PositiveLite.com editor's note: we have published this article even though it contains an inaccuracy - see our note below.

From aidsmap.com

About 10% of gay men taking antiretroviral treatment have low levels of HIV detectable in their semen, according to new research. 

In the study, a low but detectable viral load (between 50 and 500 copies/ml) was associated with the presence of HIV in semen.

There is currently a lot of discussion about the effect of HIV treatment on infectiousness and the use of HIV treatment as prevention. Research conducted in heterosexual couples has shown that antiretroviral therapy that reduces viral load in the blood to undetectable levels (below 50 copies/ml) reduces the risk of sexual transmission by 96%. (PositiveLite.com editor's note: the research to which this refers - HPTN 052  - measured the impact of early treatment, not undetectable viiral load, two entirely different concepts..  We have questioned aidsmap.com about the accuracy of their statement.  UPDATE May 20: we have since heard from aidsmap who have admitted their statement is incorrect; they will be issuing a clarification.)

But there have been rare case reports of HIV transmissions in the presence of an undetectable viral load.

Untreated bacterial sexually transmitted infections (STIs) such as chlamydia and gonorrhoea may cause viral load to increase in genital fluids, even if a person is taking effective antiretroviral treatment.

Doctors in the United States wanted to see if infection with human herpes viruses also had an impact on viral load in genital fluids.

They monitored blood and semen samples taken from 114 gay men. All were taking HIV treatment and had a blood viral load below 500 copies/ml (88% had a viral load below 50 copies/ml).

HIV was detected in the semen of 10% of the men. The average viral load in semen was low – 126 copies/ml. Whether or not this level of HIV in semen is associated with transmission is unknown.

Detection of HIV in semen was associated with the presence of two viruses of the herpes family – high semen levels of CMV (cytomegalovirus) and detectable EBV (Epstein Barr virus) in semen.

“The association between isolated HIV shedding and high-level CMV replication and EBV replication in the genital tract suggests that the presence of these viruses could play a role in HIV transmission…these findings have important implications for the development of strategies to reduce HIV transmission,” comment the researchers.

They also found that 36% of study participants with a detectable viral load were shedding HIV in semen compared to 6% of participants with an undetectable viral load.

A urethral bacterial STI was diagnosed in 4% of men, but these untreated infections were not associated with the presence of HIV in semen.

For more detailed information on HIV transmission, visit our online resource HIV transmission and testing.

This article originally appeared in aidsmap news, May 2013. Read the full article here.

This article by Gus Cairns first appeared on aidsmap.com here.  

Data from two national sex surveys in the United States show that gay and bisexual men (men who have sex with men, MSM) reported significantly fewer sexual partners in the previous year in a survey conducted between 2006 and 2010 than they did in one conducted in 2002. This decline was consistent across most ethnicities and age groups, but was particularly marked, and statistically significant, in younger men aged under 24.

In contrast, the proportion who reported having condomless anal sex at least once in the previous year did not change between surveys. In the minority of men who also had sex with women, condom use fell markedly, but on the other hand the proportion of MSM who also had sex with women fell too.  

The proportion of men who tested for HIV or for sexually transmitted infections (STIs) in the last year did not change, although the proportion who had never tested for HIV fell.

The survey

The data come from the last two National Surveys of Family Growth (NSFGs). The NSFG is a survey of 15 to 44-year-olds; participants are contacted at random by phone but due to lower contact/response rates, people under 24, black people and Hispanic people are ‘oversampled’, i.e. a higher proportion are initially contacted than are in the general population.

NSFGs used to be conducted every three to seven years, but in 2006 a decision was taken to conduct interviews (by voice-assisted automated computer interview) continuously. This study therefore compared figures from interviews conducted in 2002 with ones conducted in 2006 to 2010.

NSFG interviewed 4928 and 10403 men in 2002 and 2006 to 2010, respectively. Of these, 197 and 272 reported having a male sexual partner in the last year – 2.7 and 2.1% respectively (this difference was not statistically significant, p = 0.1).

