. Would it be better to use the correct term?... safer sex
 because there's never zero risk.

. Are they true random samples of the population?
. Are they skewed samples?
. Are those that go in a self selecting group?
 The guys that don't want to get tested aren't going to come in?
. So what does it mean?

. What is the rate of new infections?...

. In order to determine the rate of new infections would we have to have
 testing of a random sample of the general population?

. Are the studies short term studies?...

. Are the studies based on verbal responses?...

. Do potential sex partners who get tested TOGETHER BEFORE having sex
 for A VARIETY of sexually transmitted diseases prevent new infections?

. Should the phenomenon be studied?... the strategy of potential sex partners
 getting tested TOGETHER BEFORE having sex
 for A VARIETY of sexually transmitted diseases.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
by Ron Stall
Improving Safe Sex Interventions for MSM
http://tinyurl.com/24rh9m

Ron Stall
Pittsburgh USA
University of Pittsburgh
1787
VERITAS et VIRTUS
http://www.aidschicago.org/lifelube/docs/Improving%20Safe%20Sex%20Interventions%
20for%20MSM_Stall.pdf

Presentation Goals
.  To summarize current HIV risk among MSM
.  To review the efficacy of HIV prevention
  efforts among MSM
.  To show that the actions of HIV prevention
  efficacy are not addressing cutting edge
  prevention questions as raised by MSM
.  To argue the necessity for a prevention cocktail
  that taps multiple mechanisms of prevention efficacy

Does HIV Prevention Among MSM Still Work?
. Strong media attention given to:
 - Ongoing reports of STI outbreaks
 _ Reports of new forms of "unsafe sex"
 _ Very high HIV prevalence and incidence data
   among minority MSM communities
. Far less attention given to relatively low
 levels of funding support for HIV
 prevention among gay men in the US

What are the Current Rates of HIV Incidence Among MSM?
. Debate framed around a few fundamental questions:
 - Are HIV infection rates over time among MSM?
   If not, why not?
 - How can high incidence rates of HIV infection
   be explained among African American MSM?
. Less attention has been devoted to the
 question of what current incidence rates
 will yield over time.

Summarizing Incidence Estimates among MSM
. Computerized literature review : Google
 Scholar, PubMed, ISI Web of Science, Scopus

. HIV incidence, MSM, Gay Men, HIV seroconversion

. Correspondence with leading researchers in
 the field to identify unpublished data

22 Independent Studies
90 Annual Incidence Estimates
. Community-Based Samples
 - 10 independent studies; 32 incidence estimates
. HIV Test Sites Samples
 - 5 independent studies; 31 incidence estimates
. STD Clinical Samples
 - 7 independent studies; 27 incidence estimates

HIV Incidence in MSM:
32 Community-Based Incidence Estimates
0  1  2  3  4  5  6  7  8  9  10
Hogg,  1995  2
SMASH, 1995  2
Tabet, 1995  1
Hogg,  1996  1
SMASH, 1996  1
Hogg,  1997  1
MMWR,  1997, Baltimore      1
MMWR,  1997, Dallas         3
MMWR,  1997, Los Angeles    3
MMWR,  1997, Miami          1
MMWR,  1997, New York       8
MMWR,  1997, San Francisco  1
MMWR,  1997, Seattle        1
Remis, 1997      1
SMASH, 1997      1
SMASH, 1998      0
Hogg,  1998      1
Remis, 1998      1
Strathdee, 1998  2
Hogg,  1999      1
Remis, 1999      1
Remis, 1999b     1
Choi,  2000      2
Hogg,  2000      4
Remis, 2000      1
HIM,   2001      0
Nash,  2001      2
Remis, 2001      1
HIM,   2002      2
Remis, 2002      1
HIM,   2003      1
HIM,   2004      1
MMWR,  2004, Baltimore      8
MMWR,  2004, Los Angeles    1
MMWR,  2004, Miami          3
MMWR,  2004, NYC            2
MMWR,  2004, San Francisco  1
HIM,   2005                 1
Community Mean              1.93

