The New Face of HIV/AIDS

Downtown doctors fight a growing trend of new HIV infections in minority communities.

By Penny Gray

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 and 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."

This promising data has solidified the DOH's own focus on HIV testing as a means of prevention. According to its press office: "The Health Department collaborates with community partners on various initiatives that focus on areas of high HIV prevalence and work with vulnerable populations. Two such initiatives are The Bronx Knows (which just ended in June of last year after a very successful three-year run) and Brooklyn Knows, currently in its second of four years. Both are initiatives designed to routinize HIV testing in clinical settings, facilitate testing for every person who is unaware of their status (i.e. anyone who has never taken an HIV test) by providing free test kits to those who are uninsured, collaborate with non-clinical testing sites and link those who test positive to quality care and services."

Confronting HIV/AIDS

Authorities seem to agree that HIV testing ultimately leads to both care of the HIV-infected person and prevention of the spread of the disease. But everybody seems to have a different idea about how to arrive at widespread HIV testing. Robert Shiau, AIDS administrator at the AIDS Center of Beth Israel Medical Center, pointed out, "There's a lot of education out there, but we need to increase access to education on safer sex, condoms and clean needles."

Mildvan went even further in her convictions about outreach and prevention, saying, "We need to get very, very creative at this point and start making full use of social media. We need novel ways of reaching a populate at huge risk."

Mildvan pointed to HIV BIG DEAL, a social media campaign run by Public Health Solutions, as a prime example of successful social media. The brainchild of Dr. Mary Ann Chiasson, vice president of research and evaluation at Public Health Solution, HIV BIG DEAL uses 10-minute video dramas to realistically address the social and health-related dilemmas MSMs face.

But Urbina, the associate director of CCC, suggested the young minority MSM population can't be pinned down to prevention strategies so easily.

"If the prevention message doesn't resonate, it isn't going to be effective, " Urbina said. "There's actually data to show that young MSMs have higher rates of condom use than their heterosexual counterparts. And young African-American men have fewer sexual partners than their white and/or heterosexual counterparts. Hence the paradox of higher rates of infection."

"What's actually playing out here is that for a young MSM, that one chance encounter is much more likely to lead to an infection. It doesn't mean they're having any more chance encounters than a young heterosexual male. It's difficult because young men are exploring and just awakening to their sexual identities, and hyper vigilance is not a normal response for young people. Sex is a biological urge in all of us, and it's difficult for youth to accept and internalize the need for condom use," Urbina lamented.

"There are engaged, talented young men becoming infected because of one chance encounter. We see track stars, we see straight-A students coming in, infected with HIV by the time they get to high school. We're all struggling with this. "All efforts at prevention are well- intentioned, but we need to go back to the basics and realize that a community approach is the solution. The sooner we normalize our approach so that it's about health, spanning across all cultural, ethnic, economic and sexual orientations, the sooner we'll put an end to HIV."