An alarming increase in the incidence of both HIV-infection and other sexually transmitted infections (STIs) has been occurring amongst men who have sex with men (MSM) in England over the last two years.
A number of news reports highlight an alarming increase in the incidence of gonorrhoea, chlamydia and syphilis among MSM, particularly in London (http://newsle.com/article/0/122167058/). Sexual health epidemiologists suggest these sexually transmitted bacterial infections, that become clinically apparent much more rapidly than HIV-infection, are a kind of barometer for how much unprotected sex is going on in the population. Therefore, a rising incidence in bacterial STIs may be an early indicator of increased HIV exposure. In fact the Health Protection Agency reports that the incidence of STI’s in London’s general population has been rising dramatically since 2010 (http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317137359627). MSM are disproportionately over represented in these figures, accounting for 18% of new STI diagnosis in men, while estimated at only 5.5% of the adult male population. Between 2002 and 2011 there was as much as a 144% increase in the incidence of STIs in London’s MSM population, according to Health Protection Agency figures.
In November 2013 figures released by Public Health England showed that the downward trend in new HIV infections among MSM that had lasted from 2003 to 2011, had suddenly and dramatically reversed with an 8% increase in new HIV infections between 2011 and 2012 (http://www.pinknews.co.uk/2013/11/21/hiv-infections-among-gay-men-in-england-at-highest-ever-level/).The 3,250 gay and bisexual men who were diagnosed with HIV in 2012, comprise the highest annual figure for new HIV-infection since the start of the epidemic.
Public health officials state that the group most likely to transmit HIV are those who are HIV-infected and untested or unaware of their HIV status. In a report in the UK’s Pink News Professor Noel Gill, head of Public Health England’s HIV and STI department, states that: “In the UK, people who are unaware of their infection are likely to be those most at risk of transmitting HIV to others. We must increase the speed at which we’re reducing the number of undiagnosed HIV infections by encouraging earlier and more frequent HIV testing, especially by those most at-risk. Earlier diagnosis will help reduce new HIV infections across the UK.”
Numerous news reports are linking these figures to several culprits, including sex and dating mobile apps, recreational drug use and in some cases a confused and muddied public health message on safer sex in the modern era of antiretroviral therapy. In January, Channel 4 News, a national TV news programme, posed the question “Is crystal meth behind London’s rising HIV levels?” (http://www.channel4.com/news/crystal-meth-hiv-gay-men-london-sex-parties). In a news report out today, David Stuart of Dean Street sexual health clinic in London’s Soho warns that the situation has now reached crisis levels, “There’s been a flood of new drugs onto the market,” he said. “That has mixed with a lot of confusion about the changing HIV healthcare situation. Once upon a time the message was: “wear a condom and you’re safe”. Now if someone is taking their medicine it’s very hard to transmit the virus even if you don’t use a condom. Thirdly, there’s new technology – things like [gay networking site] Grindr and websites for hooking up online. There’s no training booklet for how to manage your sex life, your romantic life, using these apps.” (http://newsle.com/article/0/122167058/).
While the figures and the emerging social and technological forces that may be operating behind them are particularly worrying, I suspect there is a much broader issue at work here. In the last 10 years there has been an almost complete disappearance of public discourse on safer sex and HIV awareness in the gay community, as they have been swept under the carpet. In my own experience I’ve been pretty shocked at the astounding levels of ignorance regarding HIV and sexual health whenever I talk to gay men under the age of 40. Sure, if you really go looking for it, you can find information online about risks and whats safe, whats safer, and whats not. But you have to be very proactive. In my teens and twenties, during the 80’s and 90’s the information was in your face all the time. And now its not. Far from it in fact. Instead most gay guys discovering their sexuality today seem to learn about sexual practices and associated precautions (or lack of) from a combination of watching pornography and from their friends and peers. Public education campaigns on HIV prevention have almost completely vanished.
