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The HIV surge: Why is it happening?

Thu 10 Mar 2011 In: HIV View at Wayback View at NDHA

Figures released last week indicate a continuing surge in HIV infections and diagnoses amoingst gay and bi men in 2010. In the past when the annual figures have looked grim it has been said that there could be a backlog of infected people from past years past who are only now getting tested and so a rise in diagnoses did not automatically mean a rise in new infections. It could just mean more men were deciding to get tested. The NZ AIDS Foundation's own research certainly shows an increase in the numbers of men testing for HIV in recent years. But is it now quite clear that the surge in diagnoses is directly coupled with a surge in newly-acquired infections. “If there wasn't a clear upwards trend for a decade then maybe we might consider that there's a backlog,” says the newly-appointed Executive Director of the Foundation, Shaun Robinson. “But we are now ten years into this upward trend so I would think that it's pretty reasonable to assume that we do have an upward rate of infection on our hands. What the absolute final figures are year by year is probably less important than the trend.” That trend is now clearly up and up and up. Supporting Robinson's view is the AIDS Epidemiology Group at Otago University's School of Medicine which compiles the annual data. It notes that over half of the men diagnosed last year “were reported to have had a pevious negative test, 20 of those within the last two years. This shows new HIV infections are continuing to occur amongst men who have sex with men in New Zealand.” So, year after year more and more gay and bi men are contracting HIV, almost exclusively by not using condoms for anal sex. And yet major research projects in which many hundreds of men have detailed their sexual habits show a relatively high level of condom use. Gay and bi New Zealanders say they use condoms more than most similar countries where HIV is an epidemic primarily amongst men who have sex with men. We've been hearing that for some years now. And yet the surge continues upwards year after year. Robinson says that as bad as our infection rate has become it must be put into perspective. “This is bad in the context of it being the best in the world. Despite the increase we're actually still doing better than any other gay community at slowing down the spread of HIV. Our [condom use] rates are much better in some places such as Sydney and New south Wales, for example. We still say unequivocally that use of condoms and lube is the answer to fighting this epidemic.” Good enough to be heading off this counter-attack by HIV? “The answer, clearly, is no. We've been doing some thinking about that obviously, over the past few years and certainly since these new figures came out and as I start to get my head around things.” Robinson points out that the increasing rate of infections really became evident in the figures for 2001 and 2003 when the annual diganosis numbers increased markedly from the 20s to the low 50s. In the late 1990s HAART drug regimes capable of slowing the virus's attack on those infections and staving off illness and death had begun to create “an increasing pool” of well men with HIV. Soon after that the internet arrived. “[The net] became a really big factor in sexual networking. The thing about viruses and epidemics is that they are almost like an intelligent, very opportunistic, enemy. HIV was able to capitalise on those changes in the environment: a higher prevalence in the population and the simple maths of transmission means you are going to have a higher infection rate unless something else changes. Then you add that to different sexual networks and other factors... the environment changed around 2001 to 2003 and the epidemic has been able to capitalise on that.” Robinson says the NZAF has been active in trying to address some of these environmental issues. “We've been putting a lot of effort into trying to increase our presence and our activity on the whole internet and social media space. We've been developing social marketing and building on everything that was done before. I'm not saying that we have got everything right or that we are doing enough... But surely the inexorably surging figures mean that we aren't doing enough? Or that we must be getting things wrong? “Just as it was in the 1980s and 90s there will be a time lag in anything we do. You're not going to pull a lever in 2010 and get a result in 2011.” So we, the NZAF and the gay and bi male community, didn't pull the right levers in 2001, 2002 and 2003 and so on. “Possibly not. Or it took us some time to get our heads around what was changing in the environment. This is a wake up call to us and one of the ways that we are apoproaching it differently from here on in is that we have got to use a mixture of strategic [and specific] approaches, because just jumping from project to project and approach to approach rapidly is not going to address this. If you look at it intelligently, you have to have a strategy and you have to give it time to have an impact.” Shaun Robinson “I do believe that the overall approach that the AIDS Foundation is taking the right approaches. As for the detailed tactics of how those approaches are implemented, we have to be really fleet-footed about that. We have to be gathering up as much feedback and information as we go to fine tune the processes. And that's from all aspects of what we do. But also we have very much to be in partnership with the community, because we're all in this together really.” Brave, determined words and yet for years the NZAF has beend one of the best funded per capita organisations in the world charged with dealing with the HIV epidemic. We've got some of the best expertise in the woirld, we have the advantage of other culturally similar nations and communitys from which to learn from their successes and mistakes. And until recent years our epidemic lagged about two years behind communities such as London and New York and Sydney so we got a measure of advance warning. We had everything going for us. And yet did we somehow loose the plot? “I don't know if we lost the plot but it is a war in many respects and sometimes, I guess, the enemy steals a march on you, says Robinson. I'm sure there were some really good insights back then but perhaps we didn't understand the whole picture. Anybody who got to grips with epidemiology would have said 'widespread treatment with more people living with HIV, this is going to give a bigger pool, therefore we have got to be really careful. And sexual networking through the internet... there's been a variey of factors that have compounded.” “We're not happy with this by any manner of means. I guess the best we can say is that essentially we