USA: "Superbug" revisited: an interview with NYC's health commissioner

In February the New York City health department announced that a gay man had contracted a virulent strain of HIV that was resistant to several treatments.

Since the unidentified man was a crystal meth user who had multiple unprotected sex partners, the story triggered fears of a new wave of HIV infections -- and an explosive debate about the apparent failure of HIV prevention campaigns.

In April the health department announced that the man was responding to treatment and was in stable condition. After testing many of his partners, officials were unable to find another example of the so-called "superbug."

In an exclusive interview, PlanetOut editor Chris Bull spoke to the city's health commissioner, Dr. Thomas R. Friedan, about the "superbug," crystal meth, barebacking and same-sex marriage.

In hindsight, would you have done anything about your February announcement differently?

We initially went public because the public has a right to know. We trust people to make better decisions when they have better information. What we know now is that we have learned that our characterization of the case was accurate despite all the controversy. We can now track this [strain of the] virus to see whether it's spreading. We think it's guardedly good news we haven't identified any other cases. While we expected at least one other case, we haven't identified it. The investigation is continuing, but there is a possibility we will never identify another case.

Has any good come of it?

We are pleased there has been more discussion of safer sex. The level of interest in our announcement was greater than we anticipated. It is a good thing that doctors are giving more tests, and that people are thinking more about protecting themselves.

Some said the announcement was alarmist because there had been other cases of virulent strains in the past.

There really are no cases similar to this one. The cases from Vancouver may be on the same spectrum, but they are not even close to this level of resistance.

There's also the argument that a single case is not cause for alarm.

That's where I say the role of public health is to prevent outbreaks, not describe them. I do think that because we made the announcement, there is less likelihood this is spreading or at least spreading without being tracked. If we had waited a month to warn people -- now that would have been unethical.

HIV prevention seems to have taken on a new sense of urgency.

We refer to an event like this as a sentinel health event because it signals broader problems.

Such as?

High levels of unsafe sex among certain social networks. An increase in drug resistance among newly infected people. It signaled the lack of a monitoring system.

Some AIDS activists called for draconian prevention measures, from interventions in sex clubs and chat rooms to mandatory HIV testing.

Our primary approach is educational and providing resources. We would like to see condoms available at all high-risk venues. One thing we know for sure: Condoms work to prevent the spread of HIV.

Have you identified venues where condoms are unavailable? If so, how do you make sure they are always stocked?

That's something we're working on right now on an ongoing basis. We'd like to see a greatly improved condom distribution network.

There was a time when condoms were part of the ethic of being gay. That's still largely true, but there are definitely more men who flaunt the ethic or see it as somehow unfashionable.

There is clearly a sense today that AIDS is a treatable disease. So there is less urgency. Twenty years ago, people died within a year of diagnosis. Today, that's usually not the case. So we have to find new ways of encouraging safe sex.

How can that be achieved?

It's important we work with the [gay] community. Government can foster a certain social norm as we did with anti-tobacco campaigns, but there are limits. Smoking around other people is a whole lot less acceptable today than it was before. I'm not equating second-hand smoke with sex. Don't misquote me there. The point is to achieve social norm change, but there is only so much government can do to change social norms. By making condoms more widely available, they will be used more. There's no question about that. Social marketing and public education campaigns can encourage their use. But some of that change must come from within the community as well.

You've identified a problem here. Condom use is slipping. Yet at the same time it doesn't look like seroconversion rates are skyrocketing as one might expect, based on the situation you are describing. Why?

First of all, we don't learn about infection numbers for many years after they occur. I find this discussion of numbers disturbing. To me, it's totally unacceptable that infections are continuing even at the rate it has. Look at perinatal transmissions. Look at transmission among injection drug users. Perinatal transmissions went from 300 per year to five. Injection drug users had an 87 percent decrease. This is related to safer needle use and widespread testing. We haven't reduced infections anywhere near that degree among men who have sex with men or, for that matter, in the heterosexual community. We need to do much better.

What is the role of crystal meth in the upswing of unprotected sex?

It's not just crystal. Cocaine is also a leading cause of unsafe sex. They are both damaging and widely available, and we don't have a lot of good treatment options.

Some have put intercourse without condoms in moral terms, comparing it to murder.

I'm the commissioner of public health, not the commissioner of public morals.

Is it a mistake to put it in moral terms?

I don't want to go there. But I do think the discussion in the community around sexual health and sexual behavior is a very good thing.

Anti-gay activists have also put the problem in moral terms, using your description of this man's behavior to raise the specter of the irresponsible, promiscuous homosexual. There have been calls for quarantine and more repressive legislation aimed at gay men. Do you feel responsible for how the right wing has twisted the information you put out?

I saw some of the news coverage of that. I thought [that kind of rhetoric] is very irresponsible. We always emphasize the importance of confronting stigma and supporting communities to change and improve.

If you could communicate one thing to sexually active gay men, what would it be?

There's no question that barebacking -- unprotected anal intercourse -- is by far the riskiest act. It's at least five times riskier than receptive vaginal intercourse and 50 times riskier than receptive oral sex.

At the federal level, the Bush administration increasingly spends scare prevention dollars on campaigns promoting abstinence until marriage. And of course it is also working to ban same-sex marriage. Does that make any sense?

As you know, the mayor supports gay marriage. But it's not an issue the health department deals with. If you look at some of the public education campaigns we have done in the subways, we are pretty far out there. We get blasted all the time [for frankness]. We have the freedom here to use the best possible information to reach people.

Is same-sex marriage an HIV-prevention measure?

I don't think I can comment on that.

Why not?

Any relationship with fidelity is certainly good. The fewer the number of partners, the lesser the risk of HIV transmission. But remember -- I'm the commissioner of public health, not public morals.

Newshawk: http://www.napnt.org/amphetablog.html
Pubdate: 18 May 2005
Source: Gay.com
Website: http://www.gay.com
Author: Chris Bull, Editor