Personally I am not convinced by some of the tentative explanations for the sudden increase in new HIV infections in London’s MSM. There is an accusation that dating apps have made access to sex and drugs much easier – much as I dislike them, I doubt this is the case. For one thing instant “on tap” sex has always been a feature of life in London. It has simply moved from bars, parks, cottages and the street to your hand-held device. Another explanation is the appearance of new recreational drugs like crystal meth and GBH. I’m also not so sure about this. These drugs have been been around for a while now, and while there has been a steady rise in STI’s associated with unprotected sex over the last 12 years in London, something appears to have dramatically changed in the last 2 years.
So if it isn’t sex apps or club drugs, could it be that something has gone badly awry with the prevention message? Has the safer sex message got too confused and muddied in the advent of antiretrovirals, post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP) and the recent understanding of the low transmission risk that results from having an undetectable viral load.
Lets just think about what the prevention message has been over the last decade. Like it or not, during the noughties there was a generalised fatigue with the 100% condom use message. This came on the back of the enormous collective euphoria in our community at the revolutionary transformation of HIV from a death sentence to a manageable chronic disease. In 1996 the first studies demonstrated consistent suppression of plasma HIV viral load to below detectable limits in patients receiving triple combination antiretroviral therapy. But less than 10 years after this incredible breakthrough, even as soon as the early noughties, gay men could be heard voicing complacency about the risks they were taking with HIV infection, with the attitude “If I get it, I can just take the meds“. Bareback websites sprang up on the internet and bathhouses, once banished by a flurry of militant HIV activism and their ensuing social taboo, re-emerged everywhere. I would postulate that in this climate, public health policy makers, HIV charities and those behind prevention campaigns began to feel they had lost the race. They were working against a relentless tide that was surging in the opposite direction. That is my subjective and speculative opinion, not a fact. But I have been gravely concerned with what exactly happened in those years and why? And I will have to admit that this applies to me personally, as much as to our community at large.
Gay men began the practice of discriminating who they had sex with based on the declared status of their would-be partners. So the new dogma began, if you are HIV positive, you only have sex with other men who are HIV positive. If you are HIV negative, you only have sex with other HIV negative gay men. This practice became euphemistically known as ‘sero-sorting’. And with it came a whole new culture and a new lexicon. Suddenly you had to obtain a license to have sex with a guy where there was a mutual attraction. That license came in the form of the correct response to the pernicious acronym DDF-UB2 (disease and drug free – you be to). All over dating and sex sites gay men were posting the date of their last HIV negative test, as if it were some trophy of their smart behavior. I could go on ad infinitum about the awful social ramifications this practice has had in terms of socially segregating people with HIV and amplifying stigma against people with HIV, but that is not exactly the point here. The point is that sero-sorting was a scientifically invalid prevention practice born of a time when our community was exercising a form of plausible deniability. You could make judgements about who you have sex with, and therefore what you did with them during that sex, based on their word that they were indeed DDF, or that they had a negative HIV test two weeks ago. It may not be the case that health policy makers and HIV charities endorsed this new practice. But in my opinion there wasn’t near enough criticism of it.
It doesn’t take an awful lot of imagination to see why this practice was so ill-founded. For one thing, someone’s word that they are DDF is no basis for deciding that its ok to have unprotected sex with them. For another thing a negative HIV test two months ago or two weeks ago, is no guarantee of being HIV negative. Given that HIV can take weeks to show up in tests, trophy HIV negative test dates are utterly meaningless. But consider another factor. In the statement above by Professor Noel Gill, head of Public Health England’s HIV and STI department, the people most at risk of transmitting HIV are those who do not know their status. Where does this leave the DDF UB2 club…? The DDF UB2 sero-sorting culture in the gay community is particularly pernicious because its not just those who do not know their HIV status that are most at risk of transmitting HIV, but those who are newly infected. Viral load in the blood, which is strongly associated with risk of transmission, is sky-high during primary HIV infection, in the first few weeks before an immune response has brought the virus under control. This is exactly the time at which someone is most infectious. So all those gay men on dating sites who display their last HIV negative test date as a trophy should now be recognized as potentially the most dangerous people to go and have sex with. If they were HIV negative two months ago, and have been using that status to determine what they do in bed with other supposedly HIV negative men, and have unknowingly become infected with HIV since, the risk they present is very high.
