Our HIV crisis: All incidence is not equal

Our HIV crisis:
All incidence is not equal

By Kyle Tramonte, Staff Columnist
Published on February 18, 2015

 

Despite representing only 13 percent of the U.S. population, African Americans account for nearly half of all new HIV infections each year. Rates of transmission among injecting drug users, black women and black infants born to seropositive mothers continue to decline, but HIV incidence among gay and bisexual men who are young and black has charted a steady rise.

Centers for Disease Control and Prevention estimates are jarring: Their numbers suggest that one in five black men who have sex with men (MSM) living in a major city already has HIV. Forty percent of these cases will progress to AIDS. This is all compounded by the fact that black MSM are the most likely demographic subgroup to date other members of their own race.

Yet, if we ask Americans where the virus destroys lives, a majority will point beyond our borders.

A very clear transitive relationship exists: Socioeconomic issues associated with poverty — limited access to health care, housing and HIV prevention education — undoubtedly increase the risk of infection. The poverty rate is higher among African Americans than other racial and ethnic groups. Therefore, we should expect baseline incidence of HIV among black Americans to be higher than for other groups.

But while nearly all accept this reality, sensationalized characterizations of the black community promote misconceptions about the primary reasons for high incidence.

Take for example the false claim that HIV/AIDS is a product of irresponsibly foregoing condom usage. Black MSM confront a great paradox in HIV incidence: Meta-analyses from researchers at the CDC showed in 2012 that black MSM reported fewer high-risk behaviors than MSM of other ethnic groups. Still, at the time the authors published their study, black MSM had three times the chances of testing HIV positive and six times the chances of having undiagnosed HIV. Disparities in condom usage on racial and ethnic grounds do not provide a real explanation for this crisis.

Incarceration due to the war on drugs has of course disproportionately affected people of color. But pointing the finger at male-to-male transmission in prisons to explain the crisis is similarly incorrect. From July 1988 to February 2005, Georgia implemented mandatory HIV testing upon prison entry and subsequent voluntary testing by request or by clinical indication. Of those found to be HIV positive in Georgia prisons and jails, 91 percent were positive upon entry. The real danger of living with HIV in prisons is not the risk of infecting another inmate, but the stigma and abuse that stems from a positive diagnosis.

HIV/AIDS in the black community, in many ways, is not an isolated crisis but rather the child of a more familiar one. It is the same American dilemma of historical racial subjugation. When considering America’s HIV crisis among African Americans, especially MSM, we must look back to that first relationship between socioeconomic status, HIV incidence and black Americans’ persistent struggle to overcome structural inequalities.

Years of discrimination in housing and other resources, inadequate sexual health education in our crumbling public schools and persistent racism are the primary culprits in this crisis. And while mass incarceration doesn’t cause HIV incidence to explode in prisons, it certainly affects those who are not jailed. The women and men left behind in society must encounter a numerically restricted sexual network, increasing the chances that they will come into contact with an HIV-positive individual in small, high-prevalence communities.

HIV will not disappear without an offensive strategy. There are many factors that contribute to the crisis, but expanding access to high-quality health care is the integral first step to decreasing the racial disparity in incidence. The concept of following through on the “treatment cascade” or “care continuum” is vastly important — individuals must be diagnosed, then linked to care, then remain in care, then eventually achieve viral suppression to prevent transmission. The problem is that far too many black MSM are unable to access medical care with the frequency that other groups do.

EDITOR'S NOTE:

The first step in combatting the HIV/AIDS crisis begins with knowing one’s own status. If you or someone you know would like to receive free, confidential HIV testing, please call 203-936-8669.

The Affordable Care Act, in part, tried to address this crisis by eliminating discrimination practiced by insurance companies based on pre-existing conditions and by expanding Medicaid. But almost 20 states continue to deny Medicaid expansion, which would help those most vulnerable to HIV infection break into the care continuum and receive treatment. This is most potent in the South, where nine states have denied expansion, where African Americans are twice as likely to be uninsured and six times as likely to have HIV. And, according to a recent complaint filed with the Department of Health and Human Services, a number of insurance providers are actively discouraging HIV-positive individuals from enrolling in their plans through adverse tiering practices.

For many young black men who have sex with men, access to our health care networks is a question of life or death. We must confront this reality and take steps to ensure that they live.

