Developing New HIV Prevention Messages
There is a clear need to develop new HIV prevention messages and improve public awareness of our new understanding of HIV transmission. Research shows that many people refuse to enter a relationship with a person who is HIV positive even though the risk of HIV transmission in such relationships can be reduced to negligible levels and, in some circumstances, may be lower than entering a relationship with someone who is wrongly believed to be HIV negative. For example, in a recent survey of MSM across Canada, 49% said they would not have sex with an HIV-positive man even if they were very attracted to him.13
In addition, evidence suggests some people continue to rely only on HIV prevention strategies that depend on accurate knowledge of an HIV-negative status. For example, in the same survey of MSM across Canada, most men thought serosorting (50%), disclosure/discussion (66%), and regular STI/HIV testing (77%) were effective HIV prevention strategies while only a minority thought that taking antiretroviral treatment (39%), regular viral load monitoring (38%), and pre-exposure prophylaxis (36%) were effective prevention strategies.13
These beliefs contradict what we know about HIV transmission and prevention. Treatment as prevention and PrEP are both highly effective HIV prevention strategies if used consistently and correctly. Low awareness of these relatively new strategies may partly explain why so few MSM thought they were effective. A recent review of Canadian HIV-related websites found that a minority contained information on treatment as prevention and PrEP.14 The evidence to support the assertion that other strategies are highly effective is less strong.
Moving forward, reducing the number of HIV transmissions originating from HIV-positive people who are undiagnosed will require our HIV prevention messaging to:
- Encourage clients to question their ability to know their own, and their partner's, HIV status with certainty. If a client is unsure about their HIV status, they should be encouraged to disclose their status as unknown.
- Encourage clients to avoid making assumptions about their own, or their partner's, HIV status. Encourage them to discuss important topics such as HIV status, testing and sexual history, window periods, and HIV prevention prior to engaging in sex. Shared responsibility for disclosure and HIV prevention (as opposed to placing this responsibility solely on the shoulders of people living with HIV) should be promoted.
- Promote the adoption of highly effective HIV prevention strategies that do not rely on accurate knowledge of an HIV-negative status, such as external and internal condoms and pre-exposure prophylaxis (PrEP). These options should be promoted in situations where there is uncertainty with regard to either partner's HIV status.
- Improve awareness of the new knowledge on HIV transmission and prevention. This may help to reduce HIV-related stigma and barriers to the formation of serodiscordant relationships.
- Promote regular HIV testing to ensure a person living with HIV learns about their status as soon as possible after infection. This can help improve health outcomes and decrease new HIV transmissions. The Public Health Agency of Canada's HIV Screening and Testing Guide recommends that people involved in "high-risk practices" should be screened for HIV at least annually. The guidelines also recommend more frequent HIV testing for MSM who have multiple partners and/or have sex when they or their partners are using street drugs (particularly methamphetamine).
- Punyacharoensin N, Edmunds WJ, De Angelis D, et al. Modelling the HIV epidemic among MSM in the United Kingdom: quantifying the contributions to HIV transmission to better inform prevention initiatives. AIDS. 2015;29(3):339-349.
- Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006;20(10):1447-1450.
- Hall HI, Holtgrave DR, Maulsby C. HIV transmission rates from persons living with HIV who are aware and unaware of their infection. AIDS. 2012;26(7):893-896.
- Phillips AN, Cambiano V, Nakagawa F, et al. Increased HIV incidence in men who have sex with men despite high levels of ART-induced viral suppression: analysis of an extensively documented epidemic. PloS One. 2013;8(2):e55312.
- Van Sighem A, Vidondo B, Glass TR, et al. Resurgence of HIV infection among men who have sex with men in Switzerland: mathematical modelling study. PloS One. 2012;7(9):e44819.
- Skarbinski J, Rosenberg E, Paz-Bailey G, et al. Human immunodeficiency virus transmission at each step of the care continuum in the United States. JAMA Internal Medicine. 2015;175(4):588-596.
- Metsch LR, Pereyra M, Messinger S, et al. HIV transmission risk behaviors among HIV-infected persons who are successfully linked to care. Clinical Infectious Diseases. 2008;47(4):577-584.
- Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. Journal of Acquired Immune Deficiency Syndromes 1999. 2005;39(4):446-453.
- Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine. 2011;365(6):493-505.
- Rodger A, Bruun T, Valentina C, et al. HIV transmission risk through condomless sex if HIV+ partner on suppressive ART: PARTNER Study. In: Program and abstracts of the 21st Conference on Retroviruses and Opportunistic Infections, March 3 to 6, 2014, Boston, U.S., abstract 153LB.
- Sullivan PS, Salazar L, Buchbinder S, Sanchez TH. Estimating the proportion of HIV transmissions from main sex partners among men who have sex with men in five US cities. [Miscellaneous Article]. AIDS. 2009;23(9):1153-1162.
- Santos-Hövener C, Zimmermann R, Kücherer C, et al. Conversation about Serostatus decreases risk of acquiring HIV: results from a case control study comparing MSM with recent HIV infection and HIV negative controls. BMC Public Health. 2014;14(1):453.
- Male Call Canada. Technical Report.; 2013.
- Gilbert M, Dulai J, Wexler D, Martin S. Challenges to providing HIV risk and prevention information online to gay, bisexual and other men who have sex with men: preliminary findings from an environmental scan of Canadian agency websites. In: Abstracts of the 24th Annual Canadian Conference on HIV/AIDS Research (CAHR), April 30th to May 3rd, 2015, Toronto, Canada; abstract O047
James Wilton is the coordinator of the Biomedical Science of HIV Prevention Project at CATIE. James is currently completing his master's degree of Public Health in Epidemiology at the University of Toronto and has completed an undergraduate degree in microbiology and immunology at the University of British Columbia.