The results

The mean number of male sexual partners MSM reported in the previous year fell significantly from 2.9 to 2.3 between the two surveys (p = 0.035) and was more marked in men under 24 years old (mean 2.9 to 2.1 partners, p = 0.027). The number of partners also fell in men aged 35 to 44 from 3.0 to 2.2, though this was not quite statistically significant (p = 0.07).

The fall in the number of partners was statistically significant in men with incomes under 150% of the US federal poverty level (3.0 to 2.1) and in men living in suburban metropolitan areas (3.2 to 2.1) but not in city-centre areas (2.6 in both surveys). There were declines in partner numbers in white (3.0 to 2.5) and black (2.4 to 1.9) men, though these did not reach statistical significance. In general though, there was a consistent picture of fewer partners among most groups.

There were no changes in condom use for anal sex. In 2002, 57% of men had not used a condom the last time they had sex and in 2006 to 2010 the proportion was 58%. In the minority of men who also had sex with women, the proportion who had not used a condom the last time they had vaginal sex was 46% in 2002 but had become 67% by 2006 tp 2010, and this difference was statistically significant (p = 0.04). However, the proportion of MSM who had had female partners also decreased from 38 to 25% (p = 0.03).

One other notable difference was that fewer men reported transactional sex (sex for money or drugs) in the last year (down from 15 to 3%) and fewer men said they had injected drugs or had had sex with someone who had injected drugs (from 12 to 5%).

HIV and STI testing in the last year did not increase. In 2002 and 2006 to 2010, 41% of men said they had had an HIV test in the last year and in the case of STI check-ups 38% reported having one in 2002 and 39% in 2006 to 2010. The proportion of men who had never had an HIV test, however, fell from 25 to 15%.

Conclusions and comments

The researchers comment on the fact that HIV prevalence and the incidence of STIs increased in gay men during a period when numbers of partners and some other sexual risk behaviours were falling. They note that there have been previous studies in Seattle and Peru where STI incidence and/or HIV diagnoses have remained high even though sexual risk indicators in gay men have fallen. Studies of young black gay men in the US, including one recently presented at the 20th Conference on Retroviruses and Opportunistic Infections (CROI), have consistently shown that they tend to have fewer partners despite considerably higher HIV incidence.

The researchers speculate that this may be due to ‘network factors’: factors about partners that are not captured by the individual risk behaviour focus of most studies. For instance, some studies have found that black gay men tend to restrict sex to partners of their own ethnicity and are also more likely to have sex with men a number of years older or younger than themselves. Both of these would tend to concentrate HIV infection within the black gay community.  

Whether these are the main drivers of US black men’s greater vulnerability to HIV infection, another interesting aspect of this study is that gay men appear to have taken steps that could reduce their HIV risk by using a method that has received little emphasis in HIV prevention programmes for gay men – reducing their number of partners – while not increasing condom use, which has received the most emphasis.

Leichliter JS et al. Temporal trends in sexual behaviour among men who have sex with men in the United States, 2002 to 2006-10. J Acquir Immun Defic Syndr, early online publication, DOI: 10.1097/QAI.0b013e31828e0cfc, 2013. 

This article by Michael Carter first appeared on aidsmap.com here.  

Aidsmap.com reports taking HIV pre-exposure prophylaxis (PrEP) does not lead to increased levels of sexual risk behaviour among gay men, investigators from the United States say.

Taking HIV pre-exposure prophylaxis (PrEP) does not lead to increased levels of sexual risk behaviour among gay men, investigators from the United States report in the online edition of the Journal of Acquired Immune Deficiency Syndromes. Numbers of sexual partners fell, as did the proportion of men reporting unprotected anal sex.

“We found no evidence of risk compensation among at-risk MSM [men who have sex with men] initiating PrEP,” comment the authors. “Mean numbers of partners and the proportion of men reporting UAS [unprotected anal sex] decreased significantly from baseline during 24 months of follow-up.”