 

 

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Credits

By Kyle Tramonte, Staff Columnist

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About the series

Our HIV Crisis is a series examining the HIV/AIDS epidemic. Focusing primarily on high-incidence communities in America, as well as on the landscape here at Yale, these columns seek to inform students about the most recent trends and challenges in combatting the crisis.

© 2014 Yale Daily News


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Our HIV crisis:
Young and at risk

by Kyle Tramonte, Staff Columnist
Published on February 4, 2015

 

In most students’ minds, the HIV/AIDS crisis was an event of the past: a bleak time of public condemnation of men who have sex with men, a searing recognition of the absence of legal and human rights afforded to affected communities and, for many, a period of intense sadness and fear. Yet the belief that HIV in America is no longer a public concern couldn’t be further from the truth.

Federal research shows that the nation’s HIV rate fell by a third from 2001 to 2011. But, in the same 10-year time frame, new diagnoses of HIV among gay and bisexual men between the ages of 13 and 24 increased by nearly 133 percent. Why is this happening, and why aren’t people paying attention?

Kyle Tramonte — Green on the Vine

We can attribute this lack of awareness at least partially to a diminished sense of urgency surrounding the virus. With the advent of prescription drugs that depress HIV-positive individuals’ viral loads, it slowly fell out of the news cycle. Soon after, the same-sex marriage movement all but replaced other LGBT community issues on the national airwaves. A cohort of young men now face an increased risk of contracting a virus relegated to the past, all while the public looks elsewhere.

Yes, the virus is spread more easily through anal intercourse, making gay men more susceptible. Still, we must recognize that two behavioral trends play an outsized role in the spike in incidence: Gay and bisexual men tend to have more partners and to use condoms less often than our heterosexual counterparts. But, as Michael Specter noted in the New Yorker over a year ago, “HIV is tied up with sex, a basic human need, but also with desire, shame, discrimination and fear. What twenty-year-old man, enjoying his first moments of sexual adventure, is going to be scared because, ten years before he was born, people like me saw gay men writhe and vomit and die on the streets where he now stands?”

According to an article in the News (“Sex isn’t always safe at Yale,” Jan. 23), Yale students cite decreased sensation as a primary motivation for not using a condom. Condom usage among men who have sex with men increased in the 1980s and 1990s as a direct result of the mass death of members of the gay community. But because we as a society no longer see people dying in the street, the split-second decision to forego safety at the expense of pleasure is calculated using a misguided risk assessment.

The nature of HIV testing also provides some answers. Tests that measure the antibodies resulting from HIV infection are subject to a “window period” of six to 12 weeks. If you get tested in the first three months post-infection, you may return negative results. Even further, an individual’s viral load is highest in this time window, making the period immediately post-infection also the most dangerous. Antigen (RNA) tests can return results within one to three weeks of infection, but these tests are more expensive and offered less often.

These numbers are, of course, only relevant to those who choose to get tested; the Centers for Disease Control and Prevention report that one in five infected people do not know they are HIV-positive. The takeaway? Self-reported, medically unsubstantiated assessments of sexual health should be viewed with at least some caution for the benefit of community health.

On this campus, ignorance regarding the state of HIV in America is also a product of the predominantly white and wealthy composition of the student body. A sizeable portion of our peers identify as gay and bisexual, but as long as the HIV crisis disproportionately affects people of color and the economically disadvantaged, HIV prevention will likely remain an issue to be tackled at a later date. We must recognize that HIV is a problem that affects all of society if we are to make a dent in public consciousness.

EDITOR'S NOTE:

The first step in combatting the HIV/AIDS crisis is getting tested. If you or someone you know would like to receive free, confidential HIV testing, please call 203-936-8669.

Nearly six years ago, public health researcher Ron Stall predicted that 50 percent of gay and bisexual men in our generation would contract HIV by age 50. Quality of life for HIV-positive members of our society has improved drastically in the last 20 years, but failure to recognize this degree of incidence in any community is a crime.

In conversations with professors and students, an interesting metaphor arose: If you are standing on the bank of a swift-moving river and see someone floating by, you might try to save them. If you see 10 people float by, it’s probably best you look upstream to see what the hell is going on. In the coming weeks, I will be talking to University administrators, students and public health experts to examine what role Yale and its students can play in addressing the crisis. We have to; people are drowning and few are on the riverbank to even notice.

