, are moral creatures. We all slip up sometimes, but most people try to protect their communities. When people know their status, most reduce their risk behavior. That’s why the fourth generation testing is exciting. We don’t have to wait for the anti-bodies.

SM:     What do you think is the optimal HIV testing frequency for gay and bi men in Broward?

SF:      The CDC came out with their recommendations a few years ago and they said once a year or every 3 months or 6 months if at higher risk. This is a universal recommendation, and that’s what the CDC has to do, because they can’t tap everyone on the shoulders and give them an individualized message. 

SF:      I wrote a column that we will be playing up for national gay men’s HIV awareness day, “The Safer Selfie” ( http://southfloridagaynews.com/Health/there-are-options-on-protecting-one-s-self-from-hiv.html). The Selfie is all about “look at what I’m doing right now. Look at what interests me. Look at my hobbies. Look at my travels.” We all get our own music play lists through our smartphone. We all get to stream whatever we want. Everything is personalized today. 

SF:      The ways to stay safe should be personalized as well. For instance, I personally practice negotiated safety. What that involves is getting an HIV test with your partner to rule out a prior infection that you may not have known about. You and your partner then have to have a serious discussion about what each of you wants and whether that’s going to be sexual exclusivity (monogamy), or not. If both of you are committed to sexual exclusivity, you then have to have one more HIV test to rule out the window of uncertainty. Then you can have condomless sex without being unprotected, at least as far as HIV is concerned. 

SF:      You can’t do negotiated safety unless you’re willing to get into awkward conversations. Negotiated safety was never really discussed here in the US, because just as it was becoming studied, Highly Active Anti-Retroviral Therapy (the medical breakthrough of the mid-90s) came out. People thought these meds would just stop the virus in its tracks, and we wouldn’t need to do prevention. People who truly understand negotiated safety understand one of its key precepts. You have to agree with your partner that if he comes back and tells you “I did slip up. I did have unprotected anal sex with somebody else “. You have to promise in advance that you will not leave him, at least not immediately. Otherwise, the fear of losing you is going to keep him from admitting what he did.

SF:      For some people that won’t work. Some people will say PrEP is the thing, for me, “I don’t want to depend on the other guy, I want to know that I’m controlling my risk of acquiring HIV by taking the meds”. Other people will say, “I grew up on condoms, I know how to use them. They work fine for me.” So we don’t have one answer for everybody.

SF:      There have been a lot of studies that claimed that negotiated safety doesn’t work. One study found that 1 in 3 couples had broken their exclusivity pledges within 3 months, but this study was amongst very young gay men. I’m not sure that’s a fair comparison. The ability to handle all the “awkward conversations” involved demands emotional maturity. Not that all “older” guys are that emotionally mature either, but you’re less likely to find it in younger guys. 

SF:      At Latinos Salud, we talk to each client to find where they’re at, what they’re comfortable with, and together choose the path that reduces their risk the most we can.

SM:     What do you think about public health messages concerning the frequency of HIV testing for gay and bi men?

SF:      A recommendation should be a guideline and not a rule.

SF:      It is a good idea to have a regular schedule for HIV testing, but it has to be one that works for you and your partner(s). If you negotiate safety, it shouldn’t be “we tested once but haven’t tested again for 30 years”. Knowing that there is some schedule, whatever you and your partner decide, whether it’s twice a year or once every three years. Just knowing that the test will be coming is more likely to make you honest if you have a slip up. You should set a frequency, once a year is not bad, I guess, for a couple. But each couple has to have the right to schedule differently. The truth is we often do sense when we’re floating away; we know when we are drifting in the relationship. In which case maybe, we want to test more often than once a year,

SF:      In our lifetime, we might pick different methods for different phases, maybe condoms for now. It might be PrEP later. It might be negotiated safety at another time. Our choice might be based on our maturity, our partner selection, or our personal tolerance of risk. Public health has one goal: No new infections and education to support that. It’s up to individuals to match that knowledge with their life.   

SM:     How often do you think single guys should be tested?

SF:      If you follow the CDC, the assumption would be that a single gay man means that you’re also having some recreational sex. Their recommendation would be test twice a year or four times a year, if you’re very sexually active. If you’re single and not hooking up at all, however, you don’t need to test. 
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SM:     Is there anything that you would like to say to the readers of SFGN about background prevalence and frequency of HIV testing?

SF:      Like in the rest of life, we assume that everybody has the same level of knowledge and the same interpretation of the facts that we do. Anytime that we’re going to be entering a potentially risky situation, we should first define our terms and make sure we’re on the same page with our partner. If I say I “love you,” have I just pledged monogamy? Or did I just mean I feel close to you at this specific moment? We owe it to ourselves to make sure we heard what our partner truly meant.

SM:     You wear many hats, how would you like to be identified for this interview?   
           
SF:      As a great guy. 

Stephen Fallon, Ph.D., Executive Director, Latinos Salud (latinossalud.org/) , and Skills4 (skills4.org).

Previous consultant to the Centers for Disease Control (CDC), National Minority AIDS Coalition (MAC), Health Resources, and Services Administration (HRSA) , U.S. Office of Minority Health Resource Center, the AIDS Institute.