In her essay for Prospect this month, epidemiologist Elizabeth Pisani tells the story of the changing relationship between HIV and Aids in Britain’s gay community, and the changing behaviours associated with it.
Today, with new antiretroviral treatments available on the NHS, infection with the HIV virus is not the death-sentence it was even a decade ago. HIV-positive people can expect to live long and relatively normal lives without ever developing Aids, or the secondary conditions associated with it. It is overwhelmingly among Britain’s homosexual community that the change is being felt. Annual deaths among gay men in Britain have crashed from a peak of over 1,162 in 1994 to just 153 in 2007—and behaviours are changing to match, with fewer precautions being taken by fewer people.
All this means that, although Aids infection rates are falling, the rate of HIV prevalence is steadily climbing: the number of gay men living with HIV in Britain has more than doubled in the last decade, from around 14,400 in 1998 to over 31,000 today. Does this matter? Yes, argues Pisani, both socially and economically: the treatment of HIV is hugely expensive, while the virus itself is constantly threatening to mutate beyond the capabilities of even the most modern drugs. So what should HIV prevention look like in a post-Aids world? It’s a question, as she explains, whose complexities will be being experienced for years to come.
A thought experiment… Imagine a disease of the future. If you don’t have sex you die from an organism both parasitic and canabalistic. So A calls B, “Please come over.” B says, “I can’t. I’m going over to C’s.” A cries, “You’ve got to come over now. It’s beginning to gnaw at me.”
Elizabeth Pisani’s essay “the plague is over, let’s party” is without any doubt the best essay about HIV in Britain today. I am one of the new generation survivors who has experienced the lazerous effect - I was on deaths door and was granted new life with anti-viral medication. Elizabeth has touched upon the truths that people really need to hear. It’s absolutely true that the number of gay men living with HIV in Britain has more than doubled, from around 14,400 in 1998 to over 31,000 today and that there is a fear of appearing to be judgmental about particular behaviors.
As a HIV positive person I reserve the right to tell the truth and the truth is that the Terrence Higgens Trust have not been getting things right. If they had…. then figures would not have doubled. When HIV positive people have tried to save lives by telling THT that they have been getting things wrong THT goes into denial. The fear of appearing judgemental comes from the counselors who work with THT. Without the counsellors THT would not exist. Together they promote the sex-and-drugs norms of the gay community and refuse outright to shift down a gear or two. There is evidence at http://gaymafiawatch.wordpress.com/about/#comment-58
I am a survivor who does not take drugs. I have tried to speak out against THT promotions of drugs,saunas and crusiing grounds but they just wont listen. Using sauna’s and crusiing grounds even dungeons and are presented as solutions to social alienation or domestic violence . HIV positive people don’t want to die - that’s why we quit smoking, go to the gym, attend expert patient programs, eat well and value life that little bit more because we know that we are lucky to be alive.
The real challenge is not to prevent the survivor generation’s attitude—”the plague is over, let’s party”—from becoming the norm for a world without Aids. The true challenge is to promote healthy lifestyles that do not involve sauna’s crusing and sadomasochism. Please see Gay Mafia Watch http://gaymafiawatch.wordpress.com/about/#comment-58
Quote Gay Mafia Watch:
I am relieved to hear that The Pink Paper has decided not to publish THT’s hardcell website.
I have recently found myself being bullied for expressing my concerns about this S & M site reaching lgbt youth through an e-group called ( LGBTHEALTHUK )
My concerns were that THT who engage with teenagers some below the age of consent are enabling LGBT youth to crossover to hard-core drug n’ S & M scenes with the information THT in partnership with others market as gay lifestyle.
The Director of Pink Therapy stated online that - If one is in a relationship where one gets beaten and abused then a sauna or dungeon is probably a much safer place……this was shocking and deeply offensive and an insult to anyone who has ever been the victim of domestic violence.
As a result of expressing legitimate concerns I came under attack by the moderator, a therapist and the one other person who I believe to be a health promotion officer. I received private messages asking me to apologize or I would be removed from the group. I was given a deadline for an apology. Comments were made about my judgment. I was bullied for not knowing enough about S & M by the therapist while the moderator took the opportunity to talk about the S & M course that he had been on in America.
I think cruising grounds / sauna’s / S & M are promoted excessively - much more than
general sexual physical or emotional health. The focus is on the place
to have sex and the types of sex you can explore - on drugs if that’s your choice.
I have been suspended from LGBTHEALTHUK someone needs to check these guys out.
There is a charity called Witness - WITNESS is the professional boundaries charity. WITNESS aims to promote safe boundaries between professionals and the public. They do this by providing a range of services for professionals and the public and by working to improve public protection through policy and influencing work. There website is http://www.popan.org.uk/ It’s really important that people stand up to bullies.
Some good analysis from an economist researching sexual behavior and STD’s here.
Pisani wrote: “that people who have unprotected sex with several people in a three-month period are far more likely both to contract and spread HIV than people who have the same number of partners over a longer period”.
I understand how a newly infected guy is more likely to transmit HIV when newly infected. But can Pisani explain how in a stable epidemic a guy with three sexual partners in a week is more likely to acquire infection than another with three partners over a month? Huh?
C Men
“My guess is that 25 per cent of the men in this room have HIV, possibly a lot more” is not supported by any evidence, rather odd for an epidemiologist.
Tony Valenzuela’s article ‘Killer Gay Sex’ in Poz argues valiantly against the “AIDS industry’s” pathologising of gay men’s sexual practices and debunks that supervirus myth of the New York AIDS patient. It is ironic that Pisani rails against the “industry” but falls into the same trap.
