California! I just got back from California for the second time – and it was awesome; I didn’t want to come back. My friends and I went to Palm Springs, Laguna Beach and Los Angeles. 

In Palm Springs, when we got there, the temperature was 39 degrees Celsius. It was hot, hot hot! We had rented a house since there were five of us. The house was beautiful, with a great pool, which we spent much time in. We made tasty drinks, and had tasty snacks. I got a great tan. 

My one friend who lives in L.A didn’t know I had HIV. I decided to use the opportunity to tell her. But first she was talking about how flaming my outfit was - pink shirt and lime green capri pants, and then for the pool I was wearing super short swim shorts. She said she didn’t remember me dressing like this. I told her I am so much more comfortable with myself now. She asked “what changed?” and I told her about the group therapy program I did last year and then I told her I have HIV. 

I was scared she might react badly, as she can be abrupt and abrasive sometimes. But instead she said, “I’m sorry and I love you” and hugged me.  And then we all had a big group hug and that was that. It was awesome; a huge weight was lifted off my shoulders and we continued like nothing happened. I have amazing friends! 

We tried to go shopping in Palm Springs but it was way too hot. We walked around for twenty minutes and decided to retreat back to the house. Nothing like a nice cold beer to cool you off. We spent four great days in Palm Springs. It was amazing just to relax and not have to worry about anything nor feel obligated to do anything. 

We then headed off to Laguna. I love Laguna; it is such a cute beach town, right on the ocean, with lots of cute, unique shops.  But one shop I didn’t like because the owner was insane! 

I tell my (women) friends I am going to go take a look  at a mens clothing store I’d seen. They head down the block. I was wearing pink shoes, lime green manpris (capris) and a pink shirt. As soon as I walk in, the woman in the store comes over and says “You’re so obviously not afraid of colour, this will be so much fun.” I smile and think “cool, she seems easy going.” 

She starts grabbing clothes - pants, shirts, and shorts - puts her arm around me and shoves me into the dressing room. I humour her. First I try on the shorts. I hear her say “my rule is you have to come out and show me.” I hate aggressive sales people, so I‘m annoyed but I humour her. I show her the shorts and shirts. I try on the pants, I love the pants! They are magically soft. I look at the price tag. My heart leaps, $185 for a pair of pants! I go out and show her, she swoons over them. I have to admit my butt look fabulous in them, I would do me. 

I go back in the dressing room and try to take them off but they are too tight. What if I can’t get them off? I will have to buy them. But I’m not paying $185 for a pair of pants. I’m struggling, trying not to grunt and I’m sweating profusely. After what feels like an hour, I breathe a sigh of relief and get those expensive things off my body. 

I hear another customer come in; I think to myself I can escape without buying anything. I slowly open the door and try to make a break for it. She cuts me off and stops me. Damn it, I was so close! She says “so are you going to take everything?” I reply “unfortunately not, I'm at the end of my vacation and the clothes are just too expensive. I really love the pants but I just can’t.” She takes me to the till and says, “what if I give you $30 off, that’s 16% off?” I tell her that’s generous but I can’t. She says, “what if I give you 25% off?. I tell her that I appreciate her offer but I have to think about it. 

Now she gets bitchy: “well I can’t give you anymore than that.” I tell her “I appreciate you offering but, like I said, I need to think about it..” I try to walk away but she follows me out of the store. I am ready to snap; this is way too aggressive! She says, “think about how much you spend on other things like food, you just have to decide what’s more important.” I just smile and quickly walk away. I thank my lucky stars I've escaped. 

After that we went to The Montage Hotel (for super rich people) for lunch, a very expensive lunch. My two mojitos and my steak melt sandwich and fries came to $74 with tip, but  worth every penny. They were the best mojitos I have ever tasted. My sandwich was amazing and the atmosphere and view of the ocean were great. Great too that my $74 went to food and not that crazy woman in the store. 

