The year 1939 saw total US syphilis deaths at 15 per 100,000 and syphilis deaths of black males at 72.5 per 100,000: this is a death rate comparable to that for HIV/AIDS at the height of the epidemic in 1995 when total deaths and deaths of black males stood, respectively, at 16.2 and 80.2 per 100,000.  Subsequently, in the late 40s and early 50s, incidence and mortality from syphilis were to fall precipitously – thanks to penicillin.  A recent paper in the Archives for Sexual Behavior by an economist, Andrew Francis, argues for the importance of this collapse in the “cost” of syphilis in spurring the sexual revolution (http://link.springer.com/article/10.1007%2Fs10508-012-0018-4). His exploration of this hypothesis prompts general reflection on the link between the “cost” of disease (which he equates with absence of an effective treatment) and sexual behaviour.

The paper correlates data across US states on syphilis incidence and mortality with measures of “risky non-traditional sex” – which, in the context of the poverty of relevant data for the period, is evaluated on the basis of gonorrhoea rate, illegitimate birth ratio and teen birth share.  Coefficients are given from regressions of measures of sexual behaviour on indicators for the number of years since syphilis collapse (which varies by state).  As regards illegitimate birth ratio and teen birth share, a positive correlation emerges which goes back as early as three years or less from syphilis collapse; gonorrhoea, however, continues to decline from its WW2 peak, as we might expect.

Ultimately, however, Francis’s argument rests also on the claim that his own explanation of sexual revolution fits the facts better than the alternative explanations, of which the most familiar is that “anti-conception technology”, especially the pill, played a decisive role.  Francis admits that, from the late sixties, conception technologies and measures of risky behaviour increase simultaneously.  Yet measures of risky sexual behaviour, he claims, had already been rising sharply for a decade before anti-conception technology began to make its impact.  His own data show that the two changes do not coincide.   Nor do measures of permissive values or religious observance show any discontinuous change that would coincide with the increase in risky behaviour.  So if Francis’ hypothesis is wrong, then the precise timing of the sexually revolution remains mysterious.  Francis gestures vaguely towards the possibility of the change in sexual behaviour being triggered by still less definable “economic, social and cultural changes”.

The obvious recent parallel to the syphilis collapse in our own times would be impact of the introduction of HAART on HIV/AIDS mortality.  The concern that an effective therapy might lead to disinhibition has been widely discussed in STI journal and elsewhere.  An increase in risk-taking behaviour among MSM during the late 1990s has been established:  http://sti.bmj.com/content/77/3/184.abstract?sid=5d909365-4627-4232-8ef4-a93445f5baed (Stolte & Coutinho: Amsterdam);  http://sti.bmj.com/content/80/6/451.abstract?sid=5d909365-4627-4232-8ef4-a93445f5baed (Elford & Hart: London); http://sti.bmj.com/content/80/6/518.abstract?sid=5d909365-4627-4232-8ef4-a93445f5baed(Cox & Allard: Montreal); http://sti.bmj.com/content/79/1/7.abstract?sid=5d909365-4627-4232-8ef4-a93445f5baed (Stephensen & Williams: London).  But opinions on the contribution of HAART to changing sexual behaviour seem divided, with Stolte & Coutinho supporting the hypothesis, and the others inclined to attribute it to other factors.  The probable future emergence of multi-resistant gonorrhoea (http://sti.bmj.com/content/87/Suppl_2/ii39) represents the inverse case (loss of a therapy leading to potential inhibition).  If the diminished “cost” of an STI (syphilis) can spur an increase in risky sexual behaviour, should we not expect an increased cost to have the opposite result?  Time will tell.

How is it that the nations of the Middle East and North Africa appear to have relatively low rates of HIV (see http://blogs.bmj.com/sti/2011/09/19/bringing-to-light-the-hiv-epidemiology-of-%E2%80%9Chidden%E2%80%9D-msm-populations-in-the-middle-east/)? A recent paper in the American Sociological Review – Adamczyk & Hayes  – seeks to demonstrate that the predominance of the Muslim religion in a country may have a macro-level, cultural impact on the sexual behaviour (pre- and extra-marital sex) of its residents.  What do they mean by qualifying religious impact as, to some extent, macro-level and cultural?   They are claiming that the impact of religion is not reducible either to individual affiliation, or to formal restrictions.  In their words, it is, in their words sui generis – unique of its kind.  Behind this is a Durkheimian understanding of the religious group as something more than the sum of its parts (http://asr.sagepub.com.libproxy.ucl.ac.uk/content/77/5/723.abstract).

