Postive Nation: Features Issue 138 | Is HIV prevention succeeding for gay men?

Is HIV prevention succeeding for
gay men?

With the number of HIV diagnoses among gay men in the UK remaining high, Positive Nation asked the question – Is HIV prevention succeeding for gay men? – to two experts in the field – Matthew Hodson at GMFA and Will Nutland at THT.

To judge whether or not HIV prevention for gay men is succeeding requires that we first define success. If the goal is to achieve absolutely no new infections then prevention is going to fail. No form of ethical HIV prevention could succeed in such terms. There is no magic bullet, no formula of fear or entreaty that will be able to prevent all future infections.

Will Nutland

It is often suggested that a return to harder hitting campaigns, ‘scare tactics’, would be effective, that somehow men need to be frightened into adopting safer sex. Evaluations of such campaigns, both abroad and in the UK, do not support this theory. Hard-hitting campaigns fail to engage those men who are the target of HIV prevention activity, the men who regularly engage in sex that can transmit HIV. When confronted by campaigns that bluntly label certain sexual behaviours as wrong or irresponsible, these men are likely to turn the page. It doesn’t matter how important, impressive or helpful the information you have to communicate is, if people don’t engage with the advert, they won’t get the message.

The INSIGHT study, which compared gay men who had sero-converted to men who had not, gave us useful data on what characteristics were displayed by those men who became HIV positive. Characteristics that were associated with sero-conversion included a desire for intimacy that respondents felt they could not achieve whilst using condoms. Depression, low self-esteem and lack of control were often found to lead to unplanned unprotected sex. In large numbers men become infected not because they think HIV isn’t serious, but because they think that they’re not worth saving. So called ‘hard hitting’ campaigns fail to address these particular needs.

An advertising campaign, in isolation, can not take a man with low self esteem, and little motivation to maintain his health, and turn him into a safer sex warrior. An advertising campaign, in isolation, can not convince the starry-eyed young couple that their intimacy and trust can only be demonstrated by consistent condom use. Advertising campaigns aren’t good at creating such fundamental shifts in people’s thinking - but this does not mean they serve no function. Advertising campaigns are very good at imparting small pieces of information and at maintaining awareness, which is vital as new men come onto the gay scene every year; they can also provide useful positive role models and behaviours and provoke discussion, thus keeping sexual health on the agenda. This maintenance of awareness is essential for gay men to realise that the choice of whether or not to maintain sexual safety is a significant one.

HIV advertising often bears the brunt of any criticism of HIV prevention efforts, as it is the most visible aspect of this work.

However, to use a well worn AIDS metaphor, such campaigns are only the tip of the HIV prevention iceberg. In most urban areas condom distribution schemes target gay men to ensure that we have access to the equipment that we need for safer sex. And whilst adverts, booklets and websites give information and maintain awareness, and reach huge proportions of the gay population, far greater financial resources are given to talking and listening interventions, such as groupwork, counselling and outreach work, which reach fewer men but are able to address their needs individually. Over 90% of men who attended GMFA’s Assertiveness course felt able to say “no” to sex that they didn’t want, compared to just half of them at the beginning of the course.

HIV prevention successes for gay men in the UK are comparable to those for men in many other Western European countries. The old supposition that the course of the epidemic in the UK is following a few years behind that of the US no longer seems to be the case. In the US, which has largely adopted a different approach to HIV prevention, prevalence amongst gay men in some urban areas has hit 40%, and even more amongst marginalised groups such as Black gay men. Diagnoses of HIV are rising here in the UK but the number of men accessing HIV testing is rising at an even faster rate and the proportion of positive test results seems to be falling.

There are also significant variations across the UK. Whilst London has the biggest gay scene, and the highest prevalence of HIV amongst its gay population, it also has the lowest incidence of HIV negative men engaging in unprotected sex with men who are positive or whose HIV status they do not know. Prevalence of HIV in the population is increasing, but this is largely driven by more effective treatment. The risk of death for individuals sero-converting with HIV in the UK has fallen by 97% since the introduction of potent antiretroviral therapy in 1996. Late diagnosis has the greatest impact upon mortality and a person who is ignorant of their status is in far greater peril than someone who is able to access treatment. We cannot responsibly, or accurately, portray HIV as the killer that it once was and need to be wary that work that fails to acknowledge medical advances does nothing to encourage men to come forward for testing, and thus may serve to increase the amount of undiagnosed infection and the health dangers to those people.

I am privileged to work alongside a talented and dedicated staff team and in excess of 150 volunteers, most of them gay men, who give their time, enthusiasm and ingenuity to develop and deliver HIV prevention work in all of its forms. We are all committed to preventing new infections of HIV. We pre-test our work, consult widely and agonise over every word and comma. We work in the way that we do because the best evidence that we have, generated here in the UK and around the world, is that giving gay men clear, honest and accurate information, equipping gay men with the tools for safer sex, and empowering gay men to control the sex that they have is the most effective way of preventing new infections. Are we doing as well as we would like to be? Of course not. But do I believe that a well educated, well equipped and assertive group of gay men would enjoy no further transmission of HIV? No. It just doesn’t work that way. But neither would gay men who were given false, distorted or partial information. Neither would gay men who believed that there was little that they could do to control their own destiny. Neither would gay men who were told that they were weak or irresponsible.

