Barry D Adam University Professor Senior Scientist & Director of Prevention Research,

1. Structural dimensions of preventionwith a focus on men who have sex with men (MSM) in a context of new technologies Barry D Adam University ProfessorSenior Scientist & Director of Prevention Research,

2. Conceiving structure • Social location • Social organization of gay, bisexual, and other MSM • State policy • Organized impact of HIV industry • Structure of knowledge • Social science to be done

3. Structure as social location • In the global north • Typically measured as demographic traits • Ethnicity, income, education, age… • US CDC • “The greatest estimated annual increases [2005-2008] of HIV diagnoses among MSM between the ages of 13 and 24 were found for Asian/Pacific Islander MSM (30.8%), black MSM (14.9%), and American Indian/Alaskan Native MSM (12.8%).” • Richard Wolitski and Kevin Fenton. 2011. “Sexual health, HIV, and sexually transmitted infections among gay, bisexual, and other men who have sex with men in the United States” AIDS and Behavior 15:S9-S17

4. Structure as social location • Persistent findings that higher risk behavior and and seroconversion are associated with less income and less education • But overall magnitude of difference not great • Age: men 20-50 (sometimes men in 20s or 40s) • In global south • Elevated rates among MSM in generalized epidemics • Limited internal differentiation of MSM category

5. Social organization of gay, bisexual, and other MSM • Small world hypothesis • Esp African Americans • Millett, G., Flores, S., Peterson, J., & Bakeman, R. (2007). Explaining disparities in HIV infection among black and white men who have sex with men. AIDS, 21, 2083-2091. • Social networks & risk spectrum • Phylogenetic cluster analysis • Circuits, micro-cultures & sexual fields • Adam, B. D., Husbands, W., Murray, J., & Maxwell, J. (2008). Circuits, networks, and HIV risk management. AIDS Education and Prevention, 20(5), 420-435. • Syndemics hypothesis • Stall, R., Mills, T., Williamson, J., Hart, T., Greenwood, G., Paul, J., Pollack, L., Binson, D., Osmond, D., & Catania, J. (2003). Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. American Journal of Public Health, 93(6), 939-942.

6. Structure as state policy • allocation of resources • Global Fund To Fight AIDS, Tuberculosis and Malaria, 2.1% to MSM • 2010 International AIDS conference, 2.6% of sessions on MSM • Canadian Institutes for Health Research, 2.2% of HIV research budget (but 51% prevalence)

7. Structure as state policy • Criminalization • Of sex between men • Many laws, a legacy of British colonialism • Of HIV nondisclosure or transmission • Potential for accelerated transmission if people abandon safe sex in favor of disclosure as the preferred method of HIV avoidance

8. Robert Carr Doctrine • scientific advances in HIV prevention and treatment, while welcomed and strongly encouraged, are wasted when communities shouldering a disproportionate HIV disease burden are blatantly denied access to services or cannot access them safely. Bilateral and multilateral funding strategies that fail to prioritize investment toward hardest-hit populations, civil society advocacy, and community development will inevitably fall short of achieving an “AIDS-Free Generation.” • http://www.msmgf.org/files/msmgf//documents/RobertCarrDoctrine.pdf.

9. Structure as organized impact of HIV industry (sidacratie) • Treatment-as-prevention hegemony • After >15 years, no decrease in transmission among MSM in countries with universal access to health care • “risk compensation” • Translation: biomedical science has done all it can; people at risk are delinquent • Or HIV industry-induced/iatrogenic effect?

10. Structure of knowledge • PREP trials • Medication + social support • “After enrollment, study participants were asked to attend three monthly visits, which were followed by quarterly visits…. HIV-1–uninfected partners were encouraged to return for all visits together for counseling on risk reduction and the use of condoms…. 5% [HIV+] and 6% [HIV-], respectively, reported having unprotected sex.” (Cohen et al 2011) • Real world medication minus social support?

11. Pills vs communication • “withdrawing a “treatment” (support and education) that clearly improved men’s practice of safe sex when they entered iPrEX would seem to constitute abandonment, and quite possibly also violates international health ethics mandates that require physicians and researchers to actively seek to achieve the minimum existing standard of care.” • Cindy Patton and Hye Jin Kim. 2012. “The cost of science: Knowledge and ethics in the HIV pre-exposure prophylaxis trials” Bioethical Inquiry DOI 10.1007/s11673-012-9383-x

12. Techno-eschatology • PREP • Economic & adherence barriers • Will likely have niche effect • serodiscordant couples • condom trouble/erectile difficulties • chronically high risk men who have abandoned condoms

13. Social science to be done • Most effective tool for HIV prevention among gay, bisexual & MSM has been community mobilization • Least studied solution • Need to disaggregate MSM category • How MSM are networked with each other • How professional messages enter everyday practice