Back in the mid-1990s, when Dr. Tony Urbina was completing his residency at St. Vincent’s Hospital in Greenwich Village, he witnessed a major turning point in HIV/AIDS care. At the time, medication cocktails were just being introduced to the infected. “There were patients who looked like walking corpses; with [medication], in a matter of weeks, they would miraculously come back from the [brink of] death,” Urbina recalled in an interview.
Over 10 years later, HIV/AIDS no longer is seen as a death sentence but a chronic condition that can be treated with proper medical care. Once again, however, Urbina finds himself at a precipice in the story of HIV/AIDS. Instead of diagnosing middle-aged and older gay males, Urbina’s newly diagnosed patients are frequently minority men, some of whom are as young as 16, who have sex with other men.
What HIV/AIDS Looks Like in the 21st Century
At subway stations throughout New York City, HIV prevention posters are pasted on the wall with the message “Get Tested,” often featuring serious-looking minority men. Are they really the faces of HIV today? And if so, are posters like these promoting prevention and testing or are they alienating the at-risk community?
Data from the New York City Department of Health (DOH) suggests that the faces of the HIV prevention campaign are indeed representative of New York City’s highest HIV risk group in the city: minority men who have sex with men.
According to the DOH, in 2009, gay men and other men who have sex with men (MSM) accounted for 43 percent of the newly diagnosed HIV infections in New York City—more than any other group—and they experienced more than half of new diagnoses (57 percent) among men. Forty-eight percent of all new infections were reported from the African-American community, 32 percent from the Hispanic community and 3 percent from the Asian/Pacific Islander community.
Perhaps even more disconcertingly, a recent study of MSM in New York City showed that 53 percent of those who are HIV- infected were not aware of their status, suggesting that messages of prevention and testing are not being communicated adequately to high-risk groups.
Dr. Donna Mildvan, chief of infectious diseases at Beth Israel Medical Center at 16th Street, has been around the block with HIV/AIDS, having been one of the first doctors in the city to recognize the symptoms in the late 1970s and early 1980s. (“A point,” she said, “we don’t need to dwell on. We just have the long-range view here at Beth Israel, that’s all.”) As she sees it, the minority MSM acquisition of HIV is a recent and troubling phenomenon. For his part, Urbina said he first noticed it roughly five years ago.
“What we’re looking at is a population of young people who don’t see this as a threat,” Mildvan said. “These statistics reflect the fact of a cavalier attitude among young people.”
Indeed, for a generation most familiar with Magic Johnson’s 1991 diagnosis and successful antiretroviral treatment, HIV no longer holds the threat of AIDS and imminent death that it did 30 years ago.
“Now, we can treat patients with one pill a day and we have options about what that one pill will be. It looks easy—looks like it’s not the disease Larry Kramer wrote about in The Normal Heart. But it’s a lot worse and a lot more complicated than other degenerative diseases,” Mildvan was quick to point out.
Dr. Victoria Sharp, director of Saint Luke’s-Roosevelt’s Center for Comprehensive Care on 17th Street, has recognized similar trends in public attitudes. “This disease was once the disease of white gay men. There’s not manifestations as there was 15 years ago, when it was a lot easier to see the physical signs of the disease. These were the walking dead. Now, the younger generation senses that it’s not a problem.”
Sharp is quick to link social stigma to the heightened HIV infection rates among minority gay males. “For many of these at-risk communities, there’s stigma attached to sexual intercourse with other men. So these are MSMs, but they don’t publicly identify as such. They are on the down-low,” Sharp said.
Originally an African-American slang term, the phrase “on the down-low” has been adopted by the HIV medical community to describe men who have sex with men but for social or personal reasons choose not to socially or publicly identify themselves as homosexual.
“Having unprotected sex on the down-low affects infection rates in multiple ways. Young MSMs are infected, but women are infected through men who are on the down-low as well. After all, African-American women are the other group with rising infection rates,” Sharp reported.
Ding Pajaron, director of development at the Asian & Pacific Islander Coalition on HIV/AIDS (APICHA) and Daniel Goldman, development specialist at APICHA, confirmed the prevalence of social stigma in minority communities that makes prevention and care very difficult. Indeed, the Asian community has the highest rate of concurrent diagnosis of both HIV and AIDS, which is a signal of late testing.
“In minority communities, there is stigma associated with homosexuality that makes it difficult for people to access services,” Pajaron said. “It can be really brutal. One of our clients came out to his family; when he did, his parents brought him to the cemetery and said, ‘We consider you dead.’ As you can imagine, this sort of attitude makes it seem dangerous to access services.”
Goldman concurred. “The fact of the matter is that people at risk for this disease are disenfranchised in the city. HIV is affecting the African American population, the Latino population and the Asian/Pacific Islander population, so there is very good reason for resources to go into these communities. Our aim and mission is to provide general primary care to those who are at high risk for HIV. As we speak, we are expanding our services to more at-risk communities,” he said.
In both the public and private sectors, many HIV care facilities are moving to an all-in-one care model in an effort to combat HIV infection trends. One such facility is the Center for Comprehensive Care (CCC), the largest HIV/AIDS treatment center in New York State, which currently serves 5,000 patients in the city.
Sharp, director of the CCC, reasoned, “How can we thin this trend? Well, everybody gets HIV from someone, right? So treatment is tantamount to prevention. If we can put an HIV-infected person on medication, we can prevent them from passing the infection along. As the Center for Disease Control recommends, first get tested and then immediately get linked into care so you can’t pass it along.”
In 2011, the New England Journal of Medicine published results suggesting “a 96 percent reduction in HIV transmission risk to an HIV-negative partner…[is] definitive proof of the concept that antiretroviral therapy lowers the risk of HIV transmission.”
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