Then on to L.A. Our friend that was with us lives in L.A so we stayed at her place. The first night we went out for the best sushi I ever had, so yummy. My L.A friend ordered mussels – and  nicknamed them car tires, for good reason. They convinced me to try one, I quickly regretted it. My face cringed; I opened my mouth and shoved it in. I immediately wanted to cry. I couldn’t swallow it, I just couldn’t. I spat it out and quickly drank a lot of beer. 

The next day our L.A friend, who is Korean, took us out for Korean barbeque. In the middle of the table is a grill that you cook the various meats on. You get an insane amount of Korean side dishes and condiments. It was delicious, but I ate way too much.  We were walking to the car and I kept rubbing my belly like a pregnant lady. 

We decided to head to Trader Joes to pick up supplies for making mojitos. We get there and all of a sudden my stomach is angry, very angry. I yell I have to poop, now! Trader Joes doesn’t have bathrooms. I run across the street to this fancy burger joint. There is a waitress right there “ Can I seat you?" she asks. I try to casually walk to the washroom, clenching my ass as tight as I can. After I’m done I open the door and try to sneak out, but she is right around the corner.  “Where would you like to sit?” she asks  “Actually I just came in to get a pop.” “A what? Oh sorry, you just want a soda., “Yes that’s all I want”. She totally knows I came in there just to use their toilet. Whatever, the $2.35 was worth it to be able to not shit myself. 

It was a great trip and I am sad it’s over but I am also thankful that I am so fortunate that I get to travel. I had a great time. 

Let’s be clear from the start. My history is one of being an opponent of treatment as prevention (TasP) - and a vocal one at that. But that was then and this is now, a time where the arguments of yore are no longer at all persuasive. So I’ve changed my mind and I now fully support TasP.

To be honest, mine is not a popular stance in Eastern Canada, but I’m in good company elsewhere. I’m referring to endorsement of TasP by the  World Health Organization, the International AIDS Society, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the British Columbia Centre for Excellence in HIV/AIDS, (BC-CfE), the Terrence Higgins Trust, not to mention luminaries like Barack Obama, Hillary Clinton, Bill Clinton and Canada’s own Stephen Lewis.

But those names in themselves do not stir me.  It’s the opportunity that TasP, particularly in the absence of any other current strategy to see an end to AIDS in our lifetime, while improving the health of those with the virus. As Stephen Lewis has said utilizing TasP has become a “moral imperative”, a matter of ethics and of human rights. “What is urgently needed is for the Canadian government to do the right thing and that is to expand HIV testing and treatment nationwide.”

Leading treatment as prevention researcher/advocate Dr. Julio Montaner, a former head of the International AIDS Society, echoes his words, saying  “It is imperative for the Canadian government to mobilize political will and funds to nationally expand testing, treatment and support to people living with HIV/AIDS. This is the moral thing to do if we want to end AIDS and secure the health of our future generations.”

They are both right, of course

All of which leads me to say I was delighted to respond to the British Columbia Centre for Excellence in HIV/AIDS' invitation to endorse their efforts to secure a national AIDS strategy for Canada incorporating TasP.  You’ll find my words quoted in their press release below.

*************************

New study reinforces effect of antiretroviral treatment on prevention of HIV and calls for national action

Study stresses need for political will and funding to implement the made-in-Canada Treatment as Prevention strategy to save lives and prevent new infections 

Vancouver, B.C. [May 14, 2013] — A new study from the BC Centre for Excellence in HIV/AIDS (BC-CfE) and University of British Columbia shows there is strong and consistent evidence that expanded use of highly active antiretroviral therapy (HAART) decreases HIV transmission across a variety of geographical regions and sub populations. 

Researchers reviewed scientific evidence published in peer-reviewed journals about the benefit of HAART among HIV-positive individuals in preventing HIV transmission. Their analysis of existing literature reinforced the strong relationship between use of HAART and reduced transmission among not only stable heterosexual serodiscordant (where one partner is HIV positive) population, but also high-risk groups such as men who have sex with men (MSM) and injection drugs users (IDU).

