Prevention Strategy – Page 2

New paradigms

I’m in Sydney, sampling a day of the Australian sexual health and HIV medicine conferences. Most of the really exciting social research is presented these days at biomedical conferences, because they are prestigious.

Working in the community health sector, a day is all my PD budget can afford, unless I approach a pharmaceutical company to sponsor my attendance. It’s a big problem if community workers can’t afford to take part, because we need that knowledge too.

Graham Hart from University College London just gave an incredibly lucid presentation on the change in paradigm he’s seeing in HIV prevention.

Where research used to focus heavily on individual behaviour, and how it interacted with the biology of STI, now we’re looking at the behaviour (and structure) of people in groups, and the overall ecology of STI, plus time, because epidemics change as they ‘mature’.

In the past decade, we’ve seen a very mild upward trend in the number of men who have unprotected sex with casual partners. Hart puts up UK data showing about 20% of gay/bi men had this kind of sex in the previous year.

He puts up another slide showing the number of men who report ‘serosorting’ (deliberately choosing a partner who reports the same HIV status for unprotected sex) has increased from about 7 to about 18% in the past decade.

This he attributes to the impact of the Internet, although I’m told serosorting showed up in Australian data from the 1980’s — almost as soon as the HIV antibody test became available. My guess is that serosorting is not, actually, a new development; having a name for the phenomenon is what’s new.

This is why we need a sociology of HIV prevention research and practice, since there are trends and patterns in how long-existing practices ‘in the real world’ get named and tagged as the ‘next big thing’ in HIV prevention.

In fact, Hart touches on this issue. He talks us through a range of new approaches, including biomedical and ‘social structural’ interventions.

Biomedical techniques include circumcision, lubricating gels with anti-HIV ingredients, and pre-exposure prophylaxis (PrEP) which is basically taking PEP before you fuck unsafely.

Hart points out that even circumcision, the most effective biomedical intervention found to date, is less effective than consistent condom use.

He tells the audience, “don’t give up on condoms just yet.”

I couldn’t agree more. With Ford Hickson, I’m very, very skeptical of the claim that “condoms are failing”. Ford points out that people who say prevention is failing want it to fail so they can take the money and do it themselves.

(And not because they’re bad people. That’s just a consequence of how funding processes put us in competition, not collaboration, with each other.)

Instead, our benchmark should be about 70-80% of gay/bisexual men practicing consistent condom use during casual sex… or maybe even most of the time. That’s about the best any country ever been achieved.

Setting that benchmark lets us ask how we divide up and target the rest. Only 1-2% of them are the “barebackers” that 99-100% of media coverage and community debate has focused on. The rest are just guys who occasionally have unprotected sex.

That includes me, by the way. Once, ever. With a guy in a sauna. It was his first time being fucked. We knew and liked each other. I knew he was a consistent condom user with his other partners.

With these ‘occasional’ guys, as Michael Hurley says, the infrequency of the occasions is a marker of their general commitment to safe sex.

When it is infrequent, although there are fewer occasions of risk, the intensity of risk might actually increase, because those men have less practice in risk reduction techniques that can help prevent HIV transmission during unprotected sex.

And if it occurs without planning, they may not be prepared to ask questions about their partner’s history of occasional unprotected sex and sexual health testing.

There have been resources in Australia that talk about those ‘risk reduction’ techniques, such as HIV-Positive Gay Sex (AFAO), but nothing I know about that has talked honestly to gay men about occasional unprotected sex.

We really need to start doing that, and I’m hoping tomorrow’s policy forum on “HIV from Epidemic to Endemic” will help start that conversation.

In closing, I want to ask a provocative question. It picks up on Hart’s message “don’t give up on condoms just yet.” He wasn’t talking to gay men. He was talking to an audience of people working in sexual health medicine: doctors, nurses, researchers, and policy people.

Here’s my question: is it possible we might be pushing for biomedical interventions that are less effective than condoms just because professional audiences are bored by hearing about condoms?

Treatment as prevention: sustainability not stigma

Treatment as Prevention is the idea of treating PLHIV early and en masse, based on the slowly emerging consensus among medical researchers that HIV treatment reduces infectiousness. That consensus is an interesting story in its own right, since there’s not yet any new evidence to support it.

Based on a wildly unrealistic mathematical model — set in South Africa of all places — public health practitioners have been planning experimental trials of the TAP concept, and a recent post on Peripheries blog takes aim against stigma, cited as a major objection against treatment as prevention.

Intriguingly, the post states a couple of times that it’s not about stigma. Over the past three years I’ve been doing a fair bit of training and writing about how we conceptualise stigma in HIV prevention work, so I contacted the author to find out what he thought it really was about.

Continue reading “Treatment as prevention: sustainability not stigma”

Tender, loving financial incentives

This week, an American public health practitioner posted on the US national AIDS blog about a new program starting up in the States. The program is called TLC-Plus, short for “Enhanced Testing, Linking into Care, Plus Treatment” for PLHIV. Here’s how the author, Carl Dieffenbach PhD, explained the need for that middle component, “linking into care” —

“Unfortunately, many people don’t make it to their follow-up medical visits for a variety of reasons. Yet these individuals can continue to spread the virus in their communities until we entice them to step through the door, whether it’s giving them a pat on the back or offering financial incentives.”

