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Andrew Sullivan Declares the 'End of AIDS' - Again

The AIDS epidemic could have ended, except for the occasional stray infection. But the opposite happened. The increase in unsafe sex swamped the drop in infectiousness due to the meds.
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It's Gay Pride Month. That means parades, floats, garden parties -- and more articles by Andrew Sullivan proclaiming the 'end of AIDS.'

It's one of the most shockingly irresponsible claims ever made in the context of gay men and AIDS, and it represents a mindset whose consequences couldn't be more tragic.

The current issue of Seattle's The Stranger contains Andrew's latest installment -- a historical essay about the year 1996 entitled 'The Plague Ends.' It describes how the AIDS epidemic for gay men supposedly vanished that year when combination therapies appeared and began saving countless lives.

Andrew recounts that he wrote a similar piece for the Sunday New York Times as early as 1996, the year in question. He complains that back then he was ''flayed alive" by AIDS prevention activists for writing a piece that said "the obvious:" that the new medications were "an end to AIDS-as-plague."

And yet, 10 years on, everything in it was right. And the refusal to acknowledge that at the time, while understandable, was sad. We never got our moment of celebration. We never got that day on the beach in Longtime Companion. We denied ourselves the relief that we deserved.

He continues:

...part of the weirdness of the PC mantra that nothing changed that year, that we should not have marked the passage from plague to disease, is that we erased part of our own history and denied a critical part of our past.

But tellingly, Sullivan erases the history of why he was criticized. You get the impression that his supposedly PC critics in the gay world and the "AIDS establishment" are a bunch of whiners who can't stand good news.

So a little perspective.

In 1996, the year combo therapy appeared and Andrew wrote that piece, I also wrote a piece for the Sunday New York Times. Mine also made a few predictions.

I noted that while protease inhibitors were undeniably and deliriously great, so were their potential dangers for AIDS prevention and future generations of gay men if we didn't approach things with a solid knowledge of what might go wrong.

I recounted what happened when antibiotics were introduced to cure syphilis and gonorrhea after WWII. Back then experts predicted that both diseases would be completely eliminated from American life, and for a couple of years their rates did decline. But then they began to skyrocket. Why? Because people became complacent, prevention grew lax, and unprotected sex with multiple partners increased, thanks largely to the drugs -- and, a few years later, the Pill.

As a result, by the early 1980's 2.5 million Americans were contracting gonorrhea every year, and syphilis ranked as the third most common infectious disease in the nation. Even though antibiotics completely cured both diseases.

I predicted that if gay men allowed ourselves to become equally complacent about the new AIDS therapies -- which do not cure but merely suppress HIV -- our misguided optimism "could render the AIDS epidemic more intractable than it already is."

One of the reasons the stakes were so high was because the advent of combo therapy actually held the promise of ending the AIDS epidemic among American gay men. Not symbolically ending it. Or turning it "from plague to disease," in Sullivan's words. But ending it. Altogether.

The reason is rooted in epidemiology and begins with the fact that sexually transmitted epidemics are affected by three basic variables, the so-called Triad of Risk: prevalence, infectivity and contact rate.

Prevalence is the percentage of people who are already infected in your pool of potential partners. Infectivity is the biological likelihood you might get infected in any given sexual encounter - very high for gonorrhea, much lower for HIV, etc. And Contact Rate describes how many sex partners the average person has in a given population such as gay men.

If you decrease any one element of this Triad, such as lower the contact rate, or decrease the disease's infectivity, new infections will drop. The purpose of condoms, for example, is to decrease the 'infectivity' leg of HIV's Triad of Risk.

Which brings us to why combo therapy had the potential to actually end the epidemic.

Combo therapy drives most people's viral load way down, often to undetectable levels. This, in turn, makes such people far less infectious to others, at least on average. By the late 90s, vast numbers of America gay men were on these meds and had undetectable viral loads. In effect, they had been largely removed from the equation of HIV transmission.

