HPAC Gay Men’s Subgroup Recommendations

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COMMUNITY RECOMMENDATIONS TO ADDRESS HEIGHTENED HIV VULNERABILITY AMONG GAY MEN/MSM

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Policy Recommendation Objectives

1)      Update practices and policies to reflect contemporary understanding of HIV transmission, advances in HIV/AIDS science, health care and system reforms, and other opportunities and challenges in the current epidemic;

2)     Improve administrative accountability for coordination of federal, state, local and tribal efforts to allocate appropriate resources and services to health outcomes among gay men/men who have sex with men (MSM), particularly young Black and Latino gay men/MSM;

3)     Establish a community driven, evidence-based and outcome oriented framework to address health disparities and structural determinants of health among gay men, particularly for gay men/MSM of color, young gay men/MSM and transgender gay men;

4)     Strengthen efforts and clarify mechanisms to mitigate discrimination and stigma related to sexual orientation and HIV status that affect HIV prevention and treatment for gay men; and

5)     Reintegrate HIV into LGBT health and human rights advocacy.

Policy Recommendation Outcomes

1)      Improve HIV and other sexually transmitted diseases (STD) education and prevention efforts, early HIV diagnosis, care linkage and retention, Highly Active Antiretroviral Therapy (HAART) uptake and viral suppression for gay men/MSM, young gay men/MSM, and Black and Latino gay men/MSM as represented in the HIV care continuum[1];

2)     Meaningfully link gay men/MSM to the benefits of the Affordable Care Act;

3)     Increase access and effective utilization of biomedical advances in responding to the HIV- and other STD- related health disparities of gay men/MSM, particularly Black and Latino gay men/MSM and young gay men/MSM of all races and ethnicities, through combination HIV prevention, treatment as prevention and pre-exposure prophylaxis (PrEP);

4)     Re-establish a clear role for communities to serve in addressing HIV among gay men/MSM and modernize future capacity building availed in these communities; and

5)     Improve collaboration and communication among agencies, organizations and partners to develop best practices that can be shared and widely emulated throughout the country to address the disparate impact of HIV, STD and viral hepatitis among gay men/MSM.

Federal Recommendations

1)      The National HIV/AIDS Strategy (NHAS) seeks to achieve better coordination among federal HIV programs. It is necessary that implementing federal agencies:

a)     Reconfigure funding streams to close new service gaps via virtual (or actual) merging of legacy programs;

b)     Identify opportunities to strengthen program collaboration by blending funding streams to integrate comprehensive health services specifically designed to meet the needs of gay men. The Department of Health and Human Services’ (HHS) NHAS Strategy Operational Plan already contemplates exploring policy, budgetary and programmatic strategies to better align HHS efforts with those being conducted by other federal agencies[2]; and

c)      Develop accountability measures to ensure that funding is truly following the epidemic and that grantees are directing activities towards populations identified under the community high-impact prevention model.

2)     The HIV care continuum provides a major opportunity to address HIV transmission and enhance prevention efforts for persons living with HIV. However:

• The Centers for Disease Control and Prevention (CDC) must continue to provide funding for primary prevention of HIV targeted to key populations at highest risk for HIV infection, address social determinants of health that lead to higher risk and ensure the use of effective behavioral interventions among gay men/MSM; and
• The White House Office of National AIDS Policy (ONAP) must work with federal agencies and state and local health departments to standardize development of accurate, detailed and comprehensive HIV care continuum data across jurisdictions and by different demographic groups.

3)     To ensure that NHAS objectives to protect the rights of people living with HIV are fully implemented and that people living with HIV are not singled out for discrimination under federal and state laws:

• The Department of Justice (DOJ) must step up efforts to address discrimination based on sexual orientation and HIV status and release the report on HIV-specific criminal statutes; and
• ONAP should evaluate progress towards reaching DOJ-related NHAS goals and develop action steps to foster further progress.

4)     CDC must clarify and strengthen its HIV testing frequency recommendation for gay men. The current (2006) recommendation is that those with a heightened risk for HIV infection should be tested at least annually. A Morbidity and Mortality Weekly Report (MMWR) issued in 2011 suggested that gay men/MSM may benefit from more frequent testing (i.e. every 3-6 months). However, CDC should issue a formal recommendation on increased HIV testing frequency for gay men, which carries more weight.

5)     CDC must provide health departments with timely and accurate data from the National HIV Surveillance System in order to monitor relocation of cases, reduce duplication, more accurately report retention rates in states and improve effective use of scarce resources.

