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HIV - Treatment as prevention?

Sun 1 Dec 2013 In: Health and HIV View at Wayback View at NDHA

PART ONE: SUCCESS VS FAILURE PART TWO: DIVERGING PREVENTION PATHS PART THREE: TREATMENT AS PREVENTION? So, why is the NZ AIDS Foundation becoming increasingly vocal about what it believes are the damaging approaches to HIV prevention amongst men who have sex with men being followed or taken up in many other countries? In recent times world health agencies, especially the highly-influential United Nations global HIV/AIDS agency UNAIDS, have begun to push their belief that a new method of preventing the spread of HIV will likely see the end of the HIV epidemic by 2030. The strategy is based on the lowered likelihood of a HIV-infected person passing on their infection to another person if the level of HIV particles in their bloodstream or semen is extremely low. Will pills halt our HIV epidemic? Sophisticated combinations of medications have been able to achieve this lowered level, or 'undetectable viral load' in medical terminology, for around a decade. Get a high enough proportion of people with HIV onto the drug treatments and overall the incidence of new infections will start to drop exponentially until HIV is no longer the epidemic it currently is. That's the intention. To this end global agencies have been heartily supporting initiatives by parallel drug manufacturers in countries like India and Brazil, to produce much cheaper versions of the until recently always highly expensive HIV medications. To many governments and health agencies alike, struggling against financial constraints and cultural taboos regarding sexual matters, the new 'treatment as prevention' strategy is a seductive alternative to their currently failing strategies. And it fits within the simplistic 'see the doctor, get a blood test, take some pills' environment people are used to for so many other ailments, from heart conditions to skin rashes. The programme is being rolled out now and it is having enough initial success for the Deputy Director Programme of UNAIDS to unequivocally say it will see the HIV pandemic gone by 2030. STRAIGHTS AND GAYS ARE DIFFERENT For some people this approach just may work, although the difficulties around identifying a high enough number of people with HIV in, say, Zimbabwe or Iraq or the disenfranchised ghettoes of New York or the Caribbean, and keeping them consistently on medications which must be taken with a frequently-unattainable degree of consistency for the rest of their lives, are surely considerable. But for one group around the world in particular, men who have sex with men, there is no evidence that treatment as prevention will work at all and every reason to believe that it won't. It may work for straight people but it almost definitely won't for men who have sex with men. For those nations, communities and individuals who succumb to the siren song of treatment as prevention as the answer to their gay-and-bi-epidemic prayers, or whose unsophisticated understanding treats all people at risk of getting HIV as being the same, there is trouble ahead, according to the internationally-respected NZAF. Why? The HIV epidemic amongst men who have sex with men exists in a fundamentally different environment to the straight epidemic, the Foundation points out. For example, there's the pivotal route-of-transmission thing. Most straight people transmit HIV through the cock/vagina route. For most gay and bi men it's the cock/arse route. And due to the different physiological conditions in vaginas and arses the likelihood of effective transmission of HIV via receptive anal sex is eighteen times higher than via receptive vaginal sex. And research has shown that gay and bi men in general have way more sexual partners, and our rates of partner change are far higher, than straight people. And the prevalence of HIV infection amongst gay and bi male populations is also way higher than in the straight population of nearly every country in the world, meaning we are way more likely to have contact with way more HIV-positive sex partners. More testing, fewer condoms? CONDOMS DE-EMPHASISED Treatment as prevention specifically targets only those who have HIV, the NZAF points out, but 'use condoms every time' is a programme designed to reach 100% of the sexually active gay men in New Zealand, not just the 6.5% who have HIV. Reversing all the past successful work of 'use a condom every time' campaigning, by targeting just HIV-positive men, lets HIV-negative men off responsibility hook and places the full onus on only the infected men. And, with high promotion of treatment as prevention comes the implicit reinforcement of the message that so many people, from Catholic conservatives to misogynists to off-their-faces sex party devotees, so want to hear: that condoms aren't necessarily so important any more. As the NZAF points out, hardly any good scientific evidence exists that treatment as prevention will work amongst men who have sex with men as a population level prevention strategy. The only convincing studies supporting treatment as prevention are based on trials amongst selected straight populations dotted around the world. None of the researchers have bothered to check if and how it would work for men who have sex with men. UNAIDS, for example, crows loudly about the roll-out of its global treatment as prevention campaign but quietly mumbles about its shortcomings for men who have sex with men. Its highly-promoted big new thing may work for straight people, but it totally ignores many of the drivers of the gay and bi epidemic. As a result, the NZAF has even called this current approach of some global agencies "homophobic." If all nations had successfully and consistently promoted condom use amongst men who have sex with men since the early days of the HIV epidemic, as New Zealand and a small group of countries from the Nordic region and also some parts of Canada have pretty much been able to sustain, they would most likely also be seeing our lower incidence of HIV and our return to lowering annual rates of diagnoses. The dangers over-promotion of treatment as prevention represents to the leaders of nations with limited resources, unhelpful cultures or unsophisticated approaches to the epidemic of HIV amongst communities of men who have sex with men in their midst (and every nation has one, whether they acknowledge it or not) are obvious. But surely more 'on to it' nations, ones more like New Zealand, would see these dangers? Well... not really, or at least not yet. The Sydney Harbour Bridge lit up for World AIDS Day TREATMENT AS PREVENTION IN AUSTRALIA Let's look back across the Tasman. Australia's economic, social, cultural and geo-political nature is closer to New Zealand's than just about any other nation on earth. Like us, their HIV epidemic is almost totally amongst men