Report from the field: CHEST staff members attend a special NYAS conference on the continuing HIV epidemic
By Joshua Guthals, Brooke Wells, Ph.D., John Pachankis, Ph.D., and Derek J Essegian, December 18, 2012. New York, NY.
Several employees from Hunter’s Center for HIV Educational Studies and Training (CHEST) attended an HIV-prevention conference last Friday, December 7, 2012, at the New York Academy of Sciences (NYAS), co-presented by The Johns Hopkins Bloomberg School of Public Health. The conference, called “New Paradigms of Risk and Protection: Understanding the HIV Epidemics among Gay and Bisexual Men,” presented topics from a recent special issue of The Lancet, entitled, “HIV in men who have sex with men.” This special issue from July 2012 highlighted the ongoing challenge of HIV prevention and treatment among men who have sex with men (MSM).
Prominent speakers from a range of health disciplines examined unique issues of HIV infection among gay and bisexual men. The panelists included HIV researchers and doctors, Thomas Farley (Commissioner of the NYC Department of Health and Mental Hygiene), and Gregorio Millett (Senior Policy Advisor in the Office of National AIDS Policy and Senior Behavioral Scientist at the Centers for Disease Control).
The panelists discussed strides made in recent years, from new and improved antiretroviral medications that extend the lifespan of individuals living with HIV to the recent FDA approval of a pre-exposure prophylaxis medication (PrEP) for preventative use among sexually active HIV-negative adults at risk for HIV infection. Despite these advances, the data show that, among gay and bisexual men, HIV prevalence and incidence rates have increased. While many adults living with the virus enjoy long lives, HIV is still a difficult disease to manage, with available drug treatments being expensive, often inaccessible, and coming with significant side effects. The presenters addressed the question: Why do gay and bisexual men continue to be disproportionately impacted by HIV infection? What causes this difference in transmission rate between them and other populations?
First, it appears that the structural and biological risk factors for HIV transmission among MSM, such as an increased risk of transmission via anal sex (18 times the risk associated with vaginal-penile sex) and the effect of sexual role versatility among same-sex male partners (this versatility allows men to more easily both receive and transmit the disease than occurs during vaginal sex). According to panelist Chris Beyrer, predictive models that control for these two biological factors reduced incidence rates over the next 5 years by 80-98%, suggesting that the physical and biological mechanics of sex between men is a primary cause of the high rate of infection. These findings illustrate the need for biomedical interventions to reduce infectiousness (expanded use of pre-exposure prophylaxis, better access and adherence to HIV medications, further research into microbicides, and increased HIV testing).
Second, speakers stressed the influences of poverty and stigma on HIV transmission and access to medical care. The disparities in HIV testing, infection, and treatment among MSM, and particularly for Black MSM, are staggering and sobering. For example, despite similar rates of HIV risk behavior and lower rates of substance use among black MSM when compared to other MSM, black MSM in the UK and the USA were 2-3 times more likely to be HIV-positive and 22-60% less likely to be on HIV medication regimens (Millett et al., 2012). The authors cite structural barriers that increase HIV risk (e.g., unemployment, low income, previous incarceration, or less education). Panelists also cited the significant risks that are involved in accessing sexual healthcare in countries where gay and bisexual men may risk their lives to obtain an HIV test. In response to these data, several speakers noted that “stand-alone behavioral interventions are not sufficient to reduce HIV transmission in MSM” (Sullivan et al., 2012).
While panelists called for structural interventions that address these social and structural barriers to sexual health among MSM, there are several ways in which we should also address these social and structural issues in individual-level behavioral interventions (such as those happening at CHEST). For example, as behavioral health practitioners, how can we increase resilience in the face of structural and social barriers to health? How can we translate our research here at CHEST into policy that will impact some of these larger structural and social issues?
In the end, this conference served as a reminder of the incredible work being done by researchers, healthcare practitioners, and advocates around the world, and of the resources that are being marshaled to address these issues. For example, the State Department recently released their Blueprint for an AIDS-free generation (http://www.state.gov/r/pa/prs/ps/2012/11/201195.htmUnited States believes can save millions of lives and achieve an AIDS-free generation.
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(An audio and video overview is available here: http://www.thelancet.com/series/hiv-in-men-who-have-sex-with-men)