To test their hypothesis the authors use data from the Demographic and Health Survey (DHS).  Their most interesting findings relate to pre-marital sex.  Muslims are far less likely to report pre-marital sex than Christians/Jews (0.61: 0.77).  This effect is not explained wholly by age of first marriage.  As the proportion of Muslims in a nation increases likelihood of all residents (including non-Muslims) reporting pre-marital sex decreases substantially.  So, for a non-working rural woman, likelihood of premarital sex  is 0.71 where 1% residents are Muslim, 0.61 where 23% are Muslim, 0.28 where 90% are Muslim.  Muslims, however, are not more likely to report pre-marital sex as the proportion of Muslims decreases.  Interestingly the relationship between likelihood of pre-marital sex and percentage Muslim does not seem to be mediated by formal restrictions (exemplified here by restrictions on women’s mobility).

The tentative conclusion of the study is, therefore, that the striking relationship of pre-marital sex and percentage Muslim may not be a matter of individual affiliation (or Muslims would be more likely to report pre-marital sex where percentage Muslim decreases).  It may also not be a matter of formal restriction, for in that case the relationship of pre-maritcal sex to percentage Muslim would be mediated by women’s mobility).  Hence the relationship is likely to be explained by something other than individual affiliation, nor formal restriction – i.e. probably macro-level cultural effect.

To non-sociologists this argument from premises to conclusion might seem tenuous.  However hypothesis of a relationship between religion and behaviour is interesting, and the authors claim that this is the first serious attempt to test such a hypothesis on the basis of international data. The interest of the paper for STI journal readers may go beyond the intriguing question of why certain populations should be less susceptible to HIV epidemics than others. From the angle of sexual health policy, the claims of Adamczyk & Hayes matter because they suggest the existence of other potentially refractory cultural factors (i.e. religion in the sense of Adamczyk & Hayes ) – a “black box”, if you like – that, depending on the policy, could turn out to have negative as well as positive effects. On the face of it, this seems at least plausible, and, if it is the case, would certainly be important for health policy. To the extent it militates against “one-size-fits-all” approaches to health policy, the argument of Adamczyk & Hayes may be additional ammunition in the “armentarium” of the “programme science” based approach  that is a topic of ongoing comment in this journal (see for example Aral & Blanchard: http://sti.bmj.com/content/88/3/157.abstract?sid=a6dd8144-b34c-4bcd-a4b2-0f997ae60fd0). STI journal readers will be interested to know that STI journal continues to run a series on Programme Science, edited by Dr Sevgi Aral.

Epidemiological research has sometimes addressed the impact on men who have sex with men (MSM) sexual behaviour of being “non-gay identifying” (NGI) (Yun, Wang et al. (http://sti.bmj.com/content/87/7/563.full?sid=a367a77d-f830-46ee-b761-eec8d9e22da2 ); Mercer & Cassell (http://ijsa.rsmjournals.com/content/20/2/87.full) or of belonging to a culture in which openness about sexuality by MSM is sometimes difficult and personally costly (Lane, Kegeles et al. (http://sti.bmj.com/content/84/6/430.full?sid=ab090fad-0769-479b-a7d5-e6ba10da5609).

The position of MSM in the US military under the recently abolished “Don’t Ask, Don’t Tell” (DADT) policy was an extreme case – possibly a limit-case – of this situation:  up until September 2011, an admission of sexual orientation by MSM, or evidence such as hand-holding, could result in ejection from the military.

How does this kind of situation influence patterns of HIV transmission among MSM, and what is the impact on the sexual behaviour of those MSM who engage in relationships with men regardless?  Would we expect the repressive effects of DADT to result in a relatively lower proportion of total HIV infection due to MSM sexual contact than in the general population – or the reverse?