Mean Published Incidence Estimates among MSM, 1995--
. Community-Based Samples 1.93%
. HIV Test Site Samples   2.24%
. STD Treatment Samples   2.93%

With 1.9% incidence, what will the
burden of HIV disease be within a
cohort of MSM now aged 20?
8% prevalence rate of HIV infection at age 20
(MMWR, 2001)

No mortality due to HIV through age 60

Identical non-HIV mortality rates to other men in the
US population

MMWR (2001) HIV incidence among young MSM -- 7 US Cities, 1994-2000.

Burden of HIV Burden of HIV Disease Among MSM::
HIV Incidence Rate of 1.9%
Age-Specific HIV Prevalence
HIV Prevalence
0% 10%  20%  30%  40%  50%  60%  70%  80%  90%  100%
Age
20   10%
25   20%
30   20%
35   30%
40   40%
45   40%
50   50%
55   50%
60   60%

HIV Incidence is High Among African American MSM
. HIV incidence among African American men
 aged 15-22   4%

. HIV incidence among African American men
 aged 23-29  15%

MMWR, HIV incidence among young MSM -- 7 US Cities,
1994-2000, June 01, 2001

African-American MSM Cohort::
HIV Incidence Rates of 4..0%
Age-Specific HIV Prevalence
HIV Prevalence
0%  10%  20%  30%  40%  50%  60%  70%  80%  90%  100%
Age
20  10%  10%
25  20%  30%
30  20%  40%
35  30%  50%
40  40%  60%
45  40%  70%
50  50%  70%
55  50%  80%
60  60%  80%

African American MSM have very high HIV prevalence rates
HIV infection and Unrecognized Infection
among MSM, 5 US Cities, aged > or = 18:
Black, Non-Hispanic  46%  (67%)
White, Non-Hispanic  21%  (18%)
Multiracial          19%  (50%)
Hispanic             17%  (48%)
Other                13%  (50%)
MMWR, HIV Prevalence, unrecognized infection and HIV
Testing among MSM -- 5 US Cities,
June 2005, April, 2005, June 24, 2005.

Is HIV Prevention Effcacious Among MSM?
. 2 recent meta-analyses of published RCT trials

. Herbst (2005) review reported a:
 - 23% decrease in UAI
 - 15% decrease in numbers of sex partners
 - 61% increase in protected AI

. Herbst, J. et al., JAIDS 2005 39(2):228-241.
. Johnson, W., et al, AIDS: E&P 2005 17(6): 568-590.

HIV Behavioral Interventions Reduce Risk
. Interventions worked better if:
 - Theory based
 - Group discussions
 - Multiple (4+) message delivery methods
 - Interpersonal skill building
 - Greater intervention exposure
. Bottom line: HIV interventions can work if
 they are well funded and well fielded.

Two Worlds of AIDS Prevention

. Incidence rates for new HIV infections are
 very high among MSM

. Model HIV prevention interventions work
 in experimental settings.

. Is something lost in the translation to MSM
 communities?

Ongoing Challenges to
Prevention Efforts Among MSM
. Information: What is risk?
 - poz/poz sex, positional strategies, negotiated safety,
   negative viral loads, PREP?
. Information: Which information matters?
 - Skill sets and knowledge of own goals in sex vs.
   memorization of risk calculus
. What are the motivations for safe sex?
 - Who bears the responsibility for safety? How does
   safety work in a world without disclosure?

