CDC Investigates STOP AIDS Project
Safer Sex and Prevention Programs Under Fire
August 21, 2002—In the latest example of the increasing politicization of HIV/AIDS prevention efforts, the Centers for Disease Control and Prevention (CDC) is investigating San Francisco's STOP AIDS Project—for the second time in two years—to try to determine whether the group is using federal funds appropriately in its prevention outreach to gay and bisexual men.
The inquiry, initiated by newly appointed CDC Director Julie Gerberding, focuses on allegations that the group uses federal money to support HIV/AIDS awareness programs—such as its "Booty Call" and "Great Sex" workshops—that encourage sexual activity and violate federal obscenity standards. In November 2001, the Department of Health and Human Services (HHS) conducted a similar investigation of STOP AIDS Project's programs and determined that its federal funding could not be revoked because it did not violate San Francisco's community obscenity standards.
AIDS organizations nationwide are following the current investigation closely. Indeed, all HIV/AIDS programs that receive funds from the CDC could find themselves subject to review. In response to the allegations against the STOP AIDS Project last year, Congress called for further inquiry, adding a provision to the fiscal year 2002 appropriations bill for HHS that allows the agency's inspector general to conduct an audit of any federally funded HIV/AIDS prevention program.
STOP AIDS Project as Bellwether?
Advocates of AIDS prevention programs and many public health experts fear that the current investigation of the STOP AIDS Project presages increased scrutiny of other similar programs. Following the first investigation in October 2001, HHS Inspector General Janet Rehnquist (daughter of conservative Supreme Court Chief Justice William Rehnquist) determined that the group's "Booty Call" and "Great Sex" workshops could be construed as being obscene and promoting sexual activity. Rehnquist acknowledged, however, that community standards must ultimately determine the definition of obscenity.
Indeed, the inquiry into whether STOP AIDS uses federal funds inappropriately underscores the lack of a clear-cut legal definition of obscenity. According to CDC guidelines, HIV prevention programs supported by federal funds cannot encourage sex or intravenous drug use and must adhere to the local community's obscenity standards. There is no national benchmark for determining obscenity.
"It'd be nice if we could do AIDS 101 in a pristine setting and talk epidemiology, but to reach the folks who are getting infected, we have to talk about sex and what they're doing."
—Steven Tierney, head of HIV prevention at the San Francisco Department of Public Health
A November 2001 STOP AIDS Project press release defended the group's activities: "We are not promoting sex. We are speaking to a community of sexually active adults about reducing the risk of HIV." Further, workshops such as those being scrutinized by the CDC provide "a safe space for gay and bisexual men to talk about sex in order to reduce the risk of HIV transmission." Following the HHS investigation, the STOP AIDS Project revamped some accounting procedures to ensure that federal funds were not used for objectionable workshops. However, these changes did not prevent the CDC's investigation of the agency.
The current investigation of STOP AIDS was prompted by a July 30, 2002, letter to Gerberding from Rep. Mark Souder (R-IN), which posed a direct question: "Under your leadership, will CDC continue its financial support to the STOP AIDS Project or other organizations that have violated federal laws or misused federal funds?" In response to Souder's allegation, STOP AIDS Project spokeswoman Shana Krochmal said the organization "has always been found to be in full compliance with all of the local and federal guidelines that govern our funding."
Gerberding ordered a site visit to STOP AIDS, which relies on federal funding for many of its programs. (According to the San Francisco Chronicle, the organization receives $686,000 in federal funding, representing 38 percent of its $1.8 million budget. Of this money, $461,000 comes from the San Francisco's health department and the remainder from a CDC grant.)
Some argue that scrutiny of the STOP AIDS Project, which focuses its prevention efforts on gay and bisexual men, is unjustified given the urgency of slowing the spread of HIV among this high-risk population. A recent CDC study revealed that a large majority of young gay men with HIV, particularly young African American men, are unaware they are infected.
Further, CDC researchers found that the rate of new HIV infections among men who have sex with men (MSM) is nine times higher than among women and heterosexual men. (For more on this study, see the sidebar.) "It really is kind of mind-boggling," said Mike Shriver, San Francisco Mayor Willie Brown's adviser on AIDS and HIV policy and an amfAR Board member. "We here in San Francisco are looking at an explosion of new infections as we continue to try to get the community to take control of its health and turn the tide back again, and at the same time what do we get? Incredible oversight from the feds."
In response to the current investigation, Krochmal has defended the explicitness of the group's messages, saying they need to be provocative in order to reach the target populations. "We realize that a message that would catch the attention of a gay man walking through the Castro may also raise the eyebrows of a lawmaker in Washington," she said. "We don't expect the standards we design are going to work in Iowa. It was developed by our community for our community."
Creating Effective Messages
AIDS activists and prevention groups argue that the best prevention work occurs in an environment where gay and bisexual men feel at ease talking about sex—and that this necessitates the use of explicit language. "Communicating AIDS prevention messages is tricky," wrote Dave Ford in an August 16, 2002, editorial in the San Francisco Chronicle. "You're trying to reach a tough demographic ... young men who have sex with men. They think about sex. A lot. So you have to talk about sex."
"We know that talking in real terms about the real factors that cause HIV is what's appropriate, meaningful, and respectful for the gay community in San Francisco, and it works."
—Darlene Weide, Executive Director, STOP AIDS Project
The STOP AIDS Project says it is most effective to combine prevention messages with positive images of sex, and there is evidence that this approach works. The group claims that its surveys have found that their workshop participants do in fact practice safer sex. And an August 15, 2002, opinion piece in the San Francisco Chronicle noted that the provocative and attention-getting workshop titles employed by STOP AIDS Project are critical to reaching at-risk, sexually active populations.
STOP AIDS Executive Director Darlene Weide explains: "Few other programs in the U.S. are able to build their programs with so much direct input from the communities they serve. This input includes recommendations for the language and content of interventions that are most likely to reach the populations involved." In addition, "[the] STOP AIDS Project conducts surveys with thousands of gay and bisexual men each year regarding their sex behaviors and their knowledge of how to protect themselves."
While the scope of the government's investigation into HIV prevention programs remains to be seen, it is clear that small, community-based organizations such as the STOP AIDS Project could be particularly affected by such inquiries. First, smaller agencies tend to rely most heavily on federal funding, and they also often create the most provocative campaigns, using messages targeted to specific communities and individuals at high risk of HIV infection. "This level of scrutiny could cripple these agencies, especially [those] serving minorities," said Tom Coates, director of the University of California, San Francisco, Center for AIDS Prevention Studies.
With the U.S. government now spending an estimated $400 million annually on AIDS prevention, many community-based groups depend just as heavily on federal funds as the STOP AIDS Project does. Many express concern that the current CDC audit could threaten campaigns that utilize sexually explicit messages to promote safer sex. Those who defend AIDS prevention organizations say that now is a crucial time for the creation and implementation of effective prevention messages.
"Targeted HIV prevention that can reach those most at risk for infection is vital, particularly as AIDS medications successfully keep people healthy and the overall number of people living with HIV grows," said Rep. Nancy Pelosi (D-CA), the House Democratic whip from San Francisco. "Local organizations, such as STOP AIDS Project, which are a part of the community they are trying to reach, are best positioned to combine programmatic expertise with extensive knowledge of the target populations they serve."