Transmission between Gay Men

“By 1998, Pisani writes, it was clear that “HIV wasn’t going to rage through the billions in the ‘general population’, and we knew it”…However, more than a decade later Pisani and her colleagues continued to exaggerate both the scale of the epidemic and the threat to people outside well-recognised high risk categories…Pisani explains how she and her colleagues manipulated the figures, presenting them “in their worst light”. They “did it consciously” to foster public alarm and squeeze more money for prevention campaigns out of governments and donors. What was once characterised as the good lie of the “Don’t Die of Ignorance” campaign (which Pisani briskly dismisses as the “everyone is at risk nonsense”), Chin describes as a “glorious myth”, justified by the goal of promoting public anxieties about Aids and sexual restraint. Yet, as Pisani concedes elsewhere, “lies are lies whichever side of the political spectrum they come from”.”

“The meta-analysis [summary analysis of multiple studies] results for the outcomes of interest are shown…There were no significant differences between black MSM [men who have sex with men] and white MSM across studies in reported UAI [unprotected anal intercourse], commercial sex work activity, substance use by drug (except amyl nitrites), history of HIV testing, or sex with known HIV-positive partners. However, black MSM reported significantly fewer [!] sex partners across studies than white MSM and were less likely than whites to identity as gay or to disclose their homosexuality to others. Among HIV-positive MSM, black MSM were less likely than white MSM to report taking antiretroviral therapy (ART). The only outcome of interest that was significantly greater among black MSM than white MSM was the occurrence of STD…black MSM were significantly less likely than white MSM to use drugs associated with HIV infection (i.e., nitrites, injection drugs, crack/cocaine, opiates, and amphetamines)…Individual risk behaviors do not appear to be driving the disparity in HIV/AIDS among black MSM. Despite comparable rates of UAI and fewer sex partners, STD prevalence and HIV prevalence remained greater among black MSM than white MSM. Moreover, black MSM were significantly less likely than white MSM to report engaging in any substance use irrespective of drug type, and significantly less likely to report using any drugs associated with HIV infection.”

“Only 88 seroconversions but, because HIV testing during incarceration is voluntary, and because the total number of inmates being tested is not listed, it really provides no information on the frequency of seroconversion.”

“The Spearman's rho correlation between viral load in semen and plasma was not significant…When restricted to participants with detectable virus in semen and plasma, the correlation remained nonsignificant…There was also poor concordance between undetectable viral loads in plasma and semen; 53% of men with undetectable virus in plasma had detectable viral loads in semen and 31% of men with undetectable virus in semen had detectable plasma viral loads…Men with equal or greater virus in their plasma than their semen compared with men with greater virus in the semen than plasma showed no differences in age, ethnicity, sexual orientation, years since testing HIV positive, HIV symptoms experienced, CD4+ cell counts, current HIV treatment status, or current HIV treatment adherence…[The only correlation found was] that men with greater concentration of HIV in their semen relative to concentrations of HIV in plasma reported significantly greater rates of unprotected vaginal intercourse and total number of unprotected sexual intercourse occasions as the insertive partner…Results failed to find differences in STI [sexually transmitted infections] occurrences between men with relatively higher and lower semen viral loads.”

“Healthy HIV-1-seronegative persons >=18 years old with high-risk exposure to HIV-1 through sexual activity were recruited within metropolitan Seattle…Pre-established enrollment criteria included unprotected sexual intercourse (anal and/or vaginal intercourse without condoms) with a known HIV-1-infected person more than five times in the previous 6 months or an average of two times weekly over 4 months within 2 years of enrollment…37 study participants [were selected out of 41 volunteers]…the activity most frequently (78%) associated with repeated exposure to a known HIV-1-infected partner was unprotected anal receptive or insertive intercourse between men…The study participants remained free of HIV-1 infection…throughout the median study period of 23 months.”

“In 1995, 3,553 repeat anonymous HIV tests were performed among men who have sex with men in San Francisco…A total of 2,822 subjects met all inclusion criteria. A seroconverter was defined as a person who reported a prior HIV-negative test and whose current test was HIV positive…6 variables were significantly associated with increased HIV seroincidence in multivariate analysis: African-American ethnicity, age under 36, sex with an HIV-positive person, 10 or more sex partners, unprotected receptive anal sex, and use of the drug amyl nitrate ('poppers') during sex…Injection drug use was not associated with a significant increase in HIV seroconversion…a history of sexually transmitted disease did not appear to contribute an increased risk of seroconversion after controlling for markers of high risk sexual behavior”