 

 

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Sex isn't always
safe at Yale.

Exploring the numbers behind sexual health on campus.

By Stephanie Rogers
and Amaka Uchegbu
Published on January 23, 2015

In one of the first activities that all Yalies share in their college years, freshmen are taught to put a condom on a wooden, phallus-shaped object. Be safe — that is the message the exercise is supposed to convey.

But that message may not be taking root in students’ minds.

In a News survey on sexual health practices, completed by 241 students, 175 respondents said they were sexually active. Of these students, many reported engaging in sex without a condom and using methods of contraception that are widely considered to be ineffective. Public health experts at Yale and physicians who specialize in student health said that rates of unprotected sex on campus are worrisome.

EDITOR'S NOTE:

On Jan. 13, the News sent a 31-question survey to 757 randomly-selected undergraduates from every residential college and class year. Each respondent was guaranteed anonymity, in an attempt to ensure the sincerity of the survey’s results, which are reported here.
 
*Name has been altered to protect the identity of the student source, who spoke on the condition of anonymity due to the sensitive nature of the interviews conducted.

CONDOMS AND HEALTH

Not enough Yalies are using condoms to prevent STI infection. 

Of 139 sexually active survey respondents, almost one quarter said they rarely or never use condoms to prevent STIs. Thirty percent said they use condoms only some or most of the time, and 47 percent of students said they always use condoms. 

Interviewees’ experiences reflect these statistics. Johnny*, a freshman, said that he has had multiple, one-night stands with partners who were happy to engage in intercourse without a condom.

“I was shocked,” he said. 

But Director of Yale Health Paul Genecin and Chief of Student Health and Athletic Medicine at Yale Health Andrew Gotlin were not. Gotlin said he was unsurprised by the survey numbers showing the percentage of students who do not use condoms during sex, as they matched what he sees clinically. 

Genecin said that since the majority of sexually active respondents were monogamous, putting them at a lower risk of contracting STIs, Yalies with multiple sexual partners may produce very different results if surveyed. 

“It seems like very few people had more than one sexual partner,” he said, adding that the number of students who reported having more than one regular sexual partner is the demographic that worries him most. 

Of those who have reported not using a condom at some point, personal or partner preference for unprotected sex was the most common reason for foregoing condoms. 

Annabelle*, who never uses condoms with her boyfriend, is one of those students. 

“It just feels better,” she said. 

Not having a condom readily available was also an issue for some. In fact, a quarter of the sexually active students surveyed said they do not keep protection immediately accessible. 

“I just feel that the risks [of unprotected sex] completely outweigh the benefits of 20 minutes of slightly increased pleasure.”

—Jordan*

Jordan*, a freshman who in the past has gotten most of his condoms from the plastic bag in his entryway, said that, at times, condoms ran out. In contrast to the 30 percent of sexually active students surveyed who have opted to have sex despite the unavailability of condoms, Jordan decided to abstain on those occasions. 

“I just feel that the risks [of unprotected sex] completely outweigh the benefits of 20 minutes of slightly increased pleasure,” he said.

STIs: (NOT) PASSING THE TEST?

Even with a low-risk sample population — students who are typically having sex with just one partner — around 4 percent of Yalies surveyed admitted to having had an STI at some point.

Of those surveyed who have had penetrative or oral sex, there were 22 reported cases of an individual having a specific STI. Two percent of the 175 students surveyed said they had chlamydia, 2 percent reported having HPV and three students reported being HIV-positive.

Carl* has been diagnosed with chlamydia twice during his college years. 

Before those diagnoses, he did not take his sexual health seriously — there were times when, during anal sex, he did not use a condom with his partners, he said. Only after being diagnosed for the second time did he begin to research STIs and safe sex practices.  

Four percent may seem like a low prevalence for STIs, but 29 percent of sexually active  students surveyed said they did not know their STI status — they had never been tested, meaning that it is possible that the rates of infection are higher. In addition, 39 percent of students have not been tested in the past six months. 

The reasons that sexually active  students provided for not getting tested varied, but some fell within the following categories: they were too busy, Yale Health is too far away or they had never enaged in unprotected sex. Most, though, said they had not gotten tested because it simply was not common within their social groups. 

“I think people need to have a group of friends who think it’s a normal thing to do,” Sam Dealey ’15 said. “That will affect whether you [get tested].” 

