Anyone who was around here last summer could be forgiven for believing that there's a surge of HIV infections in Seattle. Thanks to a press release from Public Health/Seattle & King County in June 2003, a flurry of media stories announced: "Alarming HIV rise. . . . Infection rates are up sharply" (as a Seattle Post-Intelligencer headline put it). The health department said its data showed 40 percent more gay men had tested positive in 2002 than the previous year, and officials projected another 60 percent increase in 2003, suggesting a possible "new wave" of infections. The county's top AIDS official, Dr. Bob Wood, called the situation "frightening," "astounding," and "the most dramatic increase since the beginning of the epidemic." The Gay City Health Project, a local nonprofit, convened public forums to discuss the crisis, and King County Executive Ron Sims endorsed a "community manifesto" calling for more responsibility among gay men to combat what a press release called "skyrocketing rates of STDs and HIV."
A year later, the alarm is looking a bit premature. Wood concedes that "what we had predicted didn't turn out to be" and that the rate of new HIV infections appears "fairly level," at around 2 percent to 2.5 percent of the city's gay male population annually—a rate that has been static since 1997. "A year ago, we thought we were detecting an increasing rate of HIV infection," says Wood. "That turned out not to be the case."
Not that Wood is taking any comfort from the data. "The fact is [the rate of infections] is not going down," he says, "and 20 years into the epidemic, we all hoped it would be." Gay men are showing inordinately high (and climbing) rates of syphilis and gonorrhea—diseases that reflect a prevalence of unprotected sex and whose effects on the body make HIV easier to transmit. And Wood says that surveys of gay men indicate risky behaviors "have gone up considerably since the new AIDS treatments came along. . . . Things are all headed in the wrong direction," he says gloomily. "It gives me heartburn." With respect to HIV, however, Wood now says, "We don't have solid evidence that there's a second wave occurring."
The health department's alarming figures last year were based on gay men who visited the county's sexually transmitted disease clinic and tested newly positive for the Human Immunodeficiency Virus that causes Acquired Immune Deficiency Syndrome. In 2001, there were 67 such men; in 2002, there were 94—hence, the frightening 40 percent increase. But 700 more men were tested in 2002 than the previous year, so it's not surprising that there were more total "positives." Taking into account that increase in testing produces a somewhat more modest jump of 29 percent.
Drawing sweeping conclusions based on data from the public health clinic, which is at Harborview Medical Center, is suspect in any case, Wood concedes. "This is not a representative sample of the whole population. These are people who come in because they have symptoms or are worried; a lot of them are coming back because they engage in risky behaviors." As a result, he notes, the public health data "are kind of hard for us to draw strong conclusions from."
Given that Washington, like many states, has mandatory HIV reporting, why is it so hard to get a firm handle on the numbers? In part, it's because the law allows for anonymous testing. HIV and AIDS cases only become "reportable" by laboratories and doctors once a patient has sought some sort of care—which, Wood notes, can be a year or longer after a person has been diagnosed. And then, doctors might take their time filing a report. So while the county has data on the overall number of reported AIDS and HIV cases, these so-called "surveillance" figures are "not quite as sensitive to the front end of the epidemic," Wood says. Even the public health data suffer from a time lag, because months or even years might elapse between the time a person is infected and when they show up for testing.
At this point, the real mystery might be why, with risky sex and STDs apparently on the rise, there appears to be no commensurate jump in HIV infections. A possible explanation is that some of the more risky behavior is occurring among, and between, men who are already HIV-positive. "It's what we call 'sero-sorting'—positives having sex with positives, negatives with negatives," says Wood. At the county clinic, for example, nearly 70 percent of those who are diagnosed with syphilis also have HIV. "It could be that a lot of [positives] are having unprotected sex with other HIV-infected people," says Wood.