Marcus A. Conant, MD Conant Medical Group San Francisco Conant Foundation San Francisco AIDS IN AMERICA

The First 25 Years The First 25 Years The Current Epidemic The Current Epidemic The Next 25 Years The Next 25 Years

AIDS in America Total number of AIDS cases (988,376) Persons Living with AIDS (437,982) Total number of Deaths (550,394) Centers for Disease Control and Prevention. HIV/AIDS Surveillance Reports,

AIDS in America * Includes hemophilia, blood transfusions, and risk factors not reported or identified Gay Men (454,106) IV Drug/Gay IV Drug (234,776) Other* (13,967) Heterosexual Men (61,914) Centers for Disease Control and Prevention. HIV/AIDS Surveillance Reports,

AIDS in America Hispanic Males (145,176) White Females (37,785) Hispanic Females (34,397) Black Females (112,472) Centers for Disease Control and Prevention. HIV/AIDS Surveillance Reports, White Males (357,814) Black Males (282,914)

Total AIDS Cases - Females (185,822) AIDS in America Centers for Disease Control and Prevention. HIV/AIDS Surveillance Reports,

AIDS in America Heterosexual AIDS Cases (164,850) Centers for Disease Control and Prevention. HIV/AIDS Surveillance Reports,

The Current Epidemic AIDS Cases per year Centers for Disease Control and Prevention. HIV/AIDS Surveillance Reports,

The Current Epidemic Total Heterosexual Contact AIDS Cases per year - FEMALES Injection Drug Use Centers for Disease Control and Prevention. HIV/AIDS Surveillance Reports,

Why Was There No Heterosexual AIDS Epidemic in America? Gay men do not have sex with women Gay men do not have sex with women Poor transmission from receptive to insertive partner Poor transmission from receptive to insertive partner Receptive anal participants 16 times more likely to contract HIV Receptive anal participants 16 times more likely to contract HIV Poor transmission from female to male Poor transmission from female to male U of Pittsburgh, Consumer Reports 1986: 11,725. U of Pittsburgh, Consumer Reports 1986: 11,725.

Why Was There No Heterosexual AIDS Epidemic in America? Very few infected women Very few infected women Straight men do not have high-risk sex with gay men Straight men do not have high-risk sex with gay men High prevalence of circumcision in America High prevalence of circumcision in America Male Circumcision and HIV, UNAID: Dec 2006

High Prevalence of Circumcision in America White men – 81% Circumcised White men – 81% Circumcised Black men – 65% Circumcised Black men – 65% Circumcised Hispanic men – 54% Circumcised Hispanic men – 54% Circumcised Male Circumcision and Risk of HIV Transmission, CDC, HIV/AIDS Science Facts: Dec 2006

What About Bisexual Men? Out of closet/Into the baths Out of closet/Into the baths In the closet/In twin beds In the closet/In twin beds Bisexual men are generally insertive partners Bisexual men are generally insertive partners Harris, C. et al. NEJM, 1983: 308; Harris, C. et al. NEJM, 1983: 308;

Why Was There No Heterosexual AIDS Epidemic in America? Condom use increased Condom use increased Elisa testing raised awareness Elisa testing raised awareness HAART reduced risk of transmission HAART reduced risk of transmission

Why Was There No Heterosexual AIDS Epidemic in America? Heroin and cocaine do not promote high risk sex for men Heroin and cocaine do not promote high risk sex for men Crystal meth use was not an epidemic Crystal meth use was not an epidemic

Why Was There No Heterosexual AIDS Epidemic in America? American couples practice serial monogamy American couples practice serial monogamy

Serial Monogamy American male has 3.6 marriages in a lifetime American male has 3.6 marriages in a lifetime African male has one major wife and minor wives, plus barmaids and prostitutes African male has one major wife and minor wives, plus barmaids and prostitutes

Divorce Rate in the United States 2005 – 3.6 divorces 2005 – 3.6 divorces 2004 – 3.7 divorces 2004 – 3.7 divorces 2003 – 3.8 divorces 2003 – 3.8 divorces CDC Statistics Report 2006; 54 CDC Statistics Report 2006; 54

Can Straight Men Catch HIV/AIDS? Yes Yes 2004 – 90% of 5 million infections worldwide were sexually transmitted 2004 – 90% of 5 million infections worldwide were sexually transmitted 50% of the 38.6 million infections worldwide are women 50% of the 38.6 million infections worldwide are women Voelker, R. Anti-HIV Microbicide Efforts Press On JAMA 2006; 296:

Trans-African Highway

Spread of HIV Heavily traveled truck routes in Africa As many as 80% of all barmaids were infected As many as 80% of all barmaids were infected In the Heart of the Plague The Economist, 03/21/1987, p. 39 Morris, CN., Estimation of the Sexual Transmission of HIV in Kenya & Uganda on the Trans- African Highway Sex Transmission Infection. 2006;82: Morris, CN., Estimation of the Sexual Transmission of HIV in Kenya & Uganda on the Trans- African Highway Sex Transmission Infection. 2006;82: Shreedhar, J. AIDS in India Harv AIDS Rev Fall: 2-9 Malta, M., A Qualitative Assess. Of Long Dist truck Drivers Vulnerability to HIV/AIDS in Itajai, Brazil AIDS Care 2006;18: Stratford, D., Highway Cowboys, old hands, and Christian Truckers: Risk Behavior for HIV Infection among Long0Haul Truckers in FL Soc. Sci. Med Mar;50:

Highway Cowboys, Old Hands and Christian Truckers Risk Behavior for HIV Infection Among Long Haul Truckers in Florida Risk Behavior for HIV Infection Among Long Haul Truckers in Florida Stratford, D., et al. Highway Cowboys, old hands and Christian Truckers: Rick Behavior for HIV Infection Among Long Haul Truckers in Florida Social Science & Med. 2000;50:

Truckers Barmaids Village Males Village Females Village Males Village Females Village Males Village Females Village Males Village Females Male to Female / Female to Male Transmission

Spread of HIV Monogamous females infected 2% of their monogamous male partners Monogamous females infected 2% of their monogamous male partners Monogamous males infected 20% of their monogamous female partners Monogamous males infected 20% of their monogamous female partners Male to female transmission 10 times more effective Male to female transmission 10 times more effective Padian, Nancy, et al., Female to Male Transmission of HIV JAMA, 1991;266: Padian, Nancy, et al., Female to Male Transmission of HIV JAMA, 1991;266:

Serial Monogamy American male has 25 partners in a lifetime American male has 25 partners in a lifetime African male has 25 partners in a year African male has 25 partners in a year CDC information on file

Serial Monogamy American male has serial relationships American male has serial relationships African male has 5 – 8 partners simultaneously African male has 5 – 8 partners simultaneously Shumatosf, A. In Search of the Source of AIDS African Madness (NY Knopf, 1988) 171.

Serial Monogamy Lifetime median of 5 partners for men Lifetime median of 5 partners for men Lifetime median of 3 partners for women Lifetime median of 3 partners for women Jeffrey, R., et. al. Pilot Study of AIDS in the General Population Phr1992:107;

Why Is Serial Monogamy Important? Transmission is greatest with early infection Transmission is greatest with early infection Haitian children – Dr. Margaret Fischls quote Haitian children – Dr. Margaret Fischls quote

Sexual Practices by American Gay Men

Heterosexual African Men

American Gay Spread

African Heterosexual Spread

American Heterosexual Spread

U.S. Africa Serial monogamy = Infected = Uninfected Heterosexual Men

Conservative Religious View of AIDS HIVs migration from gays to IV drug users in the late 1990s proved immaterial for conservatives perception of the disease, which remain rooted in visions of moral obloquy and divine justice. Conservatives continued to understand AIDS as primarily a failure of moral rectitude, secondarily an abnegation of personal responsibility and only lasts as a human tragedy, with those few examples of victims outside of the known risk groups falling into the last category. Reports of high levels of adultery in Africa, commercial sex in Asia, and injection drug use around the globe further reinforced this perception. Engel, J., The Epidemic: A Global History of AIDS Smithsonian Books/Harper Collins, New York, 2006:p. 278 Engel, J., The Epidemic: A Global History of AIDS Smithsonian Books/Harper Collins, New York, 2006:p. 278

The First 25 Years Characteristics Gay men IDUCircumcision Serial monogamy Infected women AmericaYesYesYesYesNoAfricaNoNoNoNoYes

The Current Epidemic Why we are poised for a heterosexual epidemic Increasing number of infected women Increasing number of infected women Large populations of uncircumcised men Large populations of uncircumcised men Black men – Southern United States Black men – Southern United States Hispanic men – Southwestern United States Hispanic men – Southwestern United States Large number of uncircumcised immigrants Large number of uncircumcised immigrants Increasing use of crystal meth Increasing use of crystal meth

The Current Epidemic - New York City - 20% of Black men 40 – 49 y old HIV positive 20% of Black men 40 – 49 y old HIV positive 50% of HIV cases are in Black men and women 50% of HIV cases are in Black men and women 25% of New York City HIV population 25% of New York City HIV population 34% of new cases occur in Black women 34% of new cases occur in Black women 48% of all teenage cases in Black teenagers 48% of all teenage cases in Black teenagers Black women 27 times more likely to get infected than White women Black women 27 times more likely to get infected than White women NYT 2/4/06