think we are doing the right things now, and we really want to be working with the community. We don't have all the answers, the answers have got to come in partnership.” What is the NZAF doing now? “Social marketing is a key plank in what we are trying to do. It basically means selling the message of changed behaviour so that it actually creates a social movement of condom use. It's aheady mix of the tools of marketing, like breaking your target group down into sub-sections and thinking about how you're going to sell it to this or that group of people and what their psychological drivers are. It's marketing and it's psychology as well. We know, for example, that most gay and bisexual men know that wearing condoms will keep them safe. But why are a proportion not doing it?” Maybe most men don't like sticking a condom, once termed a “passion killer,” on their cock? Quietly sitting in on the interview with Robinson is Tony Hughes, the AIDS Foundation's internationally respected lead researcher. With Robinson just eight weeks into the job, Hughes is here to fill in some of the detail which the new boss might not yet have right at his fingertips. Hughes points to the data from the two- and three-yearly Gay Auckland eriodic Sex Survey (GAPSS) and Gay Online Sex Survey (GOSS.) He says that 5.7% of gay men who had anal sex with a casual partner in the past six mnonths said they had low condom use. A further 8% said they had medium condom use and 86.3% said they had high condom use.” So they say, but can we trust that those men tell the truth in the confidential questionnaires they offer to fill out. It seems we can. “Because,” explains Hughes, “when we ask them whether they use condoms in a relationship the overwhelming majority say they don't. Then when we ask them if they use condoms with a fuck buddy the amount that say they do goes rocketing right up. And when we ask them about condom use with a casual sex partner the number who say they do also goes right up.” Then who is ging us this record increase? Hughes points out one of the tyranies of numbers. “The increase in annual diagnoses aren't actually really big increases in numbers. This is not 500 rising to 1000. This is, say, 21 rising to 90. If it was 500 rising to 10,000 you'd say 'how on earth are we getting that, given that we have the majority of gay men using condoms in a casual context?' The answer is: we had the best results in the world in terms of new diagnoses of HIV from 1997 to 2000... just 21 more people infected in a year in a population of four million. And it tripled. There are between 70,000 and 107,000 gay men in the country. You only have to get a relatively small number of men not using condoms and it's sufficient to drive the increase.” If condom use is comparatively high, up in the 30% or so of men who say they use condoms less often that we'd hope, or even not at all, there are perhaps specific groups that need addressing. So how much do we concentrate on the broad effort to maintain condom use as a community norm and how much must we work to get in amongst those still ill-defined groups who are lurking at the bad end of the condom use statistics? “I think that it is a mixture of the broad and the specific,” says Robinson. “Part of it is creating a social movement with the broad message.” As for the specific, “While there are some age demographics involved in the latest figures it's more about the psychological demographics... its about groups of people who sexually network in certain ways and their attitudes to risk taking, to safe sex, to condoms...” So what do we know about them? “We know some information but we don't know enough. And there are different groups of them. That's part of the fine tuning that we need to keep on doing. Within the NZAF, for example, we have our health services who have in-depth conversations with about 1600 men a year and that gives us one line of insights. Because 70% of the people that they see test negative but they have obviously in many cases done something or taken a risk and a lot of the counselling around that is 'What drove you to that and what would stop you doing that in the future?'. There's a very rich source of information there. There are GAPSS and GOSS with more information in there than we have been able to analyse. And so one of our priorities is to drill down into that and answer some of those questions. We also have our community engagement team out there in various communities with bar owners, venue owners, with the different points of contact in the community and they are our eyes and ears in the community. How effective are those eyes and ears? “Well, we'll see over the next little while. I think we have to bring all the information to bear on the next phase of what we do. I mean, w are only going to be as effective as the relationships that we are going to make. I think in many cases they are really, really effective. But I certainly want it to be better. We can aleays do better, and we have to do better”. Robinson says he has sat in on meetings with some of those community people and bar owners “where they have been talking through how the bar can incorporate safe sex messages and the Get It On brand into the aesthetics of the bar. Like having it etched into pool tables' felt and all kinds of stuff. We do have strong levels of cooperation. In Christchurch we've been able to activate pretty significant condom distribution post- the earthquake. And we couldn't have done that without the social networks that exist there.” For Robinson, the continuing surge in HIV infections is “very much a call to the community to be with us in understanding that when one man uses a condom he's not just protecting himself and the person he's fucking... he's actually protecting the whole sexual network that goes out beyond that.” But do individual horny men actually care about protecting the 'whole sexual network'? “We certainly know that there are people who care because we have our Get It On Champions who are quite prepared to stand up and say that they use condoms not just for their own health but for the health of the community. Since I have been here the overridng message from people associated with the Foundation - that's volunteers, people fromlother organisations, staff - is that they have a commitment to their community. Any social issue only gets resolved if people care beyond their own self-interest. But obviously that's part of the human condition isn't it. Self-interest is what gets us into trouble and going beyond that is what gets us out of trouble.” In part two of this feature this Saturday Shaun Robinson explains why he is optimistic that the trend can be reversed. Daily News staff - 10th March 2011

Credit: Daily News staff

First published: Thursday, 10th March 2011 - 5:58pm

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