Where are we in HIV reduction among gay, bisexual, and other men who have sex with men?

1. Where are we in HIV reduction among gay, bisexual, and other men who have sex with men? Barry D Adam University ProfessorSenior Scientist & Director of Prevention Research,

2. Proposition • > 15 years after the introduction of ART • No decline in incidence rates among MSM • Lack of evidence that treatment-as-prevention (T as P) is having a significant effect • Over-reliance on biomedical solutions • Need better understanding and engagement with the sexual cultures of gay, bisexual other MSM

3. Examining the evidence for T-as-P • Montaner, J., Lima, V., Barrios, R., Yip, B., Wood, E., Kerr, T., Shannon, K., Harrigan, P. R., Hogg, R., Daly, P., & Kendall, P. (2010). Association of highly active antiretroviral therapy coverage, population viral load, and yearly new HIV diagnoses in British Columbia, Canada. Lancet, 376, 532-539. • “there was about a 50% reduction in new diagnoses per year in individuals with a history of injecting drug use, from 159 cases in 1999, to 80 cases in 2009 (p=0.003). By contrast, the number of new positive tests remained stable (p=0.6229) in individuals with no history of injecting drug use.” 534 • dubious claim for IDUs: InSite & needle exchange • MSM 34.5% of BC epidemic in 2001 • 154 or 52.6% in 2008

4. T-as-P in British Columbia BC Centre for Disease Control. Annual Surveillance Report: HIV and Sexually Transmitted Infections. 2009. http://www.bccdc.ca/NR/rdonlyres/1EB98347-949B-466B-A494-FF7B9B476F01/0/STI_2009_STI_Surveillance_Report_20101105.pdf

5. Examining the evidence • Das, M., Chu, P., Santos, G.-M., Scheer, S., Vittinghoff, E., McFarland, W., & Colfax, G. (2010). Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS ONE, 5(6), e11068. doi:10.1371/journal.pone.0011068. • falling community viral load, 2005-2008, used to explain falling transmission rates in San Francisco • No post-2008 figures yet posted to verify trend • no clear trend in California as a whole • no such trend in US as a whole

6. Age profile of San Francisco PHAs

7. Examining the evidence • Cowan, S., Gerstoft, J., Haff, J., Chistiansen, A., Nielsen, J., & Obel, N. (2012). Stable incidence of HIV diagnoses among Danish MSM despite increased engagement in unsafe sex. Journal of Acquired Immune Deficiency Syndromes, DOI: 10.1097/QAI.0b013e31825af890. • define a “Cohort Community Reproductive Rate (CCRR).... as the number of newly HIV infected MSM in a calendar year per HIV infected MSM.” • 80% increase in incidence among MSM matched by 80% in HIV+ MSM, 1995-2010 = stable • Median age of HIV+ MSM rose from 38 to 47

8. No decline of incidence in 2000s • Meta-review of mean HIV incidence rates from the entire published incidence literature on MSM from Europe, North America and Australia for the period 1995–2005 • “The stability of HIV incidence rates from 1995 to 2005 suggests that very high prevalence rates of HIV are being reproduced across new generations of gay men, and that conclusion is almost certainly true among African American MSM.” • Stall, R., Duran, L., Wisniewski, S., Friedman, M., Marshal, M., McFarland, W., Guadamuz, T., & Mills, T. (2009). Running in Place. AIDS and Behavior, 13, 629.

9. No decline in the United States Wolitski, R., & Fenton, K. (2011). Sexual health, HIV, and sexually transmitted infections among gay, bisexual, and other men who have sex with men in the United States. AIDS and Behavior, 15, S9-S17.

10. No decline in the United Kingdom Figure 2: Number of new HIV diagnoses* by prevention group, UK: 2000-2009 Health Protection Report, Weekly Report, 4 (47), 26 November 2010

11. No decline in France LeVu, S., Le Strat, Y., Barin, F., Pillonel, J., Cazein, F., Bousquet, V., Brunet, S., Thierry, D., & Semaille, C. (2010). Population-based HIV-1 incidence in France, 2003–08:. Lancet infectious diseases, 10, 682-687.

