18 ▼ fo b ru a ry 2 1 . 1807 T ju s t out
Part 2: Safer-Sex
Survival
afe sex, safer sex, HIV education, risk
reduction—whatever the name, the guiding
thread running through this effort for most of
the past 15 years has been this: Put the fear of
death into 'em.
The belief that they could very well face an
unpleasant, lingering death did effectively moti­
vate gay men, who turned condoms into a most
necessary accessory. Of course, not everyone
listened to the gospel of risk reduction-even in
the days when infection was viewed as an
inevitable death sentence. And by the early
1990s, studies were starting to show that an
increasing number of men, especially young
men, weren’t being as conscientious as they
once had been about safer sex. But there is no
question that millions of people were saved—
and that they were saved by those most basic of
human emotions: fear and self-preservation.
But now, as hype and euphoria have started
to spread about the promise of protease
inhibitors as a treatment for HIV, many of those
whose mission it is to spread the gospel of safer
sex are growing increasingly uneasy. For if it
does turn out that this therapy can change AIDS
from a terminal illness into one that is chronic
but treatable—and the jury is still very much
out on that point—then death might no longer
be the bogeyman that can drive the prevention
message. And the fear is that there may be noth­
ing powerful enough to take its place.
“Most people were willing to modify their
behavior if the result of not doing so was that
they were probably going to die,” says Mark
King, who is director of education at AID
Atlanta. ‘T he question is whether they will be
as willing to change what they're doing if we
tell them that the reason they need to modify
their behavior now is to avoid taking expensive
drugs five or 10 years from now."
This is a particularly troublesome question
considering that even with the possibility of
death as a motivator, some studies have shown
that perhaps as many as half of all gay men
weren’t using condoms consistently.
“I don’t think gay men want to use condoms.
I think that’s what it comes down to,” says John
Copeland, prevention programs manager for
L.A. Shunti. an HIV care and prevention group
in Los Angeles. “I think that pushing consistent
condom use for the rest of their lives is a hard
message to sell anyway. I don’t know that this
would make it any harder.”
At this point, what little evidence there is about
the decisions gay men are making about safer sex,
based on the news about protease inhibitors,
remains anecdotal and appears to be mixed.
At Gay Men's Health Crisis in New York
City, David Barr, the director of treatment educa­
tion, says that in the past few months, people
have begun calling the information hot line to ask
if they can toss away their rubbers. But he says
those calls have represented a very small seg­
ment of the thousands of calls made to GMHC.
“There have probably been no more than
10,” says Barr. “We're getting the questions, but
we’re not getting them that often.”
Copeland, too, says people who work on
safer-sex education programs at L.A. Shanti
aren’t seeing this issue raised that much in their
direct contact with the public. But he says many
of the doctors and health educators with whom
the agency works are expressing worry that men
might be discarding safer-sex practices.
S
or those concerned educators, the results of
a small behavioral study among gay men in
F
Florida, released in December, could hardly
have been reassuring.
From the sun and sand of Miami Beach,
from the shadows of ail that art deco, from
ground zero in the gay party universe, came this
news: In a survey of 157 gay men, about half
younger than 30 and half older than 30,
researchers
from
Florida
International
University found that almost three-fourths had
engaged in unprotected anal intercourse in the
year before they were surveyed.
Before drawing too many conclusions from
these results, it should be noted that Miami
Beach is far from a typical setting. Its hard-
charging party atmosphere is duplicated in few
other places, and the city has long had the repu­
tation of being a mecca for HIV-positive men,
both of which could explain some of the lack of
caution. But looking at possible reasons for the
prevalence of unsafe sex, FTU researchers came
to the conclusion that the news about the
promise of protease inhibitors was likely a con­
popping regimen indefinitely, perhaps even for
the rest of one’s life.
• Second, protease inhibitors are expensive—
running from $10,000 to $25,000 a year,
depending on what combination is used—and
they can have severe and unpleasant side effects,
including vomiting, nausea and diarrhea. Some
patients have reported that their skin becomes so
sensitive to pain that they can’t stand for some­
one to touch them. Though not everyone devel­
ops these side effects, in some patients the
symptoms become so severe and unpleasant that
the treatment has to be discontinued.
• Third, while some studies have suggested
that treatment with protease inhibitors can
reduce the amount of virus in the blood to unde­
tectable levels, there have been no studies
establishing whether this renders people on pro­
tease inhibitors noninfectious.
Indeed, the possibility exists that having
unprotected sex with someone who is taking a
protease inhibitor could result in an HIV infec­
this treatment and have them ask what it is like.
This isn’t like a shot. It’s not syphilis. It’s not
gonorrhea.”
