Gay men's HIV prevention in the US and Europe is 'faltering'

Gay men’s HIV prevention in the United States is faltering and renewed efforts to stop the transmission of the infection requires leadership from gay community and public health officials, as well as the acceptance of the need for behaviour change at a personal level, according to a commentary in the November 28^th edition of the Journal of the American Medical Association.

The authors express concerns about increasing numbers of new HIV diagnoses in the US and many European countries, and high rates of risky sexual behaviour amongst gay men. They note that, even in the era of effective anti-HIV therapy, 6,000 gay men died because of HIV in the US (although many of these deaths will have been in patients diagnosed late or with long-term HIV who started treatment with anti-HIV drugs before effective anti-HIV therapy became available, developed drug resistance and ran out of treatment options, or in patients who died of causes other than HIV. Deaths due to HIV-related opportunistic infections have fallen substantially and stayed at low levels since the late 1990s). They also note “living with HIV/AIDS is challenging.”

Why is HIV transmission continuing amongst gay men?

The public health experts believe that gay men are having more unprotected sex because “in 2007, AIDS is simply not as frightening as it was before highly active antiretroviral therapy became available.” The authors acknowledge that it is unclear if the existence of effective anti-HIV treatment actually contributes to high-risk behaviours in gay men, indeed a meta-analysis of 25 studies, half of which included gay men, found no association between the use of anti-HIV therapy and increased rates of unprotected sex.

But studies have shown that unprotected sex is significantly more common amongst individuals who believe that potent anti-HIV therapy can reduce the risk of HIV transmission. Researchers have found little evidence of sexual transmission in serodiscordant (heterosexual) couples when viral load is suppressed to low levels. Nevertheless, viral load in semen and blood can differ, the amount of virus in semen can increase suddenly if a sexually transmitted infection is present, and HIV can infect cells, making transmission possible even if viral load is suppressed to the very lowest levels.

The authors also point to evidence showing that lack of awareness about HIV infection status is contributing to ongoing risk behaviours. They quote one venue-based US study that showed that 10% of gay men were HIV-infected. Of these men, 77% were unaware of their infection status. Furthermore, some men who perceive themselves to be HIV-negative may be engaging in ‘serosorting’ behaviours (seeking unprotected sex with other men they believe to be HIV-negative) and unwittingly transmitting HIV to others.

Drug and alcohol use has been shown to be an independent risk factor for HIV infection in several US studies. They write, “this risk presumably involves sexual disinhibition and impaired judgment in individuals under the influence of these substances.” Indeed, a recent UK study found that HIV-negative men who inhaled poppers, which are legally available and widely used, during unprotected sex, had an increased risk of seroconversion. Several US studies have implicated methamphetamine in risky sexual behaviour, with one finding that HIV-negative men who use the drug have a greater risk of seroconversion.

Ways to cut infections

Increased HIV testing could, they believe, help reduce transmission rates, particularly as studies have shown that individuals’ reported sexual risk behaviour is reduced after an HIV diagnosis.

Substance abuse services could help address problematic drug and alcohol use by gay men and mental health services “will be needed for men who have sex with men whose behaviours may be influenced by mental illnesses, including depression.”

Although circumcision has been shown to reduce female to male transmission of HIV, the authors write that the role of circumcision for HIV prevention in gay men is unknown (however, a well-conducted study amongst gay men in Sydney presented to this year’s International AIDS Society Conference found that circumcised and uncircumcised gay men were equally likely to have HIV).

But other biological interventions could be explored, such as pre-exposure prophylaxis, herpes suppression as well as experimental HIV vaccines and rectal microbicides.

Leadership, from both the gay community and public health officials, that supports risk reduction and an increased emphasis on personal action is also needed, write the authors. It is necessary for “these issues, although potentially sensitive and stigamtising, [to] be discussed openly and free from ‘political correctness.’”

Internalised homophobia is driving risk behaviour and there needs to be leadership to challenge the way that gay men are stigmatised and to campaign for legal domestic partnerships which, the authors believe, will promote “stable, longer-term men who have sex with men relationships.”

Individuals also have the power to reduce the likelihood that they will transmit HIV or become infected with HIV. The ‘HIV Stops With Me’ campaign in the US is quoted by the authors as “good example of an approach to personal responsibility”. Although the campaign was seen as stigmatising by many people with HIV, they note that “this is not the intent; instead, it acknowledges the importance and need for personal action.” But it is arguable that the ‘HIV Stops With Me’ initiative, which targeted those who already knew their status and who were in HIV care, reached HIV-positive individuals who were least likely, due to biological and behavioural factors, to transmit the infection to others.

The aims of HIV campaigns need to be realistic. It would, they assert, be counter productive to exaggerate the dangers of HIV. Furthermore, although it might be ‘tempting’ to criminalise unsafe sexual behaviour, such a step would be unacceptable in a free society – with “the exception of penalties for intentional exposure [editor’s italics] to HIV.”

The authors conclude, “although emphasising the individual and community responsibility may seem overtly moralistic, establishment of community norms of safe behaviour can play a role in addressing the men who have sex with men HIV/AIDS epidemic…the tragedy of the epidemic for an earlier generation of men who have sex with men must not be repeated.”