Analysis: Most At-Risk For HIV Not Studied

 

New Analysis of World’s Premier AIDS Conference Finds Poor Coverage of Populations Most-at-Risk for HIV

Hundreds of Organizations Worldwide Call on Conference Organizers to Increase Meaningful Coverage of Gay Men, Transgender People, People Who Inject Drugs, and Sex Workers

A new report produced by a coalition of global advocacy organizations shows that the International AIDS Conference (IAC) program continues to lack meaningful coverage of populations most-at-risk for HIV, including men who have sex with men (MSM), transgender people, people who inject drugs (PWID), and sex workers. Over 220 organizations from more than 70 countries around the world have called on the organizers of the IAC to take concrete measures to increase coverage of HIV-related issues concerning the health and human rights of these populations worldwide.

The report features a systematic quantitative audit and qualitative analysis of the topics and countries covered by abstracts on most-at-risk populations at the 2012 IAC, also known as AIDS 2012. These populations are also called “key populations,” because they are both key to the epidemic’s dynamics and key to the response. As an in-depth examination of research presented at the world’s premier AIDS conference, the report also offers a glimpse into the current state of research on these key populations globally.

The quantitative audit of the AIDS 2012 program showed that only 17% of all abstracts presented at the conference were exclusively focused on MSM, transgender people, PWID, or sex workers. Some key populations were better represented than others. The percent of all abstracts exclusively dedicated to each key population was 8% for MSM, less than 1% for transgender people, 5% for PWID, and 4% for sex workers.

The qualitative analysis of abstracts on these populations was even more revealing, indicating that more abstracts on key populations focused on individual risk factors (40%) than any other topic, including structural factors [e.g. policy, stigma, violence] (26%); primary prevention (19%); testing, care, and treatment (15%); and surveillance (10%). Only 29% of abstracts on key populations focused on describing interventions, while 71% described vulnerabilities without offering any detailed solutions.

“This meager level of coverage on issues concerning our communities at the International AIDS Conference is unacceptable,” said Dr. George Ayala, Executive Director of the Global Forum on MSM & HIV (MSMGF) and co-author of the report. “Not only was there a comparatively low number of abstracts on key populations at the conference, but the content of these abstracts was largely divorced from the most urgent needs of key populations as identified by members of the populations themselves.”

The report cites the body of abstracts at AIDS 2012 focused on MSM as an example of the gap between the kind of research prioritized by key population stakeholders and the kind of research ultimately presented at the conference. Ahead of AIDS 2012, the MSMGF conducted a global survey of nearly 300 MSM advocates and service providers around the world to identify the topics they felt would be most important to address at the conference. The top three themes were “Prevention,” “Stigma and Discrimination,” and “Law and Criminalization.” Of all abstracts presented at AIDS 2012, the percentage dedicated to these themes in relation to MSM was 1.6%, 0.5%, and 0.3%, respectively.

“After thirty years of AIDS, we know key populations are at much greater risk than the general population in nearly every country around the world,” said Allan Clear, Executive Director of the Harm Reduction Coalition and co-author of the report. “Our communities deserve proper attention, and mounting evidence argues that addressing HIV among key populations is central to ending the global AIDS crisis. It is time for the IAC and the broader AIDS response to start addressing HIV among key populations in a more equitable, more appropriate, and ultimately more effective way.”

In addition to examining the number and focus topics of abstracts on key populations, the report also assessed geographic coverage. Of all abstracts on key populations, nearly 40% focused on North America and Western Europe. A country-level analysis revealed that nearly two-thirds of all key population abstracts were concentrated in 10 countries alone. Of the remaining 79 countries represented in these abstracts, 32 had only 1 abstract on 1 key population. Numerous regions and countries with concentrated epidemics among key populations were either underrepresented or entirely absent.