6)     The Health Resources and Services Administration (HRSA) should develop and implement a Special Project of National Significance (SPNS) initiative to improve provider cooperation on routine HIV testing and earlier treatment initiation and adherence support for gay men/MSM in their practice/clinic.

7)     HRSA must ensure that its funded programs provide a comprehensive, coordinated system of HIV care which increases access to primary medical care, specialty HIV care and specialty medical care for gay men/MSM.

8)    The Substance Abuse and Mental Health Services Administration (SAMHSA) should convene a new workgroup of its federal partners (National Institute of Drug Abuse, National Institute of Mental Health, Office of National Drug Control Policy) to identify, review, discuss and report on substance use and intervention among gay men/MSM. HIV transmission, alcohol and other substance use are inextricably intertwined among all populations at risk of infection, including gay men/MSM. Any and all policies/programs designed to reach gay men/MSM must also reflect these overlapping and mutually reinforcing epidemics (syndemics). The report from this workgroup should serve as a foundation upon which SAMHSA and its federal partners build a more coordinated and collaborative national response.

9)     The HHS Office of the Assistant Secretary for Health should develop a cross-agency initiative funded through the Center for Medicaid/Medicare Innovation (CMMI) to develop and implement a demonstration project tailored for gay men/MSM to expand the availability of integrated care for those living with HIV/AIDS. Co-occurring mental health and substance use disorders compete with necessary adherence to treatment regimens. An integrated approach to HIV/AIDS, mental health and substance use treatment can improve patient adherence and lead to more favorable health outcomes for gay men/MSM living with HIV/AIDS.

10) SAMHSA should take steps to expand screening for HIV and risk behaviors in mental health and substance use treatment settings. A 2007 Rand Corporation study that found screening for HIV and risk behaviors in mental health and substance use treatment settings was haphazard and appeared to be low priority.

11)  The National Institutes of Health (NIH) should explicitly address opportunities and challenges in effective HIV prevention and treatment for gay men/MSM through current strategic planning efforts (Office of AIDS Research, LGBT and others).  LGBT planning efforts should address gaps in knowledge and interventions in responding to HIV risk and resilience among Black and Latino gay men; intersectionality and other priorities identified in by the NIH LGBT Research Coordinating Committee. OAR should take a strategic approach and include research to improve outcomes across each step of the HIV care continuum.

12) Efforts within HHS to ensure adolescent sexual health should be supported, coordinated and where possible engage the Department of Education (DOE) and education agencies across the country. With more than 50 million young people attending schools across the country each day, schools provide a critical setting to impart sexuality education and HIV prevention information.

• The Division of Adolescent and School Health (DASH) within CDC provides a critical role in ensuring high-quality HIV and other STD prevention in schools through education and health agency collaboration. Additional evaluation of DASH efforts is vital in identifying and expanding effective programs, particularly those addressing the needs of LGBT youth and young gay men/MSM of color; and
• With evidence-based HIV prevention programs being implemented in a variety of settings, including schools, with Teen Pregnancy Prevention Initiative (TPPI) and Personal Responsibility Education Program (PREP) funds, the Office of Adolescent Health (OAH) and the Administration for Children and Families (ACF) should continue to support the focus of and expand the reach of innovative approaches to sexual health promotion among LGBT young people, particularly young gay men/MSM of color, and ensure that programs in use are medically accurate and inclusive of all young people and all sexual health needs.

13) The DOE has been a leader in combatting school bullying issues for LGBT populations. It is key for these programs and initiatives in the future to include HIV-related stigma, discrimination and the intersection of homophobia and HIV-related disparities to improve health outcomes and prevent HIV acquisition among young gay men/MSM.

14) The Department of Labor (DOL), in coordination with federal partners, should develop and implement policies to ensure that every person living with HIV will be equipped and supported to make well-informed decisions about employment, benefits and economic opportunities, through information, training, education, counseling, benefit planning and the coordinated use of these resources.

15)  Access to stable housing allows a person who is living with HIV to store their medication properly and maintain consistent communication with a medical provider and can help ameliorate the social determinants of health that lead to HIV acquisition. The Department of Housing and Urban Development (HUD) should expand access to safe and affordable supportive housing and services for gay men/MSM, particularly young gay men/MSM, who are newly homeless, experiencing Intimate Partner Violence (IPV) and/or re-entering the community from a correctional setting. 

State and Local Governmental Partner Recommendations

1)      State and local governments, particularly health departments, should:

• Support health strategies that promote the improvement of general and sexual health equity, regardless of serostatus; and
• Promote HIV and other STD education and prevention, regular/frequent HIV and other STD testing, timely linkage to care, retention in medical care, including necessary and appropriate partner services, and achieve and sustain undetectable HIV viral loads for those who are living with HIV.

