November 6, 2012
This article first appeared on PositiveLite.com, Canada's Online HIV Magazine.
The place of gay/bi men in our response to the HIV epidemic has changed. (And I say "gay/bi men" because I dislike seeing the term MSM -- men who have sex with men -- outside the realm of epidemiology.) Once, in those early days of the epidemic, we were both leaders and the focus of everything about HIV. But over time, and as other at-risk groups became more affected by the disease, that all changed. It had to.
So in looking at where gay/bi men stand today, there is history to be considered here. There are also political minefields to be avoided, and I'll try to do that too, because in highlighting the plight of one group it is too easy to neglect the needs of others. That is not my intention here at all.
Gay/bi men have always been generous in sharing the table. They remain doggedly so today. But sharing the table means sharing the spotlight also. And not just the spotlight -- money, prevention efforts, research priorities all need to be shared, so gay/bi men get a thinner share of the wedge than reflected in the proportion of those affected. In 2012 that wedge can be very thin indeed. And nowhere is this more apparent than in the advances in science that have opened up the prospect of a more robust approach to curbing the epidemic as a whole, but less so for gay/bi men.
Here's what we've seen in the last four years, the thin wedge in action.
While it was widely dismissed at the time, this statement was revolutionary. Here's what CATIE said back then:
"The Swiss commission said that a person with HIV/AIDS (PHA) would be sexually non-infectious if that person: a) is taking highly active antiretroviral therapy (HAART) with excellent adherence, b) has an undetectable viral load for the past six consecutive months, c) is in a stable and monogamous relationship and d) neither partner has a sexually transmitted infection (STI). The statement was an expert opinion based on a small number of studies in heterosexual people, but the implications were huge. If true, the statement seemed to say that some people with HIV might not need to use condoms every time they have sex."
But note that this study was on heterosexual couples. Organizations like the AIDS Committee of Toronto (ACT) were quick to suggest that this didn't change the need for condoms and to distance themselves from any suggestion that gay/bi men with undetectable viral loads were potentially less capable of transmitting the virus than those with higher viral loads. The message was, in fact, clearly "business as usual" for gay/bi men.
Dubbed "the trial that changed everything" (but clearly not for gay/bi men), this was essentially the evidence that the Swiss had been on to something, and this time the findings were more accepted. CATIE said this:
"That trial showed that in serodiscordant couples -- where one partner is HIV positive and the other negative -- potent combination therapy for HIV (increasingly called ART instead of HAART nowadays) can significantly reduce the risk of HIV transmission between heterosexual couples."
Said CATIE's James Wilton in an interview with me: "We really don't know if the relative risk-reduction while on treatment will be the same for gay men as for heterosexual couples." Wilton did acknowledge that some researchers felt that there might not be much difference. Still, business as usual was the message when it came to condom use, a message disputed by some poz gay/bi men who argued that condoms are less safe than having an undetectable viral load.
Despite the inherent logic, not to mention evidence, that reducing viral load reduces infectiousness, all other things being equal, treatment as prevention is now being suggested as ineffective in gay/bi men. Prominent Canadian researcher Barry Adam's presentation on this topic at AIDS 2012 was summarized thus: "Fifteen years after the introduction of ART, no decline in HIV incidence among MSM is evident in advanced, industrial countries. So far there is a lack of evidence that the treatment-as-prevention strategy is having the predicted effect in the population that makes up the largest part of the epidemic in countries with universal access to treatment." Adam pointed to recent rises in MSM infection rates in British Columbia where treatment-as-prevention practices are in effect. Meanwhile, other sources, like this one, suggest that widespread use of antiretroviral therapy, a cornerstone of treatment as prevention, has led to stabilizing of the epidemic in MSM despite increases in risk behavior. Who to believe?
There seems to be general agreement that gay men are under-researched. It has been suggested only 5% of HIV research in Canada is specific to gay/bi men. And the gaps are major indeed. Four years after the Swiss Study we still have no indication whether those landmark findings apply to gay/bi men because zero research has been published on this topic. Given that gay/bi men are most affected by the epidemic that situation strikes me as shocking.
Meanwhile MSM infections are on the rise. While not the only demographic where there is an upwardly trending rate of new infections, MSM have recently regained their place as accounting for the majority of new infections in Ontario. In fact that percentage has risen sharply in Ontario over the last five years from 39.8% in 2006 to 51.4% in 2012 to date. The reasons for why this might be happening are complex and varied -- but is neglect of an entire demographic one of them?
Here in Canada, we have an odd infrastructure where we have a variety of government-financed groups that represent almost every at-risk group you can think of -- women, people of color, youth, prison inmates, injection drug users, trans folks, children with HIV. But where is the group that advocates specifically for gay/bi men? Answer: there isn't one. So there are structural issues to be addressed here.
We are so used to hearing other marginalized groups vying for attention that it feels almost awkward to suggest that gay/bi men need to advocate for their share of the pie, however you define it, too. But I think we do, or the status quo will reign on.
Individually and collectively, we can also be more challenging. As a community we suffer tragically from "group think," believing everything we are told -- that HPTN 052 doesn't apply to us, that the semen of undetectable gay/bi men is dangerously loaded with virus (it hardly ever is), that condoms are the answer to everything. The result? Inertia. We just all need to be more questioning.
In short, we need to appear more needy. Still seen by some as the spoiled brats of the movement, in 2102 gay/bi men are decidedly not. So let's make noise again.
We deserve a better deal.