With St. Valentine's Day, February is the month best associated with romantic love. Within the MSM (men who have sex with men) community, however, the news this month has had less to do with Cupid and roses than with infections and "purulent anal discharge."
First, the Centers for Disease Control and Prevention sounded the alarm about a nasty strain of chlamydia that has recently resurfaced. Next came an ominous warning from New York of a possible new "super strain" of HIV -- both highly resistant to medications, and unusually aggressive. Add these unwelcome announcements to already-issued warnings in the MSM community about syphilis and drug-resistant gonorrhea, and gay men may think the only thing a bed is good for anymore is sleeping on -- or hiding under.
Dr. Philippe Chiliade, medical director of D.C.'s Whitman-Walker Clinic, seems cautious, though not alarmed. At this point, he says, this new case of HIV may be unique to a single patient. And the resurfaced chlamydia -- Lymphogranuloma Venereum (LGV) -- is treatable.
"It's not like HIV. It can be cured," Chiliade says, referring to LGV, which first resurfaced among gay and bisexual men in Amsterdam, before making its way to New York and San Francisco. Along with the handful of cases reported in these cities, cases have also been found in Belgium, France and Sweden, according to the CDC. "It's not new. It's been in the developing world. It's painful for people who have it. They can have really unpleasant symptoms. It can be painful and leave some scars, but there is no long-term effect.... Until we learn more, I would not recommend people to panic."
Chiliade adds that while the garden-variety chlamydia already well entrenched in United States and elsewhere is easily transmissible via oral sex, he has not seen oral transmission with LGV.
"There is something unusual with the LGV outbreak in MSM," Chiliade observes. "It's all rectal infection. I've never heard of any data from Europe or San Francisco [or New York] about oral infection, which doesn't make any sense. We know that regular Chlamydia can be transmitted with oral sex. So, is it possible with LGV? So far we have not seen it. Maybe it's never been seen because we've not looked enough."
Chiliade takes a similarly no-nonsense approach to the possible new strain of HIV. The mood out of New York last week, however, was a bit more fevered.
"It's just a sin in our society, where we know how it's transmitted from one person to another," said New York Mayor Michael Bloomberg, as reported in the New York Times, referring to the HIV news. "We should be able to get people to conduct themselves such that they don't catch it themselves, and certainly that they don't infect anybody else."
Granted, the unnamed HIV patient is reported to have been engaging in unprotected sex with multiple partners while using crystal methamphetamine. The LGV outbreak has similar risky-sex roots. That part of the equation may sound unsavory in the press, leading to defensiveness from "sex positive" quarters, embarrassment from the "gay establishment," and charges of "reap what you sow" from the right. But that doesn't necessarily mean much to Chiliade, or many other clinicians who are branding the HIV news, issued by the New York City Department of Health and Mental Hygiene in collaboration with the Aaron Diamond AIDS Research Center, as premature at best.
"Every medical center in a major metropolitan area will have cases like this," Roger Pomerantz, an AIDS specialist at Philadelphia's Thomas Jefferson University, told the New York Times, typifying the responses opposite Bloomberg's. "You've got to really prove something like this before you go on CNN and scream about a ‘super strain.'"
Chiliade would seem to agree with Pomerantz.
"I think it's very bad news for that patient," says Chiliade. "We know he was infected recently with a strain seeming to be resistant to three classes of [HIV] drugs. But that's like three-to-four percent of the population in big cities. We know it's possible. So far, it's not frequent. To be resistant to three classes of drugs, that part is rare.
"He had something also identified in other people: the course of the infection moving very rapidly. Some people, within a couple of years, go rapidly to advanced AIDS. It has nothing to do with the virus itself, but other factors. It was mostly due to their own immune systems not being able to control the virus, generally because of genetics. Some people, we don't know why, their immune systems can't control it, so they have advanced AIDS within a couple of years.
"It's unfortunate for that patient to have both at the same time. Is it possible that this patient was infected with something unusually aggressive? I would say it's possible. But at this point, I would say it's unlikely. I don't think that's what's happening."
Although Chiliade may not feel moved to shout from the rooftops warning about LGV or this particular HIV patient's case, he does seem troubled by the bigger picture. After all, LGV -- which Chiliade guesses is already in Washington -- makes it easier to contract HIV. And both the LGV outbreak and new HIV cases are evidence of riskier behavior among men who have sex with men.
"The big problem that we see is an increase in risk-taking behavior in MSM," Chiliade asserts. "I worry most about that.
"The big concern that I have is that patients who are aware that they're HIV infected are not taking their meds regularly, so they've developed resistance, and are still having unprotected sex. That is the problem. We have more transmission of virus that is resistant.
"I'm not worried that people aren't educated. Most people know that anal sex without condoms is risky. I think that people are taking more and more risks despite knowing. It's important to remind people, but something else needs to be done. I don't think just education will do it.
"My sense is that when you see people around you taking more and more risk, you're tempted to behave like the group. It's easier to follow. Then you try something risky, and nothing happens. So you'll do it again and again -- till the day it does happen.
"People are informed, but they take more and more risks. We need to know why. I imagine it's a combination of factors. Clearly it's happening, but I'm not sure why. Syphilis, LGV -- all that tells us people are having more and more unprotected sex."