Threat of world Aids pandemic among heterosexuals is over, report admits

A quarter of a century after the outbreak of Aids, the World Health Organisation (WHO) has accepted that the threat of a global heterosexual pandemic has disappeared.

"It is astonishing how badly we have done with men who have sex with men. It is something that is going to have to be discussed much more rigorously."

In the first official admission that the universal prevention strategy promoted by the major Aids organisations may have been misdirected, Kevin de Cock, the head of the WHO's department of HIV/Aids said there will be no generalised epidemic of Aids in the heterosexual population outside Africa.

Dr De Cock, an epidemiologist who has spent much of his career leading the battle against the disease, said understanding of the threat posed by the virus had changed. Whereas once it was seen as a risk to populations everywhere, it was now recognised that, outside sub-Saharan Africa, it was confined to high-risk groups including men who have sex with men, injecting drug users, and sex workers and their clients.

Dr De Cock said: "It is very unlikely there will be a heterosexual epidemic in other countries. Ten years ago a lot of people were saying there would be a generalised epidemic in Asia – China was the big worry with its huge population. That doesn't look likely. But we have to be careful. As an epidemiologist it is better to describe what we can measure. There could be small outbreaks in some areas."

Read the rest on the Sunday Independent.

[many thanks to ruben del prado, irma member, for putting this article on our radar]

What is to be done?

1. A resurgent HIV-1 epidemic among men who have sex with men in the era of potent antiretroviral therapy in The Netherlands - (05/29/08)

2. 41% of HIV+ MSM in UK Unaware of Status: Sexual risk behaviour and knowledge of HIV status among community samples of gay men in the UK - (05/29/08) AIDS Journal

Motivating individuals to forego an immediate benefit for a long-term one is never easy. We need the best minds to engage on this task to see if other more clever strategies can be developed.

What is to be done?

AIDS:Volume 22(9)31 May 2008p 1079-1080

[EPIDEMIOLOGY AND SOCIAL: EDITORIAL COMMENT]

Coates, Thomas J

From the UCLA Program in Global Health, UCLA David Geffen School of Medicine, Los Angeles, California, USA.

The article by Williamson et al. [1] presents a perfect storm for the spread of HIV. A total of 41.2% of the HIV-infected men had undiagnosed HIV infection; 81.1% had previously been tested and 92.2% of these were negative. Undiagnosed men were over twice as likely to engage in unprotected anal intercourse with two or more partners.

The first few examples of behavioral changes resulting in changes in HIV incidence and prevalence came from within the gay communities of the United States, Europe, and Australia. HIV incidence declined from the double digits to less than 1% per year in San Francisco between 1982 and 1986 [2,3], and this decline was preceded by important reductions in unprotected anal intercourse [4,5]. Similar reductions in HIV incidence and risk behavior occurred in gay communities in other cities in the US (e.g., Chicago, New York, Pittsburgh, and Baltimore), The Netherlands, The United Kingdom, and Australia.

It now appears that all of that has changed. The number of HIV infections among men who have sex with men is now increasing in many developed high-income countries [6] including the US, Europe, and Australia [7,8]. This correlates with the observed increases in unprotected intercourse, especially with individuals who are HIV-infected or whose serostatus is unknown.

Serosorting, reserving the highest risk activities for persons of similar serostatus, appears not to work. This could be a beneficial strategy if one knows or is able to report one's serostatus accurately. We found previously that the risk of acquiring HIV was equally high when one is engaged in unprotected receptive anal intercourse with declared negatives and serostatus unknown partners as with declared seropositive partners [9]. Williamson et al. [1] provide one explanation of why this is the case. Undiagnosed men, compared with HIV-uninfected men, were twice as likely to engage in high-risk behavior.

Williamson et al. [1] also showed that HIV-infected men who were aware of their serostatus reported the highest risk behaviors, including unprotected anal intercourse with partners of unknown or discordant serostatus. They were also more likely to have more sexual partners and more unprotected anal intercourse partners than seronegative or HIV undiagnosed men.

What is to be done? The authors suggest a number of strategies - and all of their suggestions are important - but they do not necessarily hit the heart of the matter. The early response to the HIV epidemic in the gay community was certainly one of fear. People saw their friends succumbing to the disease, and naturally wanted to avoid that fate themselves. Reductions in the highest risk behaviors, increases in condom use, and fewer sexual partners became the norm, and HIV incidence and prevalence declined as a result.

HIV is not as immediately lethal as it once was, and attempts at fear messaging fall on deaf ears or, even worse, are ignored because they do not fit the reality of the HIV epidemic today. We know that counseling, even of an intensive nature, is not sufficient over the long term to prevent HIV transmission [10]. We also know that certain factors related to high-risk sex, such as stimulant use, are highly resistant to change [11-14].

