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AIDS 2010 Roundup: Men Who Have Sex With Men (MSM)

By Kellee Terrell

August 10, 2010

Since the HIV/AIDS epidemic first hit the U.S., it has deeply and disproportionately impacted the gay community. According to the U.S. Centers for Disease Control and Prevention (CDC), men who have sex with men (MSM) account for nearly half of the more than one million people living with HIV in the U.S.; they account for more than half of all newly infected people in the U.S. each year; and they're diagnosed with HIV at a rate more than 44 times that of heterosexual men.

This year, at the XVIII International AIDS Conference (AIDS 2010) in Vienna, the MSM community -- both U.S.-based and globally -- was a topic of serious conversation. However, there were complaints from leaders that it was not enough. According to George Ayala, executive officer for the Global Forum on MSM and HIV (MSMGF), MSM-related presentations took up a measly 2 percent of all presentations given at AIDS 2010. That's better than four years ago when MSM were almost invisible, he said, but clearly not nearly enough presence given how disproportionately the epidemic affects this group of men.

That said, a number of important stories related to MSM did come out of this conference, including:

In 2012, the XIX International AIDS Conference will be held in Washington, D.C., the epicenter of HIV in this country, especially among black MSM. Hopefully, conference organizers will listen to this criticism and do the necessary community outreach to ensure that there will be more MSM-focused presentations and events at AIDS 2012. These sessions should also include presenters from different ethnicities from all over the world discussing a diverse array of topics, strategies and research. There really is no excuse for this not to happen -- the gaps in research have been clearly stated. Now is the time to start following through.

Be Heard, Speak Up: The Global Forum on MSM and HIV

The day before AIDS 2010 began, around 650 people attended Be Heard, a pre-conference event hosted by MSMGF -- an organization that works to promote sexual health among MSM. The day featured presentations, workshops and panels about government neglect; AIDS denialism; funding woes; barriers to prevention, treatment and care; human rights abuses; and AIDS-related deaths.

Leaders (such as Michel Sidibé, the executive director of UNAIDS; Joel Nana, the executive chair of African Men for Sexual Health and Rights; and Joseph Akoro, the executive director of the Independent Project for Equal Rights in Nigeria) spoke about a range of issues, including what the lesbian, gay, bisexual and transgender (LGBT) community has done to fight homophobia; the lack of a MSM presence at AIDS 2010; and the work that still needs to be done.

George Ayala described the event as a means for LGBT advocates, researchers, care providers, artists, media folks and allies from around the world to come together.

TheBody.com's community manager Olivia Ford was on the ground in Vienna and reported on the event. Ford noted that this networking reunion was especially important for those who lived in areas where stigma and homophobia were profoundly oppressive:

To better undestand what many participants in MSMGF do, imagine this scenario: You're gay and HIV positive -- already not a walk in the park in most societies. Now imagine you live in a country where there's no effective HIV treatment available; your condoms regularly tear from lack of lubricant; and what HIV prevention messages there are shut you out completely, because sex between men is a legally punishable offense. Now go out, raise your voice and fight for your rights -- without a salary, because the notion of being paid for working as an activist for MSM does not exist in your area.

Hence the importance of a worldwide association of people in similar situations and their allies -- and of a gathering every two years to learn from, network with, and occasionally hug those like-minded people.

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Human Rights, Homophobia and the African Diaspora

Two dominant themes that emerged from AIDS 2010 were 1) how to better protect the human rights of gay men in Africa and 2) how homophobia, criminalization, policing and stigma contribute to the rise in HIV rates among MSM of the African diaspora (people of African descent who now live outside Africa). Blogger Rod McCullom touched upon this topic in an article for Black AIDS Institute:

More than 80 nations have laws that still criminalize same sex behavior. In some of these countries, conviction can even result in the death penalty, reports UNAIDS.

Further exacerbating the problem, according to a report by Planned Parenthood, "58 countries have laws that criminalize HIV or use existing laws to prosecute people for transmitting the virus. Another 33 countries are considering similar legislation."

The trend is "even more pronounced" across Africa and the Diaspora, said Joel Gustave Nana, executive director of the Johannesburg, South Africa-based African Men for Sexual Health and Rights (ASMSHer). The West African laws vary in extremity -- just "exposing a person to HIV, regardless of if the virus is transmitted, is a crime in Benin, and Tanzanian law carries a possible sentence of life in prison for intentional transmission," reports Medical News Today. While the overall life for Black MSM may be better in North America, there are drawbacks. The United States and Canada lead the world when it comes to prosecuting people who infect or expose others to HIV, a surprising new study reveals. Black men have been disproportionately targeted with these prosecutions. A Black, gay, HIV-positive Michigan man was recently charged as a bioterrorist for allegedly biting a neighbor's lip during a scuffle, Black AIDS Weekly reported in June.

