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 editors 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.)

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 recent article by Sean Hosein first appeared on the CATIE website here.

Une version française est disponible ici.

It has been 32 years since AIDS was first recognized and 30 years since the cause—a virus we now call HIV—was first isolated. In that time enormous advances have been made: There are tests that can detect HIV and treatment (commonly called ART or HAART) has transformed HIV into a chronic illness. Furthermore, the power of ART is so profound that a young HIV-positive adult who begins treatment shortly after diagnosis today, who takes his/her medicines every day exactly as directed and who has no or limited co-existing health conditions is expected to live for several decades.

Although ART has helped to transform HIV into a chronic illness—particularly in high-income countries such as Canada, Australia and the U.S. and regions such as Western Europe—there are still issues. This treatment must be taken at least once a day, every day, for the rest of a person’s life. Such high levels of adherence may be difficult to sustain for many years. Furthermore, medicines to treat HIV, particularly the newest and most tolerable drugs, are relatively expensive. As the vast majority of HIV-positive people live in low- and middle-income countries, some researchers have wondered whether it is possible to provide care and treatment for all HIV-positive people in those places. At present, not every HIV-positive person in those countries can access care and treatment. Thus, a cure would be very desirable for many reasons.

Know your co-receptors

HIV needs at least two receptors to enter and infect a cell. The first receptor is CD4+, which is found on many immune system cells. HIV usually then needs one of two other co-receptors, either CCR5 or CXCR4.

Some strains of HIV prefer to use CCR5, others CXCR4, and still others use both co-receptors.

Back to the cure

Since the late 1980s, researchers have attempted to cure HIV infection. However, in the first two decades of the AIDS epidemic, such efforts were largely dangerous and unsuccessful.

Then, in 2008, a major development occurred. Doctors in Berlin appeared to have cured an HIV-positive man, who was suffering from leukemia, of both cancer and HIV. The “Berlin patient” had been taking ART for several years prior to his cancer treatment and received chemotherapy, radiation and transplants of stem cells. What was unique in this case was that the donor of the stem cells had a rare mutation (called a delta-32 mutation by researchers) that resulted in his cells having no CCR5 co-receptors. This made the cells somewhat resistant to HIV infection. After intensive chemotherapy and radiation, ART was withheld and the stem cells were transplanted and took hold in his bone marrow, helping to create his new immune system. However, the man’s new immune system attacked parts of his body, a complication called GvHD (graft vs. host disease), and doctors had to prescribe a mix of powerful immune-suppressing drugs to manage this complication. His cancer returned and he had to undergo intensive chemotherapy again as well as another stem cell transplant.

The Berlin patient survived all of these interventions and recurrent cancer. He has not needed to resume ART and sophisticated tests have revealed that either he has no HIV or he has extremely low levels of this virus deep within his body from time to time.

Why the cure?

Researchers are divided about why the Berlin patient was apparently cured. Research teams have proposed different possible reasons for his apparent cure, as follows:

• the intensive bouts of chemotherapy and radiation
• the bone marrow transplant from a donor with a delta-32 mutation
• the intensive stimulation of his immune system arising from GvHD
• the use of transplant medicines, which dampen inflammation and reduce HIV’s ability to infect cells

It is likely that more than one of these factors played a role in his recovery from HIV.

Excitement

The apparent cure of the Berlin patient has excited the imaginations of many researchers and doctors around the world. Clinical trials are underway, mostly in the U.S and Western Europe, assessing different methods for attempting to cure HIV infection. Eventually some of these trials will occur in Canada.

Caution needed

Some of the attempts at a cure, such as genetic therapy, have been relatively safe. However, in attempting to replicate the success of the Berlin patient, other HIV-positive people have died. This is not surprising, as intense chemotherapy and radiation with or without transplant drugs are very debilitating.

Researchers at Harvard University have attempted a variation of the protocol used with the Berlin patient. Although two HIV-positive patients with cancer have volunteered for this experiment and have survived for several years, they remain weak, both physically and immunologically. A major difference between these patients and the Berlin patient is that they have not stopped taking ART. Due to their poor state of health, their doctors have been reluctant to withhold ART, so it is not yet clear if they have been cured.

These experiments with stem cell transplants and chemotherapy and subsequent transplant drugs are dangerous and will not be done on a large scale because among HIV-negative cancer patients such procedures carry a death rate of about 15%. No one is certain about the death rate for HIV-positive people, but it is likely to be at least as high.

Much caution with intense monitoring and hospitalizations will be needed for attempts at a cure. This will particularly be the case as researchers use multiple methods on the same person to attempt a cure.