Spread of HIV Women - 30% of HIV cases in Mississippi Women - 30% of HIV cases in Mississippi Women - 31% of HIV cases in Alabama Women - 31% of HIV cases in Alabama Women - 29% of HIV cases in North Carolina Women - 29% of HIV cases in North Carolina

Meth Labs Discovered 1999 – 7, – 7, – 17, – 17,000 Missouri – Leading State Missouri – Leading State Huff, B., Speed Nation: Methamphetamine, HIV & Hepatitis. First National Conference on Methamphetamine. Salt Lake, August 2005

Federal Response to Crystal Meth Law restricting pseudoephedrine Law restricting pseudoephedrine Meth costs $50/ounce to make Meth costs $50/ounce to make Meth sells for $1500/ounce Meth sells for $1500/ounce Mexican drug cartels are feeding the demand Mexican drug cartels are feeding the demand Zernike, K., Potent Mexican Mth Floods in as States Curb Domestic Variety, NYT 1/23/06

Barriers to Ending the AIDS Epidemic Religious fundamentalism Religious fundamentalism Catholics opposed condoms Catholics opposed condoms …Promoting condom use to prevent AIDS was morally illicit and a violation of the authentically human sense of sexuality… - Pope John Paul II Montalbano, W. AIDS Conference Hears Papal Appeal for Unity Lat 11/16/1989 Montalbano, W. AIDS Conference Hears Papal Appeal for Unity Lat 11/16/1989

Barriers to Ending the AIDS Epidemic Black ministers wont touch it Black ministers wont touch it Magic Johnson Magic Johnson Deresiewicz, W. Against All Odds: Grass Roots Minority Groups Fight AIDS Health/PAC Bulletin, Spring 1988;5.

On The Down Low Gay Black men 25% HIV positive Gay Black men 25% HIV positive Gay Hispanic men 15% HIV positive Gay Hispanic men 15% HIV positive Gay White men 3% HIV positive Gay White men 3% HIV positive Wolintsky, R. et. al., Are we Headed for a Resurgence of the HIV Epidemic Among Men who Have Sex with Men? AJPH 2001;91:

Barriers to Ending the AIDS Epidemic Government funding Government funding Government policy Government policy Pharmaceutical complacency Pharmaceutical complacency Increasing IDU Increasing IDU Crystal Meth Crystal Meth

Barriers to Ending the AIDS Epidemic Gay men came out, got mad and Acted Up Gay men came out, got mad and Acted Up Black and Hispanic men and women would rather die than be perceived as queer Black and Hispanic men and women would rather die than be perceived as queer Christian fundamentalists believe that this is the end of days as prophesized in the Bible Christian fundamentalists believe that this is the end of days as prophesized in the Bible

Barriers to Ending the AIDS Epidemic Protests in America are passé Protests in America are passé Public believes AIDS is over Public believes AIDS is over Press has moved on to other sensations Press has moved on to other sensations Competing tragedies Competing tragedies Terrorism, Bird flu, Global warming Terrorism, Bird flu, Global warming Gay activists are dead Gay activists are dead Few physician activists Few physician activists

The Next 25 Years Black heterosexuals in the South Black heterosexuals in the South Hispanic heterosexuals in the Southwest Hispanic heterosexuals in the Southwest Clusters of immigrants in major cities Clusters of immigrants in major cities Areas of heavy crystal meth use Areas of heavy crystal meth use

The Current Epidemic - NYC 77% of MSM 15 – 29 yrs. old do not know they are infected 77% of MSM 15 – 29 yrs. old do not know they are infected MMR 2005;54:

US Map

Strategies to Ending the AIDS Epidemic Education Education Abstinence Abstinence Be Faithful Be Faithful Prevention Prevention Condom – USA Funds Abstinence Condom – USA Funds Abstinence Needle exchange – Clinton would not approve Needle exchange – Clinton would not approve Circumcision Circumcision Pre-Exposure Prophylaxis Pre-Exposure Prophylaxis Truvada Truvada The Missing Condoms, New York Times, 9/4/05 Federal Funds for Clean Needles New York Times, 2/22/1997 Voelker, R., JAMA 2006;296: ABC ABC

Strategies to Ending the AIDS Epidemic Post Exposure Prophylaxis Post Exposure Prophylaxis Treatment Treatment Vaccine Vaccine Vaginal/Rectal Microbicides Vaginal/Rectal Microbicides

Hepatitis C Epidemic Worldwide Prevalence170 Million Worldwide Prevalence170 Million US Prevalence3.2 Million US Prevalence3.2 Million US Incidences19,000 (2006) US Incidences19,000 (2006) Treatment1 year Treatment1 year Treatment Success50% Treatment Success50%

Hepatitis C Epidemic 65% develop chronic liver disease 65% develop chronic liver disease 15% develop cirrhosis 15% develop cirrhosis 4% die of liver cancer or cirrhosis 4% die of liver cancer or cirrhosis