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 naïve, 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.
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.
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