Unsurprisingly scientific studies have now shown that sero-sorting does not reduce risk of HIV transmission, but in fact increases it. Any tacit endorsement of this practice by those at a loss for a better prevention message has failed miserably. But into this prevention policy failure maelstrom enters a whole new battery of exploding bombs, which perhaps collectively have a lot to do with the current rise in HIV and STI incidence.
Over the last two years the sero-sorting culture that provides a backdrop for where we are today has been shaken by several technological advances. The first is the advent of PrEP – pre-exposure prophylaxis. Anyone at high risk of HIV infection who engages in unprotected sex can take the drug TruvadaTM to prevent infection occurring. Add to this the growing awareness that suppression of viral load to below detectable limits by antiretroviral therapy can reduce risk of transmission to negligible levels, and the picture of ‘where’ the risks are, or ‘who’ they are, starts to become incredibly blurred. The assumed risk reduction associated with sero-sorting is now challenged not by a dose of logic, but by a dose of further assumed risk reduction.
People don’t like using condoms. As the perceived risk of not using condoms reduces due to treatment advances, more and more people have apparently been deciding not to use them. But rather than throwing all caution to the wind, risk-judgments have been made in selecting the individuals condoms wont be use with based on information about those individuals. As I have argued, that information is generally unreliable. But with new advances in treatment-as-prevention, the way the assumptions implicit in sero-sorting decisions are being applied may be changing. Instead of assuming the low risk of a specific individual based on (albeit potentially erroneous) information about them, assumptions about the low risk of the collective in general may now be applied because of a new general sense that HIV is less “infectious” in the collective group. Decisions about risk are nonetheless still being made based on assumptions and misinformation. The sero-sorting culture for all its folly, has not been knocked away root and branch by new advances in treatment-as-prevention. But rather the new advances are likely modifying the way sero-sorting attitudes are being applied, while the underlying misconceptions and phobias upon which they were built remain unchallenged and are being maintained.
Placing the new complex set of conditions for ‘where’ or ‘who’ the risks are, against the backdrop of misdirected risk-identification over the last 10 years, it is no surprise that the prevention message has got confused and lost. But I suggest its the new set of treatment-as-prevention advances that have changed the perception of HIV risk over the last two years, not sex apps or club drugs. Of course these advances in and of themselves are a great thing, and should ideally reduce the overall incidence of new HIV-infections. But they can only do this if prevention policy makers stay ahead of the curve. A new coherent public health policy on HIV prevention in gay men is urgently needed. The fact that the British Association for Sexual Health and HIV (BASHH) are meeting this Friday to discuss a new “holistic approach” to address the crisis is a good thing. But lets make sure something viable and serious comes from it.
In the meantime there has been one big ingredient missing from the gay community in the last 15 years that has had a lot to do with the disappearance of discourse on safer sex and HIV in the gay community. That ingredient is HIV activism. The issues that HIV activist groups like ACT UP used to be concerned with in the 80’s and 90’s have evidently not all gone away. Without activists who stir things up in the community, on the streets, in the bars and clubs, there is no pressure from below to influence policy makers, to shape the narrative on HIV prevention, to draw attention to the issues for others in our community. It changes the narrative every where. A vibrant culture of militant HIV activists in London, Manchester, New York etc raises the profile of the issues around prevention and starts to move them from some website you have to go searching for to the conversations young gay men may be having with their first partners. If HIV activism had not vanished following the advent of combination therapy the sero-sorting culture and misdirection of risk-association might have been prevented. And so to might the current crisis emerging in London. So wherever you are, if you’ve read this far, think about how you can get HIV activism back off the ground in your town.