(The Root) — Last week the Food and Drug Administration approved Truvada to help prevent the spread of HIV infections. The announcement coincides with the International AIDS Conference, taking place this week in Washington, D.C., where those working in the fields of HIV prevention, health care and public policy have converged to discuss the pandemic. This is the first year since 1990 that the United States has hosted the summit, and it couldn't come at a more appropriate time.
Alarming new statistics from the Centers for Disease Control and Prevention show that gay males make up 2 percent of the U.S. population but 50 percent of new HIV-infection cases. While men who sleep with men are routinely a large percentage of the newly infected, recent CDC research shows that for African-American gay males between the ages of 13 and 29, the HIV-infection rate rose 48 percent between 2006 and 2009. And among Latinos, gay and bisexual men account for two-thirds of new infections.
African-American and Latino men who sleep with men are the main groups to show such large statistical averages. These figures make one wonder why these populations remain the leading infected communities — in addition to African-American women — 30 years after the HIV/AIDS epidemic began.
It's Not Just About Behavior
Donna McCree, the CDC's associate director of health equity in the Division of HIV/AIDS Prevention, said that a sense of urgency about prevention measures has been lost. "Some of the young men weren't even around when there was no medication to treat HIV; that [fact] can have an impact," she explained to The Root. "We've learned that many in the African-American and Latino communities won't get tested because of the [negative] associations that come with it."
Socioeconomic status, drug and alcohol abuse and not having access to steady health care are other factors that may have led to the increase in infection rates among young black and Latino gay men, experts have said. And for some Latinos who might be more concerned about protecting their immigration status, getting tested for HIV is a low priority.
Meanwhile, McCree also pointed out that infection-rate increases have more to do with "background prevalence" than with a preponderance of high-risk sexual practices. "We have higher rates of HIV in African-American and Latino communities, so even with less risky behavior, because African-American and Latinos tend to have partners who are also African American and Latino, they actually face a higher risk of infection with every encounter they have because there is this background infection in their community," McCree said.
In fact, according to the Black AIDS Institute, studies have shown that high-risk behavior among blacks may be lower than in white and Latino gay male communities. In addition, the institute reports that men who are on the "down low" or less likely to identify as gay (pdf) aren't to blame for spiking incidence numbers.
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For Kevin Bynes, director of Oakland, Calif.'s AIDS Program of the East Bay, it's essential to understand the nuances of how infection is spread. "Gay sex isn't itself a higher risk — anal sex is," Bynes told The Root. He explained that HIV, transmitted through blood and fluid exchange, is "attracted to anal sex" because the rectal mucous membrane is extremely thin and prone to tearing, allowing the virus to pass easily from one partner to another. For that reason, heterosexual couples who engage in this type of intercourse are also at increased risk.
"Sex without a condom is the natural way to have sex. The condom is the extra thing," Bynes added. "Our job is to convince people to do the extra thing."
Though sex without a condom can lead to HIV infection, some gay men still take their chances. "A lot of guys have turned me down because I wouldn't have raw sex with them," Khalil Hodge, a 26-year-old Brooklyn, N.Y., resident, told The Root.
Then there's the example of the Bareback Brotherhood, an online community in which men gather to hook up and tell tales of their raw-sex experiences. As McCree explained, the rising infection rates can't be separated from "the environment and the context in which these behaviors occur."
Reaching for Solutions
But there is hope. According to studies by Truvada's manufacturer, Gilead, the pill — part of a prevention regimen called pre-exposure prophylaxis, or PrEP — when taken daily and combined with condom use and consistent physician care, is highly effective in preventing transmission of the virus. Many in the health care and advocacy communities are celebrating the existence of a new tool in the HIV-prevention toolbox in addition to other PrEP methods, such as microbicides, which are currently in trials.
"As a provider who sees patients, there's a diversity of those who like this or that delivery device, so I'm glad that I will have multiple contraceptives," Dr. Damon Francis of the East Bay AIDS Center and Oakland's Downtown Youth Clinic, told The Root. "It would be great with PrEP to have options that fit different lifestyles."
One of the drawbacks, however, may be the cost. At about $40 per pill, Truvada is $13,900 for one year's supply. "Two big challenges will be determining who will pay that $13,900 per year and who will be the providers to a population who generally aren't engaged with the health care system, aren't typically insured and don't have a regular doctor relative to other groups like seniors and women," Francis added.
And those aren't the only questions. AIDS Healthcare Foundation Director Michael Weinstein said that Truvada studies done in the United States demonstrated a 42 percent effective rate among men who have sex with men. He denied accusations that AHF has a financial reason for not supporting the drug but claimed that the drug is not quite a magic solution. "Adherence is a huge issue that will result in people thinking they're protected when they're not," Weinstein said. "And if they do become infected … they will spread a resistant virus."
There is obviously still work that needs to be done on many fronts — from education about prevention to searching for cures. With its Let's Stop HIV Together campaign, the CDC is doing its part to combat the apathy, discrimination and stigma still associated with HIV. Francis has observed firsthand how those infected and their families aren't always up-front about their positive status. "I've been to three funerals in the last year of my HIV-positive patients, none of whom died of AIDS," Francis said. "It was not mentioned that they were HIV-positive."
Then there's the case of Timothy Ray Brown of San Francisco, who has claimed to be the first patient cured of AIDS. Six years ago Brown was living with the disease in Berlin when he developed leukemia. In a subsequent stem cell transplant done to treat the cancer, his doctor used a donor who was among the 1 percent of whites who are resistant to the AIDS virus. The procedure worked, and Brown has shown no signs of HIV infection for five years. His case has become part of a new cure road map from international AIDS specialists.
"Timothy is a patient of my mentor, Dr. Steven Deeks at San Francisco General Hospital, and he's real," Francis said. "They've biopsied almost every part of his body and sent the specimens across the country for research, but he's a trouper."
From Truvada to the scientific breakthrough that Brown may represent, there is promise that the increase in HIV infections among young black and Latino gay men is not irreversible. But rather than poring over numbers, perhaps tackling the social and economic triggers for these incidences may be the best path forward.
Hillary Crosley is The Root's New York bureau chief.