The truth is that individuals place other priorities over avoidance of HIV, and thus will engage in the highest risk activities - unprotected receptive anal intercourse - with individuals whose serostatus is declared negative, or unknown, or even positive. This is the toughest conundrum of health promotion, and HIV now faces the same difficulty as is faced when trying to prevent other health problems, especially the chronic ones caused by lifestyle. Motivating individuals to forego an immediate benefit for a long-term one is never easy. We need the best minds to engage on this task to see if other more clever strategies can be developed. It is also possible that technologies under test, such as preexposure prophylaxis and microbicides, might protect people from infection even when engaging in the highest risk activities [15]. HIV infection might be prevented if these strategies prove efficacious in clinical trials, and can be deployed to those at highest risk for HIV.

But the gay community, early in the epidemic, wanted to avoid inflicting HIV on others. Dealing with the HIV epidemic was necessary, not only for the survival of individuals, but also for the survival of the community. Now it seems that it is each man for himself. Missing from all discussions of HIV transmission and prevention is any sense of concern for the collective or responsibility for the health of the community. We need leadership from within the community itself to encourage concern for the collective so that the community norm, once again, can be one of balancing what the individual might want against the desire to take care of others.

Major gains have been made since the turn of the century in diagnosing and treating HIV infection in developing countries, especially those with the highest burden of disease. Those in the forefront of this effort are still working hard to ramp up services, provide voluntary counseling and testing for HIV, and provide care for those infected and in need of it. It would behoove us to prepare, simultaneously, for what is to come down the road. There is no reason to doubt that the findings of Williamson et al. [1] will be replicated as diagnosis and treatment matures in developing countries. Perhaps we can begin to prepare now, and maybe avoid the same outcomes there.

Homophobia continues to hamper HIV efforts globally

Craig McClure, Executive Director of the International AIDS Society, recently released the important statement below. Many thanks to the Global Forum on MSM and HIV for sending this out on their list.

As a chief goal of IRMA is to advance the research and development of safe, effective and acceptable rectal microbicides, we are very concerned about the pervasive, and lethal, stigma and homophobia that so many gay men and MSM face around the world. And we remain committed in the fight for the human rights of all vulnerable and disenfranchised people. To be sure, when we do have safe and effective rectal microbicides, it will not matter to millions of people who need them if gay men and MSM are denied access due to such flagrant human rights abuses as we continue to see in 85 countries.

It is an outrage that something like one in twenty gay/MSM in the world have access to prevention. This cannot stand!

Jim Pickett
-IRMA Chair

--------------



Homophobia continues to hamper HIV efforts globally
-Craig McClure, International AIDS Society

Mexico City/Geneva – (29 May 2008)


The International AIDS Society (IAS) today expressed its deep concern about continuing inflammatory and homophobic statements by political leaders in Uganda, Poland, and most recently by the President of The Gambia, and urged national and international leaders to reject homophobia and to take affirmative steps to reduce its impact on HIV.

One of the many lessons learned in the IAS' more than 20 years of leadership in HIV/AIDS, is that well-designed and appropriately targeted programs, implemented with the support of public health and political leadership, can effectively reduce HIV transmission in communities most at risk for HIV, including gay men and other men who have sex with men (MSM).

A report issued at the end of 2007, led by researchers at the Johns Hopkins Bloomberg School of Public Health in the US, provides solid evidence that HIV among MSM continues to be widespread, and in many cases, is exacerbated by stigma, criminalization and the lack of appropriate services. The study indicates that, even in countries with low HIV prevalence in the general population, the epidemic among MSM is raging.

According to UNAIDS, fewer than one in 20 MSM around the world has access to HIV prevention, treatment, and care – and even fewer in low-income settings. Compared to the HIV testing rates of 63-85 percent seen among MSM in Australia, Europe, and North America, rates among MSM in much of Africa, Asia, and Eastern Europe are often under 20 percent.

As it has been demonstrated in many different countries, reducing the social exclusion of gay and MSM communities through the promotion and protection of their human rights (including sexual rights and the right to health) is not only consistent with, but a prerequisite to, good public health. Once discriminatory policies are abolished and stigma and discrimination are confronted, country-based programs can be put in place to encourage gay men and MSM to stay free of HIV-infection, thus supporting national goals of reducing HIV burden.

However, efforts to replicate these successful strategies in more countries are hampered by recent homophobic statements made by political leaders from Uganda, Poland and The Gambia. Comments from these leaders, and other politicians who call for the arrest, detention, and even killing of homosexuals, are reprehensible.

