"It is the best of times and the worst of times," said Judith Auerbach from the San Francisco AIDS Foundation at a session on the future of HIV prevention among gay and other men who have sex with men (MSM) at the 2013 IAS conference held in Kuala Lumpur.
"We have countries passing same-sex marriage at the same time as others are toughening laws against same-sex behaviour and HIV transmission," she said. "On top of that, we have gay men being oppressed by norms on beauty within their own communities. All these are issues that need our attention."
Sessions dealing with gay and MSM issues were evident at IAS 2013, in pleasant contrast to the fact we were in a Muslim majority country famous for its anti-gay propaganda. Late last year the Malaysian government endorsed a how-to guide for parents on how to recognise gay ‘symptoms’ in their offspring (one of which, apparently, is wearing v-neck t-shirts) and the steps they could take to ‘correct’ them (at homosexual rehab centres, for example). But to be fair, Malaysian law forbids anal or oral sex between anyone — gay or straight — and public displays of affection between heterosexuals are equally taboo.
So, it was good to see Malaysia’s gay and positive community represented at the conference.
Making a particularly courageous step was the one man who spoke openly at a plenary of his experiences living with HIV in such a politically hostile environment.
Currently, about 85,000 people are living with HIV in Malaysia, 90% of whom are male.
Reportedly, homosexual transmission accounts for just 2.5% of HIV cases, while the HIV prevalence amongst MSM could be as high as 13%. The majority of cases are attributable to injecting drug use (IDU); however, harm reduction programs since 2005 have halved the number of IDU cases and sexual transmission now supersedes IDU as the cause of new infections. Malaysia provides affordable clinical care through its public health system, including free first-line antiretroviral treatment.
"Very little government funding goes directly to prevention amongst MSM," said B. Talhah, a member of the HIV-positive MSM community.
HIV stigma is a big deal in Malaysia but, as was noted by one American panellist, it is equally alive and well in countries where laws are more lenient.
Dede Oetomo from Indonesia spoke about the diversity of MSM in South-East Asia, how many are married and that ‘out’ gay men make up only about 3% of the total MSM population. The community is changing, he said.
Social media means that men can meet up more easily. While these networks can perpetuate HIV transmissions they can also be harnessed to encourage behaviour change and risk reduction.
"Treatment as prevention has biological plausibility for gay men," said Ken Meyer from Harvard Medical School. "But we need more data on its application within this population."
The new WHO guidelines are based on the mainly heterosexual HPTN 052 study where only 37 gay couples were involved.
"While you are very unlikely to transmit HIV if you are undetectable," he says, "every encounter is different. And a lot relies on adherence," he added. "We do know that pre-exposure prophylaxis (PrEP) works, so why the slow uptake?"
PrEP studies, such as iPREX, showed a 44% decrease in HIV transmissions amongst 2,499 HIV-negative men. This increased to 54% when there was a measurable amount of drug in blood to greater than 90% when adherence was really good.
"We assume that if we build a better drug then they’ll use it," said Ron Stall from the University of Pittsburgh. "We need to do a lot more work if we expect HIV-negative men to take biomedical interventions seriously. We need to focus more on building their resilience," he suggested. "It is time for a global gay men’s health movement that focuses on our psychosocial health. We need to de-silo HIV and seriously address substance use issues."