Still, researchers should be praised for showing imagination and embracing cure research. Such encouragement is necessary because many of the complex ways that HIV interacts with the immune system are not fully understood. Therefore, much research on monkeys infected with SIV (simian immunodeficiency virus), mice transplanted with human immune systems, and HIV-positive people will be needed to gain such an understanding.

The journey toward a cure will not be easy and many challenges lie ahead. Some of the challenges are known, others may only become known as experiments proceed. As with any great scientific endeavour, there will be setbacks. This means that research funding agencies and the public need to be patient. The initial wave of cure research experiments over the next five years should be viewed as exploratory and their results preliminary. This research will seek to answer important scientific questions that can then be used to build a foundation as researchers work toward a cure.

To assist researchers in developing new ideas for cure research, Canada’s premier scientific agency, the Canadian Institutes for Health Research (CIHR), will be seeking proposals from research teams across the country. These proposals will be reviewed by scientists and the most promising proposal(s) funded for five years.

Resources

Hints of a cure—the future of stem cell transplants and HIV – CATIE News

Gene therapy for HIV—outcomes from a recent experiment – CATIE News

Attempts at a cure – TreatmentUpdate

—Sean R. Hosein

REFERENCES:

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 2. Katlama C, Deeks SG, Autran B, et al. Barriers to a cure for HIV: new ways to target and eradicate HIV-1 reservoirs. Lancet. 2013; in press.

 3. Samson M, Libert F, Doranz BJ, et al. Resistance to HIV-1 infection in Caucasian individuals bearing mutant alleles of the CCR-5 chemokine receptor gene. Nature. 1996 Aug 22;382(6593):722-5.

 4. Moore JP, Kitchen SG, Pugach P, et al. The CCR5 and CXCR4 co-receptors—central to understanding the transmission and pathogenesis of human immunodeficiency virus type 1 infection. AIDS Research and Human Retroviruses. 2004 Jan;20(1):111-26.

 5. Huzicka I. Could bone marrow transplantation cure AIDS? Medical Hypotheses. 1999 Mar;52(3):247-57.

 6. Hütter G, Nowak D, Mossner M, et al. Long-term control of HIV by CCR5 Delta32/Delta32 stem-cell transplantation. New England Journal of Medicine. 2009 Feb 12;360(7):692-8.

 7. Allers K, Hütter G, Hofmann J, et al. Evidence for the cure of HIV infection by CCR5 Δ32/Δ32 stem cell transplantation. Blood. 2011 Mar 10;117(10):2791-9.

 8. Gorry PR, Zhang C, Wu S, et al. Persistence of dual-tropic HIV-1 in an individual homozygous for the CCR5 Delta 32 allele. Lancet. 2002 May 25;359(9320):1832-4.

 9. Soussain C, Ricard D, Fike JR, et al. CNS complications of radiotherapy and chemotherapy. Lancet. 2009 Nov 7;374(9701):1639-51.

 10. Krishnan A and Forman SJ. Hematopoietic stem cell transplantation for AIDS-related malignancies. Current Opinion in Oncology. 2010 Sep;22(5):456-60.

 11. Deeks SG and McCune JM. Can HIV be cured with stem cell therapy? Nature Biotechnology. 2010 Aug;28(8):807-10.

 12. DiGiusto DL, Krishnan A, Li L, et al. RNA-based gene therapy for HIV with lentiviral vector-modified CD34(+) cells in patients undergoing transplantation for AIDS-related lymphoma. Science Translational Medicine. 2010 Jun 16;2(36):36ra43.

 13. Hütter G and Thiel E. Allogeneic transplantation of CCR5-deficient progenitor cells in a patient with HIV infection: an update after 3 years and the search for patient no. 2. AIDS; 2011 Jan 14;25(2):273-4.

 14. Sauce D, Larsen M, Fastenackels S, et al. HIV disease progression despite suppression of viral replication is associated with exhaustion of lymphopoiesis. Blood. 2011 May 12;117(19):5142-51.

 15. Hunt PW, Landay AL, Sinclair E, et al. A low T regulatory cell response may contribute to both viral control and generalized immune activation in HIV controllers. PLoS One. 2011 Jan 31;6(1):e15924.

 16. Deeks SG. HIV infection, inflammation, immunosenescence, and aging. Annual Review of Medicine. 2011 Feb 18;62:141-55.

 17. Hatano H, Delwart EL, Norris PJ, et al. Evidence of persistent low-level viremia in long-term HAART-suppressed, HIV-infected individuals. AIDS. 2010 Oct 23;24(16):2535-9.