“Some sex workers and homosexual men remain uninfected despite repeatedly having unprotected sexual intercourse with HIV-infected partners”

“A highly selected cohort of 24 HIV-1 seronegative subjects with histories of multiple high-risk sexual exposures to HIV-1 were studied. The cohort [included 7] homosexual men who reported sex with multiple HIV-1-infected partners, [5] homosexual men with predominantly a single HIV-1-infected partner, and [13] heterosexual individuals reporting sex predominantly with a single HIV-1-infected partner…Among the individuals reporting exposure to predominantly a single HIV-infected partner, most were in long-term relationships involving unprotected sexual intercourse over many years during which time several partners succumbed to AIDS. All subjects were HIV-1 negative by commercially available enzyme-linked immunsorbent assay (ELISA) tests and by diagnostic polymerase chain reaction (PCR)”

“we studied 50 sexually active couples with discordant antibody results, assessing the agreement between these serological results and those obtained by p24 antigen testing, the polymerase chain reaction (PCR), and culture. 49 of 50 seropositive sexual partners were also positive for HIV by PCR; the remaining seropositive partner was positive by culture [no other seropositive partners were tested in this way]. All seronegative partners also had negative results in the other three tests. Moreover, seronegative partners continued to have negative results in all tests for a mean follow-up period of 17 months despite ongoing sexual relations with their seropositive partners. Seronegative infection was not documented in these partners at risk for sexual transmission of HIV. HIV-negative individuals in stable, monogamous sexual relationships with HIV-infected partners apparently do not have a high incidence of infection despite continued sexual exposure…approximately one-half of each group reported some instances of unprotected intercourse…intercourse with outside partners was uncommon in both groups, as was current illicit drug use…All 50 index cases were positive for HIV by EIA and western blot [antibody] testing. All 50 historically negative partners were negative by EIA, and 47 were negative by western blot [the remaining 3 were classified as 'indeterminate']…None of the 50 seronegative partners had p24 antigen in their serum. 22 (44%) of the seropositive partners had detectable p24 antigen.”

“Conclusions…(1) unprotected anogenital receptive intercourse poses the highest risk for the sexual acquisition of HIV-1 infection; … (8)the association of substance [i.e. drug] use increases the likelihood of practicing anogenital receptive intercourse [they do not consider the possibility that drug use, particularly nitrite inhalants, may be the cause of disease, and receptive anal intercourse is just an associated, not causative, factor]”

“Age, frequency of unprotected receptive anal intercourse with an [HIV] infected study index subject and length of relationship with an HIV-infected study index subject were not associated with HIV-1 infection.”

“Based on the results of HIV-1 antibody testing, of the 60 sexually active homosexual couples enrolled, 18 were HIV-1 concordant negative [i.e. both HIV negative], six were HIV-1 concordant positive, and 36 were HIV-1 discordant. The 36 members of the HIV-discordant couples who had negative ELISA tests for antibodies to HIV-1 all had negative cultures for HIV-1, negative PCR for HIV-1 proviral DNA, and negative antigen capture tests for serum p24…These results suggested the possibility that the seronegative men in discordant couples had had a low rate of exposure to HIV-1…[but] the frequency of unprotected anal insertive and anal receptive intercourse was high for both partners in the discordant relationships…Seronegative discordant partners reported a lower frequency and duration of receptive anal intercourse than their seropositive partners. Condom use was inconsistent or absent in most cases, and more than half of the seropositive men had ejaculated into their seronegative partner's rectum while not using a condom. 27 of 36 (75%) of the discordant couples had entered into their relationships before November 1985…there were no striking differences in sexual practices or sociodemographic characteristics among these groups…The same was true of antibodies to other herpesviruses and RPR for syphilis. However, a significant association between HIV-1 seropositivity and the presence of HSV-2 antibody was found in the discordant couples…The seropositive discordant partners' mean numbers of CD4 and CD8 lymphocytes were not significantly different from those of the seropositive concordant partners. In addition, the seronegative discordant and concordant individuals had similar absolute CD4 cell counts at all visits…During the 1-year follow-up period, two of 34 seronegative discordant partners engaged in unprotected anal receptive intercourse; however, no seronegative partner reported ejaculation into his rectum from any partner. 7 of 34 seronegative discordant partners reported unprotected anal insertive intercourse…In total, 10 of 34 of the seronegative discordant partners engaged in either insertive or receptive anal intercourse without protection during the follow-up period…Despite these risky sexual practices during the follow-up period, all discordant seronegative partners remained negative for HIV by serology and PCR. Three (8%) of the seropositive discordant men developed an AIDS-defining illness, and 14 (40%) experienced AIDS-related symptoms, such as oral candidiasis or night sweats…the persistent HIV-1 seronegative status of the discordant seronegatives studied remains unexplained ”