PrEP is an emerging HIV prevention technology. It involves HIV-negative individuals taking daily antiretroviral therapy to reduce their risk of infection with the virus. In 2010, results of the iPrEx trial involving gay and other MSM showed that daily PrEP with Truvada (FTC and tenofovir) reduced the risk of infection with HIV by 44% overall, with high efficacy seen in people with the best treatment adherence. Although the results of PrEP studies involving heterosexuals have been mixed, the United States Food and Drug Administration approved Truvada for use as PrEP by adults with a high risk of HIV infection.

However, there is concern in some quarters that use of PrEP may lead to increases in sexual risk behaviour. Mathematical models suggest that even modest increases in the proportion of gay men reporting unprotected sex could wipe out the beneficial effect of PrEP at a community level. However, the precise impact of PrEP on sexual risk taking is highly controversial.

Data gathered during a PrEP safety study allowed investigators to explore the impact of PrEP on the sexual risk behaviour of HIV-negative gay men with a high risk of infection with HIV.

A total of 400 men were recruited to the study between 2005 and 2007. All reported anal sex with another man in the preceding twelve months. The study was double blind and placebo controlled. Participants were randomised either to start treatment immediately or to wait for nine months. The men were interviewed at baseline and then every three months about their sexual risk behaviour and use of recreational and erectile dysfunction drugs. The study lasted 24 months.

At baseline, the men reported a mean of 7.25 sexual partners in the previous three months. This fell significantly during follow-up to a mean of 6 partners between months 3 and 9 and a mean of 5.71 partners between months 12 and 24 (p < 0.001). These declines were similar in the immediate- and delayed-treatment arms.

The mean number of reported HIV-positive partners or partners of an unknown status fell from 4.17 at baseline to 3.51 partners between months 3 and 9 and 3.37 partners between months 12 and 24 (p = 0.01). There was also a significant fall in the number of reported partners believed to be HIV negative.

Use of poppers (p < 0.001), erectile dysfunction drugs  (p < 0.001) and a higher perception of the efficacy of PrEP (p = 0.04) were all associated with reporting higher numbers of sexual partners during follow-up.

At the start of the study, 57% of men reported unprotected anal sex in the previous three months. The proportion fell to 48% between months 3 and 9  (p = 0.001) and to 52% between months 12 and 24 (p = 0.03).

The proportion of men reporting unprotected sex between months 3 and 9 was similar between the immediate- and delayed-treatment arms.

There was also a fall in the proportion of men reporting unprotected sex with an HIV-positive partner, from 29% at baseline to 21% between months 3 and 9 and 22% between months 12 and 24 (p < 0.001). Declines in unprotected sex with HIV-positive partners were seen in both the immediate- and delayed-treatment arms.

Factors associated with reporting unprotected sex during follow-up included younger age (p = 0.01), use of poppers (p = 0.02), erectile dysfunction treatments (p < 0.001) and methamphetamine (p < 0.001).

Participation in the study did not lead to an increase in the number of reported episodes of unprotected anal sex, which remained steady between months 3 and 9 and months 12 and 24 in both the immediate- and delayed-treatment arms.

There was a fall in reported episodes of unprotected sex with HIV-positive partners from two in the previous three-month period at baseline to 1.37 between months 12 and 24 (p = 0.05). This was the case for both the immediate- and delayed-treatment study arms.

In contrast, the number of episodes of unprotected anal sex with partners thought to be HIV negative increased between baseline and months 12 and 24 (2.75 Vs. 4; p = 0.01).

“These changes may represent a possible increase in seroadaptive practices, in which men preferentially have more episodes of UAS with assumed HIV-negative partners,” comment the authors.

They also note “men in this study received risk-reduction counseling, condoms and lubricants, regular HIV/STI testing, and linkage to prevention services…which may explain the observed risk reduction and could explain the observed risk declines and could mitigate any potential for risk compensation.”

Despite this, the investigators were encouraged by their results, which they believe “provide important information on changes in risk practices among MSM in the US initiating PrEP in a clinical trial setting”.

