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Past as Prologue: The Refractory and Evolving HIV Epidemic Among Men Who Have Sex With Men
  Clinical Infectious Diseases June 1 2011

Received 24 February 2011; accepted 4 March 2011.

Kenneth H. Mayer1,2 and Matthew J. Mimiaga2,3,4

1The Fenway Institute, Fenway Health, 2The Warren Alpert Medical School of Brown University/Miriam Hospital, Providence, Rhode Island, 3Harvard Medical School/ Massachusetts General Hospital, Departments of Psychiatry, and 4Harvard School of Public Health, Department of Epidemiology, Boston, Massachusetts

Correspondence: Kenneth H. Mayer, MD, The Fenway Institute, Fenway Health, 1340 Boylston St, Boston, MA 02215 (

(See the article by Levy et al, in next NATAP email report

For the past 30 years, the AIDS epidemic has been intimately associated with men who have sex with men (MSM), since the earliest reports of Kaposi's sarcoma and Pneumocystis (carinii) jiroveci pneumonia being diagnosed in previously healthy individuals in 1981 [1]. Even before the elucidation of human immunodeficiency virus (HIV) as the etiological agent causing AIDS, epidemiologists and socio-behavioral scientists were able to identify specific practices, particularly unprotected anal intercourse, often with multiple partners, that helped to potentiate retroviral spread among MSM [2-5]. The enhanced mobility of some MSM in the jet era, along with opportunities to easily meet new partners in unique sexualized environments in new cities (eg, bath houses), allowed for rapid dissemination of HIV and the establishment of entrenched epidemics in urban epicenters across the globe [6, 7]. The majority of the people living with HIV in the Americas, Western and Central Europe, and several Asian countries continue to be MSM [8-12], and concentrated MSM epidemics in Africa are also being documented in multiple settings [9, 13-15]. With the exception of countries like South Africa, where more than a fifth of the general adult population is infected, HIV prevalence among MSM in all other nations invariably exceeds that of their heterosexual peers [14, 16].

As increasing numbers of MSM became sick with AIDS in the era prior to the advent of highly active antiretroviral therapy (HAART), behavioral norms rapidly changed, and safer sex became more prevalent. From a height of >100,000 new HIV infections per year in the United States in the 1980s, the rate dropped to <60,000 new infections per year over the last decade [17]. Although some of the decline in new infections resulted from public health measures such as blood screening and harm reduction approaches for injecting drug users, it can be argued that a substantial part of this decrease was due to the increased use of protective measures by MSM [18-20]. With a highly concentrated and debilitating epidemic, MSM were saturated with reminders of the consequences of unprotected sex and changes in community norms resulted in a stabilization of the epidemic in cities in the Americas, Europe, and Australia [8]. However, as HAART decreased the visual stigmata of the epidemic and transformed HIV into a chronic, serious, but manageable infection, the tangible reminders of AIDS disappeared and increasing risk behavior among MSM reemerged in conjunction with this "therapeutic optimism" [21-23].

In the current issue of the Journal, Levy et al. [24] describe some of the most worrisome issues associated with the emerging and evolving HIV epidemic in Israel. They not only documented that the absolute number of HIV infections has been increasing over the past decade, despite wide access to HAART, but that the preponderant number of those recently infected and newly diagnosed were MSM. Particularly concerning was the finding that 29% of the men were infected with HIV that was resistant to at least 1 of the antiretroviral classes, and coinfection with syphilis was common. These findings call to question some of the recent optimism about "treatment as prevention" [25, 26], which presumed that if expanded efforts at increasing HIV testing and linkage to care could be undertaken, and individuals could be promptly treated, that the AIDS epidemic could be brought to a halt. Unfortunately, these data suggest that an appreciable subset of HIV-infected patients in care may be engaging in risk-taking behaviors, and because of either nonadherence (not documented in their paper) and/or genital tract inflammation due to intercurrent sexually transmitted infections (which they did find), they have sufficient concentrations of resistant HIV in their genital tract secretions to transmit to uninfected sexual partners. This study is not the first to document that some individuals are newly infected with resistant virus [27] and that syphilis is increasingly common in HIV-infected MSM [28, 29], but the combination of these factors and their association with an expansion of a national HIV epidemic heightens the acuity of the concern that a new generation of MSM could face an AIDS epidemic with constrained therapeutic choices.

Why is this happening?
Therapeutic optimism is only part of the explanation. Since the earliest days of the epidemic, affective disorders, like depression, as well as substance use, have been associated with unprotected sex and multiple partners [30, 31]. For some, early life experiences, ranging from sexual abuse to homophobic violence, may result in decreased self-efficacy (hence, less agency in making safer sex decisions) and lowered self-esteem [32]. The use of disinhibiting drugs and unprotected sex may serve a depressed MSM as ways to "self-medicate" in an adverse environment [33, 34]. These conditions not only tend to co-occur, they synergistically interact to enhance the risk of engaging in unprotected sex and becoming HIV-infected [35]. Thus, attenuating the spread of HIV among MSM requires the scaling up of evidence-based programs that not only encourage HIV testing, linkage to care, and treatment, but also engage providers in the provision of culturally competent care to sexual and gender minority patients [36]. For example, drug treatment programs that are tailored to substance-using MSM have been shown to be more effective than those that do not acknowledge the participants' sexuality [37]. Unfortunately, many MSM who engage in practices that put them at risk for HIV and other sexually transmitted infections (STIs) report that they are not always comfortable disclosing their behaviors to their medical providers [38, 39], creating multiple missed opportunities for slowing the epidemic every day around the world.

The Israeli study holds a mirror to the future of the epidemic in this population, suggesting that MSM should not assume that their partner is HIV-uninfected, and if he is infected, it is unwise to assume that his medication will make him noninfectious. Public health authorities and MSM community leaders need to work together to develop educational campaigns that address the complacency of some at-risk individuals who believe that HIV is not their most important health concern. At the same time, clinicians need to understand that they have an important role to play as well by creating a welcoming environment where their patients can discuss their sexual behavior; get tested for HIV; and, if found to be infected, be started on treatment and be encouraged to adhere and to avoid engaging in potential transmitting behaviors. Lastly, public officials and civil society need to understand that stigmatizing homosexuality can potentiate social norms that make MSM more likely to experience physical violence and social rejection that can lead to increased rates of depression, substance use, and subsequent risk-taking behavior. The promotion of human rights for sexual and gender minority individuals will not automatically stop all risk-taking behavior, but it is ethically correct, and, in combination with intensified community education, professional counseling, and engagement in care, the emerging epidemic among MSM may someday be arrested. By not taking these actions, a future with increased transmission of resistant HIV is guaranteed.

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