We all want to end HIV. But we need evidence-based methods of prevention, not just beliefs.
In The X Files, FBI agent Fox Mulder had a poster on his office wall with a slogan that became a blockbuster 90s catchphrase, and a mantra for a generation of desperate people swayed by pseudoscientific bollocks like the law of attraction:
I Want To Believe.
Chris Carter’s hit show operated within the realm of science fiction, though, and you would hope that in the world of HIV prevention, we’d be relying more on science fact. Unfortunately, the global zeitgeist around testing-as-prevention that’s now infected Australian AIDS organisations has been taken on board while listening to a looped tape of Dusty Springfield’s “Wishin’ and Hopin’”.
After two blogs on ACON’s latest campaign Ending HIV (If condoms are punishment and You can sell anything), I’ve been taken to task on my scepticism around this, not least of which by ACON’s Director of Sexual Health and HIV Prevention Geoff Honnor, so I feel this is important enough to tackle comprehensively: in part 2 (next week) I’ll look at the question of whether investing in this approach is realistic compared to comprehensive condom-based social marketing as a primary choice, and in part 3 I’ll look at the implications of HIV prevention being taken out of the hands of communities (us) and into the hands of the medical industry.
This week, I’ll be asking – what evidence do we have to show that testing-as-prevention even works in the first place?
Research has shown testing as prevention to be ineffective
On February 1, The Lancet published a nationwide population study that looked at whether testing-as-prevention had been effective among gay men in England and Wales. It used data spanning most of the previous decade, from 2001 to 2010.
Its findings should make any government seeking to fund such an initiative nervous: despite a four-fold increase in HIV testing during this period, there was no effect on HIV incidence or the number of undiagnosed HIV infections. This is also despite an increase in men going onto treatment – from 69% in 2001 to 80% in 2010.
Also published in February was a paper funded by the UK government’s National Institute for Health Research. It too observed that despite an increase in treatment uptake, numbers of new infections diagnosed in the UK each year among gay men have not decreased.
The reasons for this, the researchers say, is unclear although they note a “modest” increase in sex without condoms (26%). Through computer modelling, taking into account risk behaviour, testing rates, and the percentage of men on treatment, the researchers explored a number of potential scenarios.
The most alarming of these found that, had all condom use ceased in 2000, HIV incidence would be a whopping 424% higher in the UK and Wales than it is now, a staggering disaster compared to the estimated reduction in incidence when compared to ideal testing-as-prevention scenarios.
“Increased condom use should be promoted to avoid the erosion of the benefits of ART [drug treatment] and to prevent other serious sexually transmitted infections,” the researchers concluded.
Their conclusion about condom use being promoted to avoid “erosion” is a crucial point: prioritising one prevention strategy over another does have an effect, and if that strategy is less effective, the results will be bad.
Promotion of condom use will not be effective if it’s buried within the messages of a wider campaign, or tacked on summarily in a ritual genuflection. Indeed, in a 2008 paper published in the Lancet and funded by the Australian Research Council, a group of Sydney researchers cautioned precisely this: that if people came to widely believe that treatment stopped infectiousness, and condom use declined as a result, “then there is the potential for substantial increases in HIV incidence.”
The key proponent of testing as prevention advises caution
The modern prophet of testing-as-prevention is Dr Reuben Granich of the WHO. When he first introduced the idea that the HIV epidemic could be controlled by testing-as-prevention in a 2009 Lancet paper, many of his peers felt it was more utopian than realistic, and in his reply to their scepticism he conceded that his paper was “a hypothetical exercise and further research is required to assess whether
the studied approach has merit.”
Needless to say, the 2013 Lancet study of the UK/Wales situation mentioned above has given him even further pause for thought. In an editorial published in the same issue, he concludes that “increased testing and earlier treatment is no quick and easy solution.”
With their Ending HIV campaign, ACON expect it to reduce incidence by 80% in less than seven years, despite even the most optimistic studies (such as this one from San Francisco cited by NAM) noting there’s no proof that increased treatment causes HIV rates to drop.
In 2009, Granich presented a plenary talk on testing-as-prevention at an international AIDS conference in South Africa. His theoretical model, based on data from sub-Saharan countries in Africa, estimated that HIV could be reduced 95% over ten years if everyone got tested at least once a year and went immediately onto treatment if diagnosed positive.
But, he added, “it’s a model that is specifically designed to look at questions among a heterosexual epidemic, and hasn’t been applied elsewhere. I would emphasize again that it’s a theoretical model, and doesn’t represent a change in WHO policy.”
Why should it make a difference that the model is based on a heterosexual population?