But even before protease inhibitors were
added to the mix, many HIV educators already
were rethinking the do-this-every-time-or-
you’ll-die approach, which seemed increasingly
not to be working. At L.A. Shanti, for example,
Copeland says prevention programming was
recently changed to shift the emphasis from
rigid insistence on universal safer sex to encour­
aging relationships inside of which wise, mutu­
al decisions about sex can be made.
And Barr also says he believes safer-sex edu­
cators should perhaps not focus so much on a
motivating message and instead try to tackle a
more important underlying issue—why men
make the decisions they make to have unsafe sex.
“Why did people ignore the message? It was
not because they didn’t understand the informa­
tion,” says Barr, who cites relationship pres­
sures ( He won’t love me if I won’t ...’) and
poor self-esteem as just two examples o f why
men sometimes make sexual decisions that are
not in their self-interest.
“These are already very complex decisions
for men. They are very difficult issues. We have
to help them deal with these issues,” Barr says.
“I don't think anything is going to make that
more complicated.”
Part 3: To Work,
or Not to Work
hough his health was starting to fail because
of HIV, David Lanoux resisted mightily the
idea that he go on disability. Self-employed in
real estate, a series of illnesses had wreaked
havoc on his income. But, having fought HIV
with everything he had since 1986, he didn’t
want to give in.
Then, two years ago, he finally bit the bullet
after a particularly nasty parasitic infection ush­
ered in a dramatic decline where his T cells
dropped below 100.
“Everybody said, ‘You’ve got to do this,’ ”
says Lanoux, 38. “So I did.”
At his worst point medically, Lanoux’s T-
cell count had dropped all the way to two. He
had embarked on a spiritual journey, and in his
words, “1 had come to terms with the concept of
death.”
Now, thanks to treatment with protease
inhibitors, his T-cell count has risen to 87, his
viral load is now undetectable, and he feels and
looks much better. Indeed, he feels well enough
to consider going back to work.
And therein lies David Lanoux’s problem.
Because his income was so disrupted prior
to going on disability, Lanoux qualified for the
federal government’s Supplemental Security
Income program for the low-income disabled.
He receives $484 a month in payments, but,
more vital for him, he qualifies for Medicaid,
which pays for his protease inhibitors.
If Lanoux goes back to work, his SSI pay­
ments will start to decline. That, he says, he
could probably deal with. More problematic,
though, is this: Medicaid is a program designed
for the poor. With any kind of a normal income,
he runs the risk of losing that coverage, which
very well might mean that he would have to pay
his drug and medical expenses—more than
$1,500 a month— himself.
“Here I am, taking new drugs, feeling won­
derful,” Lanoux says. “I'm really very, very
energetic and feel like I could be a contributing
part of society again. But I’m held back by the
cost of the drugs.
“I’m stuck in this pseudo-poverty situation.”
T
j
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tributing factor, and they recommended that
current prevention messages be rethought.
Clearly, experts and educators say, preven­
tion remains the best option—even if protease
inhibitors eventually do live up to their
billing— for a variety of reasons:
• First, protease inhibitors aren’t a magic
“morning after” pill, readily available to fix the
impulsive, poor judgment of the night before.
People who view this therapy as akin to getting
a shot of penicillin to cure gonorrhea are in for
a rude awakening.
These drugs are administered through a
demanding regimen that requires taking 20 or
more pills each day, at specific times and under
specific conditions. Some drugs have to be
taken on an empty stomach, others after a meal.
One of the protease inhibitors now on the mar­
ket, Norvir, has to be kept refrigerated. Missing
even one or two doses, or getting the times
wrong, could render the whole treatment use­
less.
Patients will have to take all of those pills
for at least a year—and possibly a whole lot
longer. While some researchers at this point the­
orize that people might eventually be able to
discontinue the drugs if the virus is eradicated,
there is no long-term conclusive evidence to
back up that theory. So the result of not using a
condom could turn out to be enduring this pill-
tion that, from the very first day, is resistant to
treatment with the drugs. That’s because any
strands of HIV that remain in someone who is
using inhibitors have likely survived by becom­
ing resistant to them. For someone thus infect­
ed, the “magic bullets” would be blanks.
The transmission of protease-resistant
strains of HIV is still a theory at this point. But
the phenomenon has already been seen with
AZT. Estimates are that as many as one in five
people infected with HIV today will get little
benefit from that drug because they were infect­
ed by people who were on the drug and whose
HIV had developed resistance.
• Finally, and perhaps most importantly, it
may turn out that protease inhibitors don’t live
up to their hype. These drugs were approved
under an accelerated process by the U.S. Food
and Drug Administration, without lengthy test­
ing as to their efficacy. They have been used in
clinical studies for about two years, and they
have been in widespread use for less than one.
So no one knows if they will be effective in the
long term, or what the possible effects of long­
term use might be.
I
f there is anybody out there who thinks that
they no longer have to practice safer sex. they
are wrong,” says GMHC’s Barr. “I would sit
them down with a group of people who are on