Rising HIV levels: why we should care and what we can do

OPINION

HIV infections are on the rise nationwide, and the government is planning an advertising blitz aimed at gay men. If HIV is making a comeback, should positive gay men care? And if we do care, what can we do?

HIV is on the rise: between 2000 and 2005, the number of new HIV diagnoses in Australia each year rose by 41 percent. Now the federal government is considering a $10 million TV advertising campaign to combat rising HIV infections in Australia, the first such campaign for many years. HIV never went away, but it seems to be making a comeback.

The government’s plans for an advertising campaign have been cautiously welcomed by community advocates and HIV sector organisations – the injection of funds is sorely needed and there have been calls for increased investment for some years. But there are concerns about the details, still to be revealed, of how the money will be spent and what form this new campaign – which will be targeted directly at gay men – will take.

Within hours of the announcement, newspaper and television commentators were referring to the plan as ‘Grim Reaper mark 2’, and while the health minister was quick to insist that he wasn’t contemplating a scare campaign, it’s likely we’re going to see a big departure from the safe sex campaigns of the past.

So what’s going on, and what can we as gay men living with HIV do to combat rising HIV infections?

Have HIV infections really risen that much?

Yes. There has been a marked increase in HIV diagnoses nationwide, but it’s important to stress the difference between an increase in the number of diagnoses and the number of people living with HIV.

After falling substantially through the 1990s, the number of people diagnosed with HIV each year reached its lowest level around the turn of the century – between 645 and 690 a year in 1998–2001. Since then, the number has risen substantially. There was a big rise in 2002 and the trend has continued upwards. In 2005 (the most recent year for which we have figures), 928 new diagnoses of HIV were reported.

Rises have been reported in all states and territories, with the biggest states (NSW, Victoria and Queensland) showing big jumps. In NSW there was a 16 percent increase in 2002, followed by similarly large increases in Victoria and Queensland. The increase in NSW seems to have levelled off, but there’s no sign of that yet in Victoria and Queensland. The 2006 figures for Victoria were released as this issue of PL was going to press, showing a further jump in HIV notifications. The rate of HIV diagnoses is now higher in Victoria than it has been for 20 years [1] – since the early years of the AIDS epidemic.

What is causing the increases?

It’s hard to give a simple answer to this question – the issue is complex and there are lots of things which are contributing. We do know that gay men continue to account for the majority of HIV infections in Australia (about 80–85 percent of cases) and we do know that levels of unprotected anal intercourse (fucking without a condom) have risen markedly among gay men. Indeed, by charting the increase in unprotected anal sex and the increase in HIV infections, the parallel between the two is striking.

Some people have described this as evidence of ‘complacency’ among gay men. It almost seems inevitable that when a rise in HIV infections is announced, someone will claim it as evidence that gay men have become complacent about HIV and are abandoning safe sex.

Unfortunately, using a pejorative label like ‘complacency’ to describe the complex interaction between gay men, sexual practice, and HIV might work well on the evening news, but it doesn’t do a great deal to improve our understanding of what is going on, nor does it help us find a solution.

Despite the evidence of increases in unprotected sex, there is no sign that there has been a wholesale ‘abandonment’ of safe sex by gay men. It’s understandable that, as HIV has become less life-threatening, people are more likely to take occasional risks. Gay men’s understanding of the relative risk of various sexual activities has deepened too, so it makes less sense to look at sex simply in terms of ‘safe’ and ‘unsafe’ – there are lots of examples of sex which is unprotected but not particularly unsafe for HIV transmission.

Most gay men practise safe sex most of the time, and when they choose to do otherwise, most use other strategies to reduce the risk of HIV transmission – things like choosing partners with the same HIV status (‘serosorting’), choosing sexual activities with lower risk (‘strategic positioning’) and practising safer sex if their viral load [2]A measurement of the quantity of HIV RNA in the blood. Viral load blood test results are expressed as the number of copies (of HIV) per milliliter of blood plasma. is high. Of course, none of these strategies are foolproof, but they do go some way to reducing the risk of HIV transmission.

Another factor which undoubtedly influences the number of HIV diagnoses is the prevalence of sexually-transmissible infections in our community. STIs [3][Sexually Transmissible (or Transmitted) Infection] Infections spread by the transfer of organisms from person to person during sexual contact. Also called venereal disease (VD) (an older public health term) or sexually transmitted diseases (STDs). like gonorrhoea, chlamydia and syphilis make it easier to catch or transmit HIV, and these bugs have undergone a resurgence in recent years.

