Neil McKellar-Stewart, ACON's HIV Health Promotion Officer, attended the XVIII International AIDS 2010 Conference and made the following report from Vienna.

Global forum on MSM and HIV

The Global Forum on MSM & HIV (MSMGF) organised the Be Heard! Gay Men and Other Men Who Have Sex with Men in the Global HIV Pandemic at the Vienna University of Economics and Business, Vienna, Austria

The MSM pre-conference explored the challenges and best practices in achieving universal access to HIV-related prevention, care, treatment and support services for MSM communities worldwide.
There were around 600 attendees.

Web: Details of the program are at www.msmgf.org/beheard/index.htm

Growing older With HIV

The afternoon session I attended was organised by the Gay Men's Health Crisis (GMHC) and AIDS Community Research Initiative of America (ACRIA on the subject of HIV and Aging: Growing Older with the Epidemic. It discussed results from two research projects and publications.
The GMHC report which has the same title as the session was released in June 2010 and explored a range of issues around the "greying" of the PWH population in the developed world.
It discussed the epidemiology of the ageing epidemic and some of the issues faced by ageing PWH. These included:

• Risk of serious infections is increased (e.g. pneumonia)
• Slower, less robust immune recovery
• Unauthorised disclosure of HIV status and sexuality by service providers (e.g. nursing homes)
• Stigma & discrimination about HIV status and sexuality.

The second presenter explored ACRIA's Research on Aging with HIV (ROAH) program which was conducted over 5 years ago. The commonly recognised and widely discussed health issues facing ageing PWH were explored, these included:

• Heart disease (now the number one cause of death in older people)
• Cancer (40% of all PWH will develop cancer)
• Liver disease (which is currently the number one cause of death in PWH. PWH have a 4-fold risk of death by liver disease)
• Kidney disease
• Cognitive impairment
• Depression (in the ROAH study 38% PWH had moderate depression, 26% were severely depressed)
• Frailty and bone loss

None of these findings were new and will be further discussed at the main conference. Questions and comments from the floor were diverse: one participant suggested that things were not as serious as some suggested. This was challenged and a reminder issued that there is substantially increased risk of disease in the areas listed above.

MSM, HIV and activism

The Afternoon plenary was on MSM, HIV and Activism: Key Questions and Strategies for Moving Forward. A survey of MSM conducted by the Global Network of People with HIV (GNP+) and the Asia Pacific Network of Positive people (APN+) found that 40% of MSM PWH had been denied services by health care services (impacts on monitoring and general health maintenance), 25% were in a heterosexual relationship (no disclosure). Again this reflects the recent Australian research on ageing MSM with HIV in health care facilities.

The following issues were explored:

• MSM with HIV have a dual imperative to have policy address our issues sympathetically and sensitively: "Nothing about us, without us"
• Disclosure is one of the most significant issues
• Barriers exist around leadership and power: getting leaders to step up, and remain focussed (quick fixes are not possible: the issues are complex)
• Interventions need to be culturally appropriate (what works in Australia may not work elsewhere)
• Global HIV policy and advocacy must include MSM with HIV
• Discourse about prevention must move away from placing all responsibility of PWH to a mutual responsibility paradigm

Stephen Lewis, Co-Director of AIDS-Free World discussed a recent meta-analysis of 133 studies which provided unassailable data from over 50 countries which indicate the following:

• Prevalence rates of MSM with HIV are always greater that in the general PWH population
• Prevalence rates are highest amongst MSM who are also IDUs
• Where there is universal access to treatment, clinical and other health care, MSM with HIV in every country without exception had prevalence rates that were lower (For the first time ever this has been conclusively documented: Universal access is essential.)

He suggested four issues which require ongoing advocacy:

• Treatment for all to drive VL to undetectable and risk of transmission to zero
• Research and further uptake of microbicides which has the promise of passing power and control to women in control of their sexuality
• New unassailable evidence that treating MSM and providing health services for them are indicators of a healthy health system in which people test more frequently and prevalence is driven down
• Human rights are for everyone.