Matthew Hodson is Head of Programmes at GMFA (Gay Men Fighting AIDS) www.gmfa.org

Is HIV prevention succeeding for gay men?
“What’s abundantly clear is that consistent condom use amongst gay men hasn’t remained the same.”

In March this year the UK’s Health Protection Agency [HPA] released its projected HIV figures for 2007. The headlines told us some good news; that overall HIV diagnoses in 2007 were 12% down on 2005 figures – when new diagnoses peaked - and that the number of heterosexual infections acquired in the UK were down on the previous year. The greatest change was a reduction in heterosexual infections acquired abroad – but diagnosed in the UK; a change probably brought about as a result of changes in migration into the UK and a shift in immigration policy.

What the figures confirmed is that the number of HIV diagnoses amongst gay men remains high. Diagnoses were fairly stable at around 1500 new cases each year through the 1990s and early 2000s and then peaked by 2005 to around 2500 diagnoses and have remained at that level since. In 2007, gay men made up over a third of new diagnoses in the UK.

What’s going on and is this a ‘failure’ of HIV prevention?
Firstly, it’s important to look at what might be behind some of the figures. There is growing evidence that more gay men are testing for HIV than ever before and there have been year on year increases in the numbers of men testing for HIV. The HPA itself speculated that the levels of diagnoses in 2006 were partly due to men with HIV testing earlier; evidence of the effectiveness of health promotion programmes to increase early diagnoses of men infected with HIV. 4
Second, there are a number of compounding factors that might be at play here; the number of men having gay sex has increased over the last decade and a half, in part due to liberalisation of legislation and attitudes to gay sex; the opportunities to have gay sex have increased, in part due to a proliferation of the commercial sex scene including saunas, back rooms and the internet; and the numbers of gay men living with HIV has almost doubled in the last fifteen years due to the impact of combination therapies keeping gay men with HIV alive. There are more gay men, having more gay sex, with more possibilities for that sex to be between positive and negative gay men than ever before. As such, even if levels of condom use remained the same, we’d expect HIV transmission to be higher than before.

However, what’s abundantly clear is that consistent condom use amongst gay men hasn’t remained the same. Whilst most of us use condoms most of the time, increasing numbers of gay men are deciding not to always use condoms with both regular and casual partners.

This is happening because some gay men are making rational choices about who they have sex with. Some gay men are deciding not to use condoms if a man has the same HIV status (commonly referred to as sero-sorting); some men are reducing the risks of picking up or passing on HIV by the type of sex they have – being a top or a bottom, not cumming inside a partner, for example; and some men are deciding not to use condoms with their boyfriends or regular partners. Although these decisions might be ‘rational’, they are not always reliable.

Some men are not using condoms because they believe that anyone with HIV would know they had it, that someone with HIV would always tell a sexual partner this before they had sex or believe that a positive guy would never have unprotected sex. Some guys don’t use condoms because they ‘got away’ with not using condoms the last time, and the time before, and the time before that. And some guys are not using condoms because they believe there is no way they could have HIV and therefore couldn’t be passing it on.

Other men don’t use condoms because they’re looking for intimacy – and they’re afraid they’ll be rejected if they say they have HIV, or say they don’t have HIV, or they ask for condoms to be used. And others still won’t use condoms because they don’t know enough about HIV, feel that they have more important things in their life to be worried about than HIV, can’t negotiate the sex they want or don’t have the skills to do so.

What this picture paints is one of complex need. No-one should pretend that finding a way to reduce new HIV infections is simple; to say that ‘all men should use condoms all of the time’ ignores the fact that large numbers of men don’t – including large numbers of men who know and understand the risks of not doing so. Simple headline rants about what prevention is doing ‘wrong’ hides the facts that living with HIV as a community, and negotiating the ways of avoiding picking up or passing on HIV are increasingly complex. The popular held desire to see a revisiting of the late 80s tombstone adverts as the ‘solution’ to HIV infections amongst younger gay men ignores the fact that the age group with the highest number of new infections last year were men between 30-40; many of whom were the age group exposed to that very ad campaign.

The recently published Gay Men’s Sex Survey from 2006 demonstrates the different – and often conflicting – needs of different groups of gay men. A complex situation needs a sophisticated response and one that is responsive to new evidence, technological shifts and the ever changing environments in which we live and have sex. If finding a way to rapidly drive down new HIV infections – and keeping those infections down – was easy, someone would have discovered it, bottled it and be would selling it around the world by now.

Making it Count – the national framework for HIV prevention amongst gay men reminds us that our response to reducing HIV incidence is a collaborative one; one that ensures that young gay men leave education knowing about how to avoid HIV; one that ensures that our national and local funding bodies adequately and effectively commission and resource targeted HIV prevention and sexual health work for gay men; and one that sees gay men as key players in influencing, educating and caring for ourselves, our partners and our communities. If prevention is ‘failing’ then our failure is a collective one.

Will Nutland is Strategic Lead for Health Promotion and Health Improvement at the THT (Terrence Higgins Trust)