Larry Kramer, on accepting the Tony Award last month from the Theatre Guild-American Theatrical Society for The Normal Heart as Best Revival of a Play said: “To gay people everywhere, whom I love so dearly…we are a very special people, an exceptional people, and…our day will come.” My day came in 1982 when I secured an Assistant Professorship in the Department of Medicine at the University of California, San Francisco. I set about establishing a behavioural medicine clinic fully integrated into general medicine practices, researching chronic disease prevention, and teaching interns and residents about psychological issues. One guest speaker, a social worker, led a discussion with the residents about the special medical needs of gay men. He was dead a month later from what later became known as AIDS.
The “special and exceptional people” cited by Kramer had lived through the 1970s and fought for human rights in the USA. That was followed in 1981 with the scourge of AIDS that could have knocked the wind out of the gay community. Instead, the community rallied and used its skills and talents to advocate for resources to develop community-based systems of care and prevention, and to ensure that human rights were not trampled.
Unleashing that energy and skill to build a global movement to improve HIV prevention and care services for men who have sex with men (MSM) is long overdue. Momentum is building and Chris Beyrer and co-authors make an important contribution. The Global HIV Epidemics among Men Who Have Sex with Men documents the extent of the HIV epidemic and outlines what needs to happen to ensure that everything possible is being done to prevent and treat HIV infection in MSM worldwide.
This volume documents the need in terms of the numbers, but also addresses the scenarios in which HIV epidemics among MSM exist in low-income and middle-income countries. The first scenario they describe, characterising the HIV epidemic in most of Latin America, is one in which MSM are the predominant exposure mode for HIV infection in the population. In these countries MSM are ten to over 100 times more likely to have HIV than the general population. By contrast, eastern Europe and central Asia have the highest rates of HIV among injection drug users (IDUs), but MSM are still several times more likely to have HIV than the general population. A different scenario is found in sub-Saharan Africa where HIV is widespread among heterosexuals, but even in these contexts MSM can have two to 20 times higher prevalence of HIV than the general population estimates. South, southeast, and northeast Asia are characterised by epidemics that have equal contributions from MSM, IDUs, and heterosexuals, although MSM are still at least ten times more likely to have HIV than the general population.
The needs come not only from the numbers. Beyrer and his co-authors document well the lack of prevention technologies focused on male-to-male transmission. They note that much effort has been expended on encouraging voluntary HIV counselling, testing, and behavioural interventions to decrease rates of unprotected anal intercourse by encouraging less risky sexual behaviours. Although important, such strategies are probably insufficient to produce immediate or lasting change in HIV transmission. Male circumcision may be effective for reducing acquisition of HIV through anal intercourse but we will never know for sure because of the challenges of conducting a trial to prove efficacy. Antiretroviral-based prophylactic approaches provide the best opportunity for managing HIV among MSM. In the wake of the IPREX, CAPRISA 004, and HPTN 052 trials, it is now time to accelerate efforts to determine if similar benefits can be obtained with rectal use of these or similar compounds. In some countries, like Peru where the epidemic is concentrated in MSM, providing universal access to care with MSM-sensitive services could actually change the overall trajectory of disease spread.
Kramer’s use of the term “exceptional people” referred to the gay community’s creativity, resilience, and energy to ensure that the response to HIV was all that it could be in resource-rich countries of the world. But not everyone views homosexual exceptionality in a positive light. Many parts of the world view same-sex relations as abnormal, deviant, sinful, and illegal. At best, most governments and donor agencies have ignored HIV among MSM. At worst, MSM are stigmatised and prosecuted. Homosexuality is criminalised in just less than half of the UN member states with punishment ranging from jail time to the death penalty.
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