 18. Sigal A, Kim JT, Balazs AB, et al. Cell-to-cell spread of HIV permits ongoing replication despite antiretroviral therapy. Nature. 2011 Aug 17;477(7362):95-8.

 19. Mitsuyasu R, Lalezari J, Deeks S, et al. Adoptive transfer of zinc finger nuclease CCR5 modified autologous CD4 T-cells (SB-728-T) to aviremic HIV-infected subjects with suboptimal CD4 counts (200 to 500 cells/mm3). In: Program and abstracts of the 51st Interscience Conference on Antimicrobial Agents and Chemotherapy, 17-20 September 2011, Chicago, Ill. Abstract HI-375.

 20. Henrich TJ, Sciaranghella G, Li JZ, et al. Long-term reduction in peripheral blood HIV-1 reservoirs following reduced-intensity conditioning allogeneic stem cell transplantation in two HIV-positive individuals. In: Program and abstracts of the XIX International AIDS Conference, 22-27 July 2012, Washington, DC. Abstract THAA0101.

 21. Deeks S, Drosten C, Picker L, et al. Roadblocks to translational challenges on viral pathogenesis. Nature Medicine. 2013 Jan;19(1):30-4.

 22. Towards an HIV cure: a global scientific strategy. International AIDS Society Scientific Working Group on HIV Cure. Nature Reviews Immunology. 2012 Jul 20;12(8):607-14

 23. Deeks SG, Barré-Sinoussi F. Public health: Towards a cure for HIV. Nature. 2012 Jul 18;487(7407):293-4.

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 25. Bangsberg DR, Haberer JE. Lifetime HIV antiretroviral therapy adherence intervention: Timing is Everything: comment on "Managed problem solving for antiretroviral therapy adherence". JAMA Internal Medicine. 2013 Feb 25;173(4):306-7.

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

About 40% of men who answered a community survey for HIV-positive gay men in the Netherlands said they took their viral load into consideration in deciding whether or not to use condoms. This represents about two-thirds of those who actually did have unprotected sex.

This published paper adds new data to this study’s original conference presentation at the AIDS Impact conference in 2011.

The survey found that consideration of viral load was almost as common when having sex with partners who also had HIV as when having sex with partners of negative or unknown status. Disclosure and discussion of viral load was far more common with HIV-positive partners, whereas viral load was rarely discussed with partners assumed to be HIV negative, remaining purely part of a unilateral decision.

The study also found that this group of HIV-positive men, who, as part of a community consultation panel providing advice to the Netherlands HIV Association (NHA), might be assumed to be well informed on HIV prevention matters, were as a group by no means convinced that undetectable viral load protected them from transmitting HIV to partners. Not surprisingly, the more confident individuals were that this was the case, the more likely they were to take it into account as part of a decision to have condomless sex.

The study

The NHA’s Open Online Panel consists of 517 women and men living with HIV who are contacted on a regular basis by email to ask their opinion on important topics in HIV. In this case just the 212 gay men on the panel were asked to complete an online survey about unprotected sex and consideration of viral load.  

This paper only looked at the answers from the 177 men (85%) who said they had an undetectable viral load. Of these, all but two were on antiretroviral therapy.

Results: unprotected sex

One hundred and twenty (68%) of the 177 had ever had unprotected anal sex since their HIV diagnosis and of these 73 (61%, or 41% of the whole group) did it without a condom the last time they had anal sex. 

The researchers asked respondents if their last sex had been with a casual or a regular partner and of the 73 who’d had unprotected sex last time,  43 (59%) said it was with a casual partner and 30 (41%) with a regular one.

The 73 were also asked the HIV status of the most recent partner and 38 (52%) said they were HIV negative or status unknown and 35 (48%) that they were HIV positive. Unprotected sex partners were more likely to be ‘buddies’ if they were HIV positive (15 casual, 20 buddies) and more likely to be casual meets if they were HIV negative or status unknown (28 casual, 10 buddies); this is what one would expect, as HIV status is usually not discussed until people have reached  a level of trust.

Results: considering viral load

Of the 120 who had ever had unprotected sex since diagnosis, 75 (63%) said that their viral load was something they had taken into account when deciding to use condoms.

Interestingly, more said they had taken viral load into consideration with HIV positive partners (44% of the 120) than with men who were HIV negative or of unknown status (38% – some men considered it with both positive and negative partners).