12. No decline in Canada or Australia Canada HIV/AIDS Epi Update, Public Health Agency of Canada, http://www.phac-aspc.gc.ca/aids-sida/publication/epi/2010/pdf/EN_Chapter9_Web.pdf Australia Falster, K., Gelgor, L., Shaik, A., Zablotska, I., Prestage, G., Grierson, J., et al. (2008). Trends in antiretroviral treatment use and treatment response in three Australian states in the first decade of combination antiretroviral treatment. Sexual Health, 5, 125–130

13. Reasons why: bio/epi factors • higher baseline risk of anal sex multiplied over time (Wilson et 2008) • untested positives (Fisher et al 2010; Hall et al 2012) • large numbers of HIV+ people not attaining undetectability(Gardner et al 2011) • adherence problems, treatment interruptions affecting viral load (Rieder et al 2010) • viral blips (DiMascio et al. 2003; Nettles et al 2005) • undetectable blood vs detectable semen (Halfon et al 2010; Sheth et al 2009) • re-colonization of genital tract in PHAs having UAI with other PHAs(Sheth et al 2011; Politch et al 2012) • facilitation by co-occurring STIs including HSV2 (Kalichman, Pellowski & Turner 2011) • concurrency

14. “risk compensation” • Translation: biomedical science has done all it can; people at risk are delinquent • Or HIV industry-induced/iatrogenic effect? • While most HIV+ MSM are having sex with steady partners, safe sex with casual partners, or no sex at all…

15. Sexual health of HIV+ MSM • UAI higher in those aware of the Swiss statement (Brennan et al 2010; Hart et al 2010; Hasse et al 2012) • much higher rates of STIs among HIV+ MSM • Gonorrhea, syphilis, hepatitis C, LGV (Dodds et al 2012; Prestage et al 2011) • Drug-resistant gonorrhea • Specifically, “non-concordant UAI was significantly associated with use of methamphetamine, cocaine, poppers, heroin, and drugs used to treat erectile dysfunction (ED); number of sex partners; and meeting a partner via the Internet or in a bathhouse ” • Golden, M., Wood, R., Buskin, S., Fleming, M., & Harrington, R. (2007). Ongoing risk behavior among persons with HIV in medical care. AIDS and Behavior, 11, 729. • CfZablotska, I., Crawford, J., Imrie, J., Prestage, G., Jin, F., Grulich, A., & Kippax, S. (2009). Increases in unprotected anal intercourse with serodiscordant casual partners among HIV-negative gay men in Sydney. AIDS and Behavior, 13, 638-644.

16. UAI especially among HIV+ MSM • Meta-review of 53 studies published since 2000 • Van Kesteren, N., Hospers, H., & Kok, G. (2007). Sexual risk behavior among HIV-positive men who have sex with men. Patient Education and Counseling, 65, 5-20. • high levels of UAI among MSM who know that they are HIV-infected. Twenty-nine of the 53 studies showed UAI rates among HIV-positive MSM of over 40% (range 6–84%) • much of this UAI occurs with partners who are HIV-negative or of unknown HIV status (range 13–51%) • UAI is much higher among HIV-positive MSM than HIV-negative MSM; • almost all longitudinal studies of MSM document increases in UAI, providing the most consistent evidence of an increase in sexual risk behavior among HIV-positive MSM.

17. Need to delineate and engage gay cultures • deterritorialization/virtualization of sexual connection • marketization/neoliberalism • Institutional level: techno-eschatology • Professionally administered biomedical solutions • Community level • practical and emergent moral interaction • tacit norms governing sexual exchange • construction of the autonomous, male actor

18. Frontiers of viral movement • Networks, taste groups, ethnicities... • Syndemics • Community mobilization? • Researchable question • Virtual communities/virtual fora • Cultures of gay and bisexual men • Poz cultures