Reference

Liu AY et al. Sexual risk behavior among HIV-uninfected men who have sex with men (MSM) participating in a tenofovir pre-exposure prophylaxis randomized trial in the United States. J Acquir Immune Defic Syndr, online edition, DOI: 10.1097/QAI.0b013e31828fo97a, 2013.

This article by Gus Cairns first appeared on aidsmap.com here. 

Increasing HIV testing frequency, and giving everyone antiretroviral therapy (ART), would not in themselves reduce HIV prevalence in US gay men, a mathematical model suggests.

These measures would produce, in the model’s baseline scenario, a 34% reduction in the cumulative number of new infections and a 19% reduction in cumulative deaths by the year 2023. This would lead to the annual number of new HIV infections in gay men almost declining to the annual number of deaths, but not quite.

The model therefore predicts that HIV prevalence would continue to grow in US gay men, albeit very slowly. This remains the situation under a number of different scenarios; even if every gay man took an HIV test every year, and everyone diagnosed with HIV started treatment within six months of infection, infections would still slightly outstrip mortality.

The model also finds that universal treatment would lead to a doubling in the prevalence of multidrug-resistant HIV, although this would not lead to an increase in deaths or progression to AIDS.

However this particular output from the model derives from data on the prevalence of primary HIV drug resistance that is more than seven years old and 'MDR' means any resistance to two of the three main classes of HIV drug that were well-established at this point, not resistance to all options currently available.

The model’s assumptions

The model was devised by researchers at the University of Southern California. It includes a number of parameters regarding the gay male population in Los Angeles, such as HIV incidence, the proportion of people in primary infection, the proportion diagnosed, the proportion diagnosed on treatment, and the proportion who progress to AIDS – although it does not directly input a figure for the proportion who have an undetectable viral load (virally suppressed).

It also inputs variable figures for the per-partner risk of HIV transmission in gay men, the frequency of HIV testing in gay men, the adherence rate in people taking ART, and the rate at which people acquire drug resistance.

These figures are all derived from observed trends in HIV infection in Los Angeles gay men between 2000 and 2010.

The researchers perfected their model by testing different combinations of inputs against the observed figures and repeatedly discarding ones that came out with results that didn’t match what actually happened over the previous decade, until they achieved the best fit.

The researchers than tested what would happen to the rates of new infections, the proportion of people with HIV who are not yet diagnosed, the proportion on ART, deaths, progression to AIDS and multidrug resistance, if they increased the frequency of testing and/or reduced the gap between infection and treatment in gay men.

Currently, in Los Angeles, gay men have HIV tests, on average, every 4.4 years. The researchers used the model to find out what would happen if this frequency was increased to every three years, every two years, and every year.

The average time between HIV infection and starting ART in gay men has been calculated as 2.5 years. The researchers modelled what would happen if this was reduced to one year or to six months.

Other figures fed into the model included the cumulative number of new HIV diagnoses, AIDS diagnoses and deaths that would occur by 2023 if nothing changed: 54,000 new infections, 49,000 AIDS diagnoses and 42,000 deaths. The current proportion of people with HIV who are undiagnosed was set at 20%.

The proportion who enter treatment with 'multidrug-resistant HIV' (MDR-HIV) was set at 3.1% which would have increased by 2023, even if nothing else changes, to 4.8%. This figure derives from data that was becoming out of date when it was published, and in addition, the model's definition of ''MDR-HIV' includes virus that today would be sensitive to a wide range of new drugs. See below for more on the model's assumptions about MDR-HIV.

The model’s predictions

At the time the model was first devised, the US Department of Health and Human Services (DHHS) HIV treatment guidelines still recommended that ART be started when a person’s CD4 count falls below 350 cells/mm3. So the first thing the modellers did was to model a scenario in which the only thing that changed was that all those diagnosed started ART according to this recommendation. This single change led to a 6% cumulative reduction in HIV infections and deaths and an 11% reduction in progression to AIDS over the next ten years. The proportion of people undiagnosed would fall to 18.5% and the proportion with multidrug resistance would increase to 6.1%.