Participants were asked to estimate the perceived protective value of having an undetectable viral load on a scale of one (“absolutely no risk”) to seven (“absolute risk”).  The average score was three (low-to-moderate risk) when considering sex with HIV-negative partners and two (no-to-low risk) when considering sex with HIV-positive partners (where the perceived risk was presumably superinfection). Not surprisingly, men who thought the risk was lower were more likely to have unprotected sex and to consider viral load as one of the reasons involved in doing so.

When having unprotected sex with HIV-positive partners, men said they were more likely to consider viral load with buddies (over half the partners) than with casual partners (only one in five). Conversely, when having unprotected sex with HIV-negative partners, nearly 60% said they considered their viral load with a casual partner but only 40% with a buddy.

With positive partners, all but one of the 14 men who said they had considered viral load had explicitly discussed it with their partner before sex. Conversely, only three of the 20 men who had considered viral load when having unprotected sex with an HIV negative partner had discussed the subject.

Conclusions

It looks as if there are two different phenomena going on. With HIV-negative partners, men who considered their viral load are doing so in the main as part of a unilateral process of considering how liable they are to transmit HIV. In the case of HIV-positive partners, the researchers comment that “further qualitative studies are needed to shed light on the perceived added value of considering viral load”, but speculate that it may take place within the context of broader discussions about HIV superinfection and STIs.

This is a small study of quite a specific group: HIV-positive gay men who were already engaged and informed enough to join a community consultation group. They could therefore be ‘early adopters’ of viral load as a factor to take into account when considering sexual risk.

As the researchers comment, “future investigations should include the perspectives of HIV-negative MSM in the communication around undetectable viral load and unprotected anal intercourse”, and a wider consultation with less-engaged HIV-positive men would be interesting too. 

They also comment that further investigations are needed to establish the risk of transmitting HIV via anal sex with an undetectable plasma viral load.

They comment: “HIV prevention campaigners need such evidence to take an informed stance in the debate around viral load considerations and urgently so, in light of their already frequent use by MSM.”

Reference

Van den Boom W et al. Undetectable viral load and the decision to engage in unprotected anal intercourse among HIV-positive MSM. AIDS and Behavior, e-publication ahead of print: DOI 10.1007/s10461-013-0453-9, 2013.

My first concrete experience with HIV research took place in 2007. I had applied, interviewed and been selected to participate in a 2-month research and volunteer internship in the country of Namibia. The internship program that I joined had been established several years prior and had a reputation for being an incredible learning experience for those selected to participate. Undergraduate students from various faculties within the University of Toronto were selected to travel to Namibia to conduct research and volunteer within a local AIDS service organization (ASO). 

With very little applied training or education (in research methods, on HIV in a Namibian context, on community-based approaches to research), I flew overseas and landed first in Windhoek before driving eight hours north to a rural town called Ongwediva.

For the volunteer portion of my internship, I worked within an organization that provided microfinance loans and HIV education to women who were supporting orphans and/or other vulnerable children (OVC). OVC are defined as a child 18 years of age or under who has lost one or both of their parents or primary caregivers and  is in need of protection. In Namibia, more than 28% of those 18 years of age and under are classified as OVC with a shockingly high percentage of children orphaned because of HIV and AIDS. 

The first time I travelled to Namibia in 2007 (1), the national HIV prevalence rate was hovering around 15%, which is a high despite the fact that the population of the country was just under 2 million at the time. Although the country’s population isn’t large, dealing with thousands of people living with HIV in the context of a weak infrastructure is challenging. While the HIV prevalence in Namibia has shifted slightly since 2007 (the latest report shows a national prevalence rate of 13.1%), Namibia still ranks amongst the top ten worst countries globally in relation to adult HIV prevalence. I believe that the history of a consistently high HIV prevalence rate was the reason the internship program was established in Namibia. 

Outside of some readings completed prior to departure, we were not required to complete any courses or training to prepare us for the research projects we were about to undertake. On top of this, students traveling abroad were expected to create a research project that we would embark upon once we arrived in Namibia without consultation from our Namibian “partners”.

At the time, I remember feeling frustrated with these expectations; how could I be expected to develop a research project not only without the necessary training in methodologies but also without ever having been to Namibia or communicated with any of the potential organizations or ASOs that I might end up working with? 

Though I did not realize this at this time, I was operating within a colonial research structure which placed me, the undertrained, naïve, and eager (yet ignorant) undergrad, in a position of authority over the research including who would be involved and what and who would be studied. This structure positioned me as the research “expert” regardless of my inexperience both in research and in Namibia. Yet my overall academic immaturity and ignorance was irrelevant and became secondary to the incredible experience I was about to undertake. 