HIV/AIDS phobia and homophobia are harsh realities in many communities and are perpetuated not just by the government, but in churches, the media and in society as a whole. All of which make MSM deeply vulnerable to HIV infection, according to research presented at AIDS 2010. For instance, Joseph Barker presented findings about how mistreatment and stigma impact gay and bisexual men in Kampala, Uganda. Barker found that "men who have sex with men who have suffered homophobic violence or abuse are five times more likely to be HIV-positive than other men," according to an aidsmap.com report. "Just under 40% of men had ever been physically abused, four out of ten had been blackmailed at some point, and a quarter had been forced to have sex."

Aidsmap.com also notes on Barker's research:

The researchers wished to identify the demographic or behavioral characteristics that were most strongly associated with HIV infection. In multivariate analysis, factors such as condom use or numbers of partners were not significantly associated with having HIV. In fact, only two factors were: age and homophobic abuse.

Men aged 25 or over were four times more likely to have HIV (odds ratio 4.3, 95% confidence interval 1.5 to 12.8). Amongst men over 25, HIV prevalence was 22.4%.

Men who had ever experienced violence or abuse because of their sexuality were five times more likely to have HIV (odds ratio 4.8, 95% confidence interval 1.8 to 13.1). Of the whole sample, 37% had been physically abused at some point, 37% had been blackmailed and 26% had been forced to have sex.

In a panel earlier in the week, Joel Nana said that addressing the human rights issue in addition to the public health aspect is crucial in fully attacking the problem. Nana told the crowd, "The life of men who have sex with men doesn't only revolve around health or the lack of health." He added, "There are other issues -- such as extortion, harassment, expulsion from schools, unlawful arrest and detention, disownment by families and economic disenfranchisement -- that deserve equal attention."

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Transmission, Testing and STIs

Here are some noteworthy transmission, testing and sexually transmitted infection (STI) stories related to MSMs:

CDC Says PrEP Safe for Prevention Among Gay Men

On the last day of the conference, the CDC reported that a study of Viread (tenofovir) taken daily for HIV prevention among gay and bisexual men suggests no significant safety concerns. A prior study in Africa found that pre-exposure prophylaxis (PrEP) was safe for heterosexual women. In a press release, the CDC stated:

The approach of taking a daily antiretroviral drug to try to prevent HIV infection is known as pre-exposure prophylaxis, or PrEP, and studies around the world are currently underway to determine if it is effective at reducing HIV infection among individuals at high risk, including MSM. While the results of those studies will be needed to determine if PrEP can prevent HIV, this safety study lends additional assurance that the strategy may be well-tolerated among MSM, should it prove effective.

The Phase II safety study was conducted by the U.S. Centers for Disease Control and Prevention in collaboration with the San Francisco Department of Public Health, the AIDS Research Consortium of Atlanta, and Fenway Community Health in Boston. The trial examined whether a 300 mg tablet of tenofovir disoproxil fumarate taken daily was safe among 400 HIV-negative men who have sex with men (MSM) in San Francisco, Atlanta, and Boston.

And while more testing needs to be done to show if PrEP can actually prevent HIV-negative people from contracting HIV, the CDC stressed:

If PrEP proves effective, it could provide an additional safety net for MSM and other individuals at high risk, when used in combination with other proven prevention strategies, like HIV testing, correct and consistent condom use, and reduction of partners. PrEP could also provide a much needed option for women who are unable to negotiate condom use and could provide some protection for discordant couples (i.e., in which one partner is infected and the other is not).

And while this does seem promising, there are concerns. The Black AIDS Institute reported:

Experts also worry that PrEP for HIV may encourage risky behavior in individuals taking it. Yet, access to the drug itself has triggered the biggest controversy around PrEP. If there is already limited access to funds for treatment of HIV and AIDS -- as activists insisted loudly all week -- will those not infected take life-saving drugs away from those who are living with HIV and need it to survive?

"That's a valid concern," notes Jim Pickett, of the AIDS Foundation of Chicago and chair of International Rectal Microbicide Advocates. "If [PrEP] is proven to be effective how do we square that in a setting where people who are HIV positive don't have full access to treatment? Who do you decide gets the tenofovir? These are questions we are trying to ask ourselves in the field right now."

