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February 16, 2005


Well done. I thought that it was foolish to present whatever news there was here as a scare story, and I was particularly offended by one follow-up article, in which a reporter lurked in a chat room to find out how seriously the "news" was being taken by gay men.

It is indeed the drug, not the virus, that ought to have our full attention. But perhaps the fear underlying the story is not entirely bogus. As the Times made clear in charts, there are only so many drugs to contain HIV, and they seem to stop working eventually. This is an alarming reality for HIV positives and their near-and-dear. The diminished effectiveness of these fantastic medicines has nothing to do with the abuse of other chemicals, of course, but we're reminded that the link from HIV to AIDS has not yet been severed.

"Regarding AIDS in the gay community: it's the substance abuse, stupid! From crystal meth to a host of other recreational drugs, again and again those recently infected explain they weren't thinking clearly when they practiced unsafe sex. Well, duh! That's the whole point of mind-altering drugs. The question here is why do so many gay men feel the need to alter their minds so significantly their common sense evaporates?"

I agree that at least in California crystal meth is destroying as many men as AIDS--often they work hand in hand. I've lived in San Diego about 14 years. It sounds like a cliche, but you would be shocked by how many people I see who have moved here from the middle of the country (often specifically to escape homophobia), thrown themselves full on into what they see as 'the gay life' and been wrecked by their own drug use within a year or two. It breaks my heart to watch it happen, and so often they think you are just being a prude if even try to hint that the path they are travelling is dangerous. I, like Sullivan, am fairly liberal in my ideas about drug legalization--but crystal truly is a drug worse than almost any other.

That said, drug-resistant HIV is a bit of a scary thing. Another thing I find sad is the 20-25 year old guys who aren't bothering to be safe and are becoming HIV+ (often hand in hand with drug use). They seem to think that since there is treatment, they shouldn't worry about it. I don't think they have seen how ugly the routine treatment can be. After an 8-10 year complacency phase, I hope people are realizing that HIV is dangerous again.

But in both cases, social pressures are much more likely to be successful than legal measures.

There is a whole generation of gay men - the generation who came out when the generation just older than them were dying, and right-wing governments in the UK and the US were bluntly indifferent - to whom safe sex is almost a matter of faith.

(Which is to say, it's sometimes more adhered to in principle than in practice.)

The generation after that - young gay men who are now in their teens and early 20s - is about as indifferent to the risks of becoming HIV positive as straights generally are, as far as I can tell. A lot of this is via casual conversation: some of it is from a few statistical surveys.

It would seem that it takes wiping out a whole social circle to convince people that they need to play it safe.

(The fact that safe-sex leaflets directed at heterosexuals have generally recommended monogamy as if it were safe sex has always scared me, on behalf of my straight friends: I used to cross-compare the information straight people were getting with the information that gay men were getting, and it would make me furious. It still does, in a way, but I do tend to feel that straights should have demanded better information - gay men did.)

Hmm. I have different views about the different stories you're discussing. Criminalizing "reckless sex" seems to me idiotic on so many different levels that I'm not going to waste my breath on it until a bill appears. Crystal meth: I don't know much about it, but from the comments above I'm going to take it as similar, in its life-destroying properties, to cocaine in the 80s and crack later, and say: why we as a country don't get serious about drug treatment is a mystery to me. If we aren't concerned about people's lives being completely broken, we might just think of it as both a public health measure and one of the most effective steps available to lower the crime rate.

The new strain of HIV is different, I think. First, about the question why it's appropriate to get worried based on one or two cases as opposed to a large study: the basic answer is: which you need depends on what claim you're trying to support. If you're making a claim like "HIV is commonly spread in bathhouses" or "HIV is a growing danger to gay men", or even "transmission by some hitherto unsuspected means is a serious risk", you need empirical studies of large groups. But if you're just saying "an X exists, and it has the potential to be a really serious problem, then one X is all you need. (Compare: if we learned that al Qaeda had one nuclear weapon, that would be enough to cause serious alarm; we wouldn't need to wait for large studies of their weapons generally.)