Results of a recent online survey of the sexual behaviour prior to forced HIV testing of  US Navy and Marine Corps personnel who sero-converted under DADT intriguingly lifts the lid on this formerly closed epidemiological world – and perhaps, to some degree, on other similarly closed worlds.  Of course, the survey itself has major limitations: most importantly its restriction to a minority (64 (524): 26%), and an apparently not very representative minority, who responded to the survey; also the often considerable lapse of time since the behaviours reported.  Despite all these limitations the forced imposition of an HIV test on the whole group allows the survey to capture HIV prevalence at a moment in time.

Among the men who became HIV-infected  84% had had sex with men in the 3-year period prior to diagnosis: 55% reporting sex with just men, and 30% reporting sex with both men and women.  DADT would not then appear to have had much impact on reducing the burden of MSM infection as a proportion of total burden.  This higher figure relative to earlier surveys of the US military (84% as opposed to 59% reporting sex with men) probably reflects the liberalizing effects of DADT repeal.  The frequency of inconsistent condom use with anal sex was 65%, and more than three quarters expressed surprise at their HIV diagnosis.

The story these figures tell mirrors other “repressive” settings such as those with which we began our blog.  On the whole, a culture of repression drives the unwelcome sexual behaviour underground rather than eliminating it, while, at the same time, discouraging responsible behaviour and the adoption of risk-reduction strategies.  As the authors note,  “Several opportunities for primary prevention messaging now possible after DADT repeal are evident”.

With the roll-out of the Bill and Melinda Gates initiated Avahan interventions in India over the last decade, a growing body of evidence has accumulated on the contribution of commercial sex-work to the spread of the HIV epidemic, and the effectiveness of behavioural interventions focussed on this sector.  With the international effort concentrating elsewhere primarily on the deployment of ART, the epidemiological and preventative emphasis of Avahan has broken new ground: attention has been increasingly focussed on influencing the behaviour of key populations (http://sti.bmj.com/content/86/Suppl_1/i6.full?sid=8303ee2c-d0ce-4be1-92a5-f867afdc04d5 ).  Commercial male and female sex workers (FSW/MSW) seem to be an important one of these in the Indian context, due to the importance of male sex activity outside marriage as a factor in Indian HIV epidemiology (http://sti.bmj.com/content/87/6/516.abstract?sid=8133c62b-75db-4498-950e-e277d5687aed).  One neglected aspect of this behaviour has apparently been the disclosure of HIV status.  This is a gap in the research that Saggurti, Samat et al. seek to fill a recent paper (https://springerlink3.metapress.com/content/h26722575803101p/resource-secured/?target=fulltext.html&sid=d0ncj2mkanq0gcji3muoiwrc&sh=www.springerlink.com).

Their headline finding is that 58% of the 211 women (FSM) surveyed by the study, and 41% of the 205 men (clients) had not disclosed their sero-status to any sexual partner.  This would seem to have implications that are more interesting for the relationships of FSM to their non-commercial partners than to their commercial ones.  After all, non-disclosure between FSM and clients is surely what we would expect.  However, non-disclosure in the context of non-commercial and married partners, where consistent condom use may not be the norm (http://sti.bmj.com/content/87/Suppl_1/A67.1.abstract?sid=a9751fe7-af53-4e56-ac3c-352cb5079122) indicates the potential vulnerability of “bridging populations”.  Here Saggurti et al. give further data on the 18 married women and 76 married men included in the study:  39% of the women and 1% of the men had not disclosed HIV status to their married partner; while 78% of the women and 36% of the men claimed not to know the sero-status of the partner.  These findings suggest a marked imbalance – though an imbalance that might reflect behavioural differences between sex-workers and sex-workers’ clients, rather than gender differences per se.

