More than 30 years into the epidemic that was first documented among gay men in America, a disturbing trend is being noted globally: Where rates of new HIV infections are going down among other populations, they are rising among men who have sex with men.
“The epidemics are going in different directions,” said Chris Beyrer of the Johns Hopkins School of Public Health, on Thursday. “We have to ask, why is that?”
In a special edition that came out just before the July International AIDS Conference in Washington, a series of Lancet articles did ask that, examining structural, biological, epidemiological, historical and other reasons HIV epidemics among men who have sex with men are still increasing, and why programs are failing to meet their needs.
Beyrer was one of five panelists at the Center for Strategic and International Studies Thursday afternoon discussing the policy implications of the Lancet series.
Beyrer explained the statistical impact of the higher probability of HIV transmission through receptive anal sex than vaginal sex — about 18 times higher — and how the same person practicing both receptive and insertive roles in sexual intercourse aslo facilitates the spread of the virus. Those two factors explain 98 percent of the difference between the infection rates among men who have sex with men and among heterosexual populations, he said.
The potential role of “multiple concurrent sexual partnerships,” often cited as a factor to explain higher HIV incidence in some settings, “is dwarfed by these other factors,” Beyrer said.
“Behaviors comprise a minor part of the force of this epidemic,” Patrick Sullivan of Rollins School of Public Health reiterated, explaining how modelling to determine the impact of different prevention services showed a critical need to pay attention to biological realities of sex between men. Investing in the development of topical microbicides that can be used rectally, for anal sex, developing a vaccine to prevent HIV infection, getting the best use possible out of preexposure preventive use of antiretroviral medicine (preexposure prophylaxis — or PrEP) are all needed now, he said, adding “we have to make the stable of prevention technologies broader.”
While current tools can’t completely address HIV prevention among men who have sex with men, making full use of what exists would slash new infections by 25 percent, he said.
Even then, panelists said, in places where sex between men is a criminal offense, men face barriers to seeking existing methods of prevention, as well as care, information, and treatment. Overturning laws brought by British colonialists and remaining in 38 African coutnries and 10 Caribbean countries will be key to providing equitable services, Sullivan said.
Even where a man who has sex with men can safely access health care and advice, the odds of the services being relevant to his needs, provided by someone who knows what those needs are, are slim, Kenneth Mayer of Fenway Health and Harvard Medical School said.
“Not engaging the healthcare workforce is a big missing part of the puzzle,” he said.
“A lot of people providing care don’t know what they don’t know,” he added later.
And, it seems that’s likely even more, when the men they are treating are black men who have sex with men, Gregorio Millett of the Centers for Disease Control and Prevention pointed out. He headed a team that investigated common findings across studies and reports of black men who have sex with men in 22 African countries and eight Caribbean countries, that black gay men are likely to have fewer sex partners, less unprotected sex, less drug use than other men who have sex with men, and yet, “are far more likely to have HIV.”
They are also, he added, likelier to face structural barriers to adequate income, education and healthcare.
Those barriers turn the treatment cascade — from testing, to referrals, to monitoring, to treatment, to care — into an obstacle course, that will mean efforts to use treatment of HIV to prevent transmission will miss black gay men.
All of this, and more, discussed in greater width and depth in the Lancet series illustrate the importance of having funding that follows the epidemic, Chris Collins of amFAR said.
“There’s a whole array of pretty clear policy implications,” he said.
Caroline Ryan, of the Office of the U.S. Global AIDS Coordinator was there to talk about how the office has begun to respond to some of them under the Obama administration, describing measures also cited in Secretary Clinton’s address at the July AIDS Conference including challenge grants to encourage the development of programs addressing the needs of populations most impacted by HIV.
The question however, of how an epidemic could so disproportionately hit one overlooked, ignored, marginalized population, in the end had largely been answered.
“This is not a hopeless venture,” Collins said. “The science is there, and there is leadership — on the ground and at the top.”