by Kent Klindera, November 13, 2012
In July 2012, coinciding with the XIX International AIDS Conference in Washington,
DC, scientific journal The Lancet launched a special issue focused on
HIV among men who have sex with men (MSM). I read this 30-year summary of
success and failure with much hope, as it solidified what many researchers and
community activists have been saying for the past year—that we can
achieve an AIDS-Free Generation among gay men, other men who have
sex with men (MSM), and transgender individuals—what we at amfAR
collectively refer to as “GMT.”
may have noticed over the past few months that amfAR has been using the term “GMT”
more often. Now, after five successful years of activity, we have formally
re-branded our MSM Initiative to become the GMT Initiative.
Following the lead of our brothers and sisters in Latin America, we made
the switch to better capture the diversity of populations served through our
initiative and to emphasize the connection between rights-based policy and
advocacy and successful service delivery to improve the health and well-being of
addition to the brand change, amfAR has expanded the scope of the initiative,
focusing more on larger, systemic changes that are achieved through empowering
GMT Initiative will focus on several core areas:
and more formally evaluating combination HIV program models that can be scaled
the connection between rights-based advocacy and successful service delivery
targeted advocacy to influence government and donor policies
the capacity of GMT-led organizations to collaborate with and expand access to
appropriate government-funded HIV programs
epidemiological, resource tracking, and other research to advocate for
GMT-related health services
a research-focused foundation, amfAR has made this shift in order to recognize the
potential of science-based efforts.
My colleague at The Center for Public Health and Human Rights (CPHHR) at Johns
Hopkins, Dr. Stefan Baral, speaks of “truths” that The Lancet studies have indicated must be integrated into the next
generation of HIV prevention programming.
me, these truths can be summarized as the following:
- Behavior Interventions work...BUT NOT ALONE! As we have seen,
interventions that focus on reducing individual HIV/STI-related risk behavior
and increasing health-seeking behavior are powerful. These programs,
grounded in behavioral science, led the way to reductions in incidence among
GMT in the early years of the HIV epidemic. However, we have known for
years that they are not necessarily effective in reducing HIV incidence for all GMT communities. We will not
achieve an AIDS-Free Generation if we focus solely on behavioral
interventions. We need to combine these strategies with new (and old) biomedical
interventions, and address structural issues.
- Biomedical Interventions work!
- Test and Treat: New studies have
confirmed that motivating individuals to get tested is still vital.
However, testing needs to be closely linked to treatment and care. We
have learned that lowering ”community viral load” means those GMT
who are living with HIV need to know their status and actively seek treatment
to lower their infectiousness. The challenge is to motivate people living
with HIV to take action, and to adhere to their medications.
And sexually active GMT need to regularly seek clinical services for STI
diagnosis and treatment, as STIs are often a co-factor in
the spread of HIV.
- Condoms and Lubricant: An old
intervention in our playbook, we need to continue condom promotion
and increase access to quality condom-compatible lubricant—especially
in the global south. This includes advocating for lubricant to be part of
national strategic plans, as well as creating sustainable channels to supply
lubricant to community organizations.
- PrEP, Microbicides, Vaccines: These newer
science-based approaches are showing promise. Pre-exposure prophylaxis
(PrEP)—taking HIV medication to prevent an individual from contracting HIV—has already
proven effective among GMT populations throughout the world. Although the
roll-out is challenging in many parts of the global south, we need to advocate
for an increase in PrEP. Down the road, we expect to have microbicides
and vaccines that are effective as well.
- Structural interventions are needed! The latest epidemiologic
studies indicate that homophobia and transphobia
play a significant role in increasing GMT individuals’ vulnerability to HIV. We
suspected this before, but now we have scientific models to prove the
shortage of comprehensive, culturally competent health services for GMT is
attributed to the stigma and discrimination associated with same-sex
behavior. Many GMT do not feel worthy of receiving health services that
meet their needs, since they have been treated as second-class citizens by
their families, communities, faith traditions, and health care providers.
Added to this victimization are other issues such as racism, classism, and
sexism (especially for transgender individuals), which inflate these vulnerabilities.
The Lancet series refers to
“political homophobia,” legal and economic frameworks that deny GMT basic human
rights, including economic opportunities, which further increases their
vulnerability to HIV.
The structures that inhibit GMT from
getting proper health care must be addressed. We must challenge legal structures that
violate human rights and challenge stigma and discrimination in the family,
community, and health care setting through the empowerment of GMT community-led
- Sexual and Romantic Relationships matter! Finally, one study
from The Lancet that resonated with
me was about relationships, and the importance of increasing GMT individuals’ abilities
to communicate about HIV issues. Notably, discussing one’s HIV status
with sexual partners reduces risk. Other factors that reduce risks
include partner negotiation, “sero-sorting” (using condoms and lubricant when
having intercourse with someone of another serostatus), and recognition of role
reversal (not always being a top or a bottom).
However, what stands out for me is the
recognition that casual partners are associated with an increase in incidence
rates, suggesting that the more long-term sexual relationships individuals
have, the lower their risk. I’m not sure that I needed to see the data
on this one to know it is true. However, it represents an issue so often
discussed among GMT. So many GMT want boyfriends (or girlfriends), to be
loved, and to be in a long-term health romantic relationship. We need to
help GMT individuals develop the skills to find and keep long-term romantic
please join us in using the more inclusive term “GMT” as we work to achieve an
AIDS-Free Generation among gay men, other MSM, and transgender