National Gay Men's HIV/AIDS Awareness Day: Half Untreated, Most Unaware of PrEP

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Only 50% of gay and bi men diagnosed with HIV have started antiretroviral treatment and 42% have achieved undetectable viral load, according to a new Centers for Disease Control and Prevention (CDC) report released ahead of National Gay Men’s HIV/AIDS Awareness Day on September 27. A related survey from the Kaiser Family Foundation found that while gay and bi men see HIV as a top health issue, a majority do not get tested regularly and most do not know about pre-exposure prophylaxis, or PrEP.

NGMHAAD Resources

National Gay Men's HIV/AIDS Awareness Day (NGMHAAD) is an annual opportunity to call attention to the disproportionate effect of the epidemic on gay and bisexual men. According to the CDC, while gay/bisexual men make up approximately 2% of the U.S. population, they account for more than half of the 1.1 million people living with HIV and about two-thirds of new infections. Incidence is particularly high among young gay and bi men and men of color.

"Effective treatments have turned what was once considered a fatal diagnosis into a largely chronic disease. Research has also shown that early HIV treatment is perhaps the most powerful form of HIV prevention, lowering the risk of transmission by 96%," wrote Eugene McCray, director of the CDC's Division of HIV/AIDS Prevention. "Yet, these life-saving advances still only benefit a fraction of the gay and bisexual men who need them. To stop the epidemic among gay and bisexual men in its tracks, we must tackle the disparities that persist at every stage of HIV care and treatment. And we have to better reach the youngest generation -- particularly young African-American men."

CDC Report

The new report, published in the September 25 edition of Morbidity and Mortality Weekly Report, looks at the cascade or continuum of care for gay and bisexual men with HIV age 13 and older in the U.S. and Puerto Rico. The report is based on 2010 data from the CDC’s National HIV Surveillance System. That year 52% of people living with HIV and 63% of newly infected people were men who have sex with men (MSM) -- a term public health researchers use to include men who may not self-identify as gay or bisexual.

Data from 10,093 gay/bi/MSM in 19 jurisdictions with complete reporting of CD4 T-cell count and viral load test results (representing 42% of all MSM diagnosed with HIV) were used to assess linkage to care within 3 months after diagnosis and retention in care. Information from the Medical Monitoring Project were used to assess prescription of antiretroviral therapy (ART) and rates of viral suppression among men 18 and older.

Current national treatment guidelines recommend that everyone diagnosed with HIV should consider starting ART regardless of CD4 count. However, the data for this analysis were collected before this recommendation was issued in 2012. Previously, treatment was recommended for people with fewer than 500 cells/mm3 -- and before that below 350 cells/mm3 -- so people who still had well-preserved immune function likely would not have been offered treatment.

"Lack of health insurance, stigma, and discrimination might influence whether MSM access medical care, which has implications for each subsequent step along the continuum of care," the report authors concluded. "The findings in this report highlight the need for continued expansion of prevention, care, and treatment efforts for achieving improvement in linkage to care, retention in care, and viral suppression for MSM, particularly MSM aged <25 years and black/African American MSM."

The National HIV/AIDS Strategy calls for 85% of gay/bi men diagnosed with HIV to be linked to care and 80% to be retained in care by 2015, and the proportion with undetectable viral load to increase by 20%.

"It's unacceptable that treatment, one of our most powerful tools for protecting people's health and preventing new HIV infections, is reaching only a fraction of gay men who need it," said Jonathan Mermin, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and Tuberculosis Prevention. "A top prevention priority at CDC is making sure every gay man with HIV knows his status and receives ongoing medical care -- otherwise, we will never tackle the HIV epidemic in the country."

"The findings suggest that age- and race-related disparities in care and treatment may play a key role in the disproportionate burden of new HIV infections among young and African-American gay and bisexual men," according to a CDC press release summarizing the findings. "High prevalence of HIV within these communities, coupled with low rates of viral suppression, means people in these groups are at higher risk of infection with every sexual encounter."

It is equally important to reach the estimated 19% of gay and bisexual men who do not yet know they have HIV. The CDC recommends routine HIV screening for all people age 13-64 years as part of their routine health care, while sexually active HIV negative gay/bi/MSM might benefit from more frequent testing, such as every 3-6 months.

