Professor David Pantalone

Guest speaker history:

Professor David Pantalone is the director of the Clinical Psychology program at UMass – Boston. He does a lot of community outreach work with the Fenway Clinic. Professor Pantalone’s research is in HIV infection. He works as a clinical psychologist and a public health specialist to assess the psychological and behavioral factors surrounding the transmission of HIV. His goal is to bring attention to the syndemics affecting gay and bisexual men and men who have sex with men (MSM). He is usually the only clinical psychologist and public health specialist involved in the research he does, giving him a unique perspective.

Important definitions:

-Prevalence is the number of cases overall.

-Incidence is the number of new cases.

-Uncontrolled study is one in which there is no control group. No way to know if the patients would have got better through maturation.

-Controlled study is one in which a control group measures maturation.

-Syndemics is the study of diseases and their interactions with each other and the social, environmental, and economic factors which exacerbate them.

Reading Summaries:

Reframing HIV Prevention for Gay Men in the US

-HIV was known as GRID (gay-related immunodeficiency disease)

-Gay men are mostly affected by the disease, it is a predominantly gay disease

-HIV prevention framework theoretical perspectives

-Syndemics Perspective: used to explain the very low health profiles and the multiple health epidemics of urban poor populations

-The interconnections between substance use, poverty, violence, racism, and HIV are determinants of lower health profiles (Singer 1994)

- In another study, Stall et al (2003), childhood sexual abuse, substance abuse, depression, and partner violence, among gay men were seen to be factors of risky sexual behaviors both independently and combined.

-Syndemic is referred to as a set of mutually reinforcing health epidemics that compromise the overall well being of a person.

-Gay men are prone to use more illicit drugs than heterosexuals. There is a correlation between illicit drug use and unprotected sexual behaviors in gay men.

-Syndemics shows that the focus on sexual health is insufficient in dealing with HIV because it ignores the other issues mentioned above.

-The syndemics approach suggests a mixed-method methodology and measurement model for capturing data; for practitioners, intervention plans should involve unbiased discussions on the role of drugs and mental health burdens in relation to sex.

- Developmental Perspective:

-Life milestones vs the differing needs of individuals at different stages of their lives.

-Identification of vulnerabilities and risks among young black and latino men 13-29; white gay men in their 30s, and aging gay men 50 years and older (CDC, 2008, 2009a, 2009b).

- One size fits all approach is insubstantial.

-Developmental perspectives indicates that prevention programs should emphasize the importance of developmental factors as well as the interactive facet of sexual and cultural identity.

-Older gay men are at much risk as younger gay men, but older men are more likely to be affected by HIV.

- This strategy suggests the incorporation of developmental milestones as well as historical era of the development era; For practitioners, it is significant to understand that the same developmental stages of life that affect all humans are in gay men and it may be more difficult for gay men due to societal conformities.

-Overall, the perspective suggests that therapeutic approaches acknowledge and seek to lessen the burdens -homophobia, racism, discrimination- that gay men experience in relation to their current age.

- Contextual Perspective:

-Contextual understanding of human behaviors and the effects of the environment on HIV risk behaviors in gay men.

-Context affects sexual risk taking as well as drug use and mental health burden.

-Contexts that primarily influence risky sexual behaviors in gay men:

-Social venues: Social involvement in establishments such as commercial sex environments, public spaces, and circuit parties are associated with higher levels of substance abuse which in turn relates to increased unprotected sexual behaviors.

-In the wake of the HIV epidemics, efforts to curtail the disease led to the closings of bathhouses in some urban areas.

-The role of commercial sex venues in the spread of HIV is still undetermined.

-The Internet: The internet is like a “cyber-bathhouse”.

-Studies estimate that about 50% of gay men meet sexual partners online.

-Gay men who have contacted both renal gonorrhea and syphilis are likely to meet sexual partners online.

-The influence of the internet on spreading HIV is also undetermined.

-The internet can be an effective intervention method for HIV prevention messaging and counseling.

-HIV prevention approach for Gay men must be “holistic, evolving, and celebratory.”

-Plans that include syndemic, developmental, and contextual perspectives will be the most effective because it shows the linkage between HIV, mental health burden, and substance abuse.

Promoting the Sexual Health of MSM in the Context of Comorbid Mental Health Problems:

-MSM are the largest at-risk group in the US.

○28,700 new cases per year; 53% of all new infections.

-HIV interventions for MSM can be more effective by also addressing psychosocial problems.

○MSM have higher rates of mental health problems than heterosexuals. Mental health problems co-occur with each other at high rates. Mental health problems can impact efficacy of prevention programs.

-Sexual minorities are at increased risk for depressive, anxiety, and substance use disorders.

○HIV-positive men are at even higher risks.

○Due in part to stigma, prejudice, internalized homophobia, concealing one’s identity, and expectations to pass as heterosexual.

-Pathways linking stress to mental health problems have been proposed.

○Coping and emotional regulation (strategies to maintain an emotional response).

○Social and interpersonal problems (isolating oneself from others).

○Maladaptive cognitive constructs (negative thoughts about oneself).

-Syndemics

○Psychosocial problems become an additive risk in regard to risky sexual behavior.

○Treatment of mental health problems along with HIV prevention programs greatly support reductions in risky behavior.

○Treatments should be integrated and individual-based for maximum efficacy.