Genecin said that while most Yale students will get tested at least once during their four years at Yale, some students are less open about it than others.

“Often people say they are coming in for something else, and then ask for STI testing [when they get there],” Genecin said. Some students simply feel more comfortable asking a clinician in person than telling the receptionist, he added.

STI tests are free to all Yale students — even those who have waived the Yale Health Hospitalization-Specialty Coverage — and, according to Carl, the test itself is easy. Schedule an appointment, urinate in a cup and wait for the results, he said, adding that he only waited four days for his.

He thinks that to increase testing rates, Yale Health should set up a yearly or semesterly clinic in an open part of campus, like Woolsey Hall or Commons, similar to the way it administers flu shots. Right now, he said, Yale Health is not doing enough to inform students of what it offers.

While Gotlin acknowledged the important role of health care providers in STI prevention and treatment, he said that students need to be proactive and ask about their partners’ sexual health histories before intercourse.

Twenty-two percent of sexually active  students surveyed have never asked about their partners’ sexual histories or STI statuses.

Annabelle, who cited the cultural stigma around talking about STIs, said she has felt uncomfortable asking a person about their sexual health history.

“I guess I don’t always [ask] because sometimes it’s awkward to bring it up in that time frame,” one male student added.

He added that he does not ask about sexual health history when he is receiving oral sex, but typically asks when he is giving.

Acknowledging that asking can be awkward, Gotlin offered strategies. When a student newly diagnosed with herpes asked Gotlin how to discuss STI status with future partners, Gotlin responded that it is best to ask openly and regularly.

“I suggested saying, ‘I do this as a matter of rote. I ask this of everybody so this isn’t a personal question,’” Gotlin said.

PREGNANCY AT THE FORE

For many women, though, STIs are not the primary concern. Pregnancy is. Indeed, while 76.71 percent of sexually active female students surveyed are on birth control, only 55.97 percent regularly use condoms. 

The discrepancy in numbers does not come as a surprise to Jill Carrera ’17, who uses the pill but not condoms. 

“I would definitely say that people on campus are just more concerned about pregnancy than STIs,” she said.

Such sentiments were echoed by all nine women interviewed.

“Undergrads are very young and are unlikely to reach a situation where it’s realistic and pragmatic to have a child and go forward with life plans,” said Genecin, in response to suggestions that pregnancy is less desirable than an STI infection.

Thirty-four percent of sexually active  female students surveyed said they had experienced a pregnancy scare at some point in their lives. Students interviewed attributed their worries to condom breakage, missed periods and having sex while drunk.  Twenty-seven percent of students surveyed said a broken condom was the cause of a legitimate pregnancy scare.  

During one of her first sexual experiences with her current boyfriend, Lila* discovered that the condom had broken. Though she worried that she might have gotten pregnant, she was too scared to admit the possibility to herself and ended up not using emergency contraception. 

“I would definitely say that people on campus are just more concerned about pregnancy than STIs”

—Jill Carrera '17

“I probably should have [taken the morning after pill],” she said. “It’s interesting what inertia and uncertainty will lead you not to do.” 

While Annabelle did not think twice before using Plan B after a condom had broken, she worries that other women misuse it and take it as an alternative to preventive contraception. 

Fifteen percent of sexually active  female students surveyed had used Plan B at least once, averaging 2.4 uses per person. The highest usage for one person was 11 times. 

Gotlin said he is concerned about what he identifies as a misconception that condoms are for pregnancy and not STIs. 

“The implication is that if people are not worried about pregnancy [because they are on birth control, for instance], people won’t use condoms,” he said. 

Genecin suggested that because today’s college generation did not experience the AIDS epidemic, instead living through a preoccupation with teen pregnancy, they struggle to internalize the dangers of unprotected sex. 

“People these days think HIV is a risk from an older generation,” he said, adding that there is a lack of concern about STIs across age groups.

NOT TAKING NECESSARY PRECAUTIONS

Students may be worried about pregnancy, but some are not taking the recommended precautions — for either pregnancy or STIs. Fourteen percent of respondents rarely or never use any form of contraception, 7 percent use contraception only sometimes and 23 percent use contraception during most but not all of their sexual encounters. 

For those who are not using the recommended forms of contraception — the ones widely considered to be effective — the rhythm and withdrawal methods are the main alternatives. Thirty-five percent of sexually active  students surveyed, who did not always use protection from condoms, said they had used either the rhythm or withdrawal method at some point.