“There is no doubt HIV Treatment as Prevention is a game changer,” said Dr. Julio Montaner, director of the BC-CfE and senior author of the study. “It is imperative for the Canadian government to mobilize political will and funds to nationally expand testing, treatment and support to people living with HIV/AIDS. This is the moral thing to do if we want to end AIDS and secure the health of our future generations.”

Study authors noted the effectiveness of abstinence promotion, condom use and needle exchange programs have been limited. In 2010 there were 2.5 million new infections, 1.8 million AIDS-related deaths and 390,000 children infected globally, with disproportionate representation in low-income countries. Only 54 per cent of HIV-infected individuals with severe immunodeficiency are on HAART, and only 20 per cent of people with HIV know their status.

Over the years, scientific evidence has mounted nationally and internationally in favour of HAART’s impact on reducing disease progression to AIDS and death and secondarily decreasing HIV transmission. In B.C., between 1996 and 2009, the number of individuals receiving HAART increased from 837 to 5,413 and the number of new HIV diagnoses fell from 702 to 338 per year (52 per cent decrease). The rates of HIV testing increased throughout the study period. In addition, in 2011, the HIV Prevention Trials Network (HPTN) reported that HAART led to a 96 per cent reduction in HIV transmission among serodiscordant couples.

“I am living proof of the long-term benefits of HIV treatment,” said Bob Leahy, editor of PositiveLite.com, Canada’s online HIV magazine, and someone who has lived with HIV for 20 years. “HAART has allowed me to live a normal and productive lifestyle and this is nothing short of a miracle for people like myself who have been given a second chance. It makes so much sense, and is the right and ethical thing to do, to ensure we quickly scale up testing across Canada so that every HIV-positive person has access to HAART, both to improve their own health and to very significantly reduce the risk of transmission.”

The Joint United Nations Programme on HIV/AIDS (UNAIDS) recently reported a 10 per cent drop in HIV/AIDS funding from 2009 to 2010 to support the Universal Access pledge. The U.S.’ budgeted contribution to the Global Health Initiative is projected to fall 10.8 per cent for 2013.

“We have the tools to end HIV/AIDS, and B.C. is a shining example of what can be achieved through universal implementation of Treatment as Prevention,” said Stephen Lewis, co-director of AIDS-Free World and renowned HIV/AIDS activist. “We are talking about human lives and the future health of Canadians. We cannot afford any further debate or more expensive clinical trials to prove what we already know. What is urgently needed is for the Canadian government to do the right thing and that is to expand HIV testing and treatment nationwide.”

The B.C. pioneered Treatment as Prevention strategy has led to the widespread expansion of HAART coverage in British Columbia. It has demonstrated a marked decrease in morbidity, mortality and new HIV cases. As the only province to implement the Treatment as Prevention strategy, B.C. stands alone as the sole province to show a consistent decline in new HIV diagnoses since 1996.

“While expansion of Treatment as Prevention will no doubt be lifesaving, evidence shows the long-term financial benefits can be tremendous,” said Dr. Bohdan Nosyk, lead author of the study and health economist at the BC-CfE. “HAART has evolved beyond individual health benefits to the HIV-positive person to secondary preventive benefits for the community at large. Failing to expand HIV funding can reverse the gains made against the epidemic and undermine the promise of HIV Treatment as Prevention.”

Research by the Canadian AIDS Society suggests the lifetime economic cost of each HIV infection is over $425,000, including health care costs and lost productivity.

Every year, 3,300 men and women in Canada are diagnosed with HIV infection and it is estimated more than 71,000 Canadians are now living with HIV.

The full study authored by several renowned HIV/AIDS experts and published in AIDS, official journal of the International AIDS Society, can be found here.

What is Treatment as Prevention?

