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[CDC has published
several recent MMWR reports reflecting significant challenges to earlier
diagnosis of Human Immunodeficiency Virus (HIV) and other sexually
transmitted infections (STI) in men who have sex with men (MSM), and controlling the
increasing rate of HIV/STI transmission by infected men. These include (1)
HIV/STD
Risks in Young Men Who Have Sex with Men Who Do Not Disclose Their Sexual
Orientation --- Six U.S. Cities, 1994—2000; (2)
Unrecognized
HIV infection, risk behaviors, and perceptions of risk among young black men
who have sex with men--six U.S. cities, 1994-1998; (3)
Primary and
Secondary Syphilis Among Men Who Have Sex with Men --- New York City, 2001;
and
(4)
Outbreak of Syphilis Among Men Who Have Sex With Men --- Southern California,
2000. These and similar reports underscore the
the complex challenges
of reducing HIV and other sexually transmitted diseases (STD) in MSM as detailed in CDC’s November 2001 action
plan
--- No Turning Back. These and hundreds of other reports chronicling the
increasing health challanges to men who have sex with men are
indexed on Medical Advocates' MSM
Health Web.]
MASJ: Physicians
can play a central role in HIV prevention. Tanya Schreibman and Gerald
Friedman of Yale School of Medicine recently published a
paper that
provides a comprehensive guide in addressing this challenge. The physician's
role in HIV/STD prevention is also a central strategy in CDC's new
Advancing
HIV Prevention initiative, in which the initial strategy is to make
HIV testing a routine part of medical care.
A potential obstacle to
this strategy is the time that may be required to establish a comfortable and trusting rapport between physicians and some
high-risk
patients. Some gay/bisexual and/or sexually-closeted patients may not be immediately
open to a frank discussion of their sexuality and possible risk-behaviors,
and subsequently may resist testing. Time is often at a premium. We
have overcrowded and often understaffed public clinics, restrictive managed care
protocols, and economic
restraints on the amount of time that many physicians can spend with their
patients. Any comments and/or recommendations on addressing these
challenges?
Valdiserri: CDC
recognizes the substantial contribution that physicians can make in the
prevention of HIV and other sexually transmitted diseases . Prevention is a
shared responsibility. CDC plays an important role in educating the provider
community about rates of disease, prevention strategies, and missed
opportunities to diagnose HIV infection and other STDs. Doctors, nurses,
and other healthcare providers need to receive training to be able to talk
about human sexual behavior -- to know how to approach the topic with a
patient.
CDC recognizes that healthcare
providers are stretched for time. There are several steps that can be taken
to address the time concerns. Part of what’s behind our recently announced
recommendation that HIV testing be a routine part of medical care is the
notion that medical care providers need not spend 30-40 minutes in pre-test
counseling. Extensive pre-test counseling should not be a barrier to
patients receiving HIV tests. It is important that patients know that they
are being tested, and there is some basic level of information that can be
provided very quickly. We also need to continue to test rapid prevention
interventions that are suitable for medical care delivery systems, again
recognizing the constraints on physicians’ time.
MASJ: There appears
to be new challenges in promoting HIV testing and consistent condom usage
in the gay community. The perception of HIV by many young MSM who have never
had friends with AIDS is that HIV/AIDS is just another treatable STD.
Some older MSM may experience safer-sex “burn-out.” Now
we learn that sex contacts made on the
Internet may
involve increased high-risk behaviors. Then there are the old challanges
--- the gay
bathhouses, sex clubs, and
circuit parties
where recreational drugs may contribute to high-risk behavior. The
insinuation of these high-risk venues into the mainstream of gay culture
appears to contribute to the escalating incidence of HIV/STD among MSM. You and your colleagues
at CDC's National Center for HIV, STD, and TB Prevention have questioned
whether we face a potential resurgence of the HIV epidemic among men who have sex with men.
How will Advancing HIV Prevention more
effectively address this increasing HIV/STD incidence that could not
be more effectively controlled through previous efforts?
Valdiserri: The
circumstances in which the public health community promotes prevention
activities in 2003 are amazingly different than in 1983 or even 1993. There
is a sense, not only with gay and bisexual men, but with the general
American public, that HIV is no longer a threat or major health problem in
America -- that treatment is so good that HIV is like any other chronic
disease. This presents a real challenge for us. We need to get the message
out that HIV continues to be a serious, life-threatening disease. Although
the treatments for HIV are greatly improved, they are not a cure, and they
do not work for everyone. It is still much better to prevent infections in
the first place than to have to deal with HIV after someone becomes
infected.
Part of what CDC hears from the
community is that men in 2003 can’t be expected to respond to the same kind
of messages that have been successful in the past. We agree. That is why it
is important that CDC continue to do the kind of research that helps us
understand how best to market public health, including HIV prevention
messages.
