Monday, February 11, 2008

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DPH: Anonymous Warning to Gays,
PWAs over Swiss HIV Study

On February 7 DPH and SFAF, having held no public hearings and without seeking comments from anyone beyond the ivory towers of their agencies, they unloaded a joint statement on the gay community about a study from Switzerland on HIV transmission and viral loads [1, 2, 3, 4]. The joint statement is anonymous, contains no references, has no contact name, the full title of the actual Swiss report is missing, along with a way to access and read it on the web.

Before getting into the detailed questions I have about this rush-job joint statement, let’s back up to my December 3, 2007, blog entry about Swiss AIDS experts sending up a trial balloon about proposed radically new approaches to HIV prevention methods and thinking [5, 6].

As part of the Swiss plan for a transparent debate before the final report was issued, at least one public meeting was scheduled for January with Geneva’s gay community [7].

I asked for a debate to start back then with American AIDS service organizations and community activists about the what implications the Swiss recommendations might have on U.S. gays, people with AIDS and prevention messages. The debate never happened.

The deaf ears at DPH and SFAF haven’t heard the cries of anguish from the local gay community in the past four weeks of the gay staph infection controversy from UCSF. Longtime health advocate are demanding all of AIDS Inc cease with this high-minded way of making supposedly important pronouncements without transparency and community involvement [8].

The joint statement must be retracted by DPH and SFAF, an apology immediately made for lack of transparency, and a commitment that the process of making official San Francisco city policy regarding the Swiss report will start anew, and adhere to sunshine rules.

Before we go over the joint statement line by line, a few observations are in order, comparing some basics in the competing reports.

Number of co-authors:
SF - 0
Swiss - 3

Number of references:
SF - 0
Swiss - 26

Original communiqué lists contact phone number and email address:
SF – No
Swiss – Yes

And now, the joint statement, in bold, starting with the headline, accompanied by my comments:

SFAF/SF DPH Statement on the Swiss AIDS Commission’s Report on HIV Transmission

From the get-go, the San Francisco statement is focused on two agencies, not persons with AIDS. Headline for the Swiss summary: HIV-infected persons on effective anti-retroviral therapy are sexually non-infectious. And this is not just a statement, it is a rejection decree, showing how the anonymous authors are dishonest with their words before they even get into the meat of their argument.

There are nearly 1,000 new HIV infections in San Francisco and an estimated 40,000 to 60,000 new infections nationally every year.

No references provided. Why are these stats provided as the opening? The better to serve as red herrings for what follows. Considering DPH is notorious for manipulating HIV epidemiology, and had to retract claims in June 2000 of sub-Saharan levels of new infections, any HIV stats city by the department must be independently verified [9]. And CDC has been known to overestimate HIV/AIDS cases and infection rates [10]. Interesting that DPH and SFAF omit any global statistics, which the World Health Organization admitted were overestimated [11].

The San Francisco AIDS Foundation and San Francisco Department of Public Health urge individuals living with or without HIV infection to continue to use appropriate HIV prevention measures, specifically, to use male latex condoms correctly and consistently during sex.

Who asked them to urge anything? This statement is supposed to address the Swiss report, but the anonymous authors instead focus on undefined appropriate prevention strategies, deny the existence of the female condom, a polyurethane pouch device that can and should be used by gay bottoms during anal sex, and fail to mention sero-sorting [12].

A recent Swiss AIDS Commission report demonstrating that, in some cases, HIV-positive partners did not transmit the virus to their partners in the absence of condoms, is insufficient evidence to abandon safer sex practices for several reasons.

No reference provided for the report, nor a web address to help people locate and read the actual Swiss report.

The report reviewed data from four studies conducted among heterosexual couples alone.

No references provided for the four studies in question. Note the use of the word heterosexual.

One, involving 393 serodiscordant couples, found that as long as the HIV-positive partner adhered to a treatment regimen, had an undetectable viral load for at least six months, and did not suffer from any other sexually transmitted infections, the HIV-negative partner did not become infected.

No reference provided for the study under discussion. However, the authors inform us it was a relatively enormous study involving nearly 400 couples, and they are not rejecting it. Yet.

But another study that was part of the same report found that 6 out of 43 HIV-negative partners did become infected—a rate of nearly 14%—due to the fact that the HIV-positive partner was not always faithful to a treatment regimen.
Again, no reference provided for the study cited. It had a much smaller pool of people, and the authors give the six people who became infected higher significance than the four-hundred individuals in the larger sampling who didn’t become infected. Why?