“So a man can be infected when he’s being a “bottom,” then go on to infect another guy when he’s being a “top.” That’s why HIV moves so quickly in gay communities.” Actually, HIV is being transmitted to ‘tops’ from HIV in the rectal fluids; incomplete evidence suggests that viral load can be much higher there than in blood or semen, even in people on effective treatment. So, ‘versatile’ gay men is not necessarily the only reason why “HIV moves so quickly…”
“But any involuntary disclosure of HIV status is anathema to some of the “survivors” who still control much of the HIV prevention industry, people who lived through the discrimination and rejection that an HIV diagnosis used to promise.” As an epidemiologist, of course she’s pro contact-tracing. But actually there’s evidence that contact tracing is not effective. A recent study (Resik, 2007) that examined the genetic relatedness of two transmission networks in Cuba previously established by contract tracing found that between 60% and 70% of presumed transmission events were rejected – i.e., subtypes did not match or else phylogenetic analysis found no relationship between two individuals in the network. The authors of that study argued that their “analysis indicated that contact tracing, when combined with time delays in diagnosis and in sample collection, should be taken with caution.” Resik S et al. Limitations to contact tracing and phylogenetic analysis in establishing HIV type 1 transmission networks in Cuba. AIDS Research and Human Retroviruses 23 (3); 347-356, 2007.
The “discrimination and rejection that an HIV diagnosis used to promise” are both still present, and to suggest that they are a thing of the past is really irksome. I have examples from HIV patients’ networks in London of such involuntary disclosure leading to constructive dismissal by employers, of personal rejection by partners both heterosexual and gay, and of rejection by church pastors and congregations.
The pharmaceutical industry “aggressively promotes antiretroviral drugs directly to consumers”. Only in the US. Not in the UK they don’t – it’s illegal here.
“And the virus is beginning to outwit some of the drugs we have developed, raising the prospect of strains of HIV that don’t respond to treatment.” Drug resistance is not new, and if anything, prevalence of both transmitted resistance and the number of people with triple-drug class resistance is going down, not up. Again, see Valenzuela’s article for a debunking of the myth of the HIV supervirus.
“We don’t know what effects even the oldest drugs might have in the long term—many men who have been on antiretrovirals for over a decade have osteoporosis and failing livers; they’re suffering not from the infection but the remedy.” This is not the whole story, and this is only a minority – HIV is far more toxic than today’s treatments, as I can personally attest. I have been taking ARVs with far fewer side effects (mainly a slight rash at the start, lasting a week or so) than the virus they control.
@ C Men
You’re right, acquisition depends more on numbers than on timing, unless partners are so closely spaced that repeated intercourse leads to an increase in penile or rectal trauma.
@ Paul Clift
You raise many good points. For the record, the data behind “my guess”: The Health Protection Agency triangulates data from several sources including case reporting, unlinked anonymous testing of blood samples and HIV prevalence at GUM clinics. The working group also takes into account self-reported prevalence in the annual Gay Mens Sex Survey. For a detailed description of methods, see the HPA MSM pages. As I believe I said in the article, some nine percent of all gay men in London are estimated to be living with HIV.
I looked at self-reported HIV status among men who reported a recent casual sex partner as well as the age-distribution of infection, and adjusted my estimates for the men in the bar accordingly. I’m sure you know the data well, but other readers interested in more info on the Gay Mens Sex Survey sample frame, methodology and questionaires , along with reports of the survey results can find them here.
I think that what Ms Pisani is trying to say in her reply to me above is that she was wrong. Can we trust her as an epidemiologist if she makes such basic mistakes?
I was heavily involved in Australias early response to HIV. In the first years the case load was doubling every 8 months and people were terrified. in the state of Victoria we have had a substantial jump in new infections mostly amongst young men (not survivor wearyness). This hasn’t been mirrored in Qld or NSW, the major difference appears to be that victoria has reduced its prevention budget considerably whereas the other states have maintained reasonable levels of public health and peer based HIV campaigns. Is this a factor in London?
People have odd perceptions of things. The idea that there only “20 streets” in the UK where you can walk hand in hand with your gay partner is ludicrous. I know, becuase short of situations of present and obvious danger, I do it all the time.
Ad maiora. It is important not to elide this debate into older ones about the supposedly ’self-destructive’ (hence, at some level, not happy with themselves) behaviours of gay men. Would we call Keith Richards self-destructive or just a hedonist with the time and resources (financial and internal) to pursue his pleasures. Not every party loving younger gay man who takes risks with his long term health (such as smoking, excessive drug use, unsafe sex) has psychological problems - he may be contributing, depending on the particular approach to health-care funding, to increased public insurance costs, but even this latter issue is not to be put into a separate box from all the other activities (or in the case of fat lazy people, inactivities) of which the same can be said.
For the past decade, I could never understand WHY the HIV researchers, “experts” and “professionals” delibertly refuse to realize that there are THREE forms of Serosorting, and TWO involve safe sex.
Do HIV+ people have safe sex anymore?
Do HIV-(negative) people have safe sex anymore?
What if we applied Safe Sex Serosorting to the “Serosorting” HIV prevention and harm reduction strategy?
When HIV-(negative) people have safe sex with other HIV-(negative) people (Safe Sex Serosorting), what would their NEXT HIV test result be?
Just add safe sex to the Serosorting Strategy and watch the end of HIV begin!
Robert Brandon Sandor
FOUNDER
Serosorting as an HIV Prevention and Harm Reduction Strategy
http://www.hiv-ub2.net
http://www.poz4poz.com