The Treatment as Prevention strategy has been pioneered by BC-CfE’s Dr. Julio Montaner. It involves widespread HIV testing and immediate provision of anti-HIV drugs known as HAART to medically eligible people with HIV. The BC-CfE has demonstrated that the benefits of early HAART treatment are twofold: it reduces the level of HIV in the blood to undetectable levels thus improving the health of people with HIV, and decreases the level of HIV in sexual fluids to undetectable levels thus reducing the likelihood of HIV transmission by more than 95 per cent. In 2009, the BC government invested $48 million over four years in the BC-CfE-led Seek and Treat for Optimal Prevention of HIV/AIDS (STOP HIV/AIDS) pilot project. The intent of the pilot is to expand HIV testing and treatment among hard-to-reach populations such as injection drug users in Vancouver’s inner city and Prince George.

Treatment as Prevention is internationally recognized by organizations such as the World Health Organization, International AIDS Society and the Joint United Nations Programme on HIV/AIDS (UNAIDS). Treatment as Prevention has been endorsed by U.S. President Barack Obama, Secretary of State Hillary Clinton and former U.S. President Bill Clinton as an effective strategy in the fight against HIV/AIDS.

This article first appeared on the CATIE website here.  

Une version française est disponible ici.  

The importance of HIV testing, knowledge of HIV status and early diagnosis of HIV infection cannot be overstated, particularly given recent advancements in our understanding of HIV treatment and prevention. 

People who are aware of their HIV-positive status can access care and support services and initiate treatment when they are ready. Advances in treatment mean that people with HIV can live almost as long and as healthy as people who are uninfected. To get the most out of treatment, research suggests it may need to be started soon after becoming infected with the virus. Currently, however, many people in Canada are not learning about their HIV status until late in their disease, when they start to develop symptoms or opportunistic infections. At this point, antiretroviral treatment can help improve their health but not as effectively as when treatment is started earlier. 

Knowledge of HIV status is also important for the prevention of HIV transmission. Generally, once people become aware of their HIV infection, they take measures to reduce their risk of HIV transmission. Also, once diagnosed, treatment can be initiated and this can further help reduce the risk of HIV transmission. Research suggests that the majority of HIV transmissions may originate from people who are unaware of their HIV status. 

For those who test negative, testing represents an important opportunity to provide HIV prevention information and counselling. 

According to 2011 estimates from the Public Health Agency of Canada (PHAC), approximately 25% of people living with HIV in Canada were unaware of their HIV status. Therefore, undiagnosed HIV infection represents a major public health challenge and is undermining HIV treatment and prevention in Canada. 

Barriers to testing 

There are several barriers to increasing the uptake of HIV testing and reducing the proportion of people who are undiagnosed in Canada. According to a synthesis of the evidence conducted by the European Center for Disease Prevention and Control and published in 2010, these barriers include: 

• inability to accurately assess levels of risk for exposure to HIV by some clients and providers
• lack of comfort discussing HIV testing and lack of knowledge about HIV among clients and providers
• provider time constraints for risk assessments and pre- and post-test counselling
• cumbersome consent procedures
• fear of stigma and discrimination associated with risk behaviors and/or testing HIV positive 

PHAC guidelines and recommendations 

PHAC recently released an HIV Screening and Testing Guide that “seeks to reduce the number of undiagnosed HIV infections in Canada by offering a framework for care providers to explore options that will enhance their ability to provide HIV testing, as well as to better tailor their testing approaches to meet the specific needs of their practice and clients.” 

These guidelines include the following recommendations to address the barriers listed above and to improve HIV testing in Canada. 

The offer of an HIV test should be made part of periodic routine medical care.The guide acknowledges that targeted testing among populations at highest risk of HIV infection needs to continue but should be complemented with a less targeted testing approach among populations that may be perceived as being lower risk. Research shows that many people at risk for HIV infection (including those who are later diagnosed with HIV) are not requesting, or being offered, an HIV test despite multiple interactions with the health system, likely because of perceived low risk of HIV infection on the part of the client and provider. These interactions represent “missed opportunities” for HIV testing and potential diagnosis of HIV infection. 

