Rapporteur reports
Community report by Jane Galvao
Tuesday's plenary featured 3 presentations: Dr. Myron Cohen; Dr. Adeeba Kamarulzaman; and Dr. Jorge Saavedra. Dr. Saavedra delivered the Jonathan Mann Memorial Lecture.
Prevention of the sexual transmission of HIV-1: a view from early in the 21st century. Dr. Myron Cohen
Dr. Cohen delivers a powerful presentation mentioning 4 preventions opportunities such as 1) behavioral, structural; (2) vaccines, Prep, microbicides; (3) vaccines, ART, PEP; (4) and when the person is infected treatment of HIV reduced infectivity.
The speaker called for the terminology of HIV treatment to be adopted in prevention: "Highly Active HIV Prevention" using a combination of behaviour change, biomedical strategies, social justice and human rights, and treatment.
Substance use and Harm reduction. Dr. Adeeba Kamarulzaman
Dr. Kamarulzaman pointed out that only 77 countries have needle exchange programs and 63 have opiate substitution treatment, and that the US and many other governments reject harm reduction approaches. She was concerned about the how the dominance of law enforcement above health in drug policy weakens efforts to prevent HIV infection in drug users. Some of the ways to move forward would be:
- Expanding coverage of prevention and treatment services now the major priority many countries
- Raise funding health measures for drug policy to the same level as law enforcement.
- Public security and health - policy harmonization
- Integrate prevention and treatment services
- Base policy on science, public health and human rights
Dr. Kamarulzaman also urged the Iranian government to free the 2 Drs and broters Arash and Kamiar Alaei, who were detained by Iranian government in June 2008.
Sex between men in the context of HIV - Dr. Carlos Saavedra
In the beginning of his lecture, Dr. Saavedra commented: “Finally a plenary about MSM!"
The speaker started mentioned the diversity of MSM population
- MSM is a construct which tries to capture behavior and not identity
- Sexual orientation includes homosexual, bisexual, heterosexual
- MSM as a category includes gay and non-gay identified men, bisexuals, "situational" sex between men (prisons, schools militaries), male sex workers, and some transgender persons
- MSM includes a wide array of traditional and local terms worldwide
Dr. Saavedra also commented on several studies conducted showing the prevalence of HIV infection among MSM, but as he said:
Every time HIV prevalence studies are conducted among MSM we observe the same consistent results: The best way of denying this reality, is by not looking at these results, not doing any research at all on this population or simply by not believing in scientific evidence.
Factors that influence risk and vulnerability for MSM:
• Human rights violations
• Criminalization of sexual orientation
• Stigma and discrimination
• Homophobia
He also challenged the audience mentioning the Convention of Eradication of all forms of Discrimination against Women that said: “Nobody should be forced to marry against their will and people should have the right to choose who the marry”
And then he asked: Should this also apply to men? to gay men perhaps?
And also some good news: This conference began with the world’s first international march against homophobia In advance of the march we alerted the activists and government of Panama that we would highlight Panama as the only Latin American country still criminalizing homosexuality The law was changed by executive order two days before the march.
And he closed his remarks saying:
· HIV continues to disproportionately affect MSM worldwide
· Exclusion from surveillance, targeted prevention, and treatment and care for MSM still limit the global response to HIV/AIDS
· We have failed to bring down incidence in MSM because, with some exceptions - we have not tried
Mexico, Australia, Brazil show we can succeed if we try
He closed his presentation with a slide of he and his husband - mentioning his wedding in 2004.
Track C report by Gaston Djomand
Four major areas for prevention opportunities were discussed. For unexposed persons , behavioral and structural approaches such as use of condoms and male circumcision to be used in combination remain the most effective strategies. In exposed persons (pre-coital/coital), approaches for prevention include vaccines, ART- PrEPs and microbicides which have to date remained elusive. After exposure (post-coital), approaches such as PEP have theoretically been recommended by limited data have documented its success. For infected persons, HIV testing linked to ART remains the most effective approaches.
HIV preventive responses for IDUs show big gaps throughout the world. However, while there is increasing coverage for needle exchange programs and opiate substitution treatment, IDU driven epidemics continue to prevail in several countries in South East Asia and Russia, emerging epidemics are being established in African countries such as Nigeria and Kenya. Comprehensive strategies that include legal, socio-political, medical aspects as well as referral services and treatment may successfully scale up HIV prevention efforts among IDUs.
The epidemiology of the HIV epidemic in MSM indicates that HIV continues to disproportionately affect MSM worldwide. Lack of surveillance data, targeted prevention, treatment and care still limit the global response to HIV/AIDS among MSM. Approximately 60% of MSMs received prevention services in countries with no discrimination laws as compared with 30% in countries without those regulations. From a human rights perspective, efforts are needed to increase advocacy and activism, funding to meet the needs of research and provision of services, and wide implementation of successful experiences.