Literature on the epidemiology of HIV transmission stresses the importance of “bridging populations” – which in the case of FSM presumably includes the wives of male clients, on the one hand, and the non-commercial partners of the FSM themselves, on the other.  As regards the former group, a recent study of FSW in Karnataka (Shaw, Deering, Blanchard et al., 2011) indicates that clients of FSW with NCP are less likely (OR 1.8) than those without NCP to use a condom, and more likely (OR 1.5) to be infected with HSV-2.  (http://sti.bmj.com/content/87/Suppl_1/A67.1.abstract?sid=a9751fe7-af53-4e56-ac3c-352cb5079122). But with this group the findings of Saggurti et al. suggest high levels of disclosure.  The case is different with the NCP of FSW, who represent the other bridging group (though here the bridge could well be from NCP to FSW rather than from FSW to NCP).  One of the few studies of the latter group, also from Karnataka (Deering, Bhattacharjee, Alary et al., 2011) finds that levels of consistent condom use (CCU) of FSW with husbands and cohabiting partners is low (22.6% and 40.3% respectively) (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3287549/).  Thus, here, low disclosure would appear to go with low CCU.  An interesting recent study of FSW and their NCP in Vietnam that would seem to bear out this general picture, Hoffman & Niccolai 2011, examines the relationship between intra-couple “communication divergence” and low CCU, and discovers a relatively strong correlation of OR 0.54 (http://www.springerlink.com.libproxy.ucl.ac.uk/content/r562533h71367j06/fulltext.html).

What sort of impact does HIV testing (Voluntary Testing and Counselling: VCT) have on an individual’s subsequent sexual behaviour?

A number of studies of VCT clients in sub-Saharan Africa, and published in STI journal, suggest a significant preventative effect.  A two-year cohort study of 401 clients of Kenyan government health centres (Arthur & Gilks, 2007) points to a significant reduction at 7.5 months both in the proportion of clients with multiple partners (from 16% to 6%) and in the numbers reporting symptoms of STIs (16% to 6%).  A more recent study of attendees at health-centre affiliated VCTs in two Zambian mining villages involving serial interviews (Sikasote & Murray, 2011) serve to consolidate pre-test decisions concerning sexual risk behaviour and reflect clients’ desire to “regain control of their lives”.

In the view of the support these studies lend to the preventative aspect of VCT, it is encouraging to note the comparable behavioural changes reported in a recent study of a very different client group of 1,038 cocaine and heroin users taking up base-line VCT at a US Emergency Department (Bernstein and Madico, 2012).  The study involved secondary analysis of data from a randomized control trial of a motivational intervention (ineffective, as it turned out), which included behaviour change at six and twelve months, notably: a sustained decrease in the proportion of unprotected sex acts (OR 0.7 at 6 months; 0.69 at 12 months), and a sustained drop off – from a high base-line, admittedly – in the number of sex acts (OR 3.1; 0.25).  Given the screening took place during visits to an ED, this effect cannot, as in the African cases, be attributed to a pre-test decision.

These recent findings seem to endorse once again, albeit in the relation to a very different client group, the preventative impact of VCT.  It is interesting, in this regard, that the Zambian study (Sikasote and Murray, 2011) raises the issue of VCT impact for those testing negative, and the importance of post-test support for this group.  They even recommend the de-linking of counselling from testing to encourage earlier attendance.

G. Arthur, C. Gilks et al., “Sexual behaviour change in clients of health centre-based voluntary HIV counselling and testing services in Kenya”, Sexually Transmitted Infections 2007: 83;7

[Abstract][Full text][PDF]

Janet Sikasote, Scott A. Murray et al., “Voluntary counselling and testing for HIV in a Zambian mining community: serial interviews with people testing negative”, Sexually Transmitted Infections 2011:87;5

[Abstract][Full text][PDF]

Edward Bernstein, Guillermo Madico et al., “Long-term Follow-up After Voluntary Human Immunodeficiency Virus/Sexually Transmitted Infection Counseling, Point-of-service Testing, and Referral to Substance Abuse Treatment From the Emergency Department, Academic Emergency Medicine, Volume 19, Issue 4, April 2012

http://onlinelibrary.wiley.com/doi/10.1111/acem.2012.19.issue-4/issuetoc;jsessionid=7D68FDAA3B7B33CFC869B379642BA484.d03t02

How effective is HAART (highly active antiretroviral therapy) in preventing HIV transmission among MSM (men who have sex with men)?  The recent HPTN (HIV Prevention Trials Network) 052 clinical trial demonstrated, to great acclaim, that with heterosexual sero-discordant couples early initiation of HAART is associated with 96% reduction in HIV transmission.  Yet there are reasons why we might expect that for MSM the preventive effect would be less.  We know for example that rectal intercourse is an especially effective route of HIV transmission due to the thinness of the rectal epithelial membrane; high prevalence of urethritis and other STDs in this group could also increase vulnerability.  There is little or no evidence, however.  Given this ignorance, the possibility that HIV- infected MSM may be using HAART status in their sexual decision-making is a matter of concern.  How important is it that sexually-active HIV-infected MSM should use condoms and other risk-reduction strategies through all stages of HIV disease regardless of HIV treatment status?

