Gay men: current challenges and emerging approaches in HIV prevention

The early responses of gay communities to HIV are widely seen as outstanding examples of effective disease prevention. However, the current situation is one of resurgent epidemics of human immunodeficiency virus (HIV) and other sexually transmissible infections in gay communities in post-industrial countries worldwide,^1–4 including Australia.⁵ This re-emergence has led some commentators to suggest that HIV prevention in gay men is faltering.⁶ Rather than suggesting an HIV prevention failure, this review of the state of the HIV epidemic and prevention in gay men in New South Wales (NSW) recognises the complexities of HIV prevention in gay men. In the absence of a tradition of condom use informed by the prevention of pregnancy or sexually transmissible infections, the uptake of condom use by gay men in the first decade of the HIV epidemic remains a major community prevention success. However, as HIV treatments improved dramatically, some gay men saw less reason to maintain consistent condom use. There are now gay men who are making informed (and not so informed) decisions to engage in sexual practices which they know may put them at increased risk of HIV. HIV educators and health promoters need to collaborate with these men to find effective ways to minimise risk, without estranging the gay men who continue to use condoms for many if not all acts of anal sex. This article describes current trends in HIV infection in Australia and the challenges to supporting effective HIV prevention strategies in NSW.

Since 2000 the annual number of new diagnoses of HIV in Australia has increased by 38%.⁷ Gay men continue to be the most affected, accounting for 64% of people who were newly diagnosed as having HIV infection in 2004–2008, and 82% of the infections that were determined to have been acquired no more than a year before they were diagnosed. Recent trends in new HIV diagnoses differ across Australian jurisdictions. While the population rate of HIV diagnosis doubled in Victoria between 1999 and 2006, increased markedly in South Australia and Western Australia in that period and steadily increased in Queensland since 1999, in NSW over the past decade the rate has remained relatively stable.^7,8 Historically, NSW has had the highest infection rate per capita of Australian jurisdictions,⁷ but in recent years infection rates in Victoria have caught up (Figure 1). HIV infection rates in NSW are also in the range of those seen in comparable countries where the HIV epidemic mainly affects gay men, in particular Canada and The Netherlands,¹ while in the USA infection rates are markedly higher.^1,9

Differing epidemiological trends have initiated reflection on the factors that promote success in responding to the HIV epidemic in gay men in Australia.¹⁰ This process has identified partnerships between community organisations, policy makers and researchers, grounded in an adequate funding base and political support, as factors in the successful NSW response to HIV.^11,12 Nevertheless, while HIV notifications in NSW have been stable over the past decade, an increase in rates of newly-acquired HIV infections was observed between 1998 and 2003, which may however have been at least partly due to changes in the methods of notification.¹³ Importantly, while national and state HIV strategies aim to contribute to a reduction in infections, this has not been achieved since the mid 1990s.^5,7,8

In the past decade, rates of sexual risk behaviour in gay community-attached men, as reflected in particular by rates of unprotected anal intercourse with casual partners in Sydney, have also been relatively stable or even declining, but nonetheless appear to remain higher than was the case in the early to mid 1990s.^14,15 Of concern is the possibility of increasing rates of unprotected anal intercourse with casual partners in HIV-negative men, as suggested by the 2009 Sydney Gay Community Periodic Survey (Table 1). Recent years have also brought steeply increased rates of sexually transmissible infections, in particular syphilis, in HIV-positive men.^16,17

Table 1.  Proportion of men participating in the Sydney Gay Community Periodic Survey who had engaged in unprotected anal intercourse with casual partners in the six months prior to the survey, by HIV status of respondent

The potential for HIV transmission among gay men in NSW continues to be high and increases in HIV notification rates seen in other jurisdictions and overseas caution that sustained stable rates of HIV notifications in gay men require continued vigilance and effective responses. The apparent stability of the current HIV epidemic in gay men in NSW may reflect testing patterns, HIV status knowledge and disclosure and the well-reasoned use of risk-reduction strategies that this enables. This stability in the epidemic could be undermined by the loss of prevention programs that balance support for effective risk-reduction practices and continued use of condoms.

From the days of the outbreak of acquired immune deficiency syndrome (AIDS) in the early-mid 1980s, gay men have continually found ways to adapt their prevention responses to the evolving HIV epidemic. Since the early 1990s, the gay community in NSW in particular has led the way in developing an increasingly sophisticated and complex array of risk-reduction strategies other than condom use.^18,19 The massive uptake of HIV testing, and the resulting widespread knowledge of one’s HIV status, have enabled many gay men to develop sexual practices that simultaneously reduce the likelihood of HIV transmission while also ensuring that sex remains about more than preventing HIV transmission.^20,21 Notably, seroadaptive behaviours,²² such as negotiated safety (i.e. unprotected anal intercourse in a stable relationship of two men who have tested negative for HIV and established agreements regarding sex and protection outside their relationship); serosorting (i.e. unprotected anal intercourse with a (casual) sex partner of similar HIV status); strategic positioning (i.e. an HIV-positive man taking the receptive role or an HIV-negative man taking the insertive role in unprotected anal intercourse); planned withdrawal and unprotected sex with HIV-positive partners with undetectable viral load, have allowed some men to lead more satisfying sex lives.

