A table at the corner of Bourbon and St. Ann streets is a yearly fixture during the hubbub of Southern Decadence weekend in the French Quarter. Stocked with condoms, lubricant and information about HIV testing, the table is staffed by volunteers from CrescentCare, a community health center operated by NO/AIDS Task Force (NATF). Amid the crowds of revelers, the volunteers offer a reminder about safer sex during a party weekend where it seems almost anything goes.
Decadence attracts 160,000 people to New Orleans each year and generates $190 million in economic activity, according to organizers. With Decadence returning Labor Day weekend, what are organizers, public officials, and local health care providers doing to promote awareness and prevention of HIV and other sexually transmitted infections? And, more important, does it work?
"Our state is pretty ravaged with HIV and AIDS," says Nicholas van Sickels, assistant professor of clinical medicine at Tulane University and director of the Tulane CD4 Clinic in Alexandria. "What you need to do, in my opinion, is saturate the markets with information. ... In 2015, for a festival to bring that many people in, you need to start before they even arrive. I don't think a table is sufficient. You have to use other methods."
The 2013 STD/HIV Surveillance Report, released by the Louisiana Department of Health and Hospitals, paints a bleak picture. The state's HIV and AIDS case rates are the third highest in the country, while rates of HIV and AIDS cases in New Orleans and Baton Rouge are among the five highest of the nation's major metropolitan areas. Those most at risk of infection include men who have sex with men (MSMs), people of color and youth between the ages of 13 and 24.
The latter group, born after the initial AIDS epidemic of the 1980s, is at particular risk. A study published in the July 2014 Journal of the American Medical Association (JAMA), using data compiled by the Centers for Disease Control and Prevention (CDC) between 2002 and 2011, found that while the overall annual diagnosis rate declined by one-third during that time, diagnoses among MSMs between the ages of 13 and 24 more than doubled. For young people, it appears, HIV awareness, prevention and treatment initiatives have fallen short.
Southern Decadence intensifies those challenges. The festival attracts gay and bisexual men of all ages, and they remain at "greater risk of being exposed with each sexual encounter," Amy Lansky, the study's lead author, told Bloomberg BusinessWeek.
In addition, combining the use of alcohol and other drugs with the "high-risk activities that typically occur in a dense arena, where you have exposure to an increased sexual network, substantially increases likelihood of HIV transmission," says MarkAlain Dery, director of the Tulane University T-Cell Clinic and a professor of clinical medicine specializing in HIV.
"During Decadence, people drink more and start to relax more, and people do things they wouldn't normally do," says Rip Naquin, one of five Southern Decadence grand marshals this year. "We hope not, but I'm sure that does happen."
Naquin says event organizers have "wholly outsourced" awareness and prevention efforts to CrescentCare/NATF. The grand marshals instead "direct all of [their] energies toward" the annual walking parade through the French Quarter, the centerpiece of Decadence since the event's founding in 1972. That includes raising funds to cover the $10,000 outlay for parade insurance, police detail, cleanup and costumes. Monies left over are given to charity.
"The overall goal is to reduce stigma when talking about HIV and healthy sex lives," Joey Olsen, HIV testing manager at CrescentCare/NATF, says of the organization's Decadence outreach. "Part of that is normalizing those conversations by having them in a more relaxed environment rather than a clinical setting. ... Larger events are a little bit more difficult, because your focus is on quantity at that point, while quality comes more into play during actual testing. ... People are just going to grab the condoms, maybe make a joke, and move on."
It's difficult to measure the effectiveness of these strategies. Olsen reports that NATF, which tests more than 6,000 people for HIV annually, sees a "huge influx" of people coming in for testing following Southern Decadence and estimates the organization handed out more than 50,000 condom packets in 2014. But, he says, there is no event-specific equivalent to long-term epidemiological studies at the city, state, and national level, which illustrate trends in HIV infection rates.
"The science doesn't exist," Dery says, describing the practical limitations of such a study. "You would need to test people coming in, and then you would need to go around and take that random sample and test them after Decadence. Then you could determine a kind of rate of transmission."
"Is it the best bang for the buck?" asks Dorian-Gray Alexander, policy fellow at the CHANGE Coalition and chair of the Louisiana AIDS Advocacy Network (LAAN). "It's hard to know, but it's better than not doing anything at all."
Experts agree on several best practices when it comes to HIV prevention, including nonpenetrative sex, the use of condoms and, for HIV-negative individuals, pre-exposure prophylaxis (PrEP), which has been shown to reduce the risk of infection by 92 percent when taken consistently. Knowing your HIV status also is "immensely important," Dery says, because the majority of viral transmissions occur among the one in five people who do not know their HIV status. Finally, studies have shown that effective treatment for HIV-positive individuals, leading to undetectable levels of the HIV virus in the blood, nearly eliminates the chances of transmission.