In 2008, despite the accumulation of more than a quarter of a century of knowledge of successful HIV interventions, homophobia and the criminalization of homosexuality continue to be significant obstacles to the scale up HIV prevention, treatment, care and support. Though countries such as Cape Verde and South Africa have repealed their sodomy laws, and government officials in Kenya, Malawi, and Mauritius have begun discussions about the harmfulness of such laws, a resurgence of intolerance and homophobia, coupled with lack of action to repeal laws that violate the human rights of same sex practicing men and women, is posing a grave threat to the AIDS response in many countries.

Despite its much heralded success in promoting a public health response to HIV, Uganda continues to cling to a colonial-era sodomy law that punishes homosexual conduct with life imprisonment. And, Uganda is by no means the exception. Worldwide, more than 85 countries criminalize consensual homosexual conduct. Such laws give governments a pretext to invade people's private lives and deny them essential human rights: to live in peace and in health.

The XVII International AIDS Conference, to be held in Mexico City from 3-8 August 2008, will highlight successful work with MSM in several Latin American countries. The experience from Latin America, as well as from other parts of the world, can provide invaluable guidance to leaders from other middle- and low-income countries in Africa, Asia and Eastern Europe. [IRMA is presenting "Making Anal Sex Safer for MSM in the Developing World" at the conference.]

The very high proportion of MSM in Latin America who, over the past 25 years, became infected with HIV, developed AIDS and later died can only be described as catastrophic. But, in the past decade, in a growing number of countries throughout the region, there have been positive responses that continue to serve as shining examples to the rest of the world. If national and world leaders are serious about curbing the epidemic, programmes that bridge across sexual orientation, that protect public health, and transform stereotypes and prejudices must be a first line priority.

"Homophobia – whether propagated by government leaders, enforced by outdated laws, or perpetuated through stigma and discrimination – continues to fuel this epidemic, and should therefore be the number one enemy of those who are serious about ending this global tragedy," said Dr. Pedro Cahn, IAS President, AIDS 2008 Co-Chair and President of Fundación Huésped in Buenos Aires, Argentina.


With an international membership of more than 10,000, the International AIDS Society is the world's leading independent association of HIV professionals.

Gays excluded from HIV work in Uganda

Gays excluded from HIV work in Uganda
via Pink News

The head of Uganda's AIDS commission has claimed that gay people are driving up the number of infections in the country, but said they would not be targeted with prevention work.

Kihumuro Apuuli claimed a lack of money prevents him from giving any attention or treatment to gay people.

Instead soldiers, prostitutes and the transient workforce will be targeted. More than a million of Uganda's 27 million people are already HIV+.

"Gays are one of the drivers of HIV in Uganda, but because of meagre resources we cannot direct our programmes at them at this time," Mr Apuuli, chairman of the Uganda AIDS Commission, said today.

Government officials have regularly threatened and harassed lesbian, gay, bisexual and transgender Ugandans.

In 2005 Uganda became the first country in the world to introduce laws banning same-sex marriage.

Section 140 of Uganda's penal code carries a maximum penalty of life imprisonment for homosexual conduct, while Section 141 punishes 'attempts' at carnal knowledge with a maximum of seven years of imprisonment.

Section 143 punishes acts of "gross indecency" with up to five years in prison, while a sodomy conviction carries a penalty of 14 years to life imprisonment.

Last year James Nsaba Buturo, the country's Minister for Ethics and Integrity, said the government is committed to stopping LGBT people "trying to impose a strange, ungodly, unhealthy, unnatural, and immoral way of life on the rest of our society."

The leading Muslim cleric in Uganda, Sheikh Ramathan Shaban Mubajje, has come up with a novel solution to deal with gay and lesbians speaking up in the country.

He told journalists he had recommended to the country's President at a meeting that all gay people should be sent into exile on an island in Lake Victoria.

"If they die there then we shall have no more homosexuals in the country," he added.

Read the rest here.

UN human rights head decries "perpetuation of prejudice"

In a valedictory speech to the United Nations Human Rights Council today, Louise Arbour has challenged the continued oppression of women and sexual minorities.

She is to step down later this month as the UN's High Commissioner for Human Rights.

"A failure to understand or accommodate diversity has inevitably led to an erosion of the rights of minorities and vulnerable people within a country, and those of individuals who move across borders, including refugees or migrants," she told the 47-member council.

"Fears and mutual suspicions, engendered by the security environment that has prevailed in the past few years, have exposed minorities to additional risks and abuse.

"The perpetuation of prejudices continue to deny equal rights and dignity to millions worldwide on the basis of nothing more innocuous than their sexual identity or orientation, or their ancestry, in the case of caste discrimination.

"Whether these are explicitly articulated grounds of prohibited discrimination or not, it remains that they are immutable personal attributes, or, as in the case of religious adherence, they are personal choices that could only be forcibly abandoned at an unconscionable personal cost.

Read the rest here.