Since new infections among gay men had been chugging along right at the epidemic's 'tipping point' in the years before the meds arrived, epidemiologists argued that the sharp reduction in infectivity could drive new infections down below the tipping point -- the point at which the average infected person infects one other person and keeps the epidemic going. Provided, of course, that gay men continued to have safe sex at the same level and with the same number of partners as before.

If that had happened, then within a few years an even better dynamic would have begun to take hold.

As new infections remained low among younger gay men in their twenties, prevalence would also have remained low in this group. Now, the Triad of Risk would actually provide a double measure of safety. There would have been far fewer infected men in this age group than in the past, and those who were infected and taking meds would have been less infectious, thus creating a biological feedback loop driving new infections even farther below the tipping point.

In other words, for the rising generation of gay men, the AIDS epidemic could have ended, except for the occasional stray infection here and there.

But that's not what happened. The opposite happened.

As the meds came into use, people began celebrating. Opinion leaders -- most notably Andrew Sullivan -- recklessly proclaimed the "end of AIDS" in major venues like The New York Times. Mainstream journalists took their cue and largely dropped the subject.

Healthy fear -- the primary motivator of safe sex -- swiftly declined. Unsafe sex -- a vital part of the 'infectivity' leg of the Triad -- swiftly rose. Sex with multiple partners -- the 'contact rate' leg of the triad -- also rose. Sex clubs and bathhouses that allowed unsafe sex reopened without much controversy, or even notice. The Internet created a new venue for people to have multiple partners, often unsafely. 'Barebacking' became glamorized, even valorized, and the crystal meth epidemic vastly exacerbated the problem.

As the years went by, the truth became horribly clear: The increase in unsafe sex and the increase in the contact rate had swamped the drop in infectiousness due to the meds. Instead of ending, or even slowing, the AIDS epidemic among gay men has continued infecting between 2% and 3% of gay men per year. That's about the same level -- or even higher -- as before the meds were introduced.

In a landmark study last year, pioneering AIDS epidemiologist Ron Stall demonstrated that among 20 year old gay men today, about 25% will be HIV infected by age 30, about 40% will be infected by age 40, and more than half will be infected by their fifties. And for African American gay men, the numbers are even worse.

In other words, our greatest chance of actually ending the epidemic was lost, partly thanks to a widespread attitude that the epidemic was already over.

This is not to say that Andrew is wrong, exactly, when he insists that something huge happened in 1996. He is, rather, half right. Two huge things happened in 1996.

The first is that the new meds saved the lives of thousands of gay men, including many of my closest friends, and words cannot express the thanks that I and countless others feel for this miracle every day.

But the second is that a very predictable human reaction to the meds -- complacency, a rise in unsafe sex and an increase in the contact rate -- inadvertently but decisively doomed the next generation of young gay men to about the same level of HIV infection as previous generations -- for which words cannot express the horror.

Which brings me back to Andrew Sullivan and his continuous "end of AIDS" crap.

It has always been incumbent on any responsible gay opinion leader to repeatedly stress that 1996 did NOT mean the 'end of AIDS' or the 'end of a plague,' but rather a historic opportunity to bring that about.

Yes, sure, we all agree that 1996 marked a turning point in the lives of the infected and those who love them, which is Andrew's obvious and endlessly belabored point. But the responsible among us also agree that to emphasize such a self-evident fact without equally emphasizing the dangers of complacency is the height of irresponsibility. It plays into the very syndrome that now dooms a new generation of gay 20-year-olds to a 50% prevalence of HIV by middle age.

The truth is that in 1996, when Andrew Sullivan began taking his HIV meds, his own personal plague ended -- the only plague one suspects he really cares about. But for countless other gay men, their plague was about to begin, in part because of the complacency epitomized by Andrew's bullshit.

And that, sadly, is a bitter history lesson from 1996 that Andrew Sullivan will probably never acknowledge.

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