The journal Lancet Infectious Diseases recently published a new study – HIV incidence in men who have sex with men in England and Wales 2001—10: a nationwide population study (full text free with registration). The study was reported by the BBC under the headline HIV levels in gay men ‘not falling’. The Guardian picked up on the BBC story and, as is their wont, turned the doom-mongering all the way up to 11 with an article identifying this as yet more proof that gay men are uniquely damaged and inadequate people, and that our social lives are nothing more than one long wail of inarticulate despair. (This latest article quotes approvingly a description of the gay scene as ‘the biggest suicide cult in history’, which is so over the top it’s actually funny. I’ve known the gay scene for more than 20 years now, and all I see on it are people getting pleasantly intoxicated with their mates, having a bit of a boogie and occasionally trying to pull. I’ve never seen the kind of nihilistic bug-chasing that The Guardian has been telling its readers for decades is the typical night out for a gay man.)
Regular readers will be heartily sick of this point, but I’ll make it again and again until it sticks in the wider consciousness. Gay men get HIV more frequently than our straight counterparts, not because we have endless kinky sex, or harbour a secret death-wish: we get HIV more frequently because HIV is more readily transmitted during average, vanilla sex between men than it is during average, vanilla sex between men and women. That’s it. If it was more readily transmitted during straight sex, it would be more common among straight people, and that wouldn’t mean that straight people had lost the will to live, it would simply reflect the fact that they were at greater risk. HIV is just an infectious disease and, like all infectious diseases, it’s opportunistic: it goes where it can go. It doesn’t have a moral or a psychological meaning, no matter how badly people with ideological axes to grind may wish it did.
Anyway, let’s get back to the paper in Lancet Infectious Diseases. (As always, I should stress that I’m not an expert in any of this, that my highest scientific qualification is a D at A level biology, and that what follows are the thoughts of a layman. A reasonably well-informed layman, hopefully – I’ve been reading and trying to understand scientific papers about HIV/ AIDS for two decades now – but a layman nonetheless. No-one should rely on or trust anything I say here.)
The paper actually contains some disguised good news, although neither the BBC nor The Guardian drew attention to it. Among those of us who keep an eye on HIV figures, one of the really worrying things in recent years has been the upwards trend in new diagnoses of HIV among men who have sex with men (MSM). The fear was that the increase in diagnoses reflected an increase in incidence: that more MSM were getting diagnosed because more MSM were getting infected. In fact, it turns out that the increase in diagnoses is mostly accounted for by the fact that MSM are getting tested more, and thus are being diagnosed earlier – on average, 3.2 years after infection instead of 4 years. As the authors put it themselves:
Between 2001 and 2010, the estimated number of new infections oscillated between 2200 and 2800 infections a year. Incidence increased to a peak in 2003—04, but, after a slight decline, stabilised at 2300—2500 infections a year from 2006 to the end of 2010. [...] there is no statistically significant change in incidence between any 2 years over the interval and no suggestion of an increasing or decreasing trend.
This isn’t unalloyed good news, to be sure. If MSM are being diagnosed earlier then this should translate into a reduction in the transmission of HIV, partly because of a reduction in inadvertent transmission – people who don’t know they’re HIV+ infecting their sex partners without realising it – and also because of a reduction in a phenomenon the study authors refer to as ‘community viral load (the aggregate viral load within a given population or risk group)’.
Now, viral load is a measure of the amount of HIV circulating in the bloodstream of an infected person. High viral loads lead to the development of AIDS, and the medications taken by people with HIV – collectively known as antiretroviral therapy, or ART – work to reduce viral load, and so delay the onset of AIDS. (Modern ART techniques are so successful that they are able in most cases to delay the onset of AIDS indefinitely, so that a person with HIV never develops AIDS.) It’s also becoming clear that a person with a low viral load is less infectious, and so less likely to pass on HIV to their sex partners, even if they don’t use a condom, or if the condom breaks. In other words, a person receiving effective ART is not just healthier themselves, but also more conducive to a healthier population overall, because their reduced viral load means they are less likely to transmit the virus to people they have sex with.
The concept of community viral load just scales this up a level: as more people are diagnosed with HIV and placed on ART, so the overall viral load within the community as a whole will decrease, and so the numbers of new HIV infections should also decrease. Unfortunately, that hasn’t happened amongst men who have sex with men in England and Wales. Instead, this study has found that the number of new infections amongst MSM has remained the same, despite the fact that, amongst this group, testing has increased significantly, the average time-to-diagnosis has come down by about a fifth, and the proportion of undiagnosed HIV infections is estimated to have reduced by more than a third.
There’s only really one plausible explanation for this: at the same time that all these positive changes have been taking place, the numbers of MSM engaging in unsafe practices have increased sufficiently to counteract all that good. As the authors put it:
The most plausible explanation for lack of HIV transmission control (ie, the lack of any sustained decline in incidence) during this period is a resurgence in unsafe sexual behaviour (largely because of treatment optimism), and insufficiently frequent HIV testing among this population.
[N.B.: I have replaced one endnote notation in the above with a hyperlink to the study cited in the endnote.]
In other words, there is still a long enough gap between infection and diagnosis for HIV to be widely transmitted before ART is begun, especially since MSM are having more unsafe sex than they were in 2001. The authors also note that, although there is ‘incontestable’ evidence that regular testing and ART reduce transmission at the level of the individual, there’s no indication that similar benefits are being detected at the community level. This raises the possibility that, although they have a positive impact on the health of individuals, assertive testing and treatment campaigns aimed at MSM may not on their own be sufficient to reduce the number of new HIV infections among this group of people. It would appear that, as it has been ever since the disease first emerged, the best hope for reducing the incidence of HIV among MSM is to reduce the incidence of unsafe sex.