The influence of treatments uptake on HIV transmission is a controversial area that has only received limited attention. While the rate of treatments use is fairly high among HIV-positive people in Australia, the number of positive people not on treatment has risen somewhat over recent years. Positive people are delaying starting treatment longer or taking treatment breaks when they can, and this might mean that the ‘community viral load’ is higher than it was when more people were on treatment. We know that higher viral load usually means a greater risk of passing on HIV, although even with undetectable blood viral load there can still be detectable virus [4]A small infective organism which is incapable of reproducing outside a host cell. in your semen. Should we be arguing that positive gay men should be extra-vigilant about safe sex if they aren’t on treatment or their viral load is high? It’s a controversial question, but one which might merit further investigation.

Of course, not everybody who’s HIV-positive knows they’re positive, and this is another possible route for HIV transmission. The risk of passing on HIV is much higher for people who have been recently infected, and if someone doesn’t know he has HIV, he won’t be aware of the need to avoid passing it on. Levels of HIV testing have fallen a bit in recent years in our community: should we be encouraging our HIV-negative friends to get tested regularly?

Should we care?

For those of us who are already HIV-positive, what difference does it make if the number of HIV diagnoses goes up? Isn’t that just water under the bridge as far as we’re concerned?

I think the vast majority of positive guys would agree on this: yes, of course we should care. No-one knows better than we do what a burden it is to live with HIV, and no-one who has lived through the agony of passing HIV on to someone else remains unmarked by that experience.

Living with HIV gives us an acutely personal understanding of the enormous impact of this virus and the overwhelming majority of HIV-positive people believe ‘HIV stops with me’ and do whatever they can to ensure that.

As gay men we have a shared history with our HIV-negative brothers that goes back to the beginning of the HIV epidemic and before. One of the key reasons Australia has been fortunate in having relatively few people living with HIV is because of the way that shared history propelled shared purpose and community action. We have been involved in the response to HIV from the beginning – because our lives depended on it and because we cared for each other. As I hope we still do.

What can we do?

If you’ve read this far, you probably agree that rising HIV infections are something that HIV-positive gay men should care about. Here are some suggestions for ways in which each of us can make a difference and help to turn the tide.

1. Practise safe sex

You already know this – you’ve heard it a million times before. The simplest and best way to prevent the spread of HIV is to practise safe sex, and that means using a condom when fucking. If you don’t want to use a condom, there are strategies you can use to reduce the risk of HIV transmission but they are nowhere as effective or as trouble-free as safe sex.

2. Disclose your status if you can

Being honest and open about your HIV status with potential sex partners is the key to making those risk reduction strategies more effective. By letting your partner know you’re HIV positive you can both make informed decisions about the sex you have and you help to break down the stigma of living with HIV. Of course, there are risks associated with disclosure and it’s your right to keep your HIV status to yourself. You don’t have to disclose your status if you insist on using a condom.

3. Get tested for STIs

If you have casual sex, you should get a thorough STI screen every 3–6 months. Having gonorrhoea, chlamydia or syphilis increases the chance of passing on HIV dramatically, and makes it harder for your body to fight HIV.

4. Think about treatments

If you’re not on HIV treatments, talk to your doctor about whether you should start and think about starting if they are recommended. HIV treatments reduce your viral load, and reduce the risk of passing on HIV. If you’re not on treatments, or if you know your viral load is high, be aware that the risk of transmitting HIV is increased.

5. Talk about it

We owe it to ourselves and to each other to find ways of preventing HIV infections continuing to rise, and an important step forward is to talk to each other. Discuss the choices you make with your friends, talk to other positive guys about them, remind your HIV-negative friends that HIV hasn’t gone away and help them stay safe. Encourage your friends to get tested and support them as they wait for the results. Join your local PLWHA organisation and get involved with their work. Find a peer support group. Join a committee, stand for the Board, or volunteer for the speakers’ bureau. The old slogan, ‘silence = death’ – and its counterpart, ‘action = life’ still applies.

Paul Kidd is the Editor of Positive Living. The opinions in this article are his own.