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If Peter Duesberg and others are right about HIV having nothing to do with AIDS, those who are unaware of being HIV positive may be the lucky ones. - SM

http://www.nytimes.com/2002/07/08/health/08AIDS.html

Many Gay Men in U.S. Unaware They Have H.I.V., Study Finds

By LAWRENCE K. ALTMAN

ARCELONA, Spain, July 7 — The vast majority of young gay and bisexual men in the United States who were found to have the AIDS virus in a new study were unaware of their infection, according to findings reported as the 14th International AIDS Conference opened here today.

The rates of unawareness among minority gay men ages 15 to 29 in the study were staggeringly high. Among those found to have H.I.V., the AIDS virus, 90 percent of blacks, 70 percent of Hispanics and 60 percent of whites said they did not know they were infected.

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Most of these infected men perceived themselves to be at low risk of being infected, despite having engaged in frequent high-risk sex like unprotected anal intercourse, said Duncan MacKellar, an epidemiologist from the federal Centers for Disease Control and Prevention in Atlanta, which conducted the study.

The study involved 5,719 men who were interviewed at dance clubs, bars and other places frequented by gays in Baltimore, Dallas, Los Angeles, Miami, New York City and Seattle. It tested the men for exposure to the AIDS virus, finding that 573 had H.I.V. Of those, 440, or 77 percent, had said they were unaware they were infected. The results of the H.I.V. tests were available to the men, but it is not known how many sought them, or learned that they were infected.

"It is alarming that in the third decade of the epidemic we don't know why so few black gay men know their status," said Phill Wilson, executive director of the African-American AIDS Policy and Training Institute in Los Angeles. Mr. Wilson said more research was needed to send "the best prevention messages to ensure that these men know their risk and understand how to prevent infection."

The study's findings got the conference off to an unnerving start as health officials reported that the spread of H.I.V in the United States continued to be disproportionately high among blacks.

Disease centers officials, who are responsible for tracking the AIDS epidemic in the United States, reported that 55 percent of new H.I.V. infections in 25 states from 1994 through 2000 were among blacks, who make up only 12 percent of the population in the United States.

Blacks have also accounted for most new H.I.V. infections in the United States since 1994. In 1995, blacks surpassed whites in the percentage of Americans who had a diagnosis of AIDS.

In 2000, the latest year for which data are available, blacks accounted for 43 percent of AIDS cases, whites for 34 percent. Hispanics, who make up 13 percent of the population, accounted for 21 percent of the cases. Other ethnic groups accounted for the rest.

"The study shows that the very men who are at greatest risk of H.I.V. infection are those who are least likely to think they are at risk," Mr. Wilson said. "That's a direct call to develop not only new prevention messages but also new messengers."

He added, "The reality is also that many African-Americans are not within the health care system at all."

In presenting an overview of the AIDS epidemic in the United States at the conference, Dr. Ronald Valdiserri, an AIDS official at the disease centers, described what he said was a growing apathy about the H.I.V. epidemic in the country.

Dr. Valdiserri joined many of the 17,000 conference participants who called on the world to change its attitude about the disease and to put new energy into the fight against it.

"We can't sit back and wait for a vaccine," Dr. Valdiserri said.

Health officials say it will most likely take several more years before an effective vaccine is developed, if one ever is.

As Dr. Valdiserri called for a revival of the old passion that advocates expressed in the early years of the epidemic, scores of participants marched outside the conference hall. They called for increased spending and action to combat a virus that has killed 20 million people and infected an additional 40 million, mostly in Africa.

Because not all states report new H.I.V. infections, federal health officials use data from the 25 states that have monitored H.I.V. the longest to help gauge national trends. One problem officials must consider in extrapolating information elsewhere is that the 25 states account for only one-fourth of the nation's AIDS cases.

Federal officials said they felt confident in reporting that the number of new H.I.V. infections has been stable in recent years, with an estimated 40,000 Americans becoming infected each year.

Government officials estimate that 900,000 Americans are living with H.I.V. or AIDS. The number has increased by 50,000 since 1998, largely because advances in treatment have controlled the infection in many people, allowing some to go back to work and live longer.

One reason for the continued spread of H.I.V., however, is that about half of the 900,000 infected Americans have not been given a diagnosis or treated or both. Many unknowingly transmit the virus to their sex partners.

Dr. Valdiserri renewed the disease centers' pledge to reduce by 50 percent the number of new infections in five years.

Health officials cautioned that the stability in the number of new infections may be deceptive by masking increases among gay, bisexual and heterosexual people in some areas.

Gay men account for the largest proportion of new H.I.V. infections, or 43 percent, followed by people infected by heterosexual sex, 27 percent, and intravenous drug users, 23 percent.

Among those who acquired H.I.V. through heterosexual sex, black women accounted for nearly half from 1994 through 2000; black male heterosexuals accounted for an additional 25 percent, for a total of 75 percent, a hugely disproportionate share of infections in the United States, Dr. Valdiserri said.

Interviews by disease centers epidemiologists with people who were recently given diagnoses of H.I.V. infection or AIDS show that 70 percent reported having been sexually active within the previous year, with their use of condoms varying. Women with steady male partners were least likely to report condom use; 57 percent said they used condoms. Heterosexual men with more than one partner were most likely to report condom use — 75 percent. About two-thirds of gay men said they used condoms whether they had sex with a steady partner or more than one partner.

Health officials said they were troubled about trends in the incidence of sexually transmitted diseases and risk behavior in California, Florida and New York, which are not among the 25 states from which the disease centers reports its findings of trends.

Syphilis rates among men in New York City rose to 6.9 per 100,000 people in 2001, from 2.8 in 2000. Most cases were among gay men. In San Francisco, the number of reported syphilis cases rose to 116 cases in 2001, from 22 in 1999. Preliminary figures suggest the number will rise even higher in 2002.

Dr. Ron Stall reported a behavioral study involving 2,881 gay men in Chicago, Los Angeles, New York City and San Francisco. Dr. Stall said the study had found a striking correlation between high-risk behavior, H.I.V. infection and four psychosocial health problems: drug use, violence against a partner, history of childhood sexual abuse and depression.

The percentage of men reporting high-risk sex increased steadily, from 7.1 percent among those with none of the four psychosocial health problems to 33.4 percent for those suffering from all four. Of those with no such health problems, 13 percent were infected, compared with 25 percent of those who had all four.

The findings underscore the need to develop more sophisticated prevention programs, Dr. Stall said.

At the opening session of the conference, Dr. Peter Piot, an assistant secretary general of the United Nations, said that lack of knowledge was not the barrier to effective prevention and treatment of AIDS. "It's political will," said Dr. Piot, who directs the United Nations program on AIDS.

Dr. Piot said he was encouraged by the growing interest of government leaders in AIDS, which he said is now "a global political issue."

Controlling the spread of H.I.V. requires greater efforts in both prevention and treatment, Dr. Piot said.

Dr. Morten Rostrup, the president of Doctors Without Borders, said: "Not only is it medically unethical to deny people living with H.I.V./AIDS existing treatments, it is also ineffective to separate prevention and treatment interventions. Access to treatment creates conditions that improve the effectiveness of prevention programs."

The world can afford the estimated $10 billion a year that is needed to control H.I.V., Dr. Rostrup said.

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