A US study (Politch, Anderson et al.) published in AIDS has attempted to cast some light on this difficult area, by assessing HIV levels in paired semen and blood samples from 101 HIV-infected MSM who had been on stable ART regimens for at least 3 months.  Given the impracticability of undertaking anything like HPTN 052 on an MSM population, prevalence of HIV viral shedding in blood may offer the best approach to determining the relative infectivity of this group.

Of the 83 men with undetectable HIV in blood plasma, 25% proved to have HIV in semen with copy numbers ranging from 80-2,560 (median 200), as against 50% of those with HIV in blood plasma.  Large recent studies of blood plasma in HIV positive men on HAART (not MSM) have reported levels of viral shedding in semen of 2-3%.  In attempting to quantify the real infectivity risk associated with this higher level of compartmentalized shedding, the authors refer to a theoretical paper (Chakraborty, Eron et al., “Viral burden in genital secretions determines male-to-female sexual transmission of HIV-1: a probabilistic empiric model”, AIDS 2001:15:621-627) and a clinical study (Baeten, Nakku-Joloba, et al., “Genital HIV-1RNA Predicts Risk of Heterosexual HIV-1 Transmission”, Sci Transl Med 2011:3:77ra29) which both conclude that <1000 copies of HIV RNA pose a low but real risk of male-to-female HIV transmission.  Thus, reckoning on a five-fold reduction in this copy number for rectal transmission among MSM, our authors place the threshold of significant risk at <200 – which is well within the range of values reported in their own study.

All this may seem speculative.  In the absence of any more reassuring evidence, however, readers will no doubt agree that “it would be prudent to advise sexually active HIV-infected MSM to use condoms, … regardless of HIV treatment status”.

Joseph A. Politch, Deborah J. Anderson et al., “Highly active antiretroviral therapy does not completely suppress HIV in semen of sexually active HIV-infected men who have sex with men”, AIDS 2012:26

http://journals.lww.com/aidsonline/Abstract/publishahead/Highly_active_antiretroviral_therapy_does_not.98952.aspx

Papers on related issues published in STI journal:

For a sceptical view of the influence of perceptions of ART status on sexual risk taking, see:

J. Cox, J. Beauchemin, and R. Allard, “HIV status of sexual partners is more important than antiretroviral treatment related perceptions for risk taking by HIV positive MSM in Montreal, Canada”, 2004:80:518-523

http://sti.bmj.com/content/80/6/518.abstract?sid=cf57e9d8-2698-4361-8290-d88035309990

In the face of 340 million incident cases of STI worldwide each year, UNAIDS in a recent statement deemed the male latex condom “… the single most efficient, available technology to reduce the sexual transmission of HIV and other sexually transmitted infections”.  Sadly, though the condom may be effective in vitro, this potential proves hard to realize use in real life.  Sustained condom use requires levels of commitment such that, even in the case of discordant heterosexual HIV couples, studies indicate fewer than half of participants report regular use.  In the light of this, the Australian journal Sexual Health has devoted a special issue to condom use – recognizing it to be a “complex behaviour embedded in the fabric” of social relationships.  Attention is given both to data regarding the behaviour itself (including errors and problems of condom use), and to the methodological problems affecting its evaluation by recent research.

Individual reviews cover China, Central and Eastern Europe and Sub-Saharan African.  There are also papers on the female condom and on the issue of “risk compensation” – i.e. where the introduction of one preventative method (e.g. vaginal microbicides) impacts on the use of another (e.g. condoms).

Two systematic review papers, reflecting the two-fold concern of this special issue with the behaviour itself and methodological issues around its evaluation, offer a global perspective on condom use.  The first of these – a review of the literature regarding condom use errors and problems (Stephanie A. Sanders et al.) – leaves the reader with a bewildering sense of the disparity in the importance assigned by studies to the various causes of “condom failure”.  Statements abound such as that “breakage rates ranged from 0.8% to 40.7% of participants across 15 studies”.  The reader may wonder what there is to learn from such data, other than that condom use is indeed a complex behaviour and difficult to evaluate scientifically.