Neither the San Francisco AIDS Foundation nor the Department of Health endorse the Swiss AIDS Commission statement, because:

I wasn’t aware of anyone requesting city policy be established on the Swiss study, and that a San Francisco government-sanctified position was necessary.

  • all of the studies involved heterosexual intercourse and may have little bearing on intercourse among men who have sex with men;

How many studies, exactly, are we talking about here? Of course, no references are provided. Please note for the second time, the word heterosexual is used. The comparable term homosexual is absent, as is gay. If DPH and SFAF were linguistically consistent, heterosexuals would be labeled men who have sex with women and women who have sex with men.

In their haste to consign the Swiss report to the dustbin, DPH and SFAF are not willing, because gays were excluded, to grant that the straight studies’ findings should at least be applied to the heterosexual community.

The straight studies may also have tremendous bearing on intercourse among homosexuals, if they looked at anal and oral sexual intercourse habits of the heterosexuals.

  • HIV-positive people with apparently undetectable viral loads can experience occasional spikes in viral load;

I am tired of repeating no references provided by the authors. If the PWA has an undetectable viral, how is it determined it is spiking? This point may be more about the reliability of the viral load test.

  • HIV-positive people who carefully follow their treatment regimen may develop viral resistance;

No references provided for this claim, which may be absolutely true, and have great bearing on the Swiss report and its impact for San Francisco.

  • people with other sexually transmitted infections can be asymptomatic yet still capable of transmitting or contracting HIV; and

No reference provided. I’d like to know more stats and see research about this point.

  • the Swiss report, since it did not use randomized, controlled studies, has not yet verified its causal conclusions.

Who appointed DPH and SFAF to decide randomized, controlled studies are the only necessary studies that would prove the Swiss causal conclusions? This point, like all the others, cries out for a full public debate.

Even the Swiss commission acknowledges that the data they reviewed do not assume a total absence of risk.

No direct quotation from the Swiss report. However, at least DPH and SFAF are obliquely acknowledging the Swiss weren’t naïve about total lack of risk, but they stop way short of telling San Francisco citizens that the risk was very slight. From the Swiss report: “Residual risk can not be scientifically excluded, but is, in the judgment of the Commission, negligibly small.”

In short, HIV-positive people cannot be entirely certain that they meet these criteria or that the criteria themselves are an indication of safety.

I don’t believe DPH and SFAF have logically and conclusively shown they should be trusted on these assertions. A one-page slapdash commentary isn’t enough anymore for me to say I swallow San Francisco’s high-minded and transparency-challenged decrees related to PWAs and gay men.

The San Francisco AIDS Foundation and Department of Public Health advise everyone to continue to use appropriate, evidence-based measures to prevent sexual HIV transmission.
I suppose there are a handful of people who were waiting for this advice and will heed it, but I’m not one of them. In any event, this clumsy and reference-challenged document should serve as the starting point for a new effort at creating official San Francisco policy on the Swiss report.

These are a few questions I would like addressed:

Who was on the panel that drafted the joint statement and why is it unsigned?

When did meetings to create take place and where are the agendas and minutes from the meetings?

Why were no public forums held soliciting community input and who was clamoring for a joint statement?

Who from the DPH and SFAF emailed and telephoned the Swiss researchers and began a dialog with them, before the joint statement was released?

Why weren’t the HIV Prevention Planning Council and the Health Commission allowed to first debate the Swiss study, then offer guidance to the DPH and SFAF before they decreed what city policy would be on this matter?

Who listens and looks to DPH and SFAF, two institutions responsible for many “gay health + gay sex = alarming crisis” panics, when making decisions about sexual safety and relationships?

References:

1. SF DPH web-posting of joint statement

2. SFAF web-posting of joint statement

3. Two-page Swiss communiqué on their report, in English

4. Five-page Swiss abstract, in French

5. Petrelis Files, December 3, 2007

6. Geneva Tribune, November 30, 2007

7. Flyer for January forum hosted by Geneva's DialoGai group

8. Bay Area Reporter, Staph Gaffe No Laugh, February 7, 2007

9. Bay Windows, Cooking the SF HIV Books, July 20, 2000

10. CDC Weekly Morbidity and Mortality Report, June 29, 2007

11. WHO November 20, 2007 release

12. Bay Area Reporter, February 29, 1999, article on gays and anal condoms


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