Track A report by Guido Silvestri
At the plenary session Dr. Myron Cohen from the University of North Carolina discussed what are the perspectives of prevention of HIV transmission: “A view from XXI century”. For efficient prevention, he emphasized a complex approach combining behavioral, and barrier methods. He emphasized that the earlier data on the low probability of HIV transmission (1/1000 sexual acts) is true only for very restricted situation. For many time-periods (e.g., of high viremia) as well as for many couples (that may have lesions, STDs etc) this probability jumps up to 1/20. Unfortunately, transmission occurs in millions cases, hence the urgent need for preventative strategies including vaccines. Dr. Cohen discussed the possibility of the use of existing anti-HIV drugs for prevention purpose, as suggested by data generated in non-human primate models that show some promise. Also, a similar strategy can be used for topical approach (microbicides). Nevertheless, if transmission occurs there is another important strategy, that is post-exposure prophylaxis and post-infection therapy, for which we need a highly effective treatment. If successful, such treatment will affect not only the infected person but also his/her sexual partner by decreasing viral load and therefore the probability of infections. In summary, our challenge is to combine (“marry”) all three aspects of anti-HIV strategies—something that did not happen yet, but without which the epidemic will not be stopped.
Track E report by Stefan Baral
Adequate investment into HIV prevention strategies is a necessary component of a successful and comprehensive approach to curb the HIV pandemic. Treating those already infected with HIV is a also necessary, and it has been consistently shown that the combination of treatment with adequate prevention is the most efficient manner in decreasing new HIV infections. Given the dynamics of a free market, the great majority of investment has been in the development of the 22 available antiretroviral agents. However, there has been relatively little investment into prevention tools ranging from research into HIV vaccines and microbicides to the adoption of evidence-based prevention tools such as needle-exchange programs, safe drug use facilities, network-level peer education, and programs targeting sex workers, young people, and MSM and other sexual minorities.
And the magnitude of the HIV epidemics among gay men and other MSM is staggering. While MSM have generally been considered in the HIV epidemics in high income settings, there is now overwhelming evidence that they are also a large part of the epidemics in the lower income settings of Asia, Latin America, and Africa. Structural risks including criminalization, stigma, and systematic homophobia limit access to HIV prevention services and in turn likely continue to drive these epidemics among MSM. Even in the context of high and consistent HIV risk, less than half of all countries report any indicators on MSM, and in the UNGASS reports of 38 countries released this year, only 1.2% of prevention expenditures targeted MSM. Moreover, only 1% of these expenditures targeted sex workers, and 2% were appropriated for IDUs, while 96% was appropriated for heterosexual and vertical transmission. These figures represent a continued and ongoing massive underinvestment into the populations well known to be at risk for, and carry a disproportionate burden of, HIV infection globally.
Leadership report by Richard McKay
Dr. Myron Cohen of the University of North Carolina addressed Tuesday's plenary session with a discussion of the current state of efforts to prevent the sexual transmission of HIV-1. Cohen noted that the field had long focused on only one of several opportunities for HIV prevention - keeping people unexposed. In his talk, Cohen discussed exciting developments in other key areas, including pre-exposure prophylaxis, and topical treatments. He urged researchers not to be discouraged by recent setbacks in vaccine research, declaring that failure was not an option in this area. He also suggested that recent studies - which suggest that STD interventions do not lead to a decrease in HIV infection – were not indicating that STDs are not significant infection amplifiers, but rather demonstrating that the interventions themselves were not adequate.
Dr. Adeeba Kamarulzaman, of the University of Malaysia, urged the audience to move from debating the merits of harm reduction for IDUs to enacting its implementation. She highlighted the fact that many countries devote far more of their resources to enforcement and only a fraction to harm reduction, while at the same time continuing to uphold laws which criminalise drug use. Kamararulzaman paused her presentation to make a moving appeal to the Government of Iran, asking them to release the two Iranian doctors recently detained there. She noted that it was as a result of their encouragement that doctors from Malaysia had visited Iran and eventually duplicated similar harm reduction approaches in Malaysia.
This year's Jonathan Mann Memorial Lecture was delivered by Dr. Jorge Saavedra, Director of Mexico's National HIV/AIDS Programme in Mexico. Saavedra began by saying: 'Finally, a plenary dedicated to sex between men,' noting that this group was, in many countries, at much higher risk of becoming infected with HIV, and yet often neglected. This increased risk was true in the US and Europe, but also in China, India, and several African countries where MSM issues are not being adequately addressed. He urged governments to rectify socio-structural conditions hindering MSM which further the spread of HIV. In this regard, he presented the example of a Senegalese and married HIV+ MSM, who had to meet partners secretly and had felt pressured to marry due to social stigma surrounding homosexuality. Throughout his address, Saavedra emphasized the importance of improving surveillance on MSM, and increasing funding for prevention and health services targeting this group.
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