Therefore, a major recommendation in the guide is that providers take a more active approach and routinely offer HIV testing to clients—whether or not they have asked for a test. Routinely offering HIV testing to patients will help overcome some of the barriers to testing. Also, it may help normalize HIV testing and further reduce stigma and discrimination associated with HIV. 

To reduce the fear often associated with an HIV diagnosis, which can be a barrier to testing, the guide recommends that care providers emphasize the benefits of treatment and that HIV is now considered a chronic manageable condition. 

Simplify risk assessments. 

The guide acknowledges pre-test risk assessments as a potential barrier to HIV testing. Therefore, it states that instead of providing an in-depth comprehensive HIV behavioural risk assessment prior to offering an HIV test, a more brief assessment is sufficient. This assessment should ensure that clients understand the following: 

• how HIV is transmitted
• the advantages and disadvantages of HIV testing
• how to interpret the results 

After the brief assessment, a client should simply be asked if they want an HIV test. This approach allows the client to assess their own risk without feeling compelled to provide sensitive personal information. This helps to overcome any discomfort the tester and/or client may feel in discussing these issues, which can sometimes be a barrier to testing.  

HIV testing must remain voluntary and based on informed consent. 

The guide states that verbal consent prior to HIV testing is sufficient and written consent prior is not necessary. 

Use a flexible approach to pre- and post-test counselling. 

The guide encourages care providers to use a flexible approach and tailor the extent of pre- and post-test counselling to each client’s unique needs and situation. While providing extended counselling is preferred, the guide acknowledges that this may be a barrier for both the provider and client, particularly due to time and resource constraints. More specifically, the guide states that shorter counselling may be more appropriate for certain testers, such as pregnant women in labour, well-informed patients and repeat testers. The provision of print, video, mobile and web-based resources can help streamline the pre-test process and inform decisions with regards to HIV testing.

 Offer couples testing. 

The guide stresses the importance of testing together for those in an ongoing sexual relationship with a regular partner as it allows: 

• a common understanding of the risks associated with HIV transmission
• a shared understanding of each other’s HIV status
• an opportunity to make decisions about prevention, treatment and care together 

Research studies suggest that couples who test and learn their status together are more likely to adopt preventive measures than those who test alone. 

Integrate HIV testing services. 

The guide encourages the integration of HIV testing into other services, particularly those that test for infections that can be transmitted the same way as HIV and/or negatively impact the health of people living with HIV. 

These services include the following: 

• clinical services for tuberculosis (TB), sexually transmitted infections (STIs) and hepatitis C
• antenatal care services
• sexual Health and family planning services
• drug and alcohol treatment services
• newcomer and travel health clinics
• mental illness treatment and psychiatric services
• cancer or oncology clinics 

Integrating HIV testing into these other services provides additional opportunities to test for HIV and identify undiagnosed individuals. 

While positive results should always be provided in person (preferably by the initial care provider), alternate approaches can be used to provide negative results. 

Ideally, negative test results should be provided in person, however, the guide acknowledges that this can be challenging to do for all individuals. Therefore, providers can use a previously agreed upon alternative for those who are unlikely to return for their test results. These alternative approaches may include a secure telephone call, letter or email. The guide emphasizes that effort should be made to ensure that the information is provided confidentially. 

It is important that clients are not informed that only HIV-positive results will be provided in person. This may create anxiety when a person is asked to return to get their results in person. 

Discuss the window period with those who test HIV negative. 

If someone is “in the window period,” there is a chance that even though they may have been infected with HIV, the test won’t be able to detect the infection and will give a negative result. The window period differs for each type of HIV test and also depends on each individual. To ensure that a person was not in the window period at the time the test was performed, the guide recommends that follow-up testing be performed at three weeks and three months following the most recent possible exposure. However, the guide states that additional HIV testing during the window period, particularly following a “high-risk” exposure, may help identify infection earlier. 