Continue reading “Tender, loving financial incentives”

Rising infections in gay men under 30

If current rates continue in 2009, new cases of HIV in gay men under 30 will be double their number in 2007. That goes against the overall trend for gay men in Victoria, which levelled off in 2008.

I have expressed concern in a couple of interviews about the lack of campaigns targeting gay men under thirty — I think the last one was in the nineties. That gets taken as an attack on the current Victorian AIDS Council campaign using porn images, but I actually think the plateau in overall infection rates shows the current mix of campaigns is doing good.

I also acknowledge the Victorian Government Department of Health for funding and coordinating a reinvigoration of our state’s HIV response.

While I think the explicit sexual imagery matches the sexual confidence and sophistication of men in their thirties and above, it doesn’t work as well with younger men, who are generally less confident, more conservative, and dealing with different issues, like coming out and the gay scene.

Not invariably, but generally.

That’s not just my opinion: it shows up in the social research. Garrett Prestage from the National Centre in HIV Clinical and Epidemiological Research has reported that while they have around the same total number of sexual partners as men in older age brackets, younger men tend to organise their sex lives differently, practicing “serial monogamy” (long strings of short, supposedly monogamous relationships).

Campaigns targeting young gay men need to include relationships and the scene as themes, and they need to address prevention issues relevant to guys in relationships.

Older men might remember the campaign advising men in relationships to close out the HIV test “window period” before they stopped using condoms with each other, but there hasn’t been a campaign about that since the nineties; how is a 23yo guy supposed to know that?

I feel quite uncomfortable raising the alarm about rising infection rates, because I don’t think infection rates should be the focus of campaign strategy in the first place.

The cultural processes that influence sexual behaviour are like a P&O cruise liner: they take a long time to stop. So by the time infection rates begin to rise, you’ve got a big job ahead of you, just trying to turn them around; and you are no longer doing prevention, only damage control.

In their report on The Contemporary Context of HIV Infection in Victoria, researchers Sean Slavin and Marian Pitts quote one young newly HIV-positive man saying:

Then I had my risk re-evaluation. I think a lot of people have it in
their early twenties. As a teenager I was really a safe sex fundamentalist. I redrew my risk profile a bit and started taking more mid-level risks, which were fine by themselves. They probably wouldn’t have caused me to convert. Then I started to top bareback. (p17)

Many of the attitudes our campaigns target in men aged 30 plus were formed in the intense sexual and social learning process men undergo in their twenties. It’s just good sense to invest in campaign work specifically targeting gay men under 30. I am only forced to make a fuss about the infection rate because that good sense has not yet been acknowledged.

Abstinence (Education) Doesn’t Work

Conservatives promote abstinence education using a simple syllogism. Abstinence means not having sex. If you’re not having sex, you can’t get pregnant or become positive. Of course, that’s treating abstinence education as abstinence in fact. They’re assuming the education is 100% effective. Now it’s official — abstinence is a crock.

WASHINGTON, April 14 (AP) — Students who participated in sexual abstinence programs were just as likely to have sex as those who did not, according to a study ordered by Congress. Continue reading “Abstinence (Education) Doesn’t Work”

High transmission risk among recently-infected people

Press Release from Infectious Diseases Society of America
Source: News-Medical.Net 09 Mar 2007 – 19:00 PST

New evidence suggests that the risk of HIV transmission may be highest in the early stages of infection. According to a study published in the April 1 issue of The Journal of Infectious Diseases, now available online, early infection accounted for nearly half of all transmission occurrences in an HIV-infected population in the province of Quebec, Canada.

Bluma Brenner, PhD, and Mark Wainberg, PhD, of the McGill AIDS Centre in Montreal, and colleagues from several hospitals and health clinics in Canada studied HIV transmission through phylogenetic analysis – essentially, drawing the virus’s family tree. The technique follows the history of a virus as it spreads from one person to another by looking at the evolution of viral genetic material in infected individuals.

Drs. Brenner, Wainberg, and colleagues found that 49 percent of early infections formed phylogenetic clusters – very close branches on the family tree. This indicated that a large portion of HIV acquisition could be attributed to individuals transmitting the virus who were themselves in the early stages of infection, before the virus had had time to mutate much. Therefore, early infection – also known as primary infection – which represented “less than 10 percent of the total samples, disproportionately accounted for about half of subsequent transmission events.”

A high viral load associated with early HIV infection is what makes newly infected individuals so infectious, according to Drs. Brenner and Wainberg. In an editorial accompanying the article, authors Deenan Pillay, MD, of the Health Protection Agency and University College London, and Martin Fisher, MD, of the Brighton and Sussex University Hospitals, pointed out that diagnosis of HIV reduces the risk of transmission. But, they note, symptoms of primary HIV infection are non-specific. Only a small proportion of infected individuals are diagnosed in early infection, thus compounding the difficulties in preventing transmission at that stage of infection.

“The early infection stage can be entirely asymptomatic,” Dr. Wainberg added. “This is why people who are recently infected may not know it, and will probably often test negative by conventional antibody screening. Hence, we must do a much better job of identifying recently infected people if we are to be able to counsel them to modify high-risk sexual behavior and desist from transmitting the virus.”

He suggested the development of affordable tests such as polymerase chain reaction assays to directly monitor the presence of the virus, instead of relying on the current method of antibody screening.

In addition, Dr. Pillay and Fisher asserted that more innovative and effective prevention strategies are needed to stem HIV transmission during primary infection and block the spread of drug-resistant viruses.