Despite two generations of prevention, awareness and treatment, gay and bisexual continue to have high levels of HIV infection, a new study led by the Johns Hopkins Bloomberg School of Public Health shows. 

HIV is highly treatable now, something only imagined in the early 1980s when it first came to prominence. Critics of the time contended it was more of a lifestyle disease, like obesity, and decades later they seem to be right, even if they contended it for the wrong reasons. In the past, it was assumed prevention was the best thing, and then treatment for cases like rape or mother-child transmission at birth.  Today, treatment is so good people are back to being reckless about their lifestyles, and so scholars writing in The Lancet have issued a funding call to expand access to pre-exposure prophylaxis (PrEP) which has been highly effective in dramatically reducing transmission among this population.

HIV rates overall have flattened, but they would have declined dramatically if the HIV epidemic was not going in the wrong direction among gay men. The reason it has not declined is, ironically, because it's no longer a death sentence and is highly treatable, so it's not as scary as it once was and so condoms are not used as they should be. Many are living long lives with antiretroviral treatment. New HIV infection rates are falling among heterosexual men and women in many countries, but not among gay men. And where condoms are not culturally acceptable, it is even a coin flip.  The U.S. Centers for Disease Control and Prevention estimates that in the United States a 20-year-old gay black man has a 50 percent chance of becoming infected with HIV in his lifetime. 

Study leader Chris Beyrer, MD, MPH, the Desmond M. Tutu Professor of Public Health and Human Rights at the Bloomberg School and president of the International AIDS Society, will oversee the 21st annual International AIDS Conference from July 18 through 22 in Durban, South Africa where failure to meet the needs of gay men will be one of many topics. "It's a tragic situation and it's painful that the history of AIDS is looking like its future, but that's actually where we are. But the first step in taking on a problem is recognizing and articulating it and we've really done that here." 

For their study, Beyrer and his colleagues analyzed published medical research from January 2007 through October 2015, to identify which elements of their call to action from 2012 had been achieved. They found a few successes. A new $100 million investment fund from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) has been set up for key populations affected by the virus, including gay and other men who have sex with men. Several nations have either approved or initiated PrEP projects to facilitate its use by gay men after research studies have proven its effectiveness in preventing HIV infection.

But for the most part, Beyrer says, the failure to get PrEP to the people who need it most --those who are HIV negative and are at high risk of infection -- and the backsliding in terms of civil liberties for the gay community in nations such as Russia, Nigeria and Uganda have contributed to the continued high HIV rates among gay men. 

While PrEP is available in the United States, Beyrer says it is accessible only when people have health insurance to pay for it, and there are real racial and economic disparities when it comes to who actually gets it. Beyrer says in low-income, predominantly minority communities - particularly in the South, where in most states Medicaid has not been expanded to provide wider health coverage - epidemics continue. He says the United Kingdom refuses so far to cover PrEP, despite evidence of its effectiveness.

Despite its availability in poor nations for pennies on the dollar, Beyrer says often the politics of providing medical care to gay men are difficult in many countries. While many nations have made great strides in the past four years in terms of gay marriage, in other nations sodomy remains a crime and other discriminatory policies remain in place, making even getting tested for HIV a potentially dangerous ordeal. In Russia, for example, HIV information websites have even been shut down in the wake of new propaganda laws.

Beyrer sees some good news on the horizon. He expects Mexico and other nations such as Argentina and the Netherlands to expand the use of PrEP. He says he hopes to see some nations repeal their anti-gay laws.