As the HIV epidemic enters its fourth decade, HIV transmission in several parts of the world shows no sign of abating—for example, in sub-Saharan Africa an estimated 1·9 million people became newly infected in 2010.1 Certain affected populations in the epidemic are more marginalised than others, notably gay men and other men who have sex with men. A biologically heightened vulnerability to HIV and the limited uptake and use of barrier methods, especially among younger cohorts of men who have sex with men, fuelled by stigma and in some parts of the world criminalisation, makes addressing the issue of HIV/AIDS in men who have sex with men complex, as this Lancet Series shows.2—9

In the past year, the dialogue around HIV/AIDS has centred on ending the epidemic after release of the HPTN052 study findings, which showed that early initiation of antiretroviral therapy reduced the risk of HIV transmission to uninfected partners by 96%.10 Several studies have confirmed the potential of similar interventions to help prevent HIV infection. These scientific advances have to some extent prompted a renewal in efforts towards achieving an AIDS-Free Generation. Indeed, last year Hillary Clinton announced the US Government’s commitment towards this goal,11 one that builds on the global programmatic successes of treatment and prevention technologies to date. And from a research perspective, the HIV cure agenda has had a recent resurgence of interest and optimism with the launch of a global scientific strategy.12 Although these efforts are welcome, there is a sense that the HIV/AIDS response is taking the wrong road.

The power of science has been, and continues to be, a huge benefit to the AIDS response. But science is also the Achilles’ heel of HIV prevention and control. The science of HIV can mislead us into thinking there are technical solutions to the epidemic. If we could only roll out more antiretrovirals in the developing world, develop the right regimen for treatment as prevention, or develop an effective vaccine or the right microbicide all will be well. But, in truth, the underlying challenge of HIV is only partly technical. A more important barrier is cultural: stigma and alienation apply not only to the HIV epidemic among men who have sex with men but also among heterosexuals.

Our Series aims to unite two vital elements in the fight against AIDS. One is the application of science to defeat the epidemic, and the second neglected, yet crucial, element is the cultural dimension of stigma and homophobia. Men who have sex with men have been, and continue to be, pushed to the margins of the HIV/AIDS response. Our Series not only aims to put men who have sex with men back into the centre of those debates, but to reassert the importance of the cultural and political dimensions of HIV/AIDS, which have been neglected in our fascination with technical breakthroughs.

Although there are many countries that should be credited for showing enlightened responses to HIV/AIDS in communities of men who have sex with men, such as Brazil and South Africa, the extraordinary global polarisation around basic human rights for these men—in what Dennis Altman and colleagues9 in this Series call “political homophobia”—points to the existence of deeply rooted cultural barriers. While South Africa led the world in recognising sexual rights in its Constitution, about 80 countries still criminalise homosexual behaviour. In many African and Caribbean countries, the former Soviet Union, and most of the Middle East, citizens face persecution for discussing safe sex behaviour, are unable to access harm reduction services, are unable to talk openly about their lives, and cannot get tested for HIV without the fear of being stigmatised.

There is no technical solution to HIV that is a panacea for all communities and all countries. There is only going to be a solution that involves a broad understanding and acceptance of diverse sexual behaviours among men and women. Achieving this goal will mean discussing matters that people often wish to avoid. These issues invite us all to ask challenging questions about human sexuality and behaviour. Whether it is the Catholic Church or academia, aid donors or recipient countries, these predicaments are not being prioritised as they should be. These attitudes towards men who have sex with men combine to create a cultural crisis faced by other communities—for example, women, injecting drug users, and sex workers. If we are to succeed in this fourth decade of the HIV/AIDS response, we must show our commitment to this welcome human diversity as well as to gender equity.

Source: Lancet