Studies of heterosexual HIV risk cannot be applied to gay men
Because our risk profile as gay men is completely different. The rise of the internet and hookup apps give us a much greater ability to get sex on tap. Sexual behaviour research in all Western countries shows that, on average, we have sex with more people, more often than heterosexuals. This is not a moral judgment, it is merely a fact.
Add on top of this that anal sex, particularly if you’re the bottom, is around twenty times riskier than vaginal sex in terms of HIV transmission (why do you think emergency medicines in hospital are delivered up the arse instead of orally?).
Finally, the third layer in our rapidly-collapsing cake is the 1-3 month window period during which HIV is undetectable through testing.
Put all these three things together and you’re left with the uncomfortable truth that most gay men who become infected will infect at least one other person (probably unknowingly) before they reach the golden target of diagnosed + on treatment + viral load low enough to reduce transmission risk.
But according to Geoff Honnor, ACON “accept the research findings that underpin the treatment as prevention approach”.
They must really want to believe.
Shayne, I just want to say, you aren’t a fringe dweller. In fact, I think you already know that there are quite alot of us pozzies out there who are completely disenfranchised by ACON and the other HIV organisations.
I’m more than slightly concerned about this joke of a campaign. For starters, it doesn’t address the fact that viral load in semen can be a lot higher than the viral load of blood. In fact, viral load in blood can increase if you are co-infected by something as simple as flu. Of course, you won’t know that, as at best, a viral load test takes a week to come back and even then, it’s only really a snapshot in time. Not the reality over ones entire life.
Next is the ethics of the medical fraternity putting any pressure on any positive person to start treatment. Apart from the fact that it’s unethical to force someone to take a medication they are not comfortable in taking, it also spells disaster for compliance. (And you can take that from very the very personal experience of me)
Next is what I can only describe as the bullying nature of some of the campaigns posts on Facebook. For example, they ask people to discuss with the positive friends if they are on treatment. Now, I lost my temper at this post and have to admit, let a few choice words out. To summarise in slightly less offensive words, I told them that it was nobody elses business if I am on medications or not. It is the business of me and my immediate medical team. The only time anyone else can ask about that, is if I’m taken to hospital, then I expect to be asked if I’m on medications and what type. I do not take kindly to being blackmailed by friends, family or friends of friends. Nor is it my responsibility to make the negative population feel “safer” because I may or may not have an undetectable viral load.
In summary, I will start taking HIV medications when I’m good and bloody well ready. ACON and the rest of them can go bugger off.
Pingback: Ending HIV: How much is that lemon in the window? | Bipolar Bear
I do think testing that reduces the window period, combined with early treatment and lowered viral load has the potential to impact the HIV epidemic considerably. That’s great.
The difficulty is throwing all these things at all gay men as different strategies to avoid HIV. Social Marketing should have a clear behaviour change in mind. Is it condom use? Is it testing? Is it Taking Meds? adn I think are muddled.
I agree. Even IF the acon website worked, its digfficult to know what it is actually trying to say. The recent NAPWA ‘Start the conversation today’ campaign was the same. I wrote to NAPWA to ask them, but had no conversation there.
I agree on almost all your points: the study out of the UK is particularly concerning. it’s also worth noting that the NZAF’s reinvigoration of the condom message has already shown a reduction in new diagnoses among queer men. Details are in the annual report.
But a few points I’d like to challenge:
anal sex is higher risk than vaginal sex: theres NO basic science to back this up. None. It’s based on the biased presumption that the anus is more liable to tears or abrasion during fucking than the vagina. The sigmoid colon is more tender–and rarely involved in anal sex. This is scientific homophobia.
We have no idea about the anal sex practices of straight Africans. Most research doesn’t ask women and men if they fuck each other in the arse–the presumption is that it doesn’t happen. HIV among teen girls in the US–using anal sex to avoid pregnancy–shows that this needs to be interrogated further.
There is now testing for live HIV that works within days of infection, eliminating the 1-3 month period. But people need to ask for it and the health worker needs to know about it. The old anti-body testing is relatively useless IF someone wants to go onto treatment in the early onset (and hyper infectious) first 1-6 months.
Thanks Jawn, I think NZAF has the right idea with what they’re doing, they are also very visible in the community both on and offline which is great.
I can’t agree with you on the anal sex risk, though, this is not homophobic science but simple biology. The lining of the arse absorbs material like a sponge, hence – as referenced in the post – why many medicines are delivered that way. HIV is present in both blood, sperm and precum, so it’s not necessary for skin to be broken for transmission to occur.
