In one of the articles for the print edition of this issue, Dr. Adaora A. Adimora discusses her work on structural barriers fueling the epidemic ("Black Women, Society and HIV," September/October 2012). At the International AIDS Conference held in Washington, D.C. in July, the discussion of the concept of structural barriers was plentiful, primarily focused on men who have sex with men (MSM). Structural barriers -- those aspects of the world that negatively impact the epidemic -- include such problems as homophobia, discrimination, and criminalization of gay sex.
For example, Dennis Altman, a professor at La Trobe University in Australia, noted that gay men in some countries believe anal sex is safe from HIV infection because no health information is given about homosexuality, especially in places where it is illegal. The fact is, of course, that anal sex is the most efficient sexual route for HIV transmission, especially among MSM.
The British medical journal The Lancet hosted a discussion of structural barriers in a session stemming from its July special issue on HIV in MSM.
According to the cover of the issue, underneath a graphic by Keith Haring of two men of different colors with a supportive arm around each other, "In much of the world, [men who have sex with men] remain hidden, stigmatized, susceptible to blackmail if they disclose their sexual lives, and criminalized, even in health-care facilities... To address HIV in [these men] will take continued research, political will, structural reform, community engagement, and strategic planning and programming, but it can and must be done."
"The focus [in the epidemic] has been on individual risk," said Richard Horton, editor-in-chief of The Lancet and co-chair of the session, "but more and more we see the impact of structural risk, stigma, and discrimination." He said stigma and discrimination in clinical settings prevent people, including MSM, from being able to gain access to health care.
Professor Patrick Sullivan. Photo via ABC.net.au.
Patrick Sullivan, associate professor of epidemiology at Emory University School of Public Health in Atlanta, said, "Current efforts [in prevention] have failed and we must do more. We know with the HIV prevention technology we have today we can do more and help curb the epidemic globally.
"We also need to have safe places for prevention and culturally competent care," Sullivan continued. "In many places in the world, gay men cannot seek prevention services because male-to-male sex is criminalized." Among the problems ensuing from such criminalization, he explained, have been threats to close down clinics for enrolling MSM in research.
Speaking at the session, Dennis Altman said there are different levels of homophobia, noting specifically the following three: denial and ignorance; social and official discrimination; and legal and extra-judicial persecution and violence. The roots of homophobia, he said, include religion; fears about "traditional" gender power relations; "political homophobia"; and authoritarian states. All of this then links back to HIV transmission through the lack of basic prevention services due to criminalization, stigma, and denial -- to the point that MSM don't even learn that anal sex is a route of infection, as noted above.
"The greatest challenge is that we are being told at this conference that we have wonderful new prevention tools, but [access is a problem]," Altman said in his conclusion. In his slides, Altman, the author of the groundbreaking book Homosexual: Oppression and Liberation, noted that, "There is an urgent need to move beyond denial of homosexuality in the name of tradition, culture, and religion."
Kenneth H. Mayer, M.D., Medical Research Director and Co-Chair of The Fenway Institute at Fenway Health in Boston, discussed "the whole man," or comprehensive care to MSM, not just HIV concerns.
"Our thesis is that that these are not vectors of transmission, but people, and prevention will only work when people are respected and get comprehensive care," said Dr. Mayer. Instead, verbal and physical abuse can lead to internalized homophobia and depression, he said, with a resulting potential for health problems. He said the majority of MSM remain resilient against the effects of these syndemics, or overlapping negative realities.
"Health is not just an absence of disease," Mayer went on, "but safe and pleasurable experiences." He urged counselors to pay attention to their client's social environment, not just the person's individual behavior.
It remains an open question whether structural changes, such as civil rights, will improve health care for MSM. He reported that Fenway saw a decrease in medical and mental health care cost for MSM after marriage equality, which allowed gay couples to marry in Massachusetts, and that there were more teen suicides in "non-supportive" Oregon counties compared to those with gay-straight student alliances. Rates of sexually transmitted diseases, however, including HIV, are not down in the U.S. and Europe, and more data are needed, he said.
"In conclusion, I just want to beg, to plead, that we need culturally competent care and this means training," Dr. Mayer said.
Richard Horton noted that discrimination against MSM does not just occur in other parts of the world. He noted, emphatically, the brutal beating of a gay male couple on their way home, leaving one of the men with a broken cheekbone.
The attack took place in D.C. on Sunday, July 22, the opening day of the international AIDS conference in that city.
Author's note: Not all speakers and topics in The Lancet session are discussed here. See the special edition, free online: www.thelancet.com/series/hiv-in-men-who-have-sex-with-men. Many other sessions and posters also addressed structural barriers affecting MSM and HIV. Go to www.ias2012.org.
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