Social research in NSW and Australia has been instrumental in documenting these community risk-reduction responses and has been pivotal in showing that not all unprotected anal sex is risky.^18,19,23 These insights also provide a counterpoint to discourses that see HIV prevention in gay men as failing because of complacency within the community.²⁴ The practice of risk-reduction strategies reflects the continued importance gay men attach to HIV prevention and illustrates a culture of care that values HIV prevention. Risk-reduction strategies reflect gay men’s extensive knowledge and understanding of HIV-treatment efficacy and can be understood as rational and sophisticated ways to balance risk and pleasure in times when the threat of HIV is reduced. The communities of gay men engaging with these evolving risk-reduction strategies may no longer have the goal of fully eliminating new HIV infections and accept that their behaviours carry some risk of HIV transmission and infection. Bridging the gap with the public health goal of eliminating new HIV infections will benefit from the increased use of technologies such as rapid HIV (antigen) testing and early treatment for prevention.

A testing-and-treatment approach is the cornerstone of the National Gay Men’s Syphilis Action Plan, which responds to the increased notifications of syphilis that is seen worldwide, in particular in HIV-positive gay men. This action plan underscores the importance of promoting regular testing for syphilis, and treatment if needed, in ways that reflect men’s level of sexual activity and potential exposure. When successfully implemented, this approach may not only be effective in curbing the syphilis epidemic,²⁵ but it is also acceptable to large parts of the gay community, including sexually adventurous men who engage in sex with substantial numbers of partners and who have moved away from consistent condom use. While the current evidence base for a direct impact of the control of syphilis and other sexually transmissible infections on HIV prevention is limited and discouraging,²⁶ when embedded in an appropriate, comprehensive approach to HIV prevention, regular testing for sexually transmissible infection offers additional opportunities to address and support HIV prevention, including for gay men living with HIV (positive prevention).

HIV prevention today is perhaps more complex than it has ever been before and involves implementing responsive services and messages that support gay men with increasingly diverse prevention needs, preferences and practices. The daunting task of contemporary HIV prevention in gay men benefits from a sound understanding of the factors that shape men’s sexual and risk-reduction practices in different situations. This understanding remains limited and patchy. While it has been important to show that risk-reduction strategies are rational and informed responses, current theorising and research acknowledge that risk-reduction practices are not always enacted in reasoned ways, are influenced by a range of motivations and desires that play out in a specific situation and can be supported by advance planning.²⁷ These conceptual developments in health promotion theory hold substantial promise for a new generation of HIV-prevention programs for gay men, as do evolving health promotion and communication technologies.

The normalisation of ‘gay’, the decentring of gay identity in favour of the adoption of multiple identities, the change from community to more individualised responses and the transfer of social connections and meeting new people to the internet and away from physical venues suggest that traditional media and venue-outreach approaches can no longer ensure adequate coverage of HIV prevention for gay men. To be effective, HIV prevention will now have to use highly targeted and tailored offline and online strategies that reach specific communities and combine these targeted strategies with broader ones to reach the wider audience of gay men, as well as other men who have sex with men. This approach not only increases the costs of HIV prevention in gay men, but may also require the effective use of non-gay media for HIV-prevention messages.

The increased reliance on risk-reduction strategies and the social changes that have occurred in the gay community also underscore the continued importance of other foundational aspects of community-based HIV prevention in gay men, such as preventing HIV-related stigma and supporting community-wide engagement with HIV prevention. Risk-reduction strategies based on HIV status and viral load have an important place in contemporary prevention, as they can jointly enable men to have pleasurable sex and prevent HIV. However rational these responses may be from an individual perspective, they also bear the potential risk of contributing to at least a sexual divide in the gay community.²⁸ Gay men’s HIV-prevention practices no longer occur within the context of the same sense of ‘community in adversity’ that existed in the past. A conversation is needed regarding the ethics of HIV prevention, sexual practices and relationships²⁹ that shape how gay men live when HIV is endemic and no longer carries the risks that it once did.

Since the advent of the HIV epidemic in gay men in the early 1980s, its meaning has evolved substantially, as have gay men’s adaptive responses. Prevention, surveillance and social and behavioural research have often struggled to keep up with the pace of change and to remain relevant and useful. The key to the success in NSW has been partnership and reflection, informed by strong research. Thirty years after the HIV epidemic in gay men was recognised, NSW has achieved a stable yet potentially fragile rate of HIV notifications, in contrast to resurgent epidemics seen internationally. The major challenge for the future is to reduce the rates of new infections in a context of increasingly diverse and complex prevention responses. The development of the new NSW HIV Strategy provides an opportunity to develop a blue print for the NSW response to HIV prevention into the future and to define the surveillance and research agendas to inform and support successful HIV prevention in gay men.