This is especially true in this case. Earlier in the history of HIV, people had no idea what they were dealing with, so they needed to gather a lot of facts to figure it out. But here we know that drug-resistant strains of viruses emerge, from other cases like TB. We know that once they get out, they are incredibly hard to deal with, precisely because they can't be treated by a lot of the normal means. We also know that even when, as in this case, there is a drug that still works, the fact that you're treating a virus that's already immune to many drugs with the one remaining effective drug creates huge evolutionary pressures favoring the survival of viruses that don't respond to this drug either, and thus you're running the risk of creating a virus that's immune to all the drugs we have. We were expecting something like this to happen with HIV. Now it has, and the really bad news is that not only is the strain resistant, it's also unusually virulent. (It could be resistant but also relatively sluggish and slow to progress. No such luck.)

So there was this possibility that was waiting to happen, and now we find out that it has. One case is enough to establish this. I don't know whether panic is appropriate, but it is certainly very bad news: as noted, it makes the emergence of a virus that's immune to all treatments much more likely, and that would return us to the 80s, when HIV was a death sentence.

As to the measures being considered: they want to get info about things like: patients' viral load and responsiveness to treatment. It would, in my opinion, be part of normal decent medical practice for a doctor treating an HIV patient to get this information, especially now that this strain has appeared. The question is, should the doctor share this information with public health agencies? A couple of points about this question: first, the Times article doesn't say whether the proposal is to share it in some anonymous form, without patient identifiers. A lot of public health info is stripped of anything that could allow people to identify particular patients, and that information is incredibly useful. If the proposal is to share information in that anonymous form, I wouldn't have a problem with it. On the other hand, if it involves sharing the information in some form that does allow the identification of particular patients, then that's another matter entirely. I wish the Times article had made this clear.

"I don't know much about it, but from the comments above I'm going to take it as similar, in its life-destroying properties, to cocaine in the 80s and crack later, and say: why we as a country don't get serious about drug treatment is a mystery to me."

Actually much worse than cocaine, probably on par with heroin except more dangerous to non-users because instead of being a mind-dulling opiate, it is a hyper-activity inducing paranoia drug.

I agree that steps proposed by the doctors seem appropriate.

If you're making a claim like "HIV is commonly spread in bathhouses" or "HIV is a growing danger to gay men", or even "transmission by some hitherto unsuspected means is a serious risk", you need empirical studies of large groups. But if you're just saying "an X exists, and it has the potential to be a really serious problem, then one X is all you need.

The current dialog seems to combine both though. X exists and since we haven't totally stopped the spread, we need to up the efforts to stop the spread because X is so deadly.

On the surface that makes sense. It's the way it's being discussed, in panic mode, that's alarming. Regular people who need compassion in dealing with their disease get trampled during panics.

I'm sure from the Public Health point of view if the panic makes someone who might otherwise have unsafe sex think twice, then it's performing a service, but it will also re-elevate anxiety and hostility toward the HIV-positive folks who are simply trying to get on with their lives.

I think the privacy issues are a bit overblown, but then that's easy for me to say. I was shocked when characters on a popular crime drama show were counselling each other not to be tested for HIV "through the police department" because of the impace it could have on their career. Are we really still in that place?

two comments.

1. geez, don't you guys read Dean's World? don't you know that HIV doesn't cause AIDS? [end sarcasm]

2. as the husband of a public defender, my exposure to meth is from my wife's stories. Meth heads are the worst whiners in the system, even worse than crack whores. [and on the second point, if you ever find someone who looks like Julia Roberts working Sunset, she's a cop.]


Edward: I suspect that 'the way it's being discussed' where you are differs from the way it's discussed where I am, and I completely agree with you that panic mode, especially if it leads to the further stigmatization of HIV positive people, is counterproductive. 'Where I am' is: not particularly in the gay community (meaning: there are about the number of gay people you'd expect in the circles I move in, given those circles' size), but quite particularly in the public health world, where lots of the people I work with are from. I haven't heard a lot of panic, though I wouldn't expect to, since I move in crowds in which people tend to be extremely knowledgeable about HIV and its epidemiology; but on the other hand a real sense that this is very bad news.

I mean: we know that the best chance we have of containing a drug-resistant virus is when it's first discovered, since at that point there's a chance that it isn't yet widespread; and also that the more widespread it becomes, the harder it is to stop, but also: the more likely it becomes (for reasons I mentioned earlier) that we're in for the really, really bad news, namely a strain of the virus that doesn't respond to any known treatment. We have seen this happen with other illnesses, and it's not pretty. We have also lived through a time when HIV was not treatable, and that wasn't pretty either. We're in a much better position to deal with this now than we were in the early 80s, since we've done a lot of research on the basic science of HIV since then, but I hope we manage to stop this strain before we reach that point.

