Visual AIDS Signs On to an Open Letter to CDC Regarding Testing, Risk of Gay, Bi and Other MSM

CDC Die-In, 1991, Brent Nicholson Earle

Open Letter to the Centers for Disease Control and Prevention (CDC) on 2013 MMWR Report on HIV Testing and Risk of US Gay, Bisexual and other MSM[1]:

A call to re-evaluate language, methods and recommendations
in order to support men's health and HIV resiliency:[2]
CDC urged to reduce its own risk of misleading depictions of
Gay/Bi/MSM sexuality, HIV prevention practices

Seeking the spotlight of World AIDS Day, CDC released a report in their Morbidity and Mortality Weekly Report (MMWR) focused on gay, bisexual and other MSM (men who have sex with men) in the United States -- the population that remains both disproportionately affected by HIV and drastically underserved by federal HIV/AIDS prevention resources.

The press release for the report, headlined "Sexual risk lower among U.S. gay and bisexual men who accurately know their HIV status,"[3] provides a constructive and accurate emphasis on the success of gay and bisexual men who know their HIV status. Thus, it delivers an encouraging message about the importance of HIV testing.

However, the full MMWR article is quite different in its messaging and emphasis, skewing sharply to language that could encourage sexual stigma and blaming.

Both documents use increasingly antiquated language on risk, miss the opportunity to take a bold and scientifically-validated stance on systems change to facilitate more frequent HIV testing for bisexual and gay men, and does not clarify if transgender women are included in the historically-confusing category of MSM.

We urge CDC to take this opportunity to re-evaluate language, methods and recommendations regarding the sexuality and HIV prevention practices of gay, and bisexual men and other MSM.

We look forward to further dialogue with you on these and other issues:

1) "Unprotected anal sex" and "unprotected discordant anal sex" are the key terms for looking at sexual behavior across the three years of the NHBS cohort.

However, these terms have grown increasingly non-specific, or even inaccurate, in the current landscape of HIV prevention and the parameters of sexual decision-making by gay men, other MSM and their partners.

Insertive anal sex and receptive anal sex are distinct acts with very different levels of risk -- a spectrum of risk that is further broadened through widespread sero-adaptive practices. In addition, the use of virally-suppressive HIV treatment is a relevant factor in accurate risk assessment and sexual decision-making.

In the report, unprotected is used to refer to the non-use of condoms. However it does not mean that sex occurred in an environment of heightened HIV risk. Although much of this data was collected before PrEP licensure, reports emerging today should use clearer language -- such as "sex without condoms," rather than "unprotected."

These distinctions are neither political nor semantic. They are integral to reaching the goals of the National HIV/AIDS Strategy and curtailing the epidemic.

Gay, bisexual and other men who have sex with men and their partners need accurate information for sexual risk reduction. There are noted methodological models for data collection that effectively clarify and refine descriptions of sexual behavior that should be adopted across research conducted or supported by CDC.

2) We agree that increased HIV testing is a priority, and that "the data suggest that some men may benefit from more frequent testing."

However, we believe that "at least annual HIV testing" that is only to happen more frequently at provider discretion is insufficient in the current environment.

Once again, CDC has missed the opportunity to take a bold and data-supported stand in favor of more frequent HIV testing for all gay and bisexual men and other MSM. Sticking to the once-a-year standard, leaving it at providers' discretion to advocate for more frequent testing (which many do), is not warranted given the strong -- and historically consistent -- findings of behavior change by those who test positive as well as the recognized role of treatment as a prevention modality.

By formally recommending testing on a quarterly basis, CDC will encourage systemic changes that will result in more men learning earlier if they are infected and allowing them to make informed decisions about their health care and sexual practices. Individuals who tend to lag behind in testing with the recommended interval will be prompted to test more frequently.

A system that is set up to facilitate more frequent HIV testing is a resource not only for case-finding and entry into care, but also to support the use of PrEP, which requires testing every 3 months.

In addition, we support efforts at the time of testing that would help identify HIV negative men who would benefit from access to PrEP and other prevention interventions, and increased vigilance in opposing the stigma, discrimination and criminalization of those who test positive.