A quarter-century of AIDS in the Bay Area

San Francisco was the logical choice for the 13th annual U.S. Conference on AIDS organized by the National Minority AIDS Council and held last week at the Hilton Hotel. While it was 29 years ago in Chicago where the first AIDS case was diagnosed, since then San Francisco has been ground zero for the worldwide HIV/AIDS pandemic.

Reflecting on the 25-year epidemic of HIV/AIDS in Alameda County, Dr. Barbara Green-Ajufo said that while the epidemic in San Francisco started with young, white, gay men and has remained that way, the epidemic in the East Bay now consists of mostly gay African-American men.

HIV, Green-Ajufo said, is the evidence of infection on a laboratory test, while AIDS is the actual disease with evidence of wasting, lymph node enlargement, fatigue, and other findings. The sources of infection,  Green-Ajufo said, remain the same in the East Bay, including Solano County, as in San Francisco:

• Men who have sex with men (MSM).

• Intravenous drug use (IDU), primarily through the use by addicts of contaminated needles to inject heroin or methamphetamines.

• The combination of MSM and IDU.

• Heterosexual exposures, primarily men who don’t know or don’t care that they are infected having intercourse with women who either don’t know or don’t care that their partners are infected.

• Other rare causes such as contaminated transfusions and contaminated blood byproducts. This has become extremely rare worldwide and unknown in the U.S. since advanced testing of transfusion blood was implemented.

• Tattoos in prison.

Heterosexual infection presents specific complications, according to Green-Ajufo.

“About 18 percent of people with HIV/AIDS don’t know they have it,” she said, “and they become a source of infection of other people.”

Some men are exposed in prison to HIV/AIDS through consensual intercourse, rape, or — rarely — tattoos. When released, they return to the community and infect their wives, girlfriends or prostitutes. However, most HIV-positive inmates enter the system infected.

While condoms are effective in preventing transmission in prisons, only a small fraction of prisoners have access to them. According to Green-Ajufo, there is no difference in the rates of risk factors such as MSM, IDU, and heterosexual exposure among racial and socio-economic groups. The big problem, she said, is the “young-invincibles.”

This is a group of young men and women in their late teens and early 20s who have a limited concept of the future or of the danger they face in their own lives. The military harnesses this phenomenon to recruit young men to storm beaches and jump from airplanes. Unfortunately, the attitude also leads to health problems such as motor vehicle accidents and sexually transmitted diseases, including HIV/AIDS.

According to statistics from the Centers for Disease Control and Prevention, 48 percent of American high school students report having had sexual intercourse, with 15 percent reporting four or more partners and only 39 percent reporting the use of condoms during their last sexual intercourse. In Alameda County, 75 percent of young-invincible males and 25 percent of females have sexually transmitted diseases, including syphilis, gonorrhea, chlamydia, and HIV/AIDS.

The problem of the young-invincibles is echoed by Susan Scheer, Ph.D., of the San Francisco Health Department (SFHD).

“The epidemic (in San Francisco) remains mostly young, white, gay men,” she said, “of which San Francisco has a seemingly inexhaustible supply.”

Sheer, who has observed the epidemic from the beginning, gave a historical perspective from the unique observation point of the SFHD: In 1977, health officials first starting seeing a constellation of diseases such as a rare pneumonia called Pneumocystis carinii and a skin cancer called Kaposi’s sarcoma that had previously only been seen in elderly men.

In 1980, the first San Francisco man was formally diagnosed with AIDS. Three years later, the number of new AIDS cases peaked, and by 1990, with the invention of a new test for HIV and the use of antiviral medications to lower the number of viral particles in the blood — called “viral load” — the disease reached the lowest rate of new cases.

Between 1995-2001, the rate of new cases plateaued because more people were living with the disease and sharing needles during drug use or having unprotected sex, Sheer said. The plateau occurred despite aggressive treatment to reduce the viral load.