I would hope that the public health people wouldn't contribute to a sense of panic needlessly (where 'needlessly' is meant to distinguish between soberly reciting the facts in a way that's not designed to provoke panic, but might in some cases do so anyways, people being what they are; and being unnecessarily inflammatory.) I think they probably will, since they tend to be attuned to these issues. But I would also hope that they would act quickly to try to contain this, since, as I said, it is very bad news. And since a lot of the containment measures can be done in ways that don't involve violating people's privacy, that seems to me appropriate.

Story time.

When I was about 18 or 19, I was briefly addicted to meth. One of my coworkers dealt it, and as I was working graveyard and going through a fairly self-destructive phase in my life where I'd try anything, I tried it.

The high is indescribable. It's like the feeling of falling in love, the excitement of Christmas morning, the rush of danger, and the joy of success all rolled into one. It was so good that I lost myself in it for the better part of a month, taking it nearly every day. I was only happy when I was high, and that was most of the time. I blew money I didn't have, was short on rent, and generally scared what few friends I had at the time.

I was lucky: the coworker who sold it to me was ethical, insofar as that goes. He told me that if I ever asked him to, he would cut me off, because he knew how hooked it could get you. I ran out of money one week and couldn't buy any; when I sobered up, I realized how bad things had gotten and asked him not to sell it to me anymore. And after that, when I had money again and desperately wanted some, he refused to sell to me.

I wept for days. And have been grateful to him ever since. That was over a decade ago, and to this day I won't go anywhere near where I know or suspect someone might have some--I won't risk the temptation. I've tried a lot of things in my time, but nothing--and I mean /nothing/--ever hooked me like this, not even tobacco. The shit scares me.

hilzoy: the public health workers I know are true all-around mensch, so I believe they're aware of the impact of their decisions and announcements on individuals, but their responsibility is obviously to the public at large and I've seen a few of them lose patience with the individuals preventing them from doing what they consider their higher calling (having worked as an AIDS volunteer for a number of years). With other diseases, this is perhaps understandable. With HIV/AIDS, though, it strikes me as incongruous with some of the best practices of the health official/patient relationships (e.g., the fact that they won't just tell patients their status over the phone and counselling is mandatory in most places before folks can be tested...it's much more one-to-one, and rightly so, IMO).

Right now, however, this new "Patient Zero" is having his whole life turned upside down as the officials look for each and every partner he's had over the past few months. I can't fathom what that kind of invasion would feel like. I understand why they want it, but still.... So, because he's the unlucky schmuck who this virus turns up in, he's been dehumanized. At a time when he's most likely going through an emotional hell, he's being talked about like some Typhoid Mary in all the papers around the nation. It's so Kafka-esque.

There's a reality to this that's inescapable, I know...but putting myself in his shoes, I can't help but be terribly saddened and more than a little disgusted that we're not any better at this sort of thing as a society.

Catsy Thanks for sharing that. I've seen what meth does to folks...it's a particularly insidious drug. Glad to hear your supplier was true to his word.

In the Netherlands it is not meth but GHB. And it is not just a reaction to 'insecurity' or discrimination IMHO.

We have several policies (pdf file) to pro-actively stimulate acceptence of gays (95% of the population does not have a problem with toleration of gays), we register *all* contagious diseases (on an anonimous basis obviously) from rubella till HIV, and do extra monitoring (Dutch) of/for gays with questionaires about testing, sexual behaviour, partners, etc.

Last monitor (Dutch) showed a.o. that 71% of (male) respondents had done a hiv-test at least once and 22% tested HIV positiv. 28% of the 'single' gays had had unprotected sex in the last 6 months. Of the GHB users 62% had unprotected sex, of the non-users 25%.

STD's have been on the rise in homosexual circles for about 5 years now. People think that is is viewed more like a chronical disease than a terminal one by a lot of folk.

OK, re-reading this:

There's a reality to this that's inescapable, I know...but putting myself in his shoes, I can't help but be terribly saddened and more than a little disgusted that we're not any better at this sort of thing as a society.

I must admit my first response if someone else had written that would be "Suck it up. We're talking about saving people's lives here." So take that melancholy drivel with a bit of salt please.

"it" being HIV positiv, or AIDS

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