If average testing frequency increased to one test a year, then the cumulative number of new infections by 2023 would fall to 35,800 (a 34% reduction), of new AIDS cases to 30,000 (a 39% reduction) and of deaths to 34,100 (a 19% reduction). This would reduce the number of people unaware of their infection very considerably, to only 4%. But the proportion of people with multidrug-resistant HIV would increase to 9.1%.

If, in addition, the gap between HIV infection and treatment initiation was reduced to one year, this would lead to a 42% reduction in cumulative new infections and a 28% reduction in deaths, and if reduced to only six months, to 47% fewer infections and 34% fewer deaths. But the proportion of people with multidrug-resistant HIV would increase to 11.9% and 13.7% respectively under these scenarios.

The modellers found that HIV testing and putting more people on treatment were not synergistic – in other words, that they worked independently to reduce HIV infections and deaths, but did not reinforce each other’s effects. Increasing test frequency from every 4.4 years to annually, for instance, resulted in an absolute 28% reduction in cumulative new infections regardless of the length of time between infection and starting treatment. Conversely, reducing the gap between infection and treatment from 2.5 years to six months resulted in a 13% reduction in new infections, regardless of testing frequency.

Cautions, caveats and conclusions

The modellers do make one other crucial assumption: they assumed that when gay men become aware of their HIV infection, they very considerably reduce their sexual risk behaviour. In the model the researchers reduced the likelihood of someone transmitting HIV by an average of two-thirds post-diagnosis, a figure based on US studies. These reductions have not necessarily been matched by figures from other parts of the world, and the researchers found that sexual risk behaviour was the assumption fed into the model that had the biggest influence on cumulative new infections.

The researchers do point out that their model lacks certain subtleties. Firstly, it doesn’t attempt to stratify HIV risk in different age groups, ethnic groups, or by risk behaviour – it assumes all sexually active gay men are approximately at the same risk of HIV. Secondly, it does not add in any allowance for the possible future use of pre-exposure prophylaxis (PrEP). And thirdly, they point out that "mathematical models are only as good as the available data used for the parameters and calibration".

It is also interesting that they use estimates of the average time between diagnosis and treatment as their parameter for the influence of treatment on prevention, rather than using the more direct figure of the estimated proportion of people with HIV with an undetectable viral load. They explain that this is because we do not have high-level evidence for the efficacy of viral load suppression as a prevention measure in anal sex. However, they do feed in an assumption that anyone starting treatment at a CD4 count over 350 cells/mm3 who mainains adherence becomes 96% less infectious.

The researchers suggest that, given that starting people on treatment earlier leads to a prediction of higher rates of multidrug-resistant HIV, and given that increased testing and more treatment do not seem to be synergistic, it might be better to concentrate on getting people to test more frequently rather than treating everyone diagnosed.

The finding that the number of patients with MDR-HIV will increase, however, is based on very old data. The figure of 3.1% the model uses for the proportion of people who start therapy with MDR-based HIV is derived by taking the median figure for primary MDR resistance from a single review (Van de Vijver) which was published in 2007, and includes no data collected after 2005. Even in this review it was noted that MDR resistance was lower in other parts of the world than the US. In addition, it was just after this point that studies started to find that drug resistance in people with HIV was starting to decline, and epidemiologists soon confirmed that it had in fact been doing so for several years (see Health Protection Agency). This trend has been sustained in more recent studies.

This brings the finding of the model that each 10% increase in average testing frequency, or each 10% decrease in average time between infection and starting ART, leads fairly consistently to a 0.45% absolute increase in the proportion of people starting therapy who have MDR-HIV, into some question.

In addition, however, they also use an outdated definition of multdrug resistance, namely resistance to two of thre three drug classes in use at the time of the 2007 review, nucleoside and non-nucleoside reverse transriptase inhibitors (NRTIs and NNRTIs) and protease inhibitors (PIs). Even this review noted that it was not taking into account resistance to the then-recently developed fusion inhibitor enfuvurtide (T-20, Fuzeon). Since then ARVs of two other classes (integrase inhibitors and CCR5 inhibitors) have been developed, as have a number of drugs of established classes that work against HIV with resistance mutations to those classes.