We also need the active support of
the gay community if we are going to continue to make any headway in terms
of preventing HIV. Government can’t do it alone. To effectively protect MSM
from HIV and other STIs, there needs to be a dynamic partnership between the
gay community and the federal government.
MASJ: Are gay
bathhouses, sex clubs, and circuit parties viable venues for rapid HIV
testing?
Valdiserri:
Prevention outreach in gay bathhouses and sex clubs are important strategies
used by the public health community to reach high-risk populations. When we
think about HIV prevention for MSM, especially sexually active MSM with
multiple partners, we might want to work with a community based-organization
to offer HIV testing in gay baths, sex clubs, or other venues. We want to
encourage HIV testing in medical care facilities, but we also realize that
some individuals may not have access to medical facilities or may not feel
comfortable being tested in such an environment. We therefore want to work
with community partners to explore other opportunities to provide the HIV
test.
MASJ: Is
pre-sex antiretroviral (ARV) prophylaxis a potential strategy for HIV
prevention?
Valdiserri:
Antiretroviral therapy, before or after possible exposure to HIV, should
never be considered a primary form of prevention. Outside of a monogamous
relationship with an uninfected partner, correct and consistent use of a
male latex condom is the most effective HIV prevention method for sexually
active individuals. Use of a condom also avoids the very real risks of drug
toxicity and the difficulties of compliance that accompany such therapy.
MASJ: There have been
several studies on
post-sex ARV prophylaxis for MSM as a subset of studies on
non-occupational HIV exposure. Post-sex ARV prophylaxis
has become an informal standard of care in many emergency rooms for
women who have been sexually assaulted. Is there a potential role
for
post-sex ARV prophylaxis for MSM?
Valdiserri: There is
no conclusive information on the effectiveness of antiretroviral therapy in
preventing HIV transmission after non-occupational exposures. It is
therefore very difficult to make definitive recommendations regarding its
use. Because the therapy remains unproven and can pose risks, physicians
should consider its use only in individual circumstances when the
probability if HIV infection is high, the therapy can be initiated promptly
and adherence to the regimen is likely. It should not be used routinely and
should never be a primary form of prevention.
MASJ: No Turning
Back detailed the relationship between stigma and the
understandable resistance of some young African-American MSM in identifying
themselves as gay or bisexual. Does the role of stigma present special
challenges in marketing HIV-testing to this population who may not utilize
medical providers or attend gay venues that offer HIV testing?
For some of these
non-gay/bisexual-identified African/American men, do we need to explore non-traditional venues where HIV/STI testing would not have a gay
implication or judgmental patina? Are there specific venues and groups that
the CDC might specifically target for funding? What about community- and
faith-based health fairs that offer a smorgasbord of various
diagnostic tests?
Faith-based health initiatives - especially those by African-American
churches, are often less-judgmental about behavior. It's been my experience
that many African-American churches are equally concerned
with the physical well-being as well as the spiritual well-being of their
congregation and others in their community. Would faith-based initiatives
qualify for funding for Rapid HIV-1 Antibody Test programs? What about
colleges that have a large African-American male enrollment ?
Valdiserri: We plan
to work with community partners who want to provide HIV testing outside of
medical-based settings. Now that there is a rapid test [OraQuick
HIV-1 Rapid Test] available that has
been deemed as waived under the CLIA (Clinical Laboratory Improvements
Amendments of 1988) standards, we have an available technology that enables
us to do just that.
CDC distributes most of its
prevention funding through two basic mechanisms: state and local health
departments and community based organizations. Through both funding
sources, faith-based organizations could receive funding, but the
determination of where and how money is best spent is made at the local
level. We must also work with other federal partners to ensure that
resources are available for persons who test positive.
When we are reaching out to offer
HIV testing, diagnosis, and referral into care and on-going prevention
services, we should offer it in as many different types of formats as
possible to meet the needs of different communities. But we are not trying
to encourage “test everyone” scenarios. We need to look at targeted testing
based on information that about where new infections are occurring, who
might be at risk, etc.
MASJ: Thank you for your time and
insights into this critical health challenge to men who have sex with men.
From our discussions and review of the data,
Advancing
HIV Prevention holds great promise in diagnosing thousands of new
cases of HIV/STDs among MSM, and reducing the transmission of HIV/STIs from
men who were not aware of their HIV/STI status prior to testing.
Unfortunately, there appears to be a continued challenge in reducing the
increasing high-risk behavior among some MSM, and in the provision of
timely and appropriate care to the newly diagnosed medically indigent with
HIV disease to whom the AIDS Drug Assistance Program is
closed. |
