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Thursday, October 2, 2014
- Unlike the flattening or even declining rates of HIV infection among nearly all other communities, the epidemic among gay men globally is rapidly expanding.
But according to new research, the reason for this fast expansion is biological, not behavioural, thus countering some of the core priorities of traditional AIDS funding.
“The trajectory of HIV epidemics among MSM” – men who have sex with men – “is expanding virtually everywhere we look, in low-, middle- and high-income countries, and across all regions,” Chris Beyrer, a professor of international health, told a panel discussion here on Thursday.
“Much of this comes down to a fundamental biological reality: it’s not about gender but about the gut.”
Beyrer, who contributed to a recent groundbreaking special issue of The Lancet, the British medical journal, on HIV in MSM, says that researchers have found that the HIV virus is far more efficiently transmitted through the gut, hence leading to a far higher transmission probability in anal sex, for either a man or a woman – around 18 times more likely than through vaginal transmission.
Further, because gay men can switch sexual roles in a way that is impossible among heterosexual couples – acting as both the acquisition and transmission partner – the efficiency of transmission among MSM networks appears to be far higher than previously understood.
In a hypothetical MSM group in which men did not alternate their sexual roles, Beyrer reports that HIV incidence could be reduced by up to 55 percent.
“The network-level effects are really trumping the individual level,” he says. “So, people who have modest individual-level risks but who are having sex in high-risk networks and communities have very high lifetime acquisition risks.”
Taken together, the ramifications of these two findings are startling. These two factors, the new research suggests, account for a full 98 percent of the difference between HIV epidemics among MSM and heterosexual populations.
“What this means is that all the things that we had been focusing on – multiple partners, behaviours, etc. – only explain about two percent” of new infections, Beyrer says. “We have got to have programmes that are more responsive to the actual realities of transmission – focusing on the tail of the problem is unlikely to have the impacts we’d like to see.”
Rethinking donor priorities
The policy implications of these new findings are both clear and significant, for both Western and developing countries. In 2011, after all, the developing world for the first time spent more on AIDS – 8.6 billion dollars – than did rich donors.
At the 19th International AIDS Conference, held in July here in Washington, the U.S. government, backed by numerous organisations, set a formal goal of an “AIDS-free generation”. Yet according to this new data, such a goal will be impossible without a significantly larger focus on new and existing interventions tailored specifically for those communities experiencing this continued expansion of HIV infections.
While the administration of President Barack Obama, which provides the single largest tranche of AIDS funding in the world, is generally lauded for bringing about an increased focus on MSM-related issues, those who contributed to the Lancet research papers are calling on the international community to increase MSM-related HIV funding five- to tenfold.
The researchers note that, worldwide, just 10 to 20 percent of this community have access to any targeted HIV prevention.
“This biological reality is fundamental to how we need to be thinking about doing prevention, suggesting that just behavioural strategies are not going to be sufficient to curb HIV epidemic among MSM,” says Patrick S. Sullivan, a professor of epidemiology.
“But we also can’t say that we need more research before acting. Using a package of the tools we have today, we estimate that we could avert about a quarter of new HIV infections among MSM in the next 10 years.”
One lesson for national governments and donors is that funding for fighting HIV “needs to be following the epidemic”, says Chris Collins, the director of public policy at the Foundation for AIDS Research here in Washington. “There is clear evidence from around the world that there is a real mismatch between funding for HIV among gay people and their piece of the pie in the overall epidemic.”
Two issues that many advocates have highlighted as having received insufficient international focus have been, first, the sensitisation of public-health practitioners and, second, LGBT (lesbian, gay, bisexual, trangender) rights more generally. Both of these issues, researchers say, are central to the hope of continuing to make progress against the AIDS epidemic.
“Around the world, health-care professionals are not sufficiently equipped to provide support for individuals who are not heterosexual,” says Kenneth Mayer, a visiting professor of medicine with the Harvard Medical School. “This is a substantial structural problem and is really impeding an effective response to the AIDS epidemic – health-care providers are a big missing piece of the puzzle.”
Health and rights
Ultimately, the single most important structural issue in this regard is almost certainly the continued social and legal hurdles faced by gay people around the world.
This includes outright criminalisation in 30 African and 10 Caribbean countries, a factor that frequently leads governments to justify a lack of investment in prevention while further exacerbating the lack of self-agency experienced by many LGBT people around the world.
Some advocates are increasingly suggesting that this and the broader issue of ensuring an enabling environment be viewed not just as a human right but also as a critical issue of public health.
Chris Beyrer suggests that, to a certain extent, this understanding is being undermined by an international funding priority that feeds billions of dollars into AIDS research but a relatively miniscule amount into strengthening global LGBT rights.
Still, he points out, the issue of HIV overall has largely fallen to the side for the single most important constituency in the anti-AIDS movement – the LGBT community itself.
“If you look at the data, I think our failure right now is with young MSM, those under 18 and those 18 to 26 years old,” Beyrer warns.
“We need a community reinvigoration. People today have strong mobilisation around marriage equality and the issues that really matter to the community, but right now HIV is insufficiently on the short list – and we have to get it back.”