However, even with their own assumptions about resistance, the researchers found that the development of multidrug resistance actually had relatively little clinical effect and that even projecting the model into the far future, which would lead to a 23% rate of multidrug-resistant HIV, would not lead to more HIV cases or deaths than we have currently.

The model includes, buried within its parameters, a number of other interesting assumptions, which are not entirely explained. It assumes, for instance, that if people start therapy at a CD4 count over 350 cells/mm3 their adherence rate will be just under 90% but that if their CD4 count is under 350 cells/mm3 their adherence rate will be nearly 99%. It is not clear what data these inputs are based on.

However, even though some of its parameters are based on somewhat out of date findings, this model, by basing its assumptions carefully on what has actually been observed to happen in gay men, may avoid exaggerated predictions of the success of ‘test-and-treat’ for which some other models have been criticised.

Reference

Sood N et al. Treat and treat in Los Angeles: a mathematical model of the effects of test-and-treat for the MSM population in LA County. Clinical Infectious Diseases, early online publication, doi: 10.1093/cid/cit158. See abstract here and supplementary data here (requires payment). 2013.

Van de Vijver DAMC, Wensing, AMJ and Boucher CAB. 'The Epidemiology of transmission of drug resistant HIV', in Hahn B et al (editors), HIV Sequence Compendium 2006/7, pages 17-36. Thoretical Biology and Biophysics Group, Los Alamos National Laboratory. LA-UR 07-4826. 2007.

Health Protection Agency. HIV drug resistance in the United Kingdom: data to end of 2005. Health Protection Report 1(31): 2007.

The Canada-wide survey Male Call interviewed 1,235 men who have sex with other men  (MSM)  - and the results have now been published. It’s been described as “one of the most innovative, ambitious and comprehensive studies ever of this demographic.” It contains quite a few surprises.                      

Why the survey? “Men who have sex with men are the most  vulnerable to HIV, and yet – until now – a clear sense of the attitudes, opinions,and behaviours of many in this group have been missing',” says Dan Allman, Assistant Professor at the University of Toronto’s Dalla Lana School of Public Health. “With responses from both rural and urban areas, in all regions of the country, our survey provides new directions for health policies and programs that can serve this group, prevent further HIV infection and improve overall health and well‐being”.           

The Male Call Canada telephone survey captured mens’ attitudes, opinions and behaviours on topics such as sexual identity, homophobia, general and mental health, condom use, HIV testing and disclosure, the criminalization of HIV and transactional sex. By employing a method in which respondents chose when and where to anonymously call into a toll‐free telephone line, researchers were able to collect responses from men aged 16 to 89, and from an impressive 40 per cent of Canadian postal codes.

The campaign had a celebrity endorsement. PositiveLite.com interviewed gay soccer player David Testo who gave his name to promoting the campaign in January 2012 – you can read my interview here. Testo’s involvement apparently generated a huge upswing in the number of respondents.

The Male Call website contains a series of attractive fact sheets  (designed incidentally by poz Toronto artist Raymoind Helkio, who also designs for PositiveLite.com.) The fact sheets make for fascinating reading, or those with more time can go to the full report here.

In one of the more startling revelations, 49% of men surveyed agreed with the statement “I would not have sex with a man who is HIV-positive even if I am very attracted to him.”

Here are some other fascinating tidbits . . . 

On casual sex, 67% of MSM surveyed reported having had some in the last six months.  How much?  6% of men reported 20 or more partners in that same period, 18% had 6-19 partners, 37% had 2-5 partners, 22% had only one casual sex partner and 17% had none.  52% of partnered men reported having casual sex.

Attitudes to Condoms

Here’s what people agreed with . . 

