Comments on: Looking the PEPFAR gift horse in the mouth

By: elizabeth

elizabeth — Mon, 11 Aug 2008 17:42:34 +0000

Thomas: I’m not sure I have a theory; just observations. The clearest distinction between >30 and <30 is of course that those under 30 have become sexually active in the post-AIDS world. Could it be that while treatment makes AIDS less scary for older me, there is still residual fear associated with strong memories of friends infected and dying? These memories don’t exist for anyone who started having sex after around 1997.
A second point about differing incidence: Among the over 30s, those most prone to risky behaviour will have been infected long ago. Among younger people the riskiest have not yet been “saturated”. While I know that risk varies over a life time, some of us are just more prone to expose ourselves to it than others.

By: Thomas Strong

Thomas Strong — Mon, 11 Aug 2008 16:21:51 +0000

Hi there,

I was thinking of recent reports showing sustained decline in incidence in SF and in NYC. For SF there is an article here:
http://ebar.com/news/article.php?sec=news&article=3197

I do see the increase in transmission among young MSM that you indicate. I am not sure how I understand the idea that lack of fear of AIDS would impact this group differently than the 30+ group, where declines are reported. Can you make explicit your behavioral theory here and why there would be this differential response? Why would the ARV phenomenon differentially affect young ‘MSM’ versus older ‘MSM’?

I think you have a great blog!

By: elizabeth

elizabeth — Mon, 28 Jul 2008 20:56:12 +0000

Jim: "do you think you can reliably infer the impact of increased access to treatment on the behavior of uninfected persons in Africa based on research conducted in developed countries?" Reliably? No. For one thing, we're unlikely to see as much of an "undoing" of safe behaviour in part because there is less safe behaviour to "undo" among heterosexuals in many African countries than there is among gay men in developed countries. But do I think it plausible that the relationship between percieved risk and actual behaviour will be similar. In communities where the major motivation for using condoms is avoiding death from AIDS, the disappearance of AIDS surely undermines the motivation. Thomas: The only NYC incidence data among gay men in NYC I know of are from case reports. Newly reported cases have drifted down slightly since 2001, but annual reports in gay men under 30 (those most likely to be negative, and to have come of sexual age in the post-treatment years) have risen significantly. In San Francisco, which has better trend data including from sentinel surveillance, incidence rose between 1995 (when HAART became available) and 2001 (along with several other markers of risky sex such as syphillis and rectal GC). This caused some alarm, and prevention efforts were strengthened, according to this interesting presentation from the San Francisco Department of Public Health. Incidence has since remained stable, as far as I know. I'd be only too happy to be corrected. My point is not that more treatment inevitably leads to higher incidence; it is simply that it is a likely consequence of a (very desirable) increase in treatment UNLESS WE ALSO do better at prevention.

By: Thomas Strong

Thomas Strong — Mon, 28 Jul 2008 19:14:22 +0000

Elizabeth, I’m curious what you think of recent numbers out of San Francisco and New York City that seem to indicate a continuing decrease in incidence over the last several years. Do these numbers problematize your thesis that risk behavior is on the rise in those communities, and do they further therefore problematize your thesis about the relationship between access to ARVs, perceptions of risk, and resulting behavioral change?

By: Jim

Jim — Thu, 17 Jul 2008 21:46:31 +0000

HOPEfully some of the funding restrictions will be taken care of by a new administration. I agree that the prevention aspects of PEPFAR represent a huge missed opportunity, both in the level and in targeting. However, I think we need to focus on growing the whole pie, prevention and treatment, albeit with a much larger focus on the former than what currently exists.

One question, do you think you can reliably infer the impact of increased access to treatment on the behavior of uninfected persons in Africa based on research conducted in developed countries? I have only cursory knowledge of behavioral research in the U.S. and know nothing about Africa so I’d love to have some light shed on this issue. Thanks!