C.A.R.E. Knowledge Blog

Long Beach HIV Testing Data

Yesterday I tallied our HIV testing numbers for December and all of 2011. In total we conducted 131 HIV antibody tests with 26 of them coming out positive. That's a positivity rate of almost 20% or one in five (19.85%). When I've talked to coordinators of other testing sites, I hear about 2 to 3 percent of their clients testing positive. 

One of the reasons for the big difference is that we're not out casting a big net to meet numbers. People come to us because of their perceived risk, and many times their assessment is correct. We also get referrals from out positive clients in the CARE Clinic. Often when people are at risk and they know someone who is positive, they'll turn to that person for information on local resources. I also suspect that some of the folks who test positive are coming here because they expect a positive result, and they know their next step will be to sign up for care. 

The Potential to Reduce HIV Transmission

Science and Nature are the two biggest peer reviewed journals around. For an article to make these magazines, they have to be a significant scientific breaktrhough. So (according to Science Magazine) what was the biggest scientific breakthrough of 2011? It wasn't the discovery of habitable earth-like planets orbiting other suns, or evidence of Higgs boson by the Large Hadron Collider; it was in the field of HIV and public health, or more specifically, using HIV treatment as prevention. From MedPage Today:

In the history of our time, 2011 could be remembered as the year the tide began to turn against the HIV/AIDS pandemic.

Equally, it could be remembered as the year we fumbled the opportunity to end one of our greatest scourges.

The key event was the release in May of data from a single randomized clinical trial — the 052 study by the HIV Prevention Trials Network (HPTN) — that showed that treating people with HIV reduced the risk of transmission by some 96 percent.

The study has been "catalytic," according to principal investigator Myron Cohen, MD, of the University of North Carolina in Chapel Hill, N.C.

Considering that condoms are about 85% effective at preventing HIV trasmission, you would think the government would be all for something that reduces HIV transmission by 96%,  but that might be seen by some as giving tacit approval for folks to have sex. Up in San Francisco, public health has already adopted "Test and Treat" as their policy, promoting testing and offering therapy to everyone no matter what their CD4 count. As a result, the number of new positives has dropped while STD rates have remained steady, a good indication that it's working. 

Other studies coming from places as diverse as Taiwan and Brittish Columbia show that increased testing and earlier treatment is reducing new infections. 

Here in LA, they're looking to combine HIV prevention and treatment planning bodies, so the main object of prevention will eventually be promotion of HIV testing and getting people into care. Unfortunately bureaucracies change slowly, and the sex police will be digging in their heels. I'm reminded of the H. L. Mencken definition of Puritanism: the haunting fear that someone, somewhere is having a good time. 

Here in Long Beach, those undiagnosed with HIV are the main drivers of the epidemic. Consider the hypothetical person who tested six months ago and has had a few partners since then. It's these folks who think they're negative (because that was the indication on their last test) who are recently infected that have the high viral load that makes the virus easier to transmit. Public health estimates that there are 6,000 people living with HIV in Long Beach. If 1,500 of them don't know they're infected, that can mean there are easily over a thousand gay men typing "I'm negative, UB2" in their on-line profile, when in fact they're carrying the virus. 

In the early days of the epidemic--before HIV testing--the gay community rallied together and reduced transmission by assuming all  partners were positive--or they might be positive themselves (and took appropriate precautions). Perhaps we can set aside the viral apartheid contained in terms like "clean" or "disease free" and start thinking about the well being of the community. "Test and Treat" shows you care about yourself and you care about others. Getting tested for HIV every six months if you're sexually active is the first step; if you do test positive, seeking treatment is the best thing you can do for yourself and for the community.

 

Dirty Pools

Among my duties here at the CARE Program I also do the HIV testing. CARE offers free rapid testing for HIV using an oral swab, with results in twenty minutes. 

As part of the testing process I fill out a risk assessment form with the client. By the time the client leaves my office, they should have a pretty good idea of their own risk of aquiring HIV. The questions fall into two categories--those that address the mechanics of transmission--like sharing needles, or what body part is going in what orafice. The other questions assess risk in terms of risk groups. 

Everyone is a individual, but some groups have higher numbers of people living with HIV. In public health, this is called prevalence. If you have sex with someone in a high-risk group, you're more likely to be having sex with someone who is positive. 

By far the group with the highest prevalence is gay men. In Long Beach, like most urban areas, HIV prevalence among gay men is as high as one in four or one in five. Other high-risk groups include sex workers, people who inject drugs, transgenders, and men who have been incarcerated. 

It's good to protect yourself by using condoms--or clean needles if you inject, and it's also good to be aware of the amount of HIV in the "pool" of people you're swimming with.

If you'd like to get tested for HIV, our office is located at 411 East 10th Street, Suite 107, Long Beach, CA 90813. To schedule an appointment, call (562) 624-4900. Testing hours and information are located here. 