It’s interesting to note that the study authors identify ‘treatment optimism’ as the major driver of a resurgence in unsafe sex. This, of course, contradicts the standard Guardian line that gay men are having unsafe sex because our collective self esteem is so poor we don’t care if we die. On the contrary: it’s not that gay men have stopped worrying about HIV because they’ve become blasé about death, but that they’ve become blasé about HIV because infection no longer means automatic death.
The truth is this ‘treatment optimism’ isn’t misplaced. Thanks to ART, in the overwhelming majority of cases an HIV diagnosis is no longer a death sentence, and hasn’t been for many years – though it’s important to keep in mind that several hundred people in the UK are still developing AIDS and dying every year. (The main reason people develop AIDS is that their HIV is diagnosed late: this is why it’s important for people at risk of contracting HIV to get tested frequently – at least once a year.)
If fear of death was the main reason people were having safe sex then it was inevitable that, once the fear of death was removed, risky behaviour would resurge. It also follows that, if we’re serious about trying to reduce the incidence of HIV among MSM, banging on about a collective death wish in the manner of The Guardian will not be an effective strategy. The likelihood is that MSM are having more unsafe sex for a variety of reasons, and that will require a variety of responses from those of us – professionals and lay people alike – who are interested in promoting better sexual health.
One aspect that I think needs urgent attention is the issue of ‘serial monogamists': that is, MSM who don’t think of themselves as promiscuous because they don’t have one night stands, and never have more than one sexual partner at once, but who nonetheless have multiple partners over time. Because they don’t think of themselves as promiscuous – and because HIV is routinely presented as a “slut’s disease”, or, as in The Guardian article, the preserve of deliberate bug-chasers – they may underestimate the risk they take. That may lead on to what I think is a fairly common situation, where people are careful about condoms the first few times they have sex, but become gradually more lax over time, even though they still don’t know their partner’s HIV status. Combine both these things – people having multiple partners over the average length of time it takes to be diagnosed with HIV, and a tendency to stop using condoms – and it’s clear that there’s great scope for HIV to continue to circulate, even among people who may think of themselves as low risk.
Something else I think needs urgent attention in the era of apps and websites like Grindr and Gaydar is the difficulty of getting condoms and lube to men who enjoy casual hook-ups at the time and in the places where they’re meeting each other. When they were meeting in bars, clubs and saunas, distributing free condoms and lube in these venues was a reasonably effective way of reaching the men concerned: the condoms were to hand at the time and in the place where they met and decided to have sex, even if they went somewhere else to do the deed. But if hooking-up is more and more commonly happening online – and, in the case of mobile apps, when people may be away from both a home supply of condoms and gay venues where they can pick them up – then that development may be leading not only to an increase in the number of impulsive hook-ups (as the authors of the Lancet Infectious Diseases article suggest), but also to a greater risk that impulsive hook-ups will result in unsafe sex.
My guess is that these – and the other issues that are contributing to MSM neglecting safe sex – will be extremely difficult problems to crack, but I also think there are strategies that can still work. I think we can be smarter in the way we talk about risk. For example, I was struck by a passing mention in the Health Protection Agency’s 2012 report on HIV in the UK that 1 in 12 MSM living in London are HIV+: that kind of information, punchily presented, could concentrate minds in a useful way. Information that was even more local – as local as it can be without compromising anonymity – would probably be even more effective.
I think – without stigmatising people with HIV, or needlessly worrying them – we can talk more openly about the fact that living with the disease still isn’t a walk in the park. We can talk about the side-effects of ART (which affect some people worse than others). We can talk about the hassle and inconvenience of living a life that’s ruled by medication (to be most effective, ART has to be taken at a specific time – or times – every day, and meals may have to be timed to fit so as to minimise side-effects). We can talk about the relationship issues (when do you tell a prospective new partner? too early and you might scare them off, too late and they might think you’d been lying to them). Mentioning these difficulties isn’t to say we’re complacent about them, or think that HIV+ people somehow “deserve” them – of course they don’t. It’s just to point out that there are still good reasons why people should want to avoid HIV, even in the era of effective treatment.
I think we can speak about safe sex in a way that’s relevant to more people’s lives. Yes, men who have sex with lots of different men are at risk, but they’re not the only ones, and it’s a mistake to target HIV information at them exclusively or predominantly. I think we can make the point more clearly that HIV is transmitted via particular acts, not between particular kinds of people, and that anyone who has unprotected anal sex is at risk – even if they think they can’t be because they always insist on condoms at the start of a new relationship, and they never have casual sex.
At the same time, I think we can be a lot less prudish and judgemental when we talk to men who enjoy having lots of sex with lots of different partners. We can be clearer that we have no interest in moralising. We can be clearer that safe-sex promotion isn’t part and parcel of the mandatory hearts-and-flowers, marriage-for-all approach to gay rights that has so alienated some MSM. We can be more specific about all the many kinds of sex – oral, rimming, watersports, toys, bondage, dominance & submission, and so on – that carry little or no risk for HIV, even while they’re “dirty” enough to make conservative gay couples in the suburbs clutch their pearls in horror. We can make the point more effectively that safe sex isn’t all about condoms, but also about making sex more interesting and enjoyable than a monkey see, monkey do copy of some run-of-the-mill bareback video could possibly be.
The bottom line is that all of us need to talk to everyone – in the right way, using language and techniques tailored to catch their attention and interest – about the continuing threat of HIV, and why people should want to avoid it, and what they can do to minimise the risk to themselves and the people they have sex with. Of course, saying what we need to do is simple, it’s actually doing it that’s difficult. Still, I’m going to try harder to do my bit, going forward. Will you try to do yours?