“The poor coverage of topics concerning key populations, especially from lower-income countries, may reflect inequitable global funding for research on key populations as much as it reflects the IAC’s processes that reinforce these inequities,” said JoAnne Keatley, Director of the Center of Excellence for Transgender Health at the University of California, San Francisco and co-author of the report. “The IAC’s organizers must update the conference’s processes to ensure the event is as valuable as possible for addressing the urgent HIV epidemics among key populations. As the premier platform for sharing the latest research on HIV and AIDS, it must lead the global AIDS research field to do the same.”

“The IAC represents a unique and powerful opportunity to impact the global AIDS epidemic,” said Anastacia Ryan, Global Policy Officer on HIV and Sex Work at the Global Network of Sex Work Projects (NSWP). “The conference offers unparalleled potential to shape the industry’s discourse, funding priorities, and locus of scientific inquiry, giving key affected populations the recognition they deserve as partners in fighting the epidemic. By updating its processes to increase meaningful engagement with and coverage of key populations, the IAC will not only support the development of more effective strategies to address the needs of key populations, it will bring the global AIDS response closer to developing the comprehensive solutions we need to end the epidemic.”

The report concluded with a set of 5 recommendations for measures that can be taken by conference organizers to increase meaningful coverage of key populations at future IACs. The recommendations include conducting community consultations, issuing targeted calls for abstracts, and advocating with large funders and research institutions for more appropriate funding and support for research on key populations. A total of 221 organizations from 73 countries endorsed the recommendations for action.

The full report, entitled “Coverage of Key Populations at the 2012 International AIDS Conference,” is available online at http://www.msmgf.org/files/msmgf//Advocacy/AIDS2012_KeyPopulations.pdf  The report was jointly produced by the Global Forum on MSM & HIV (MSMGF), Global Action for Trans* Equality (GATE) , the Center of Excellence for Transgender Health (CoE), the Harm Reduction Coalition, the International Network of People Who Use Drugs (INPUD), Different Avenues, and the Global Network of Sex Work Projects (NSWP).

The full list of recommendations and endorsements can be found online at http://www.msmgf.org/files/msmgf//Advocacy/Action_Alerts/AIDS2014_CCC_Signatures.pdf

 

CDC: HIV Cases Decline for Black Women, Increase for Gay Men

Some disturbing news. From Reuters:

The CDC reported that the number of new cases of HIV among black women declined 21 percent between 2008 and 2010, while the incidence of HIV among young gay and bisexual men rose by 22 percent in the same time frame. The rate of HIV infections among black women remains 20 times higher than the number of new cases in white women, and HIV-infected black women account for 70 percent of HIV incidence among all women. Men who have sex with men comprised almost two-thirds of all new HIV infections in 2010.

Joseph Prejean, chief of the Behavioral and Clinical Surveillance Branch in CDC’s Division of HIV/AIDS Prevention, attributed the decline in new HIV cases among black women to HIV testing and the success of HIV

Drugs

Drugs (Photo credit: Images_of_Money)

awareness campaigns. “Treatment advances” for AIDS may have caused young men to underestimate their risk and the health threat posed by HIV”, said Prejean. Although anti-retroviral treatment prolongs life, HIV-infected individuals can expect to take medicine for the rest of their lives, at an estimated lifetime cost of $400,000. (emphasis mine)

Young black men who have sex with men have the highest HIV incidence of any population group within the United States. An earlier CDC report stated that 26 percent of new HIV cases occurred among young people age 13 to 24. Half of HIV-infected young people do not know their HIV status, reported CDC Director Thomas Frieden, MD.

Read the full article here.

Bisexual Men and Women Less Likely Than Gay Men, Lesbians to Disclose Sexual Orientation

English: Illustration of the double moon symbo...

English: Illustration of the double moon symbol used by bisexuals who wish to avoid the use of triangles. This example is in the colours of the Bisexual Pride flag. (Photo credit: Wikipedia)

New research shows that bisexual men and women are less likely than gay men and lesbians to disclose their sexual orientation to healthcare providers.  The study, which examined nondisclosure of sexual orientation among lesbians, gay men and bisexual men and women, found that concealment of sexual orientation from healthcare providers was related to poor psychological wellbeing.