What about Context?
. Context: Do other health issues affect risk?
 - Syndemic effects on increasing risk
. Context: Community Viral Load
 - Increased efficacy of social network approaches to
   finding unknown positives
. Context: Addressing Violence and Racism
 - Increased efficacy of social network approaches to
   finding unknown positives

Intertwining Epidemics among Urban MSM
(Significant OR estimates, controlling for age,
education, race, income, HIV status and sexual risk)

           Childhood  Partner   Depression  Substance
           Sex Abuse  Violence              Abuse

Childhood   - - - -    1.9       1.9
Sex Abuse

Partner     1.9        - - - -   1.6         2.2
Violence

Depression  1.9        1.6       - - - -     1.4

Substance              2.2       1.4         - - - -
Abuse

Intertwining Epidemics Predict
HIV Prevallence and High Risk Sexual Behavior

No. of Psychosocial Health Problems
            0            1          2          3 or 4
            (n = 1,392)  (n = 812)  (n = 341)  (n = 129)

Recent high  7%  11%  16%  23%
risk sex

HIV         13%  21%  27%  22%
prevalence

All associations have p's < 0.001.
All p values are two-tailed. From Stall et al., 2003

What about Prevention Practice?
. Prevention Practice: Efficacy into Effectiveness
 - Multiple challenges of translational research
. Prevention Practice: What resources exist to
 support prevention in the real world?
 - If it works, quit funding it
. Prevention Practice: Safe sex maintenance
 over long periods of time

Towards a Prevention Cocktail
. HIV prevention practice is primarily framed
 at the level of the individual, or at the level
 of a single mechanism.
. What would HIV prevention look like if
 it incorporated multiple mechanisms of
 treatment efficacy?

Multiple Mechanisms of Prevention Efficacy
. The individual
. Goal setting and skill building
. Identifying unknown positives
. Access to HAART for positives
. Treatment for co-morbid conditions
. Supportive policy environment for ongoing
 prevention (stigma, racism, adequate funding)

Depression: A Highly Prevalent Epidemic among MSM
. Additional Correlates of Depressed Mood:
 - Not having a primary partner
 - Not identifying as gay/queer/homosexual
 - > or = 1 anti-gay violent attack in past 5 years
 - Alienation from gay community
Mills, T., et al., Distress and Depression among Urban MSM,
Am J Psychiatry, 2004; 161(4):776

Would changes in domestic
partnership//marriage laws lower rates of
depressiion among gay men by::

Acknowledgment of the Depth of
Our Commitments to Each Other?

Strengthening Connections to and
Protection of Our Families?

Strengthening Connections to Our
Traditions and Spiritual Lives?

Strengthening Connections
Within Our Community?

Strengthening Connections
to Society at Large?

Conclusions
. HIV incidence rates within the published
 literature cluster near the 2% range among
 HIV testing and community based samples;
 at about 3% for STD clinic samples.

. Ongoing incidence rates at this level will
 yield very high HIV prevalence rates within
 each new generation of gay men.

Conclusions
. We have strong evidence to show that
 model HIV prevention programs that are
 subjected to rigorous RCT trials are
 efficacious.

. We have less evidence to show that these
 programs are being translated into field
 programs and disseminated widely enough
 to lower HIV prevalence rates among MSM.

Conclusions
. A standard set of intervention qualities are
 associated with intervention efficacy.

. Few of these intervention qualities directly
 address questions that gay men are
 struggling with in the third decade of the
 epidemic.

Current Questions, Outside the Prevention Box
. What ~specifically~ is risk?
. How safe do I want to be?
. What skills do I need to ~maintain~ safety?
. How do co-existing conditions shape risk?
. What about community viral load?
. How do I maintain safety when I'm under constant attack?

Creating a Prevention Cocktail
. Multiple mechanisms of intervention
 efficacy will have to be tapped to respond to
 such challenges over time.

. Such mechanisms will need to manipulate
 context.

. Intervention strategies that test multiple
 mechanisms of intervention efficacy must
 be attempted.
http://www.aidschicago.org/lifelube/docs/Improving%20Safe%20Sex%20Interventions%
20for%20MSM_Stall.pdf
http://tinyurl.com/24rh9m
by Ron Stall