Greg Millett
Ron Stall
The "Gay, Sexy, Healthy: Strengthening Prevention for Men Like Us" event with the dynamic duo - CDC's Gregorio Millett and Ron Stall of the University of Pittsburgh (a burgeoning hotbed of gay men's health research) - was a big success. Great turnout, fabulous presentations, insightful comments and questions - very engaging all around. Many, many thanks to Greg and Ron and all the attendees. We all left energized and ready to take on the enormous challenges before us.
We realize that many of our dear LifeLube readers do not live in Chicago and were unable to participate. So we are pleased to let you know that the LifeLube homepage has both Greg's and Ron's PowerPoints available for download. Please take advantage of the up-to-the-minute research these men presented.
. Would it be better to use the correct term?... safer sex because there's never zero risk.
ReplyDelete. 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 _ _ _ _ _ _ _ _ _ _
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%20
Interventions%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 risk sex 7% 11% 16% 23%
HIV prevalence 13% 21% 27% 22%
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%20
Interventions%20for%20MSM_Stall.pdf
http://tinyurl.com/24rh9m
by Ron Stall