Creating an AIDS-Free Generation

Secretary of State Hillary Clinton spoke November 8 at the NIH about United States AIDS policy. She began the policy announcement by speaking about prevention of mother-to-child transmission, and reducing transmission by male circumcision in Africa, two evidence-based approaches to reducing trasmission through medical intervention. 

In June, I visited the Buguruni Health Center in Tanzania, and there I met a woman living with HIV who had recently given birth to a baby boy. She had been coming to the clinic throughout her pregnancy for medication and information because she desperately wanted her boy to get a healthy start in life, and most especially, she wanted him to be born HIV-free. When we met, she had just received the best news she could have hoped for. Her son did not have the virus. And thanks to the treatment she was getting there, she would live to see him grow up.

This is what American leadership and shared responsibility can accomplish for all mothers and children...

In addition to preventing mother-to-child transmission, an effective combination prevention strategy has to include voluntary medical male circumcision. In the past few years, research has proven that this low-cost procedure reduces the risk of female-to-male transmission by more than 60 percent, and that the benefit is life-long.

Here in Long Beach, thanks to the Bickerstaff Clinic at Long Beach Memorial, there hasn't been a case of mother-to-child transmission. Here in the developed world, anti-viral therapy is the standard of care for HIV-positive pregnant women. 

We probably won't be seeing male circumcision here in the West. Studies in the devloped world haven't shown the same protective effect, either due to the different strains of HIV, the different routes of transmission, or other confounding factors. 

Clinton third method is something that isn't being done in the United States, and shows great promise for reducing new cases of HIV here at home; it's what will be known as "test and treat":

Thanks to U.S. Government-funded research published just a few months ago, we now know that if you treat a person living with HIV effectively, you reduce the risk of transmission to a partner by 96 percent.

Of course, not everyone takes the medication exactly as directed, and so some people may not get the maximum level of protection. But even so, this new finding will have a profound impact on the fight against AIDS.

For years, some have feared that scaling up treatment would detract from prevention efforts. Now we know beyond a doubt if we take a comprehensive view of our approach to the pandemic, treatment doesn’t take away from prevention. It adds to prevention. So let’s end the old debate over treatment versus prevention and embrace treatment as prevention...

Treating HIV-positive people before they become ill also has indirect economic benefits. It allows them to work, to support their families, contribute to their communities. It averts social costs, such as caring for orphans whose parents die of AIDS-related illnesses. A study published just last month weighed the costs and benefits and found that – I quote – “the economic benefits of treatment will substantially offset, and likely exceed, program costs within 10 years of investment.” In other words, treating people will not only save lives, it will generate considerable economic returns as well.

This is great news for developing countries currently receiving PEPFAR funding for HIV treatment. What's so unfortunate is that here in the United States, we have thousands of HIV-positive people on ADAP waiting lists.  Just last week I received a call from someone who has my job in Florida, and she said it can take two years from intake before a new patient can receive life-saving medications. I know that for person with an impacted immune system, help may come too late. 

As George Ayala pointed out in is opinion piece in the Advocate, for treatment as prevntion to succeed, a concerted effort needs to be made to target populations most severly affected by the virus. When you come in to the CARE Program for a free rapid HIV test, we'll ask about risk factors--specific behaviors that put you at risk. But just as importantly, we'll be asking about the types of people you may be having sex with. Transgenders, men-who-have-sex-with-men (no matter how they identify), the recently incarcerated, sex workers, and injection drug users--are all groups with high percentages of people living with HIV.

Since one in five of people with HIV don't know they're infected, it's essential that folks in high risk groups get tested on a regualar basis--and have quick access to medications. 

 

Who is Next?

Last month The Body ran a piece on 10 famous people with HIV. What was interesting to me is that there wasn't anyone who has disclosed their status since the mid 1990's, a time before effective combination therapies became available. For those on the list who are still living--Magic Johnson and Greg Louganis--their disclosure came at the height of their athletic careers, and almost required some reason for their retirement at the top of their game. We could add Rudy Galindo to this list, the last person I remember going public with his or her HIV status. 

Even if Magic wasn't such a vocal advocate for HIV, his disclosure has done much to promote testing and condom use. His continuing success in business and sports shows that one can have a full life--not only after HIV, but also after disclosure.  As I wrote in the comments section:

Does the lack of any new celebrity spokespersons living with HIV/AIDS in the last fifteen years mean that celebrities are all using condoms and no longer put themselves at risk? I don't think so! 

Having famous people living with this disease does much to promote HIV awareness, condom use, and access to treatment. It's unfortunate that there are probably 10 more celebrities we see in concerts, on ESPN, on TV, and in the movies every day who would make incredible advocates, but because they might loose that romantic role or Nike endorsement, choose to hide behind their pills.