who have sex with men, and both nations have been massively ramping up their testing of at-risk people. Australia's still a good point of reference for comparing 'the New Zealand way' and 'the non-New Zealand ways.' The Aussies are an intelligent, well-educated, free-thinking, well-resourced and well-informed society. Their well-funded HIV researchers, such as those at the Kirby Institute, are amongst the absolute best in the world. Surely they wouldn't suggest such a deeply flawed and unproven strategy? Just months after international agencies, notably UNAIDS, set a global target of zero new HIV infections by 2030 the Australian federal and state health authorities decided this target was just what they needed, and that treatment as prevention was the answer to their run-away epidemic amongst men who have sex with men. They announced that they would embrace the UN goals and even set a national target of reducing new sexually transmitted HIV infections to half their 2012 level by 2015. That's the year after next. And how will they do it? In the words of the Western Australia Department of Health: "Australia will need to increase HIV testing of people at risk of HIV to reduce the pool of people with undiagnosed HIV infection and achieve earlier diagnosis." In other words, treatment as prevention. Nowhere in their published Melbourne Declaration national statement of intent are condoms or encouraging gay and bi men to have safe sex mentioned, unless it's where they briefly and somewhat obliquely mention "increasing investment in current effective HIV prevention." In fact, seventeen months into Australia's treatment as prevention approach versus NZ's 'condoms every time' programme the all-important trend scorecard for new HIV diagnoses amongst men who have sex with men over the past two years shows Australia 26% up (and rising) and New Zealand 12% down (and dropping). Even in the latest official progress report on last year's Melbourne Declaration of their goals the Aussies admit that their progress so far has been "poor" and "falls well short of what is needed." It's no secret that many Australian clinicians at the coalface of their HIV epidemic, who now find themselves co-opted into the frontline of prevention, are sceptical of the task they have been given. As professionals concerned for the health of their individual patients they will execute it to the best of their abilities. But their position on how well it will really work in stamping out HIV is exemplified by the openly sceptical Professor Don Smith, director of Sydney's Albion clinic which has the highest patient load of HIV+ gay men of such clinics in Australia. Detailing his country's aims at the most recent two annual HIV Treatment Forums in New Zealand and in an exclusive Daily News interview just over a year ago, Smith all but rolled his eyes in exasperation. Straight vs gay prevalence of HIV around the world THE PROBLEM IS GLOBAL AND MASSIVE And the Australian result is being repeated in all kinds of countries all around the world. A major independent review of world-wide HIV infection and prevention programmes, released earlier this year, warns that "epidemics of HIV in men who have sex with men continue to expand in most countries in 2013 and rates of new infection have been consistently high among young [men]... In most parts of the world, denial, persecution, and refusal to include men who have sex with men within prevention programs intersects with individual behaviors to place [these men] at heightened risk of infection." It notes that there has been very little research done on the prevalence of HIV amongst gay men in many parts of the world, while straight populations have been much more comprehensively investigated. Here are a few more examples from countries similar and disimilar to New Zealand. The USA has the most rapidly increasing rate of new gay and bi HIV diagnoses in the world. It now easily exceeds 33,000 new infections amongst men who have sex with men each year, according to the latest available figures, and shows no sign of varying from its upwards trajectory. (It's sad to note that New Zealand's early work on HIV programmes looked to work being done in San Francisco and New York in particular, in the early days of the epidemic. We learned much from the strategies their gay HIV activists and educators were recommending. Our government resourced our community through the NZAF to put the gay-generated and -focussed plans into action with demonstrably excellent overall results. The USA federal and state authorities all but ignored those recommendations with increasingly tragic results.) Since this graph was produced, in 2011, the blue gay line rose even further In the UK the rate of new diagnoses amongst men who have sex with men continues to rise inexorably year upon year, with 3,250 diagnoses last year alone. It's a national and global situation that the National Director, Health and Wellbeing, for Public Health England just three weeks ago described as "potentially catastrophic." The U.N. Special Envoy for HIV/AIDS in Eastern Europe reports "alarming growth of outbreaks" of HIV infection amongst men who have sex with men in his region. In South Africa, the country with more people living with HIV than any other, HIV is now twice as common in men who have sex with men as it is in other people. Nearer home, in Thailand, where much emphasis has historically been focussed on the straight epidemic, especially amongst sex workers, a recent combined Thai Ministry of Health and US Centres for Disease Control study has revealed an "explosive epidemic" amongst white-collar and professional, educated gay men. A staggering thirty percent of gay and bi men visiting the Silom Community Clinic in Bangkok in recent times have been diagnosed with HIV. Further north, the UN itself admits that "in China, gay men alone account for more than 33 percent of new HIV infections." And, it says, "projections indicate that gay men may account for half or more of all new infections in Asia by 2020." Yet within days of this admission UNAIDS Deputy Director Programme, Luiz Loures, blithely predicted only "a few cases" of HIV infection "here and there" by 2030. In the face of this continuing "catastrophic" increase in diagnosed HIV infections amongst men who have sex with men all around the world, and the NZAF's clear denunciation of treatment as prevention as almost certainly unworkable amongst gay and bi men, the much-trumpeted next big thing in HIV prevention appears, to quote Oscar Wilde's Lady Bracknell, "radically unsound" for gay and bi men. Tomorrow, begins our one-on-one discussion with the most vocal and influential international cheerleader for treatment as prevention, Luiz Loures of UNAIDS. Jay Bennie - 1st December 2013

Credit: Jay Bennie

First published: Sunday, 1st December 2013 - 1:30am

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