The other systematic review paper (Richard A. Crosby & Sarah Bounse) is complementary to this.  It deals specifically with the methodological problems of evaluating the link between condom use and STI, focussing exclusively on prospective studies.  Forms of misclassification bias are rife, the authors claim.  The most serious derive from the difficulty of determining, when infection takes place within the recall period, whether events of condom-protected sex occurred before infection, or after infection.  Other sources of misclassification bias involve failing, where figures are given for number of infections for a given level of condom use, to control for “use errors” such as breakage, slipping, or incomplete use.

Ultimately the critical question facing policy formers is this: whether protective effect of condom use warrants the full support of public health efforts to keep condoms to the forefront of STI prevention?  It should be borne in mind that all the potential forms of study bias regarding condom use tend towards the nul hypothesis (i.e. they underestimate the effectiveness of condoms).  In the light of this, the authors affirm that the threshold for sufficient protective effect has probably already been crossed.  Yet clearly more definitive findings would greatly assist the cause of deploying condoms as part of public health efforts.  To this end, the paper seeks to explain, and thereby avert, the causes of “error variance” between studies of condom effectiveness (variance not determined by real differences of the relation between condom use and STI).

Sexual Health 9: 1, 2012

http://www.publish.csiro.au/nid/164/currentissueflag/1.htm

Stephanie A. Sanders, Robin R. Milhausen et al., Condom Use Errors and Problems: A Global View, pp.81-95

Richard A. Crosby and Sarah Bounse, Condom Effectiveness: Where are we Now, pp.10-17

FOR FURTHER DISCUSSION OF THIS ISSUE  in this journal, see:

R. Crosby, W.L. Yarber et al.,  ”Two heads are better than one: the association between condom decision-making andcondom use errors and problems”, Sex Transm Infect 2008;84:198-201 doi:10.1136/sti.2007.027755

http://sti.bmj.com/content/84/3/198.full?sid=cae33837-335c-4d59-bb95-439830fe5e00

And for a perspective on promoting condoms through religious leadership, Willms et al in Sex Transm Infect 2011;87:611-615 doi:10.1136/sextrans-2011-050045

http://sti.bmj.com/content/87/7/611.abstract?sid=d4d99386-88d5-4037-a7a1-64be1f1c1751

Does the experience of sexual coercion predispose the sufferer to the kind of sexual behaviour likely to render him/her more vulnerable to HIV?  Knowing the extent and the mechanisms of such influence could be helpful to those planning public health interventions in high risk populations.  How important to HIV prevention is it to modify coercive behaviour?  Of course, answers to such questions are likely to differ from one culture to another.

Results of a recent study on 1,200 university students at Mbarara University Uganda, based on a self-administered questionnaire, has established, for this setting at least, a strong association between coercion, measured on a validated scale of six items, and 3 out of 4 “high-risk” sexual behaviours.  Significant odds ratios (OR), adjusted for various social and other confounders, are given for: (1.) having previously had sex: OR 1.6; (2.) early sexual debut (≤18 years): OR 2.4; (3.) having had ≥3 sexual partners: OR 1.9.  There was no significant association with the fourth type of high-risk behaviour: inconsistent condom use.  The results obtained also indicate a significant correlation between coercion and 3 social factors: namely, religious background, mental health scores and capacity to trust.  The authors conclude that religion, high trust in others, and good mental health help to buffer the negative effect of sexual coercion.

These results will no doubt be of interest to anyone planning HIV interventions in settings that could be considered culturally comparable to those of a Ugandan university.   However, the study seems to fall somewhat short of demonstrating causal mechanisms, even for the setting of the study – something that the authors themselves acknowledge would be hard to achieve.

One particularly interesting aspect of this study – which, according to its authors, marks it out from previous work – is that males report coercion almost at the same levels as females (29% as against 31%), and most of the associations between coercion and high-risk behaviour (as well as the buffering effects of social and religious factors) apply, in varying measure, not just to females but to both sexes.  It will be interesting to see how far this is borne out by future studies in this area.