Discuss frequency of retesting with those who test HIV negative. 

The guide recommends that individuals involved in “high-risk practices” be screened for HIV at least once a year. Since many variables determine an individual’s potential risk of HIV infection, the guide does not recommend an exact frequency of HIV testing for different levels of risk. However, when considering the need for retesting, the guide recommends that care providers consider factors such as populations at increased risk for HIV exposure, characteristics of partners and local epidemiology. 

Provide information and referrals—regardless of test results—and link newly diagnosed individuals to care. 

HIV testing is an important opportunity to educate individuals at risk of acquiring HIV and those who are newly diagnosed and link them to additional services. For example, all people tested for HIV—regardless of their results—should be provided with information and linked to services to help them reduce their risk of acquiring or transmitting HIV. Therefore, in preparation for HIV testing, the guide suggests that providers contact care and support organizations to obtain referral resources to provide to clients. 

Research shows that people living with HIV who are linked to and engaged in care have better health outcomes than those who are not. Therefore, newly diagnosed individuals should be referred to an infectious disease specialist who treats HIV. Also, effort should be made to complete baseline testing for CD4 count, viral load, drug resistance and co-infections (hepatitis B and C, STIs, TB) as soon after diagnosis as possible. 

For those who test HIV positive, develop a partner notification plan and discuss public health importance of disclosure. 

Previous and current partners of newly diagnosed individuals represent a population at high risk of HIV infection. Therefore, notifying previous/current partners and encouraging them to get tested may help identify undiagnosed HIV infections. The guide encourages care providers to develop partner notification plans with newly diagnosed individuals. Also, care providers should inform clients that positive test results will be shared with Public Health, which can help with partner notification while maintaining the client’s anonymity and privacy. 

Voluntary disclosure of HIV status to partners has several potential benefits. For example, it may motivate partners to seek testing and/or adopt measures to prevent HIV transmission. Also, it provides an opportunity for the HIV-positive person to receive social support, develop risk-reduction strategies with partners and prevent co-infections. Therefore, the guide states that care providers should emphasize the importance of voluntary disclosure of HIV status to those who are newly diagnosed. 

Conclusion 

PHAC’s new HIV Screening and Testing Guide contains a series of recommendations to increase the uptake of HIV testing, reduce the proportion of people who are unaware of their HIV infection and diagnose people as early as possible after HIV infection. These goals are critical for improving the health of people living with HIV and for preventing HIV transmissions in Canada. One way the guide seeks to meet these goals is by normalizing HIV testing and making the offer of such testing a routine part of medical care. More nuanced and detailed information can be found in the full guide. 

It is important to note that PHAC’s guide is only meant to complement existing efforts and “does not supersede any provincial/territorial legislative, regulatory, policy and practice requirements or professional guidelines that govern and inform the practice of care providers in their respective jurisdictions. Care providers should comply with local Public Health regulations with conducting HIV testing.” 

- James Wilton 

Resources  

HIV Screening and Testing Guide – Public Health Agency of Canada 

WHO guidelines encourage couples HIV testing and counselling and use of antiretroviral treatment for prevention – Prevention in Focus  

Recently infected individuals: a priority for HIV prevention – Prevention in Focus  

Detecting HIV earlier: Advances in HIV testing – Prevention in Focus  

A rapid approach to community-based HIV testing – Prevention in Focus  

How do you know if you have HIV? – Managing your health  

References  

Johnson LF et al. Life expectancies of South African adults starting antiretroviral treatment: collaborative analysis of cohort studies. PLoS Medicine, 10:4. E1001418. 

May M et al. Life expectancy of HIV-1-positive individuals approaches normal, conditional on response to antiretroviral therapy: UK collaborative HIV cohort study. Eleventh International Congress on Drug Therapy in HIV Infection, Glasgow, abstract O133, 2012. 