Critical considerations about how to ethically engage in an international research expedition were not a focal point and emphasis was placed on ensuring that the experiences of the University of Torontop (Western) students were monumental. Though I was aware that entire bodies of critical literature existed on research methodologies and approaches, HIV engagement and international work yet community-based research and ideas around the greater involvement of people living with HIV and AIDS (the GIPA Principle) failed to make an appearance in the internship program or research structure we were being churned through. 

(The Greater Involvement of People Living with HIV & AIDS (GIPA) Principle was introduced and formalized at the 1994 Paris AIDS Summit when more than 40 countries committed to “support a greater involvement of people living with HIV at all ... levels ... and to ... stimulate the creation of supportive, legal and social environments”. )

The GIPA Principle aims to ensure people living with HIV and AIDS are the backbone and key contributors to program development, policy-making and implementation and that this involvement is meaningful rather than tokenistic. This principle seeks to highlight the rights and responsibilities of those living with HIV and AIDS including the right to self-determination and the ability to play an active role in decision-making processes that impact their lives. Despite the widespread acceptance and global approval of the GIPA Principle, there is still much work to be done in order to more fully immerse this approach into various sectors including international student research on HIV and AIDS. 

While the benefits of applying the GIPA Principle are evident, there are often many challenges which stand in the way of successful implementation/involvement of people living with HIV including HIV-related stigma, inexperience with research, distrust of researchers, and that involvement in research may not be prioritized compared to other components in life (social, health, family, etc.) (2) Within the context of academic, social research, community-based (participatory) research (CBR) has emerged and solidified itself as a methodological process for conducting research in a way that positions itself in opposition to many of the more historically conventional approaches. CBR not only emphasizes the involvement and collaboration of community members at all stages of research (from project design and development to data collection and analysis to knowledge dissemination and translation) but rather understands meaningful community involvement as imperative and integral to the research process; in essence, meaningful community involvement is non-negotiable. 

Theoretically and depending on the goals and objectives of a research project, CBR represents an almost utopian approach to research which moves away from some of the more historically troubling aspects associated with some research practices. In practice however, CBR is far from perfect and – like the GIPA Principle – faces barriers in practice. The insider-outsider dilemma is often sited as a consistently challenging issue for CBR as is the general distrust that communities often/may have towards researchers. (3) 

My own university experiences with international research on HIV prevention serve as a case study to demonstrate not only the invisibility of the GIPA Principle and CBR in practice but the near complete absence of them. Many Western universities not only offer but promote student involvement in exchange or abroad programs which provide these students with infinite opportunities to expand their minds, experience different socio-cultural perspectives, increase their chances of accessing additional opportunities and importantly, aggrandize their CVs. This was my experience in both my undergraduate and graduate degrees at two academic institutions in Canada; this was also the experience of many of my university peers. 

While I felt I had learned many valuable lessons on my first excursion to Namibia during my undergraduate degree, in hindsight, it is evident that many more lessons remained unexamined. While I made the effort to think more critically about my social and global location in the work I was participating in, this critical thinking did not permeate my thought process in a way that drastically impacted my actions as I still actively chose to pursue a graduate degree which included traveling back to Namibia to conduct research. 

While I take full responsibility for my actions and choices within both my undergraduate and graduate degrees, I think it is also important to recognize that I was operating within a system which very much facilitated my goals of engaging in international work yet simultaneously did not provide adequate training in order to do this work critically, ethically or meaningfully.

As one would expect, my initial experience of travelling overseas to conduct “research” in Namibia created a slew of subsequent opportunities. Even though several years have passed since both my excursions to Namibia, I am still reaping the benefits of them via conference presentations and publications. Conversely, I doubt very much that the organizations and participants I worked with are fairing as well.

(1) I travelled to Namibia a second time in 2009-2010 to conduct my MA field research. This time, I travelled to Walvis Bay, an area in Namibia that experiences high levels of mobility via two transnational highways and the country’s only deep-water port where international boats can dock. In addition to high levels of mobility, Walvis Bay also experiences rates of HIV around 10-15% higher than the national prevalence rate (25-30%); it was for this reason that I chose to conduct my research in this town.

(2)Travers, R., Wilson, M.G., Flicker, S., Guta, A., Bereket, T., McKay, C., van der Meulen, A., Cleverly, S., Dickie, M., Globerman, J., & Rourke, S.B. (2008). The greater involvement of people living with AIDS principle: Theory versus practice in Ontario’s HIV/AIDS community-based research sector. AIDS Care. 20: 615-624. 

(3)Fockler, L.A. (2010). Community researchers’ experiences with community-based research. (Unpublished master’s thesis). McMaster University: Hamilton.