Despite the medical consensus, however, both Alexander and Brandi Bowen, program director of the New Orleans Regional AIDS Planning Council, say the stigma associated with HIV/AIDS, Louisiana's lack of comprehensive sex education, and several other factors create significant barriers to overcome in public outreach efforts.
"At this point, I would say that we've not yet brought nearly enough resources to bear," Bowen says. "Until we change the larger mentality, it would not matter how many tables and how many volunteers we have."
In the context of the HIV/AIDS crisis in New Orleans and across Louisiana, the imbalance between the scale and economic impact of Decadence and the resources devoted to sexual health care is striking. In 2014, through the New Orleans Department of Health's Ryan White HIV/AIDS Program, the city administered nearly $9 million in federal grants to community-based organizations spread across eight parishes. In the same year, Decadence created $190 million in economic activity, with the tax revenues going to the city of New Orleans.
"With the help of the Ryan White Program, we are serving more individuals and have finally exceeded pre-Katrina levels," Brad Howard, press secretary to Mayor Mitch Landrieu, wrote in a statement. "As a result, the New Orleans area has seen a decrease in unmet need for care and a reduced number of AIDS-related deaths. ... The promoters of events such as Essence [Festival], the Bayou Classic and Southern Decadence actually assist in prevention efforts by increasing awareness and promoting safe sex."
"With the economic boost that the city gets at this time of year, I think the first item on the wish list would be to have a task force or committee to consider how we can tap the resources that come into the city to tackle issues related to HIV/AIDS," Alexander says. "The problem is, how do you begin those conversations?"
Of course, Decadence is just one of many large festivals that might allow for important discussions of safe sex, HIV/AIDS and other sexually transmitted infections. But the fact remains that an event by and for the LGBT community —which historically has suffered disproportionate effects from HIV/AIDS and has led three decades of activism and advocacy on the issue — relies solely on CrescentCare/NATF, funded in part by the Ryan White HIV/AIDS Program, to promote safer sex each Labor Day weekend.
"'Ask about PrEP.' 'Get tested.' 'Know your status.' It's the same message, you just need to pump it out differently," says van Sickels, citing marketing through social media, including hookup apps like Grindr, as a specific area for improvement. "I wish there was more publicity. Advertise the crap out of 'Ask your doctor' or "Come here to get tested.' Just blast it. ... It gets people talking more than, 'Blah, blah, blah, wear a condom."
In a state where 23 percent of those infected with HIV don't know it — compared with 13 percent nationwide — even ample resources and infrastructure must be accompanied by changes in practice that make rapid HIV testing as routine and readily available as blood pressure screenings, Olsen says. Still, he says, Decadence and other large events remain important sites for community outreach.
"We have a good-sized volunteer base right now, and our volunteers are responsible for much of what we can accomplish, but having more funds for extra tables and informational materials is always welcome," Olsen says. "Always, more is better."
Sexual Health Activities
8:30 a.m.-3:30 p.m., Friday
New Orleans Marriott at the Convention Center, 859 Convention Center Blvd.
CrescentCare/NATF kicks off Southern Decadence weekend by sponsoring Greater New Orleans' only conference focused specifically on people living with HIV. This year's event, the theme of which is "Embracing Your Journey: A Guide to Making Treatment Decisions About HIV/AIDS," will feature panels and roundtable discussions with experts of medical research, clinical care, and PrEP (pre-exposure prophylaxis), as well as keynote speaker Greg'ry Revenj, one of HIV Plus magazine's "20 Amazing HIV+ Gay Men." For more information and to register, visit www.noaidstaskforce.org/empowerment-conference
NO/AIDS Task Force
5 p.m.-9 p.m., Friday
3 p.m.-9 p.m., Saturday & Sunday
Corner of Bourbon and St. Ann streets
Visit the NO/AIDS table or seeone of the organization's roving volunteers for free condoms, lubricant and information throughout Decadence weekend.
In addition, NO/AIDS offers free, rapid, finger-stick HIV testing at a variety of locations throughout the greater New Orleans area, including its offices and several local bars and venues. Walk-in tests are done one-on-one with a state-certified counselor, and the entire process takes less than an hour.
Regular testing is canceled during Southern Decadence to make staff available for outreach, and will resume the Tuesday after the festival. For more information, visit www.noaidstaskforce.org/testing.