"HIV testing is the gateway into care," the CDC release continued. "Fully capitalizing on the benefits of antiretroviral therapy -- both for individual health and for prevention -- will require significant investment in closing gaps across the board, from testing to retention in care and adherence to treatment."

Kaiser Family Foundation Survey

The Kaiser Family Foundation survey, also released this week, highlights attitudes and knowledge about HIV/AIDS among gay and bisexual men in the U.S. Funded by the MAC AIDS Fund, the survey was conducted in English and Spanish between July 17 and August 3 of this year. Survey respondents were a sample of 431 men age 18 and older who self-identify as gay or bisexual; half said they were in a committed relationship and 20% were married.

Although HIV/AIDS was most often cited as the leading health issue facing their community, 56% of gay and bi men said they are not personally concerned about becoming infected and only 32% were aware that new infections are increasing in this group. Gay/bi men of color were more likely to be concerned than white men. About two-thirds (68%) said they rarely or never discuss HIV with friends and half do not do so with casual sex partners.

Bucking CDC recommendations, just 30% of survey respondents said they had been tested for HIV within the last year, including 19% tested within the past 6 months. Nearly one-third (30%) reported that they had never been tested, rising to 44% among young men age 35 and under. More than half (56%) said they had never been advised by a doctor to get tested -- perhaps not surprising, as 61% said they rarely or never discuss HIV with their providers. However, 75% said that gay and bi men not knowing their status is a major reason why it has been hard to control the spread of HIV.

Complacency (62%) and stigma (56%) were also cited as factors fueling the epidemic. A majority of gay and bi men said they would be uncomfortable having a long-term sexual relationship (66%) or casual sex (77%) with someone HIV positive. Not surprisingly, gay and bi men under age 35 are much less likely than older men to report having lost someone close to them due to HIV/AIDS (8% vs 47%, respectively).

Regarding treatment, nearly half (46%) of respondents knew that current treatment guidelines call for everyone diagnosed with HIV to promptly start ART. Most recognized that ART is very (57%) or somewhat (25%) effective in prolonging survival and very (44%) or somewhat (33%) effective at improving the health of people with HIV. However, only a minority thought ART was very (14%) or somewhat (22%) effective for preventing HIV transmission -- in fact, studies indicate that "treatment as prevention" can dramatically reduce the risk of transmission.

Also on the prevention front, nearly half (46%) of respondents said they use condoms all or most of the time, while 24% said they never use them. Men of color were more likely than white men to report regular condom use (61% vs 39%), consistent with studies showing that black men have a higher rate of HIV infection despite engaging in less sexual risk behavior.

Pre-exposure prophylaxis using once-daily Truvada (tenofovir/emtricitabine) has been the subject of much news and debate this year, yet most gay and bi men surveyed said they have heard "only a little" (25%) or "nothing at all" (55%) about it, and only 10% knew someone (including themselves) who had used it. Interestingly, 64% of men age 35 and older think PrEP should be widely used compared with 43% of younger men.

"These survey results underscore the importance of getting the word out among gay and bisexual men about risk and new treatment and prevention options," said Kaiser Family Foundation President and CEO Drew Altman.

9/26/14

Sources

S Singh, H Bradley, X Hu, et al. Men Living with Diagnosed HIV Who Have Sex with Men: Progress Along the Continuum of HIV Care -- United States, 2010. Morbidity and Mortality Weekly Report 63(38):829-833. September 25, 2014.

Centers for Disease Control and Prevention. Only Half of Gay and Bisexual Men Diagnosed with HIV Received Care and Treatment in 2010. Press release. September 25, 2014.

E McCray. HIV Care for Gay and Bisexual Men is a National Priority. Blog.AIDS.gov. September 25, 2014.

L Hamel, J Firth, T Hoff, et al. HIV/AIDS in the Lives of Gay And Bisexual Men in the United States. Kaiser Family Foundation. September 25, 2014.

Kaiser Family Foundation. Gay and Bisexual Men See HIV as the Top Health Issue Facing Their Community, But Majorities Are Not Personally Worried About Getting Infected & Not Getting Tested Regularly. Press release. September 25, 2014.