This week Kellee Terrell picks up on the theme in their post, "Will This Generation's Magic Johnson Please Stand Up?"

Maybe the media, TheBody.com included, needs to write more articles about straight men living with the disease. And maybe more health care professionals need to check their own biases at the door and be less worried about offending patients and just test them anyway.

Or maybe what we need to set all of this into motion is another Magic Johnson.

Someone who possesses the same level of fame, power and swagger as the Dwyane Wades, the 50 Cents and the Jay-Zs of the world, and who is willing to go public with his HIV status. While this person has yet to materialize, given the HIV prevalence rate in this country, I know he exists.

And to take it one step further, maybe we also need a famous woman with HIV to disclose her status. I know she exists as well.

When I first started woring in the HIV field, Magic's disclosure sent lines out the door from the Long Beach Health Department's STD clinic. I'm sure there were a few who did test positive, and can thank Magic for their getting tested and getting into treatment early. If it's been a while since your last test, maybe it's time to come back and get tested. 

The CARE Program offers free confidential HIV testing with results in twenty minutes. We're located at 411 East 10th Street, Suite 107, Long Beach, CA 90813. You can walk in, or make an appointment by calling (562) 624-4900.

 

Black Gay Men and HIV in Long Beach

Last week I blogged about the CDC's report on the stable number of new infections; buried in the report's subtitle was the growing numbers of new HIV cases among Black gay men. Frank Oldham, preseident of the NAPWA (National Association of People with AIDS) has sent out an open letter, which is worth quoting at length here.

NAPWA and I personally salute the CDC for reporting Wednesday what we all already guessed: the number of new HIV infections is level for the country as a whole but is steadily rising in young gay Black men. Tom Frieden spoke for all of us when he said, "We're very concerned about this trend." As an openly gay Black man who has lived with HIV for twenty-two years and seen friends and partners die, I wholeheartedly agree: we have to change this.

Studies show that young gay Black men are at least as likely to use condoms as their non-Black peers, so we cannot blame the rapid spread of HIV among them on riskier behavior. On the contrary: it is driven by the high number of young gay Black men already infected and the high number of them who do not know they are infected. The special impact of HIV on these young people is caused by structural issues in American society that mainstream politicians and press don't like to talk about - especially in this Tea Party-driven political climate.

Structural issues are always hard to talk about. Poverty and prejudice are harder than any. But let's face facts: HIV's disproportionate impact on African-Americans and other Americans of color is the price this country pays for letting color mean poverty, and poverty mean substandard healthcare and health literacy. And HIV's disproportionate impact on young gay men has everything to do with stigma and homophobia, which discourage young men from learning their status and seeking treatment. Let those two problems come together and you have the perfect storm.

We need to address unequal economic and educational opportunity, which keep poor people poor, but that will be a generation's work. In the mean time, all lower-income Americans, White and Black, straight and gay, need fairer access to healthcare and support services. Achieving that, in this political climate,  means driving home relentlessly the objective truth that three-quarters of HIV-related healthcare costs are borne in the public sector, and it costs the public less to test aggressively and treat early than to do nothing and let more people get sick. Our best defense in the coming deficit reduction negotiations is a good offense: it costs more to do less, and we can prove it.

Good figures on local HIV statistics are hard to come by. In Long Beach about 13% of the population is African American, yet they make up one quarter of new HIV cases. As Frank Oldham points out, drivers of the epidemic are not riskier behaviors, but riskier partners: if you're having sex with a segment of the population that is one quarter positive, the chances of being exposed are much higher. Compounding the problem is the number of people who have HIV but don't know it. Here in Long Beach, it's estimated to be 1500 people who are positive and have yet to find out. Because their HIV is not treated, levels of the virus are higher, making it easier for them to infect someone else. 

As Oldham states, it costs less to test agressively and treat early than to do nothing and let people get sick. Here at the CARE Program we offer free confidential HIV testing with results in 20 minutes. Call 562-624-4900 to scedule a test. 

HIV: Thirty Years and Counting

 
The mainstream media are starting to cover stories on HIV and AIDS as we approach the 30th anniversary of the first reports of a handful of gay men in Los Angeles showing symptoms of an opportunistic infection. A few days after the June 5th anniversary, forty of the world's leaders will gather at the United Nations to address the progress made--along with the unmet need. 

To put things in perspective, if we had an AIDS quilt for everyone living or dead from HIV it would cover all of Washington DC instead of just the grass along the Capitol Mall. One of the highlights of the past few weeks is the news that getting HIV-positive folks on medication greatly reduces the risk of transmission. But to get treatment to play a role in prevention, we would need the one in four who are positive and don't know it, to get tested. 