2)     In order to build and further strengthen the capacity of state and local health departments to address the HIV and STD disparity among gay men/MSM, health departments should:

• Identify and allocate dedicated resources to prioritize the health needs of gay men/MSM, cultural competency training and workforce development;
• Recruit and retain staff with expertise in working with gay men/MSM of all races, ethnicities and gender histories; and
• Work with state and local planning bodies, coalitions and key stakeholders to actively engage gay men/MSM.

3)     In order to create an integrated and coordinated response across communicable disease areas that disproportionately impact gay men/MSM, health departments should promote primary prevention methods including correct and consistent condom use and ensure coordinated prevention (including vaccination), screening and treatment services for HIV, human papilloma virus (HPV), syphilis, chlamydia, gonorrhea, tuberculosis and hepatitis B and C.

4)     In order to improve the quality and reach of HIV and other STD prevention education in schools, health departments and education agencies at both the state and local levels should coordinate their adolescent sexual health promotion efforts.

5)     Health departments should define and promote holistic implementation science across the prevention and care continuum. Health departments should work to identify strategic partnerships with state and community stakeholders, including gay men/MSM living with HIV and those who are HIV-negative, and facilitate relationships with clinicians, federally qualified health centers/community health centers and other health care providers.

6)     State and local governments must improve data collection systems to provide an enhanced understanding of the health, social, economic and structural realities of gay men/MSM. A greater emphasis must be placed on collecting data on gender identity, immigrant/refugee status, housing status, income level and work status, insurance coverage status and health issues such as history of mental illness, trauma, imprisonment and substance use. Data collection on sexual practices should reflect best practices on gender identity, as well as specificity about practices (e.g., insertive vs receptive anal sex, use of sero-adaptative strategies, viral load status of positive partners, use of biomedical prevention) reflecting current factors in gay men/MSM decision-making and risk reduction.

7)     State and local governments must work to assess and adopt policies that support the lives and health of gay men/MSM (e.g., marriage equality, domestic partner benefits, comprehensive sexuality education, immigration policies and employment discrimination laws), as well as construct funding announcements that require training of community-based organizations to address issues that impact the community.

8)    State and local governments must identify, spotlight and scale up employment/economic initiatives and proposals in collaboration between state departments of labor or workforce development and health departments that would deliver employment/vocational rehabilitation services and benefits planning designed specifically for gay men/MSM, including those living with HIV.

9)     Health departments should work to effectively utilize the internet, social media and other online and traditional platforms to reach gay men/MSM and address the barriers to reaching them.

10) Health department HIV care and prevention programs must meaningfully engage gay men/MSM, both living with HIV and those who are HIV-negative, in planning bodies and advisory boards and ensure involvement of gay men/MSM in review of marketing and products geared toward gay men/MSM, especially gay men/MSM of color.

11)  Health departments must update all HIV prevention efforts to ensure accurate and affirming information on current practices and technologies, including sero-adaptation, treatment as prevention, PrEP and post-exposure prophylaxis (PEP), Expedited Partner Therapy (EPT), and clarification of language when referring to “safer” or “protected” sex in a prevention landscape that includes and extends past condom use.

Non-Governmental Organizations[3] Recommendations

Community based, civil rights, LGBT, minority-serving and other non-governmental organizations must ensure that the disproportionate burden of HIV on gay men/MSM continues to be a priority. Specifically, NGO’s must:

1)      Increase HIV, STD and viral hepatitis testing

• Ensure insurance coverage for HIV, STD and viral hepatitis testing;
• Herald the advancement new testing technologies to diagnose acute infection and improve linkage to care;
• Employ new health information technology to encourage testing and improve health literacy;
• Promote quarterly HIV testing for gay/MSM and train providers about the importance of a more frequent HIV and STD testing schedule; and
• Make HIV, STD and viral hepatitis testing widely available in all clinical and community-based settings.

2)     Prioritize ending stigma and discrimination against gay men/MSM living with HIV in organizational activities.

• Support efforts to modernize HIV criminalization statutes and practices at the municipal, state and federal levels to oppose prosecution or sentencing on the basis of HIV status; and
• Develop, promote and evaluate campaigns to confront HIV stigma within, between and beyond gay communities, including stigmatization of sexually-active gay men, gender identity and gender performance.

3)     Prepare communities for scale-up of biomedical HIV prevention strategies.