“This study adds to a growing literature that shows that a one-size-fits-all approach to understanding the health of sexual minorities ignores differences among subpopulations within this community,” said Laura Durso Ph.D., Williams Institute Public Policy Fellow.

Nondisclosure was higher among bisexual men of whom 39% did not disclose to any medical provider and bisexual women of whom 33% did not disclose to any medical provider.  Disclosure was much more prevalent among gay men and lesbians among whom only 13% and 10%, respectively, did not disclose their sexual orientation to any medical provider.  Among lesbians, greater nondisclosure was found among racial/ethnic minorities, women with lower educational level, and women with children. Among both gay and bisexual men, greater nondisclosure was found among younger men and men who were born outside the U.S.

The study, entitled “Patterns and Predictors of Disclosure of Sexual Orientation to Healthcare Providers among Lesbians, Gay Men, and Bisexuals,” was funded by the National Institute of Mental Health and is published in Sexuality Research and Social Policy.

Full study: click here.

Study: Access to HIV Services for Gay Men Worldwide Stunted By Homophobia

Global study finds homophobia, comfort with service provider, and community engagement make significant impact on access to condoms, lubricant, HIV testing, and HIV treatment

A large-scale study of gay men and other men who have sex with men (MSM), conducted by the Global Forum on MSM & HIV (MSMGF), indicates that only one third of MSM can easily access condoms, lubricant, HIV testing, and HIV treatment. Combining a multi-lingual online survey and focus group discussions, the study suggests that structural barriers like homophobia play a significant role in blocking access to HIV services for MSM, while greater comfort with service providers and community engagement are associated with higher levels of service access.

The MSMGF’s study aimed to identify barriers and facilitators that affect access to HIV services for MSM. The online survey conducted this summer included 5779 men from 165 countries.  In addition, the MSMGF collaborated with African Men for Sexual Health and Rights (AMSHeR) to conduct focus group discussions with a total of 71 MSM across five cities in South Africa, Kenya, and Nigeria.

Of men who participated in the online survey, only 35% reported that condoms were easily accessible, 21% reported easy access to lubricant, 36% reported easy access to HIV testing, and 42% reported easy access to HIV treatment. Levels of access differed across low-, lower-middle-, upper-middle- and high-income countries, with reduced access to services more commonly reported in lower-income countries.

Percent of MSM reporting that condoms, lubricant, HIV testing, and HIV treatment
are easily accessible
(organized by country income level using World Bank country income classifications)

“Such poor levels of access at the global level are unacceptable,” said Dr. George Ayala, Executive Director of the MSMGF. “The differences in access by country income level are especially important to note as the Global Fund moves into a new funding model where countries are grouped into bands by income level. Even in upper-middle-income countries, MSM still have extremely low access to services. Without targeted funding to MSM and other key populations, the new funding model may continue to deteriorate levels of access for the groups most affected by HIV.”

The MSMGF research team also conducted analyses to identify barriers (factors associated with lower access) and facilitators (factors associated with higher access) that impact the ability of MSM to obtain condoms, lubricant, HIV testing, and HIV treatment.

Adjusting for country income, greater access to condoms, lubricants and HIV testing were associated with less homophobia, greater comfort with health providers, and more community engagement. Among participants living with HIV, higher access to HIV treatment was associated with less homophobia and greater comfort with service providers.  Greater access to lubricants and greater access to HIV testing were also associated with less outness (the degree to which others know of one’s sexual orientation) and fewer negative consequences as a result of being out, respectively.

“As we collectively forge ahead into the new territory of treatment-based prevention, it is clear that many of the old challenges remain,” said Noah Metheny, Director of Policy at the MSMGF. “Addressing structural barriers remains essential to realizing the potential of HIV interventions for MSM, and it becomes more important with each new prevention and treatment option that is made available. Investments in the development of new interventions must be accompanied by efforts to increase access.”