The idea is that with a reduction in the viral load, it is less likely that a person with HIV/AIDS can infect another person even if the sex is unprotected. A second, but less intense, wave of HIV/AIDS occurred in 2001 as the young-invincible gay men started having more sex with infected partners and more women were either knowingly or unknowingly infected by their male partners. Gay men, Sheer said, started taking an attitude that they could have as much sex in as many ways and with whomever they wanted because, even if they got the disease, it was treatable — a false assumption, as it turned out.

This second wave has led to what Green-Ajufo and Scheer call a “hyper-endemic state.” The continued MSM of young-invincible gay men, the persistent use of intravenous drugs with contaminated needles, and heterosexual exposure has produced a stable level of new cases that is not decreasing.

Christopher H. Bates, the director of HIV/AIDS policy in the U.S. Department of Health and Human Services, attended the conference last week. Bates reports directly to Secretary Kathleen Sebelius who, in turn, reports to President Obama.

“The plan,” Bates said in an exclusive interview with The Herald, “is to prevent HIV infection through testing and education. If the person is HIV-positive, the plan is to prevent the person from passing it on to another person by education and decreasing the viral load and to keep the disease from progressing to AIDS. If the person progresses to AIDS, the plan is to provide aggressive medical treatment to keep the person well and out of the hospital and to prevent them from infecting others.”

Easily said and difficult to do, Bates admitted.

“We’re not there on a vaccine yet,” he said. “The problem is not policy or money, it’s technical.” He explained that the HIV virus is the hardest ever evaluated for a vaccine. The type of virus and the speed in which it mutates are just the beginning of the problem. The HIV virus also has reservoirs in the lymph notes and brain where it can hide from the body’s immune system.

A recent study sponsored by the U.S. Army and conducted in Thailand (and only partially successful) used two types of vaccines injected at the same time. It delivered immunity in only 30 percent of the population.

“Even those numbers are being challenged,” Bates said.

Educational programs are also disappointing. In a change of strategy, various nonprofit organizations and the DHHS have teamed up to develop programs geared at separate socioeconomic niches rather than the general population. If white and African-American “young-invincible” gay males are a problem, then advertising and education programs are being developed to reach that population. The same problem exists for intravenous drug users and heterosexuals at risk.

What may reach one population may insult another, so separate programs are being developed to target various ethnic groups. And testing is becoming even more important to catch HIV at early stages. More programs are being developed to catch the 18 percent of infected people who don’t know they have HIV before the disease progresses and before they infect others.

There are a lot of barriers to testing, Bates admits, including the stigma of the disease, lack of money, legal and bureaucratic barriers, and the fear in some Latinos that the results may be reported to immigration.

“There is no cure,” Bates said. “The virus hides out in brain and lymph nodes. All treatment is geared at increasing the T-cell count (a cell in the blood that provides immunity) and decreasing the viral load (the number of viral particles in the blood). “

The problem with treatment, Bates said, is that a lot of people don’t tolerate the medications and it is ineffective in others. As with cancer chemotherapy, new medications have fewer side effects and are more likely to be taken by the patients — but, contrary to what the “young-invincibles” may think, a large number of people still die when their treatment regimen fails.

“In a way,” Bates said, “we are victims of our own success. The successes in treatment gave people, especially the ‘young-invincibles,’ a false sense of security that they could do what they wanted without consequences.”

Nevertheless, there are dozens of medications on the market today that are effective in decreasing the viral load, preventing secondary infections, and providing a meaningful life to infected persons. Many infected persons have returned to the workplace and been successful.

According to Bates, if a person has HIV and no insurance, the Federal Ryan White Care Act will pick up the costs of treatment. Signed into law by President George W. Bush and reauthorized last month by President Obama, the law is specifically geared at reducing the infective spread and progression of the disease.

If the person progresses to AIDS, then he or she can qualify for Medicare.

The key, Bates reiterated, is early detection and diagnosis. The treatment is easier, cheaper and more effective in the early stages. In addition, there is greater success in preventing other infections such as pneumonia and fungal infections with early treatment.

Dr. Jim Lessenger is a Benicia resident and docent at the Benicia Historical Museum.