Abdi* said those numbers were not particularly baffling — most members of his senior society confessed to having used one of those methods before. 

“I’m not at all surprised, but I would not at all use [them] myself because I’m not a dumbass,” he said. 

“If I was in the jungle and didn’t have a condom, sure,” said Dwayne*, a sophomore. “But since we have technology it’s best not to use what people in Ancient Rome used when they didn’t want kids,” he said. 

As a Community Health Educator, Carolyn Collado ’16 said she never recommends using the withdrawal method to avoid pregnancy. 

According to a study from the Office of Population Research at Princeton University, after using the withdrawal method for one year, 22 in 100 women will become pregnant. After using it for 10 years, 92 in 100 women will become pregnant. 

Marah* is one of those students who uses the rhythm and withdrawal methods. She tracks her cycle with a cell phone application, and said she knows when it is safe for her to have sex without risking getting pregnant.

The main reason Marah has not opted to take a birth control pill or have an IUD inserted is because she does not want to overload her body with “unnecessary hormones,” she said. 

Her decisions about her sexual practices do not sit well with her friends, who urge her to use condoms. But Marah said that she finds their admonishments hypocritical — most of them, she said, do not use condoms, even though they are having sex with multiple partners with whom they have not had conversations about STI status. 

But friends are not the only ones opposed to the rhythm method. According to Gotlin, stresses that exist in academic environments can make predicting ovulation particularly difficult.

“It’s neither accurate nor reliable,” he said. “I would not bet my pregnancy prevention method on the rhythm method.”

IS YALE’S SEX ED SUFFICIENT?

While sex education at Yale levels the playing field for students coming from places all across the country and world, it does not continue the conversation, students interviewed said.

“I don’t think sex education at Yale is entirely great,” said one student. “I just realized in this interview that I don’t know about STIs that could be passed through oral sex.”

Another student, Joshua McGilvray ’18, said he had no education about the mechanics of sex while at an American boarding school for two years. He said he worries about students’ range of sexual knowledge.

“Schools are so deregulated [in America]. You can’t count on good sex education happening in high school,” he said. “It seems worthwhile to continue with consent education and teach people about contraception.”

Rachel*, who grew up in rural Mississippi, is one of those students about whom McGilvray is concerned. She only received abstinence-only education at her public high school. Her STI education, she said, consisted of the teacher saying the students would be “hurting everyone around them by having sex.” He proceeded to show the students “horrible and graphic” images of STI infections, she said.

Gotlin noted that education about safe sex should not consist of dissuading people from having intercourse.

“Abstinence is a yucky option — who wants to do that?” Gotlin said.

Eduardo*, a senior who grew up in Miami, falls on the opposite side of the spectrum. The city, he said, is a “hotbed for venereal disease,” so he had a comprehensive sex education that included lessons about protection, the effects of STIs and the importance of always wearing a condom.

One of the obstacles students recalled facing in their middle school sex education is the gender divide in who learns what. Alexandra* said that, in middle school, she was brought into a separate room from the boys and taught her own anatomy and reproductive cycle. Meanwhile, the boys sat in the other room learning about theirs.

She said this division makes communication between heterosexual partners difficult. They are simply less aware of how each other’s anatomy works.

“I don’t think sex education at Yale is entirely great. I just realized in this interview that I don’t know about STIs that could be passed through oral sex.”

Eduardo, whose sex education was relatively comprehensive, said he was unaware of the different birth control options women have until recent conversations with female friends.

Steven*, a biology major, did not know that contraception is necessary at all points during a woman’s menstrual cycle. He asked if it was possible for a woman to get pregnant during her period. It is.

While Collado said she feels the CHE program is important to level the knowledge playing field for all freshmen, Sexual Literacy Forum co-director Jez Marston said it is important to have continued conversations about how to communicate and ask difficult questions during sexual encounters. He said he did not know much about female birth control until he began participating in SeLF his junior year.

“We can see it’s reasonable to enhance our sex education [at Yale],” Gotlin said, talking about the survey results.

According to Rachel, that sex education needs to touch on more than medical aspects of sexual health.

“Safer sex also goes into taking care of your partner during the act. [It] involves communication,” she said. “[It] doesn’t end with STDs and pregnancy.”