The quantitative data from the online survey was supplemented with qualitative data from focus group discussions, helping to place barriers and facilitators in the broader context of the sexual health and lived experiences of MSM. Focus group discussion participants identified barriers and facilitators that were highly consistent with those found in the online survey, and many participants explained the ways that structural barriers at the policy, cultural, and institutional levels cascade down through the community and individual levels to block access to services for MSM.

Focus group discussion participants described how structural barriers like stigma, discrimination, and criminalization force MSM to hide their sexual behavior from health care providers, employers, landlords, teachers, and family members in order to protect themselves and maintain a minimum livelihood. The inability of MSM to reveal their sexual behavior to health care providers was linked to misdiagnosis, delayed diagnosis, and delayed treatment, leading to poor health prognosis and higher risk of transmitting HIV and other sexually transmitted infections to partners.

Conversely, focus group discussion participants explained that the negative consequences of structural barriers were moderated by the existence of safe spaces to meet other MSM, safe spaces to receive services, access to competent mental health care, and access to comprehensive health care. Participants described MSM-led community based organizations as safe spaces where they could celebrate their true selves, receive respectful and knowledgeable health care, and in some cases receive mental health services.

“The study’s findings underscore the urgent need to improve access to essential HIV services for gay men and other MSM worldwide,” said Dr. Ayala. “Interventions must both disrupt the negative effects of barriers and bolster the protective effects of facilitators. Study participants clearly indicated that community engagement and community-based organizations are central to moderating barriers and facilitating service access. Successfully addressing HIV among MSM will require a real effort to address structural barriers, and the findings from this study suggest that investing in MSM-led community-based organizations may be the best way to do that.”

Agreed. MSM-led community-based organizations must continue to work tirelessly to eliminate fear, shame, stigma and ignorance. They are all still very much with us.

And they’re killing us.

Related articles

For Men Only- Your Sexual Health

From the National Association of State and Territorial AIDS Directors (NASTAD) and the National Coalition of STD Directors (NCSD) comes a new pamphlet aimed at helping men who have sex with men (MSM) take charge of their sexual heath:

“Whether you are gay, bisexual or any man who has sex with other men (MSM), there are certain health services that are important for you to talk about with your doctor to protect your sexual health. This brief pamphlet is designed to help you get the best sexual health care during your visit to the doctor.”

An amazing array of helpful information about special health concerns and working with your healthcare provider.

View “For Men Only- Your Sexual Health” here.

Hard Truths (About Gay Men & HIV)

From NAPWA’s Positive Voice Newsletter:

National Gay Men’s HIV/AIDS Awareness Day – NGMHAAD – is coming September 27, three months to the day after National HIV Testing Day, and hard on the heels of July’s landmark International AIDS Conference (IAC) in Washington, D.C. We have two messages this year: Be aware, know your risk, and, Let’s end this epidemic! Because we matter – and we can.

Speaker after speaker at IAC returned to this year’s good but challenging news: yes, we still need more science to stamp out HIV – more and better antivirals, an effective vaccine, and a functional cure – but we already have all the biomedical tools we need to make new HIV infections a thing of the past. The hard part is reaching “key populations” – groups with high rates of existing infections and new infections because they have been marginalized, stigmatized, denied civil rights, and excluded from health care.

NGMHAAD is for one of those “key populations:” this country’s men who have sex with men (MSM). NAPWA founded NGMHAAD in 2008 because we want them to know the epidemic isn’t over. We want them to know how high their HIV risk really is – because so many are already infected, and too many don’t know it. And we want them to know that we’ve come a long way since AIDS was first reported in 1981, and even further since Stonewall, but stigma is still driving this epidemic and gay men don’t have to take it anymore.

So let’s look at some numbers and see what that the gay men’s HIV epidemic looks like in the U.S.