Here at the CARE program we offer free confidential testing for HIV Monday through Friday from 9:00 am to 4:00 pm by appointment. Our number is (562) 624-4900. We use Ora-Quick testing, so you'll have your results in 20 minutes and because it's an oral test for HIV, there's no needles. 

 

Asian and Pacific Islander HIV/AIDS Awareness This Thursday

 
This Thursday May 19th is National API AIDS Awareness Day. From the California State Office of AIDS:

Currently, there are over 4,000 A&PI individuals living with HIV in California.  Due to social and cultural barriers, such as a lack of recognition of the impact of HIV/AIDS within some A&PI communities, and the notion of saving face among some individuals from A&PI communities, the number may be even higher. 

One of eleven AIDS awareness days that target various facets of the epidemic, Asian communities have historically been seen as being less affected than other at-risk populations. Anecdotally, the newly diagnosed support group I help facilitate at The Center always has newly diagnosed Asian or Pacific Islanders in attendance. The good news it that they're coming out, and learning to be advocates for their own health. For others who read about these awareness days, realize their own risk and want to be proactive and test, the CARE Program offers free, quick, and confidential oral (no needles) HIV testing by appointment. Our office number is (562) 624-4900.

 

Serosorting and HIV Transmission

Two interesting research papers came across my desk this week. The first, Characteristics of HIV epidemics driven by men who have sex with men and people who inject drugs (Wilson et al) used innovative mathematical modeling techniques to evaluate various strategies for reducing the number of new HIV infections in adversely affected subpopulations. Since the first signs of the virus in the early eighties, we’ve learned to identify and test for HIV, determine the body fluids and behaviors that contribute to a higher probability for transmission, and then develop behavioral interventions that would reduce risk. In the early years—before it was even possible to test for HIV—the mantra was, “Since we don’t know who’s infected, assume all your partners are positive, or that you may be positive yourself.” The underlying morality of this model was showing care and respect for ourselves along with showing care and respect for the consenting adults we had sex with.

Over the years, educational programs, counseling and testing, outreach, safer-sex workshops and the like have met with varying degrees of success. Just having a gander at our fellow residents struggling with obesity, addiction, and other preventable health problems should make it evident that changing behavior isn’t simple or easy. With the advent of effective therapies for HIV in the mid-nineties, and the resulting reduction in viral load and transmissibility of the virus, another model for reducing new cases of HIV emerged. Currently known as Test and Treat, the underpinning idea is to identify those who are infected through easy access to regular testing, and then get those who test positive on medication. By reducing the community’s viral load, less transmission will occur, and the number of new cases will go down.

In the Wilson paper they look at serosorting, which is based on the idea of choosing a partner with the same HIV status. The logic behind this is that if two HIV-negative persons have sex, there is no HIV to transmit, and if two HIV-positive partners have sex, no new cases of HIV will occur. One issue noted with this practice is that it can create a type of “viral apartheid,” and labels like “disease-free, you be too,” can exacerbate stigma for those who are living with the virus. The other fly in the ointment becomes those individuals who have never tested and those who have had a previous negative test, but later became infected. Since they see themselves as still being a part of the negative camp, limiting oneself to other “negative” partners can be fraught with peril. Wilson modeled the acquisition of HIV associated with serosorting and found that,

 “… (It) is only beneficial when the percentage of undiagnosed HIV-infected MSM is below 20%. These modeling studies are consistent in their findings and have assessed sero-sorting to be effective at the population level in developed setting with high testing rates such that there are a minority of HIV infections which are undiagnosed. However, in most parts of the world serosorting with casual partners is likely to increase risk of HIV acquisition.”

 The other paper, Predictors of Unrecognized HIV Infection among Poor and Ethnic Men Who Have Sex with Men in Los Angeles (Young et al) notes that approximately 25 – 48% of HIV+ people may be unaware that they are positive. The percentage of persons unaware of there HIV positive status is much higher in younger age cohorts than persons over 35. Here in Long Beach, County epidemiologists estimate that one out of four infected people don’t know they’re positive. Young’s paper also notes that when subjects were assessed for homonegativity (that means negative perceptions and feelings about homosexuality) higher negative feelings were associated with not being aware of one’s HIV-positive serostatus.

In places like San Francisco where Community Viral Load is monitored, and the Test and Treat model is aggressively promoted by public health officials, the number of new HIV infections has fallen by half, while the rates of other STD continued to climb.

Taken together, these two papers point out the need for more HIV testing, and regular testing for those most at risk. Choosing a partner because of their perceived or posted negative status may actually increase one’s risk of acquiring HIV.

Here at the CARE Program, we offer free confidential testing for HIV, with results in twenty minutes. Call for an appointment at (562) 624-4900. We test Monday though Friday from 9:00 to 11:30 and 1:15 to 4:00. If you test positive, CARE offers comprehensive medical, dental, mental health, and social services. We can also help you enroll in benefit programs to help pay for your care.