• The benefits of using condoms outweigh the disadvantages 88.1%
• I would only have anal sex with an HIV positive man if we used condoms 69.4%
• It feels good to wear a condom because I feel safe 67.8%
• I feel guilty when I don’t use a condom 57.7%
• Condoms make sex less pleasurable 48.6%
• The intimate act of giving or receiving cum is lost when using a condom 48.4%
• When a person brings out a condom I feel physically aroused 32.1%
• Safer sex is less important now that HIV treatments are available 10.2%

74.8% of Male Call participants had been tested for HIV and 34.5% of participants had been tested in the previous six months. 6.6% reported having HIV, 26.2% reported they were unaware of their status.

Expectations

Male Call participants were asked “When is the best time for an HIV-positive man to disclose his HIV status to a new sexual partner?”

• before any penetrative sex (e.g. oral or anal) without a condom 56.2%
• when they first meet 25.9%
• before any non-penetrative sex (e.g. mutual masturbation) 11.9%
• before any penetrative sex (e.g. oral or anal) with a condom 0.9%.

Knowing a Partner's Status

These question relate to the importance of knowing a partner’s HIV status  before engaging in the following sexual acts

• 96.3% before unprotected anal sex.
• 84.4% before protected anal sex.
• 75.4%  before oral sex.
• 43.3% before mutual masturbation

Shared Responsibility

• 98.4% agreed that both sexual partners are equally responsible for preventing HIV transmission.
• 87.4% agreed with the statement “In order to know a partner’s status for certain, it is an individual’s responsibility to ask his partner his status.”
• 49.0% agreed with the statement “I would not have sex with a man who is HIV-positive even if I am very attracted to him."

Positive men

Turning now to the questions pertaining to HIV-positive men, 88% of HIV-positive participants rated their mental health as good to excellent. 87.3% rated their physical health as good to excellent.

68.3% of HIV-positive participants slept less than 8 hours per day. Only 31.7% reported 8 hours of sleep or more.

What do HIV-positive participants worry about? I worry about, they say...

• Being discriminated against and stigmatized because of HIV.82.5%
• Being rejected by gay and bisexual men in my community because I am HIV-positive 67.7%
• The fear of being prosecuted by someone for not disclosing that I am HIV-positive 51.6%
• Not understanding medical information about HIV 30.2%

On the issue of criminalization, the survey generated headlines like this one from the Sun and this one from the Globe and Mail because it appeared to find a large number of men who supported criminalization. In fact 83% of all men indicated non-disclosure before anal sex should be a crime, with 42% believing failure to disclose is criminal in the case of oral sex, while 17% opposed criminalization of non disclosure in any circumstances.

Here are some more disturbing numbers, straight from the report . . 

The Globe and Mail Story headlined with the worrisome title “HIV-AIDS non-disclosure should be a crime, study of gay and bisexual men finds.“  However the news is not all bad. PositiveLite.com asked Richard Elliott, Executive Director, the Canadian HIV/AIDS Legal Network, for a comment.  Here’s what he said:

“Unfortunately, some important details of the Male Call study about HIV and men who have sex with men got lost in summation and a simplistic headline (“HIV-AIDS non-disclosure should be a crime, study of gay and bisexual men finds”, Apr. 11).  The result, I fear, is to simply perpetuate some knee-jerk and widespread stigmatizing attitudes about people with HIV and unjust applications of the criminal law.

"The study data in fact showed the following: men were virtually unanimous in supporting early disclosure of HIV and a strong majority expected a casual sex partner to disclose if he has HIV, but they were also virtually unanimous in agreeing that there both partners have equal responsibility for HIV prevention. Less than one-third of study participants thought criminal prosecutions for not disclosing HIV status are effective public policy when it comes to preventing the spread of HIV. In fact, the study data suggest public health harms: 62% think that criminal prosecutions increase stigma and discrimination against people with HIV, close to half agree that such criminalization deters people from seeking HIV testing and indeed 18% agreed that, given the current legal context of possible prosecution, it’s better not to get tested for HIV.

"But perhaps most significantly, the headline seriously oversimplifies the issue in suggesting that the strong majority of gay men and other men having sex with men support criminal prosecution for HIV non-disclosure. In fact, only 42% held this view without qualification. An equal number felt criminalization is not justified in some circumstances. Of these men, 70% said there should be no prosecution in cases where a condom is used – a sensible position that, regrettably, the Supreme Court of Canada rejected in its most recent pronouncement a few months ago. Similarly, 58% think criminal charges for not disclosing are not warranted in cases of oral sex. These more nuanced views quite properly reflect the available science we have about the exceedingly low risks of HIV transmission in such circumstances."