Van Sighem AI, Gras LAJ, Reiss P, Brinkman K, De Wolf F. Life expectancy of recently diagnosed asymptomatic HIV-infected patients approaches that of uninfected individuals. AIDS. 2010 Jun 19;24(10):1527–35. 

Nakagawa F, Lodwick RK, Smith CJ, Smith R, Cambiano V, Lundgren JD, et al. Projected life expectancy of people with HIV according to timing of diagnosis. AIDS. 2012 Jan;26(3):335–43. 

Nakagawa F, May M, Phillips A. Life expectancy living with HIV: recent estimates and future implications. Curr. Opin. Infect. Dis. 2013 Feb;26(1):17–25. 

Siegfried N, Uthman OA, Rutherford GW. Optimal time for initiation of antiretroviral therapy in asymptomatic, HIV-infected, treatment-naive adults. Cochrane Database of Systematic Reviews. 2010 Mar 17;(3):CD008272. 

Althoff KN, Gange SJ, Klein MB et al. Late presentation for human immunodeficiency virus care in the United States and Canada. Clinical Infectious Diseases. 2010 Jun;50(11):1512–20. 

Fisher, M. (2008). Late diagnosis of HIV infection: major consequences and missed opportunities. Current Opinion in Infectious Diseases. 21(1):1-3.

 Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. Journal of Acquired Immune Deficiency Syndromes. 2005 Aug 1;39(4):446–53. 

Cohen MS, Chen YQ, McCauley M et al. Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine. 2011 Aug 11;365(6):493–505. 

Government of Canada Public Health Agency of Canada (2010). HIV/AIDS Epi Updates. Available from: www.phac-aspc.gc.ca/aids-sida/publication/epi/2010/2-eng.php 

European Centre for Disease Prevention and Control. HIV testing: Increasing uptake and effectiveness in the European Union. Stockholm: ECDC; 2010. 

Government of Canada Public Health Agency of Canada (2013). HIV screening and testing guide. Available from http://www.catie.ca/sites/default/files/EN_HIV-Screening-Guide-2013.pdf 

El-Bassel N, Gilbert L, Witte S et al. Couple-based HIV prevention in the United States: advantages, gaps, and future directions. Journal of Acquired Immune Deficiency Syndromes. 2010 Dec;55 Suppl2:S98–S101.

From Bradford McIntyre of PositivelyPositive.ca  comes this notice of Vanocover’s up coming candlelight memorial . . 

“We have a stellar cast of speakers and performers this year to celebrate and perform a musical tribute to people affected and infected by HIV and to all of those friends and family we have lost to HIV/AIDS.

This year marks AIDS Vancouver's 30th Anniversary. This year also marks the AIDS Candlelight Memorial’s 30th Anniversary.

AIDS Vancouver is the host of the 30th Vancouver International AIDS Candlelight Memorial.

In this special year, this event is a musical tribute.

In Solidarity: A Musical Tribute to People Infected and Affected by HIV and those we have lost to AIDS.

As vice-chair on AIDS Vancouver’s board of directors, I have spent the past three months organizing the 30th Vancouver International AIDS Candlelight Memorial, planning the program and inviting this year’s participants. I will be master of ceremonies (MC) for the event. Learn more about it here.

The Program:

The 30th Vancouver International AIDS Candlelight Memorial

In Solidarity: A Musical Tribute to People Infected and Affected by HIV and those we have lost to AIDS.

May 19th 2013 at 7:30 PM in Alexandra Park, 1755 Beach Avenue, at Bidwell

Master of Ceremonies: Bradford McIntyre

Speakers and Performers

Chief Bill Williams

Bob Baker & The Eagle Song Dancers

Vancouver Men's Chorus

Leora Cashe

Jess Cullen

PALS Chorus

Andrew Hiscox

James Johnstone

Ending with the Lighting of the Candles "

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.