The July 28 issue of The Lancet opened an admirable series of articles on HIV among gay men worldwide with a look at epidemiology, and reported that HIV prevalence among men who have sex with men in its North American region is a jaw-dropping 15.4% – almost one in six. The real prevalence may be a little lower - The Lancet assumes that only 3.7% of American men are MSM, a number we think is too low, and raising the estimated number of MSM would reduce the calculated prevalence a little – but it’s still clear that prevalence is breathtakingly higher among MSM than in the rest of the population.

Let’s calculate just how much higher.

About 251 million Americans are 15 or older. If 5 percent of the men are MSM, we have 6.3 million MSM and 245 million “others” 15-and-older in this country. We’re all familiar with the CDC’s estimates that 1.2 million Americans are living with HIV, and 60% of them are MSM. That gives us 480,000 infections in 245 million “others,” for a prevalence of 0.2% – one in five hundred. It also gives us 720,000 infections in 6.3 million American MSM, for a prevalence of 11.5% – just shy of one in eight. HIV prevalence among American MSM is almost 60 times what it is in the rest of the population.

That means HIV-negative MSM who are active with partners whose status they don’t know are at much higher risk than many realize. So the first and most important message of National Gay Men’s Awareness Day is – simply – be aware. Know your status. Know your risk. If you aren’t absolutely sure you know your own and your partner’s status, keep your condoms handy.

In September 10’s Positive Voice, we’ll write about how we got to where we are and what’s needed to deal with the MSM epidemic on the ground. Why near-universal testing is so important when prevalence is already so high. The need to confront stigma and talk frankly about sex in communities where this is deeply uncomfortable. The need for pride and love. The need to have culturally competent and welcoming health care for MSM.

And in the September 24 issue, just three days before NGMHAAD, we’ll remember the quarter-million (at least) American MSM who have died of AIDS and examine our responsibility as their survivors to demand action to end this epidemic once and for all. Now that we can, we must.

Gay Men’s Wives, Homophobia and HIV

(click for source)

Discrimination and homophobia are often more prevalent in rural areas. Outreach workers in Montana know that there are certainly barriers for men to being tested for HIV. One of the most significant is the fear of being harshly judged, labelled and dismissed. It’s one of the reasons some gay/bi men get married to women and start families- they want to be ‘normal’- even though they already are. The sense of shame and guilt can be overpowering- and it’s adding fuel to the fire as far as HIV is concerned.

Rural outreach workers have known this for years- it may be one of the reasons that HIV is spreading so rapidly in the south. It’s almost certainly one of the reasons that HIV is spreading in the African American population. But we haven’t paid much attention- at least scientifically- to this issue. Now it looks as if science is actually catching up to reality. From The Sobering Truth About HIV Among MSM by Gregory Trotter, Chicago AIDS Foundation blog (July 25):

The idea of “turning the tide” against the AIDS epidemic will prove to be no more than a slogan if more is not done to address the growing number of gay/bisexual men infected with HIV worldwide, experts said today.

Speaking at an afternoon press conference today, a panel of experts presented new research – recently published in a series in the medical journal, The Lancet – that confronted the reality of HIV prevalence among MSM (men who have sex with me).  The series concluded that, in addition to medical and scientific advances, more must be done to eradicate the cultural and societal impediments of homophobia and discrimination. Until that happens, ending the AIDS epidemic is unlikely, said Chris Beyrer, a professor at Johns Hopkins Bloomberg School of Public Health. (emphasis mine)

We routinely encounter discrimination in dealing with MSM in Montana- some of whom do not openly identify as gay. In fact, some are married- with children- and do not plan on leaving their families. But they’re having sex with other men- and some are not using condoms with their wives. “If I did, she’d know I was having sex with someone else,” one client told me.

The fear of being exposed for these men is great. One man told me, “I can’t afford to be seen as gay. It would kill me- it would kill my wife.”  Shame from society, churches and social groups abut being gay have forced men to create false lives. But they haven’t stopped sexual behavior. This type of internalized shame is not uncommon here- and the wives of these men could be put at risk as a result.