The Sexual Abuse and HIV Infection Connection

Researchers from the Multicenter AIDS Cohort Study (MACS) reported that gay and bisexual men who reported sexual abuse and homophobic experiences in childhood have a substantially higher risk of HIV infection. AIDSmeds.com wrote:

[Researchers] found that almost 10 percent of the volunteers reported that they had been victims of childhood sexual abuse and nearly 30 percent had experienced gay-related victimization between the ages of 12 and 14, including verbal insults, bullying, threats of physical violence and physical assaults.

MACS volunteers who experienced childhood sexual abuse and a sense of "masculinity failure" were more likely to engage in substance use, experience depression and sexual compulsivity and to be involved in intimate partner violence -- all known to be independent risk factors for unprotected anal sex and, ultimately, HIV infection. This finding, Lim reported, confirmed the occurrence of syndemic outcomes in this particular population of men.

"Our study shows that the early socialization experiences of gay men can be deeply stigmatizing and increase their risks for these syndemic conditions in adulthood," Lim said. "Given the long-lasting impacts, effective interventions should address multiple interrelated social issues early on rather than focusing on each problem in isolation."

Prevention Is Failing Young MSM in the U.S.

While safer sex information is out there for gay and bisexual teens, somehow the information is not setting in. Past studies show that young MSM understand how HIV is transmitted, but still engage in unprotected anal intercourse anyway. A recent study conducted by researchers from Emory Healthcare in Atlanta looked to understand why this dichotomy exists and expose the reasons why young men are not making the connection that what they are doing is risky.

AIDSmeds.com reported:

D. Dennis Flores III, from Emory Healthcare in Atlanta and his colleagues conducted interviews with 10 young MSM from that city who had recently been diagnosed with HIV. Nine of the men were African American, and one was Latino. Their ages ranged from 18 to 24. The interviews with the young men covered four topic areas: risk behavior, HIV education, the Internet and healthy role models.

As has been found in previous studies, the majority of the young men had viewed themselves as either unlikely or very unlikely to contract HIV in their lifetimes, and half reported experiencing coercion and sexual abuse at the time of sexual initiation. ...

Flores and his colleagues found that while all the young men had undergone sex education while in middle school or high school, none reported that these classes included information about gay sex. Moreover, only one of the young men reported having any gay role models while growing up. This meant that relevant sex education occurred on the Internet, which from a sexual risk perspective, can be quite perilous. When these young men went online, most of them saw graphic high-risk sexual encounters, and this behavior quickly became what they perceived as normal and desirable.

One of the most interesting findings from the study was that by the time prevention messages reached the young men, it was too late -- unprotected sex had become a normal part of their everyday. Flores recommended the following: that sex education should happen as young as elementary school and middle school; parents need to be more supportive and teach their sons about the dangers of sexual coercion; and that new online prevention strategies need to be developed to reach the young people where they are.

HPV Vaccine Prevents HPV Lesions and Infection in Men

While Gardasil -- a vaccine designed to protect against the four strains of human papillomavirus (HPV) -- has been approved for young girls and women for a few years, there has been much interest in whether the vaccine can work for gay and bisexual men. HPV in men can lead to anal, penile and other cancers.

AIDSmeds.com wrote that the first ever clinical trial to test the safety and efficacy of Gardasil in gay and bisexual men "demonstrated a significant reduction in the number of pre-cancerous anal lesions caused by HPV." The trial was led by Heiko Jessen, M.D., of Praxis, a private medical clinic in Berlin.

They also wrote:

Jessen's group randomized 4,065 men -- 3,463 heterosexual men between 16 and 23 years old and 602 MSM between 16 and 26 years old -- to receive three doses (a first injection, followed by a second two months later and a third four months after that) of Gardasil or placebo and were followed for about 36 months. The men were enrolled at sites in 18 countries on five continents. ...

Safety data were available for 1,945 men in the Gardasil group and 1,950 men in the placebo group. About 64 percent of Gardasil recipients experienced one or more vaccine-related adverse event -- including injection-site problems and systemic complaints -- in the study, but so did 58.2 percent of those in the placebo group.

Serious adverse events -- including appendicitis, cellulitis, chest pain and peanut allergy -- were documented in 0.3 percent and 0.1 percent of those in the Gardasil and placebo groups, respectively. However, when the researchers looked for serious adverse events clearly attributed to vaccination, the rates were 0 percent in both groups.

Another study is planned for a vaccine designed to protect against nine types of HPV.

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