Combination HIV Prevention: Significance, Challenges, and Opportunities:

-Effective HIV prevention requires multiple prevention strategies.

○Knowledge of HIV serostatus, behavioral risk reduction, condoms, male circumcision, needle exchange, treatment of curable STIs, and antiretroviral medications.

-Implementation should be well-thought out.

○Interventions designed to match epidemiologic profile of population, delivered at population level evaluated for safety, acceptability, coverage, and effectiveness.

-Preventions with proven, but partial efficacy need to be delivered together as a single package.

Discussion Summary:

-Stigmatization

  • HIV was strongly in the public’s consciousness in the dark days of the 1980s. There were no tests and no treatments available. Diagnosis was a death sentence.
  • The stigma of the death sentence persists, even with the synthesis of reliable treatments.

-1990s

  • Medicines and HIV tests became widely available.
  • It was found that treating the disease with one drug did nothing, but three drugs could keep a person perfectly healthy and positive-undetectable.
  • Changed the disease from a death sentence to a chronic illness which could be managed, something unique in public health.
  • Transmission prevention is behavioral. Use barriers during sex, don’t share needles.

-PrEP (Truvada)

  • Pre-Exposure Prophylaxis – medication to prevent HIV infection.
  • Must be taken daily, though missing a dose or two doesn’t do much harm.
  • Current research being done into the lowest dosage and frequency which will still be effective.
  • Transmission prevention is bio-behavioral.
  • Slow to gain widespread use because health care providers either don’t know much about it or don’t feel comfortable talking about it with patients.
  • Prohibitively expensive without insurance.

-HIV research

  • Much of the HIV work comes from the public health community, which prefers to use terms like MSM instead of gay or bi, which are identities.
  • FDA approved truvada for MSM in 2012
  • It can also be effective for intravenous drug users.

-The facts of HIV

  • Early in the epidemic, CDC used “four Hs” to identify the highest risk demographics

▪Homosexuals, Hemophiliacs, Haitians, and Heroin addicts

▪One of the most embarrassing moments in public health history

▪Disease is spread through behaviors which have nothing to do with being Haitian or gay, etc.

▪The misstep was essential in understanding that behavior and identity are not synonymous.

  • Infection unfolds in a cascade of processes.

▪Virus particle infects white blood cell (CD4) intended to fight the infection.

▪That CD4 cell becomes a factory making copies of the virus.

▪Spread through bodily fluids

●Blood, seminal fluid, vaginal fluid, and breast milk.

●Either by sex without barrier protection or needle sharing.

▪Normal range of CD4 cells is 1,200 to 2,000 per mL of blood. Natural history of the disease done before advent of treatment found the virus particles and the CD4 cells pushed back on each other, but the virus won over time. Viral load could be as high as 1 million per mL of blood. However, viral load in blood not perfectly aligned with viral load in genital tract.

▪Other STIs make it easy to transmit HIV because the body sends white blood cells to fight the infections right where HIV particles are entering the body during sex.

  • HIV and AIDS

▪HIV is the infecting virus.

▪AIDS is the cluster of symptoms which sometimes develops due to the body’s inability to other diseases. An obliterated immune system.

▪HIV is always correct; AIDS is only sometimes correct.

  • Number of cases

▪Prevalence worldwide is about 42 million cases.

▪Prevalence of HIV in U.S. is about 1.1 million cases.

▪Prevalence in Massachusetts is about 30,000 cases, mostly near Boston.

▪Incidence has been steady for the last several years at 40,000 new infections per year. Researchers are frustrated because the knowledge grows and the treatments/preventions get better, but incidence rates don’t decrease. Could be because of treatment optimism, condom fatigue, or discomfort around talking about it with partners, among other reasons.

  • Antiretroviral Therapy

▪Can decrease the viral load so much that a person can be positive-undetectable and will not transmit the virus to partners. Stated very recently by the CDC.

-Mental health and HIV

  • Only two behavioral targets to change, needle sharing and sex, but they can be very difficult to get people to change them.
  • Mental health can be a facilitator for HIV infection.

▪Mental health issues can make it difficult to find the motivation to get treatment.

  • Much more work to be done to get mental health and physical health aligned.
  • The assumption of the rational actor has prevailed for a long time, but we know that people aren’t acting rationally when it comes to sex and needle sharing.
  • Social factors prevent ability to take in preventions and make behavior changes. Those factors should be planned for by public health community.
  • In study which treated depression in HIV-positive adults to promote medication adherence, all treatments worked well.

-Meth and HIV

  • Meth users reported that everything was better while high. Older men felt desirable. When not high, everything seemed dreadful. Anhedonia sets in.
  • Led to risky sexual behavior.
  • Treatment of risky behavior and drug abuse worked really well.
  • Further study found that the population who continued to use meth was different. Everyone who could stop using it had. The remaining individuals were a different demographic and the interventions had to be changed to suit them.

-Problems with identifying cases

  • Self-reporting issues

▪Demand characteristics and social desirability lead people to give the answer they feel is morally “right” as opposed to the truth.

▪People are much more likely to give the truth to a computer than an interviewer.

  • Newly-infected may not know they’re infected and will behave as though they aren’t.
  • Non-monogamous relationships add another partner or set of partners to the mix.

▪Can’t be assumed that those in relationships are safer.

  • Unstable use of meds could lead people to risky behavior thinking they are protected or undetectable when they aren’t.