Agardh A, Odberg-Pettersson K, Östergren, “Experience of sexual coercion and risky sexual behavior among Ugandan university students”, BMC Public Health 2011, 11:527 (4 July 2011)

http://www.biomedcentral.com/search/results.asp?terms=sexual+coercion&x=29&y=8&chkJBiol=chkJBiol&area=2024&registerlist=&Submitted=

Last month saw the publication by the US Institute of Medicine (IOM) of a report commissioned by the National Institute of Health (NIH): The Health of Lesbian, Gay, Bisexual and Transgender (LGBT) People:   Building a Foundation for Better Understanding.  The report is a systematic review on the existing literature on all aspects of LGBT health, concluding with a number of recommendations.  These include: the development of a research agenda by NIH; the collection of data both by federally funded surveys and in electronic health records; the promotion of methodological research and research training.   The collection of LGBT data is clearly a central concern here, and evidently arises out of the gaps identified in the systematic review.  Other recommendations are upstream of this, leading us to surmise that the precise data to be collected and means of collection – even standardization of LGBT critera – remain to be determined.

It is an easy matter for a systematic review to give the impression that there is research still needing to be done.  The reader may find themselves asking why the populations in question, especially when they are very small, should be accorded a higher or lower priority that other populations known to the reader (e.g. occupational or disability groups), especially where the latter have health needs which seem just as distinctive in their way and just as pressing as those of LGBT populations.  The report makes no attempt to justify the preferential focus on populations distinguished by sexual orientation.

On the positive side, the review chapters of the report, which follow health status over life course, bring home the very distinctive health profile of each of the LGBT populations.  They also show up gaps in the data for important areas of concern.  For instance, no data for sexual orientation are collected by the National Cancer Institute.  Consequently, the question of the susceptibility of the Lesbian population to breast cancer remains unresolved; similarly, the known risk of anal cancer for the gay population remains inadequately assessed, and there are no current guidelines for screening.  In other areas relevant to LGBT well-being, such as access to reproductive technology, such data would presumably be impossible to collect, since the American Society for Reproductive Medicine explicitly states that requests should be treated without regard to sexual orientation.

This leads me to a final point.  Of the recommendations made by the authors, the collection of data on sexual orientation in electronic health records could prove the most challenging to implement.  The authors themselves remark on “the discomfort on the part of health care workers with asking questions about sexual orientation and gender identity, a lack of knowledge by providers of how to elicit this information, and some hesitancy on the part of patients to disclose this information”.  Such discomfort and hesitancy may be rooted in considerations that go deeper than just a concern with “adequate privacy and security protection”.

http://www.iom.edu/

Why did Zimbabwe experience a remarkable decline in HIV prevalence, from 29% to 16% of adult population between 1997 and 2007, with incidence decline strongly accelerated between about 1999 and 2003?  Why was this decline experienced in Zimbabwe and not in other countries?  Are there lessons to be learnt from Zimbabwe’s experience?

Basing itself on a multi-disciplinary synthesis of available data (including household survey and qualitative data), a recent study (http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000414 ) convincingly attributes the proximate cause to behavioural change involving a reduction in partner concurrency.  Underlying causes of behavioural change prove harder to ascertain, but increased awareness of AIDS deaths is likely to have been responsible, with some secondary impact from the country’s economic deterioration.  The study is disappointingly unable to pinpoint specific public health interventions.

The authors attribute difference between Zimbabwe and other countries in the region to higher levels of secondary education and higher levels of marriage.  The former is associated with better understanding of HIV transmission, the latter with a greater ability to act on “be faithful” messages.  In the context of the paper these factors seem to have been plucked out of the air, though they are plausible enough.  There is no uncertainty, however about the “one lesson emerging” from the review.  This is clearly the importance of concurrent partner reduction in curbing the epidemic.  “Public and private sector programs in Zimbabwe are now building upon this knowledge by more assertively warning against multiple and concurrent partners and promoting sexual fidelity, in addition to consistent condom use and other effective approaches such as male circumcision”.

Daniel T. Halperin, “A Surprising Prevention Success: Why Did the HIV Epidemic Decline in Zimbabwe?” PLoS Medicine, February 2011

http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000414