Shame, homophobia and discrimination are fueling the epidemic- so are apathy and denial (see my essay Gay Men Are Flunking The Test). Part of me wonders when we’re going to start seeing a rise in HIV infection among rural women- the wives of gay/bi men. Back to Mr Trotter:

On average, MSM are 19 times more likely to be infected with HIV than the general population in low- and middle-class countries, according to Dr. Kevin Fenton, director of the National Center for HIV/AIDS.

Many African countries do not accurately report numbers of MSM and some do not even acknowledge they have MSM among their population, said Paul Semugoma,  Uganda physician who serves on the steering committee for the Global Forum on MSM &HIV (MSMGF).

Homophobia is rampant in such countries, he said.

“If we don’t start solving these impediments for MSM, we’re not going to do much about the epidemic,” Semugoma said.

In a recent study in Jamaica, 82% of Jamaicans self-identified as homophobic, largely out of fear of HIV prevalence among gay/bi men, said Maurice Tomlinson, legal advisor on marginalized groups for AIDS-Free World, an international advocacy group.

Such homophobia has engendered a climate where gay men are afraid to buy condoms for themselves, Tomlinson said. Their female friends often buy condoms for them, he said, but refuse to buy lube, as that would imply a female “deficiency.”

And so many gay/bisexual Jamaicans use petroleum jelly, saliva or even hairspray as a lubricant, he said.

“In those cases, it would be better if they used nothing at all,” Tomlinson said.

To learn more about how HIV affects MSM throughout the world and possible solutions to problem, read the full series in The Lancet titled HIV in Men Who Have Sex with Men.”

HIV Is In Montana- It’s No Bull

The second video in the Montana social marketing campaign for HIV Awareness:

This HIV prevention animation targeting the MSM population is a playful look at a young bull elk that is looking for a relationship in Montana. As the party music plays he searches the herd for another bull who has been “Checked” (tested) for HIV. This is a creative project that was created by Laura Dybdal and Amber Bushnell as a part of Montana’s HIV Prevention Social Marketing Campaign. It also directs viewers to getcheckedmt.org, a resource to find the nearest HIV testing location in Montana.

The first one was posted yesterday….

HIV In Montana: It’s Not Classified

One of two new Montana public service message targeting men who have sex with men- check back tomorrow for the second:

This short point of view video targeting Montana’s MSM population looks at the Classified Personal ads and points out some HIV facts that should not be classified and offers some excellent reasons to get tested (checked) for HIV. It also directs viewers to getcheckedmt.org , a resource to find the nearest HIV testing location in Montana.

This creative project was created by Laura Dybdal and Jason Gutzmer as part of Montana’s HIV Social Marketing Campaign.

Related articles

Young Men’s Retreat In One Word: AMAZING

I had the privilege to spend the weekend with 14 young gay/bi men from across the state of Montana for a weekend of fun, education, fun, community building, fun, discussion and did I say, fun?

Whenever I go away for the weekend I have a lot to catch up on- thus the reason for no posts for the last two days. But I wanted to say that being around these guys, watching their enthusiasm for life, their interest in making life better for young gay men in the state and the strength and energy they brought to (and hopefully took home from) this weekend, energized me and gave me renewed energy to do what I do.

It might sound sappy, but I don’t care. This retreat was the best I’ve ever been involved in- and the (I want to call them kids, but I don’t want to sound condescending) participants made me realize that the future is in pretty good hands.

That’s excellent, because I’m not getting any younger.

Special thanks to FDH and Associates (David Herrera, Chantz Thilmony) and the Montana Gay Men’s Task Force for their dedication to the wellness, safety and education of gay/bi men in Montana. And to Bernie Kneefe for being the Den Mother.

If you’re a young gay/bi man who wants to be involved in this next year- go here. They’ll hook you up.