Other speakers emphasised these arguments. Some produced statistics to show that in some countries (including Eastern Europe) 90% of MSM cannot access services for PWH.
Robert Carr from APN+ suggested some key areas:

• HIV programs for MSM must target social inclusion
• Policy must disengage from unhelpful church-state discourses
• UN has to democratise process
• Civil society has to be independently funded

Take away messages from the final plenary

• MSM leadership needs to be listened to respectfully
• Prevention resources (campaigns etc) have to be better targeted to reach at-risk communities
• Up-coming leaders need to be supported
• MSM with HIV organisations need to be visible and network at the community, country and regional level
• Common cause should be identified and embraced, with a unifying theme around human rights

XVIII International AIDS Conference proper - Sunday 18 July

Opening Session SUPL01 - Treatment Guidelines

The opening session had six major speakers some of whom addressed the following issues:

Julio Montaner, President IAS highlighted some recent advances: WHO treatment guidelines were moving to treatment at 350 CD4+ cells, the concept of treatment as prevention had been clearly demonstrated to be true, with recent Lancet articles reporting reductions in transmission of 90% in heterosexual couples and 50% in IDU populations. He indicated that the wife of the French President had recently argued passionately for universal access. He indicated that human rights issues underpinned the global HIV policy development with reduction of stigma and discrimination a key platform.

Community representatives from Eastern Europe and Central Asia indicated that the 18 countries in this region had the world's fastest growing rate of new infections. 300,000 PWH needed treatment and 500 new infections were identified each day. Every second person with HIV is also co-infected with HCV. Every 4th PWH is imprisoned. HIV is a real threat to national integrity.

HIV Epidemiology: Progress, Challenges and Human Rights Implications

Yves Souteyrand, Switzerland provided a State of the Epidemic HIV Epidemiology: Progress, Challenges and Human Rights Implications report. Key data included:
7400 new infections daily, of these 1200 are children <15yo, 5000 die daily of HIV-related disease, 3000 commence treatment. 97% of all PWH are in low to middle income countries, 70% are in sub-Saharan Africa. HAART is having an impact on the epidemic in Sthn Africa and the observed prevalence is failing.

Vulnerable communities were then discussed, these include:

• Migrants with HIV in Western Europe who suffer double discrimination
• MSM who have 19.5 times the risk of acquiring HIV than the general community
• MSM with HIV in the Caribbean whose behaviours are criminalised in some countries. Where this occurs, prevalence rates among MSM reach 20%, where there is no criminalisation prevalence is <5%.

Conclusions drawn from this state of the epidemic included the following:

1. To respond adequately to the epidemic there must be strong health information and vital statistics registries
2. Human rights abuses hide the true state of the pandemic
3. Expanding and responding to the needs and rights of minority communities is vital
4. Universal access to treatment to prevent transmission and treat the virus cannot proceed without universal access to human rights

Strategies for a cure

Sharon Lewin, Australia, reported on the State of the Epidemic: Strategies for a Cure and highlighted that although there had been significant gains e.g. 5M people on treatment (only a third of what is required!) a functional cure was absolutely necessary to stop the spread of the pandemic and save millions of lives.

She noted that even with effective full life, expectancy was not restored even in countries with high effective HIV treatment and clinical care. The probability of PWH reaching 70 yo is 50% less than the general community, and for every 2 people going on HAART there are 5 new infections: the pandemic is clearly not under control. She discussed the barriers to eradicating the virus.

Treatment does not remove the virus altogether, when treatment ceases the virus rebounds, it is estimated that between 1-3 copies of virus remain in blood plasma in the most effective treatments: there is no such thing as an "undetectable" viral load. HIV is present in latently infected T cells, there is residual viral replication and there are anatomical reservoirs of the virus outside the circulatory system.

She addressed several differing approaches to finding a cure: the so-called "sterilizing" cure in which HIV is eradicated totally from the body, the second a cancer or remission cure in which the virus, though present, is rendered relative harmless. She then went on to review the various strategies.

About the author

Neil McKellar-Stewart works for ACON in the position of HIV Health Promotion. The position is partly funded by Positive Life NSW. Neil is a member of the NAPWA Treat-Aware Outreach Network, and regular contributor to the national publication Positive Living.

Find out more

Web: AIDS 2010 - The XVIII International AIDS Conference