• Update all HIV prevention efforts to ensure accurate and affirming information on current practices and technologies, including sero-adaptation, treatment as prevention, PrEP and post-exposure prophylaxis (PEP), Expedited Partner Therapy (EPT), and clarification of language when referring to “safer” or “protected” sex in a prevention landscape that includes and extends past condom use; and
• Advocate for expansion of access to PrEP, PEP for HIV and ETP for STDs.

4)     Develop program and policy initiatives to address social determinants that adversely affect gay men’s health and wellness.

• Address employment issues and the needs of gay men/MSM, including strategies for evaluation and development of program policies and procedures to remove/reduce disincentives to employment, increase assessment of employment needs of individuals and integration of employment information, needs assessment and supports (through linkage and referral or targeted services) throughout service provision.

5)     Augment and support networks of gay men/MSM across the country, both living with HIV and those who are HIV-negative, by championing and empowering them to advocate on behalf of HIV prevention and treatment.

Cross-Cutting HIV Care Continuum Recommendations

1)      Federal, state and local partners must develop programs with a clear focus on improving gay men/MSM’s health outcomes as reflected in the HIV care continuum.

2)     Federal agencies should require state and local grantees to implement routine mechanisms to meaningfully engage gay men/MSM in policy making, program development and planning. Jurisdictions should work with gay men/MSM to identify and address opportunities and challenges to utilization of emerging biomedical modalities. Federal partners should evaluate these efforts based on standard agreed upon metrics.

3)     Best practices should be promulgated through the Ryan White Program and Affordable Care Act (ACA) implementation. Since some essential supportive services may be perceived as having been addressed through ACA expansion of health insurance coverage, it will also be important for gay men/MSM to help program administrators and service providers understand where gaps exist and develop comprehensive integrated strategies to address those needs.

4)     HHS should develop and publish a cross-agency strategy and coordinated plan to guide implementation of biomedical HIV prevention interventions targeted to gay men. This strategy should address consistent drivers of the epidemic and prevention barriers among gay men. The strategy and guidance should extend beyond just CDC and HRSA to include SAMHSA and other operating divisions and staff offices.

5)     Federal agencies, health departments, NGOs and medical providers should provide gay men/MSM with information about PrEP and other biomedical options that prevent HIV acquisition and encourage gay men/MSM, particularly young Black and Latino gay men/MSM, to make informed decisions about their prophylactic choices against HIV acquisition. CDC, in particular, must conduct and share real world PrEP studies to understand the effectiveness of this strategy.

Research Recommendations

1)      NIH should provide an overall assessment of how responsive its HIV research portfolio and funded networks are to the needs of gay men, including a report about how its six funded National Institute of Allergy and Infectious Diseases (NIAID) Division of AIDS (DAIDS) research networks are responsive to gay men. NIH should demonstrate that there is a clearly articulated expectation as part of the current re-competition of those six networks that they examine and are responsive to the unique needs of and issues facing gay men.

2)     NIH should support an HIV research agenda that specifically targets and identifies effective strategies to improve health outcomes as they are measured in the HIV care continuum for gay men/MSM and addresses how research funded across the NIH portfolio is helping to move gay men/MSM across the continuum to increase the numbers and percentages successfully engaged and retained in care at each stage. Specifically, NIH should increase funding for research seeking to identify and address the unique HIV prevention, care and treatment barriers experienced by gay men/MSM in urban, rural and institutional areas and their unique strengths/resilience that can be leveraged in HIV prevention, care and treatment interventions that lead to services that improve outcomes along the HIV care continuum.

3)     NIH should include in its HIV research agenda an intentional and deliberate agenda that looks at behavioral factors and psychosocial issues that influence adherence as it relates to treatment, PrEP, PEP and eventually rectal microbicides particularly among gay men.

4)     Because sexual lubricants are not required to go through human safety testing before going on the market, NIH should implement a robust lubricant safety research agenda to understand safety concerns with the use of water-based lubricants and possibility of higher risk factors between different types of lubricant of HIV and STD acquisition and transmission.

5)     Research is needed to assess the impact of HIV-specific criminal statutes on people living with HIV, particularly the impact on gay men, the impact on testing, linkage to and adherence in care and stigma placed on clients.

6)     Research is needed that explores how sexual networks contribute to furthering disease transmission and effectiveness and uptake of interventions.

7)     Connection with the criminal justice system creates added complications among gay men/MSM of color. Research is needed to clearly document the relationship between housing instability and HIV acquisition and transmission (especially among Black and Latino young gay men/MSM).

For questions, contact Oscar Mairena (omairena@NASTAD.org) or Leo Rennie (lrennie@apa.org), HPAC Gay Men’s Subgroup Co-Chairs.