April 15, 2013 - A new study indicates that young men who have sex with men (YMSM) around the world experience higher levels of homophobia, unstable housing, violence, and other factors that hinder access to HIV services, compared to older MSM. Conducted by the Global Forum on MSM & HIV (MSMGF), the analysis shows YMSM fare worse than older MSM in their attempts to access numerous HIV services, including HIV treatment. 

“Existing data indicates that rates of HIV are rapidly increasing among YMSM in low and high income countries alike,” said Dr. George Ayala, Executive Director of the MSMGF. “However, most research fails to disaggregate data focused on YMSM from broader samples of MSM and young people, making it impossible to understand the unique needs of this population. This is the first study to look at these issues among YMSM on a global scale, and the results are alarming.”

The analysis uses data from the 2012 Global Men’s Health and Rights study (2012 GMHR), a multilingual online survey of 5779 MSM from 165 countries, including 2491 YMSM (aged 30 and below). Data from YMSM participants was examined to assess levels of access to HIV services and factors that impact access to services for YMSM. Results are presented in a new policy brief entitled “Young Men Who Have Sex with Men: Health, Access, & HIV,” released today by the MSMGF.

The policy brief reveals that only 33% of YMSM surveyed reported that low-cost condoms were easily accessible, and even lower percentages of YMSM reported easy access to low-cost lubricants (18%), low-cost STI treatment (14%), HIV education materials for MSM (9%), and HIV risk reduction programs for MSM (7%). Of participants living with HIV, nearly half of YMSM with a CD4 count below 350 were not engaged in treatment (44%), compared with 17% of older MSM. Only 38% of YMSM living with HIV reported viral suppression, compared to 73% of older MSM.

Findings also indicate that 20% of YMSM surveyed had no income and 30% had no stable housing, which have both been linked to greater HIV vulnerability and reduced access to HIV services. Compared to older MSM in the 2012 GMHR sample, YMSM experienced significantly higher levels of homophobia and violence. Among all MSM surveyed, homophobia was significantly associated with reduced access to condoms, lubricants, HIV testing, and HIV treatment.

“While homophobia can be damaging to gay men of all ages, it can be particularly harmful to younger gay men,” said Daniel Townsend, MSMGF Steering Committee member. “Like many young people, they often have no income and depend on family for housing. If their family does not understand or accept their sexuality, they risk ending up on the street. Without stable housing or resources, many young gay men face extreme challenges in meeting their basic needs.”

YMSM not only reported greater barriers to HIV service access compared to older MSM, they also reported significantly lower levels of community engagement and comfort with service providers. These factors, along with family support and availability of safe spaces, were associated with increased access to HIV services among MSM of all ages in the 2012 GMHR.

“This data shines light on our collective failure to ensure that YMSM have the resources they need to keep themselves healthy,” said Dr. Ayala. “Moreover, it is a powerful reminder that HIV among MSM is an international development issue, inextricably linked with housing, health, education, and security. Donors and policy makers must treat HIV among MSM of all ages with the same level of urgency afforded to other international development priorities, and they must take concrete steps to ensure that the unique needs of YMSM are accounted for.”

Produced in collaboration with the MSMGF Youth Reference Group, composed of 18 YMSM advocates from 11 countries around the world, the policy brief concludes with a set of recommendations for addressing HIV and its social drivers among YMSM. Recommendations include addressing housing stability and economic dependence, providing comprehensive HIV prevention tailored to the needs of YMSM, improving treatment and care for YMSM living with HIV, taking action to reduce barriers and increase facilitators to HIV service access among YMSM, and supporting YMSM leadership and involvement in the HIV response.

The full policy brief can be found on the MSMGF’s website  here. http://tinyurl.com/br5qn6d.