“some individuals whose sexual behavior places them at extremely high risk for infection have nevertheless remained HIV-1-seronegative…Five very high risk men who had recent sexual exposure to HIV-1 were studied…One of the 5 high-risk men has subsequently seroconverted, while 4 have remained seronegative. All were initially culture-negative, and those who have remained seronegative were also virus-negative by polymerase chain reaction (PCR) testing 10 months after they were first studied”

“The Maharashtra state health director Subhash R. Salunke calls it an unseen killer – India’s Chernobyl. ‘It is a silent bomb that has already exploded among us,’ he says. Dr. I.S. Gilada of the India Health Organization says simply: ‘Millions will die’. And Dr. Mahendra Trivedi, who caters to the prostitutes of this city’s infamous Falkland Road, forecasts it will utterly decimate his high-risk clientele. ‘They will die on the streets. They will drop dead on the footpaths. And no one will come to claim them.’…India admits to fewer than 5,000 HIV cases, but according to the World Health Organization, at least 500,000 people have probably been infected. Undiagnosed they are spreading it to thousands daily, contributing to a sombre process that, if unchecked, will sooner or later make the Indian subcontinent the new AIDS killing ground, surpassing the devastated sub-Saharan region of Africa…Tests conducted by the Indian Health Organization show one in three Bombay prostitutes are HIV positive. Testing in clinics in the heart of the red light districts put the rate much higher – at more than 60% [yet later estimates were no higher than this, and as low as 45%, between 2000 and 2004]. In addition, at least one in 10 of the city’s homosexuals is infected. And testss at non-professional blood donor clinics in the city have produced an HIV positive rate of more than 0.8%, which means that at least 80,000 of the general population…have already been infected…Some experts place the eventual infected rate in major cities like Bombay at 20%. [by contrast, a report ten years later reported only 1440 AIDS cases in Mumbai in 2001 and an overall prevalence of 0.6%]”

“the sexual practices by which HIV is transmitted between homosexual/bisexual men are insertive anal intercourse by infected men, which disseminates infection, and receptive anal intercourse among uninfected men, by which they acquire infection [but how do men who practice only insertive anal intercourse ever get infected?]”

“…the areas where absorbed concentrations of volatile nitrites would be expected to be highest - the skin surround the nose and in the nasal/pulmonary mucosa - are also reported to be the areas in which KS occurs in persons with AIDS. This association logically leads to the hypothesis that there is a causal relationship between nitrites and KS, perhaps mediated by the formation of N-nitroso compounds.”

“receptive anal intercourse was the only significant risk factor for seroconversion to HIV, the risk ratio increasing from 3-fold for one partner to 18-fold for five or more partners…Receptive anal intercourse accounted for nearly all new HIV infections among the [2507] homosexual men enrolled in this study…”

“only receptive rectal intercourse, douching, rectal bleeding, sexual contact with a person known to have AIDS, and use of intravenous drugs were significant predictors (P<.05) of anti-HTLV-III positivity.”

“Of eight different sex acts, seropositivity correlated only with receptive anal intercourse...and with manual stimulation of the subject's rectum…HTLV-III seropositivity was also associated with frequent nitrite inhalant use during the 12 months before phlebotomy…and was inversely correlated with insertive anal intercourse [note that receptive anal intercourse is associated with higher use of nitrite inhalants]”

“Of the first 19 homosexual male AIDS patients reported from southern California, names of sexual partners were obtained for 13. 9 of the 13 patients had sexual contact with one or more AIDS patients within 5 years of the onset of symptoms. 4 of the patients from southern California had contact with a non-Californian AIDS patient, who was also the sexual partner of 4 AIDS patients from New York City. Ultimately, 40 patients in 10 cities were linked by sexual contact [but in several cases sexual contact was between a person with Kaposi’s Sarcoma (a skin cancer) and one or more persons without KS but with PCP (Pneumo-cystis carinii pneumonia), or vice-versa. Also, this data is compatible with a shared lifestyle factor, such as use of amyl nitrite poppers, as well as with sexual contact]”

“In the period October 1980-May 1981, 5 young men, all active homosexuals, were treated for biopsy-confirmed Pneumocystis carinii pneumonia at 3 different hospitals in Los Angeles, California. 2 of the patients died…2 of the 5 reported having frequent homosexual contact with various partners. All five reported using inhalant drugs [probably nitrites], and one reported parenteral [injected] drug abuse.”