Earlier this week, the Minnesota Department of Health announced that the number of people with newly diagnosed HIV in 2009 had increased by 13 percent, marking a 17-year high. The increase was driven primarily by an uptick in the number of cases involving males 15 to 24 years old, 88 percent of whom reported male-to-male sex as the primary risk factor.
Dr. Frank Rhame, an HIV specialist with Allina Medical Clinic, says the new numbers didn’t come as a surprise to him.
“We’ve certainly seen that trend in our office,” Rhame told me. “I see these young gay men taking risks, and they’ve gotten infected, and it breaks your heart. It’s probably true that it [HIV] is not going to shave much off their life expectancy, but it’s sure going to change their lives.”
To help stem the tide, MDH plans to use federal grant money to target this young male group with expanded HIV testing and education programs. That sounds good, but it brings up an obvious question. Is there anybody out there who doesn’t know about HIV and the dangers of unprotected sex?
“In the U.S., I think people generally know,” Rhame explained. “But they’re not saying you need to spend more money on education, they’re saying you need to spend more money on behavior change. And behavior change is a lot harder to create than education.
“From the finances of it, if you could affect a behavior change at a reasonable cost, you wouldn’t have to pay for all those HIV infections in the future,” reasoned Rhame. “On the other side of it, though, no one has really shown that behavior change can be accomplished. We’re not very good at it. If you look at obesity, exercise and all those things we need to accomplish health-wise, it’s hard to show that any efforts have worked.”
However feeble our attempts at healthy behavior change can be, Rhame isn’t suggesting that we shouldn’t try. He points out that there’s a public health rationale for fighting communicable illness that doesn’t exist for things like obesity or tobacco use.
“Fundamentally, smoking hurts the smoker, and apart from the second-hand smoke issue, it doesn’t hurt other people,” he said. “Whereas this one [HIV] is transmissible, and therefore when you can get rid of it in the community, you do everyone some good.
“That certainly works for something like tuberculosis, where people don’t willingly participate in an interaction that gets them infected; it’s a little harder argument to make for HIV, because everybody who gets it was a willing participant, just about, except in cases involving rape.”
So if the dangers of HIV infection are well known, what explains the rising number of cases? Rhame see two independent forces at work.
“The role of crystal meth is large, at least in terms of men who have sex with men. It’s not everybody, but a lot of them will acknowledge that it was during crystal meth use that the infection arose,” he said.
The MDH wasn’t able to provide me with any firm data, but Rhame estimates that in his practice, perhaps 50 percent or more of newly HIV positive gay males became infected while using methamphetamine.
While he doesn’t claim to be an authority on the subject, Rhame has noted that in his clinical practice men who have broken their addiction to crystal meth have had to relearn how to have sex.
“Many of them will be sexually abstinent for six to 12 months after their crystal meth sober date, because the association is so strong — they have to relearn to have sober sex,” he said.
The second reason Rhame cites for this increase in HIV infection within the gay male community has to do with risk taking and what he terms “cohort succession.”
“If you look at new [HIV] infections over time, you see that between 1985 and 1995, there were probably 100,000 or more gay men getting infected every year. And then it came way down, and now it’s drifting up,” Rhame said. “Now it may be that it’s drifting up not so much because people are losing resolve, but because a new crop of risk takers is coming along.
“Between 1985 and 1995, we sort of saturated all the risk takers. There are risk takes and non-risk takers. It’s taken time for a new crop of gay men to come up, of whom, let’s say 10 percent are risk takers, and therefore there’s more to get infected now.”
Although the risks of contracting HIV haven’t changed since 1985, sophisticated medications have drastically reduced the risk of dying from HIV. That makes it easier for a physician to deliver the bad news. “They’re all fairly distraught when they get the diagnosis,” Rhame recalled, “but not as distraught as they used to be because it isn’t the death sentence it once was.” But it also means HIV, stripped of its mortal implications, appears less threatening.
Fred Evans would agree. In his role as a health coordinator for the Fremont Community Clinics in Minneapolis, Evans heads “Seen on Da Streets,” a unique street outreach initiative designed to reach out to at-risk youth in north Minneapolis. He cites a lack of education “and this new-found notion that some people have on the street that this thing can be cured, and that it’s not as bad as it seems” as being some of the main reasons why HIV is on the rise.
I asked him the same question I asked Dr. Rhame: if the public is already fully aware already of the risks of unprotected sex, why do they need more education? In the young people that Evans interacts with on the street, he uses repetition and re-education to fight a combination of youthful invincibility and a “not-me” attitude that spans all ages.
“It’s human nature to think that nothing is going to happen to me,” Evans said. “That’s how we all kind of function, in this whole scheme of things: ‘Wow, that’s really bad that that happened to them.’ From that standpoint, the flaw is in us as humans, in not believing that things can happen to us.”
So what do these youths and young adults say when Evans talks with them about HIV and risky behaviors?
“They all say that they know that, and they all tend to believe that they’re not messing with anybody that has HIV,” Evans told me. In his experience, heterosexual young adult males tend to see HIV as a problem for gay males, something they don’t have to worry about.
“But still, at the same time they’re having unprotected sex with four or five different girls, and those girls are having unprotected sex with four or five unprotected guys,” Evans said. “But they don’t see that as an issue.”
No scare tactics
For Evans, taking it to “da streets” involves opening a dialogue with at risk youth and young adults.
“It’s not scare tactics, it’s education tactics,” he said. “We’re not trying to frighten anybody into anything, because we found out that that doesn’t work at all. You have to be up front. You have to be real. You have to be direct. If they’re ready for the conversation, you’ll know, because you’ll have it. And if they’re not ready for the conversation, then they’ll tell you to move around.”
If they’re ready to talk, Evans hopes that the conversation progresses to the point that young men will agree to provide a urine sample, which can be taken back to the clinic and tested for sexually transmitted disease; or a mouth swab, which can be used to test for HIV. For Evans, getting a urine sample means first convincing these youths that he is not an undercover police officer, looking to make a drug bust.
To that end, Evans makes sure that these people understand that agreeing to testing for HIV is a tacit acknowledgement of risky sexual behavior, and nothing else.
“They’re admitting that they’re having unprotected sex, that’s all they’re admitting, without using any words,” he said. “We need to be professional in identifying that and moving on, and not being judgmental and asking any other questions. Just accept what we get. If you accept what you get from an individual, the next time you have an encounter, you can get so much more.”
When I inferred that Evans was dealing with a primarily heterosexual community, he was quick to point out that his work has shown him that the lines of delineation are not as sharp as many would suppose.
“I think that we’re talking about the same population, because I think people are intermixing so much now that the populations are kind of the same. I think we have put labels on populations ourselves, but with more people coming out, especially females coming out, and more males actually coming out and identifying themselves as either bisexual, gay questioning, or both, I think the label comes from us. The labels don’t come from them.”
To that point, according to the MDH data, almost 90 percent of newly HIV positive males age 15-24 years said that male-to-male sex was their main risk factor. And the ethnic breakdown of this age group was as follows: 45 percent white, 39 percent African-American, 11 percent Latino and 3 percent Asian.
As for the role of crystal meth in the rise of HIV, Evans thinks that the association is definitely possible, but because his outreach program is focused on sexual health and not drug use, he doesn’t have any hard data.
“I would definitely agree that anyone who is using some kind of substance would make some very poor choices when they’re inebriated.”
Rhame would agree. “Condom, condom, condom,” he suggested, “and if you can divorce sex from intoxication, that would be nice, but that’s not going to happen in our life time.”