There’s no science to back that claim up–and lots to refute it. The same cells render a person vulnerable to HIV in men and women: langerhans cells. There’s lots in both the vagina and uncircumcized penis: HIV hates air and water so that’s a differentiator between men and women. The rectum is not fragile or porous compared to the vagina: different, but comparable mechanisms.
Women use vaginal suppositories for medicines; it’s easier for manufacturers to make one that works for everyone, hence anal suppositories.
I haven’t got time to look up the Lancet paper that this news article refers to right now, but it was my understanding that the anal vs vaginal transmission risk data was pretty sound: http://health.usnews.com/health-news/news/articles/2012/07/20/biology-leaves-gay-men-highly-vulnerable-to-hiv-study
If you could link to some studies that show an equivalent transmission risk for receptive vaginal sex vs receptive anal sex when you have a minute, I’d appreciate it.
It doesn’t reinforce condoms, it’s an option…along with risk reduction…which causes a shitload of confusion.
http://endinghiv.org.au/stay-safe/risk-reduction-strategies/
Apart from the blanket message ENDING HIV and I’M IN, its hard to know what the new campaign is. I assume its linked to the site where you do a series of tests to determine how important using a condom is for you. The site never works anyway. All very obscure, when the simple message that guys need to hear is, ‘Life is better lived without HIV.’ Once they understand that, and not, ‘Life with HIV is just a pill a day and life’s a walk on the beach,’ then they WILL make the initiative to protect themselves and others.
Apart from the huge letters “ENDING HIV’ and “I’M IN’ its hard to know what the campaign actually is. There’s a test online, which never seems to work for anyone who uses the site, which apparently is a way to determine how important it is for you to use a condom. Its all very obscure, when the information guys really need to hear is simple: ‘Life is better lived without HIV.’
That’s an interesting deconstruction, thanks. Almost as interesting is the way that the NSW gay community, government and queer media accept every posit from acon without question. I, however, have reason to be more skeptical of them. Mr. Honnor failed to make a meeting with me to discuss the new campaign and i gave up on him being all that interested. Spending only $800k on all programmes and services, from a budget of $12 mill does not show a great commitment to community imho, when the rest of that money goes to staff and their perks. Previously I met with him a few times to discuss his industry making a submission to the Senate hearing into how changes to DSP criteria would affect those 50% of HIV+ living on welfare. At that time he said, ‘what we do now defines us.” He was right, in the end, they sent the submission to the wrong address and 10,000 poz guys were not represented at the hearing. The two tables relating to HIV for the DSP were removed.
And so to this new campaign, following the condoms on bananas in pyjamas and my fave, the GLAM Reaper. I live with HIV and I’m still waiting for it to be glam. Six months in St Vinnies on chemo was remarkably glam-less. And that’s the point. To make informed choices, gay men (the primary target) needs accurate, honest information about what it will mean if they get unlucky and have to live with HIV. The HIV Futures study is an eye opener, showing a third live beneath the breadline and issues with depression are chronic. The simplest way to communicate the reality that those who seroconvert will face is to allow the HIV+ to speak for themselves. But most pozzies in this state feel voiceless and dialogue with acon is frustrating and pointless. At least Geoff Honnor was willing to chat, his boss at acon told the media I am only a fringe dweller of his community so my opinions are void.
Anyway, it seems the drive is to give up on getting guys to use condoms and just get everyone on meds to lower the viral load so it becomes harder to transmit. There’s even talk of making Truvada available as a /vaccine/ for the HIV negative. This is seriously flawed because at least a third and probably a half of new HIV infections come from guys who do not know they are carrying the virus. HIV seroconversion can be asymptomatic, or seem like just a cold. And unless HIV meds are taken consistently, the virus soon mutates to develop a resistance to the drugs. Gay men who are unknowingly poz, taking the meds for a big weekend and not for the rest of the week will be breeding new strains of drug resistant virus, which they’ll then be sharing with the rest of the community.
Acon, instead of focusing on galas and self congratulatory parties for themselves at Slide, really need to give some serious thought to the job they are chartered to perform. And as i have said before, if they find that too boring or they are incapable of doing it, the funding should be given to an independent professional organisation that IS committed to the task.
Your arguments might make sense if the current campaign included the message “you can stop using condoms”. On the contrary, it reinforces the message that condoms remain the best preventative measure and we should continue using them, as well as getting tested more regularly (or at all).
As I understand it, the majority of transmissions are from HIV-positive men who are unaware of their status and are not using condoms. So by the logic of this post, three decades of messaging imploring us to use condoms has also failed, and we should abandon that strategy as well?
The strategy has three facets (testing, treatment and condoms), and by focussing on just one of them and denying the existence of another, you’re misrepresenting it.