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Carlos F. Cáceres, MD, PhD Professor and Director

Rethinking HIV Prevention among Gay, other MSM & TW in Peru at the start of the 4th Decade. Carlos F. Cáceres, MD, PhD Professor and Director Institute of Studies in Health , Sexuality and Human Development Universidad Cayetano Heredia, Lima, Perú.

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Carlos F. Cáceres, MD, PhD Professor and Director

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  1. Rethinking HIV Preventionamong Gay, other MSM & TW in Peruat thestart of the 4th Decade Carlos F. Cáceres, MD, PhD Professor and Director Institute of Studies in Health, Sexuality and HumanDevelopment Universidad Cayetano Heredia, Lima, Perú

  2. HIV EpidemicProfile in Peru: Concentratedon MSM/transwomen • 90,000 estimated cases (about 0.4% adults) • At least 1/3 of PLH in Peru are MSM/TW • Stabilized at 2.5 to 3 male cases per female case • MSM HIV prevalence: > 5% in largecities (10%-Lima) • HIV prevalenceamongtranswomen: 30% (Lima) • HIV incidenceamong `higherrisk’ MSM/TW: 5% • Stabilized at about 1000 new AIDS cases* per year • Treatmentcoveragewasabout 80% with CD4 < 200 • Free treatment in public sector (allwellcomed)

  3. Response to HIV among MSM/TW over time in Peru • Since 1990´s: A sanitary control model • Periodicmedicalcheck-ups in STI clinics • STI syndromicmanagement/ free rx • HIV testing • Condomprovision – oftenused as an incentive • Targets: Nr of MSM with at least 4 visits per year. • Peer promoters • Initiallytrainedtoprovideinformation and condoms • Over time their role restrictedtorecruit MSM/TW forperiodicmedicalcheck-ups; paymentbasedon N recruited • Indirectly: empowerment of peer promoters (smallercities) • Over time: increasedcommunityparticipation • Empowerment a goal per-se; some legal/HR actions

  4. Whatisnot done yet/anymore • In sex venues • Free condoms/lubricants/outreach; safer sex campaigns • Formal involvement of MSM-focusedbusinesses • Media campaignsfocusedon MSM • Subpopulations: TW, non-gay identifiedmen, youth • Clear content of sexual diversity in sex education • Promotion of HTC • Focuson link tocare and treatment • Consideration of serodiscordancy, disclosure • Internet-basededucation-serviceprovision • Programmaticfocuson sex betweenmen in prisons • No informationaboutprogress in treatment & prevention • Clear focusonhomophobia and humanrightsviolations

  5. Whatis happening with MSM now? • Partial HIV normalization • Lessfear – not a deathsentence, but… • HIV remainshighlystigmatized – no discussion • HIV closet (exceptamongclosefriends) • Certaindegree of reduction in condom use – no clear • Youngerpeople – stillcondomnorm, but no referents • Oldergenerations – ‘condom fatigue’ • Serostatusdiscussionsdifficult • No overtserosorting – mostlyseroguessing • No otherseroadaptivebehaviors (exceptwithdrawal) • Positive MSM – Disclosureonlytosteadypartners in the capital; viral load onlyrecentlyfactored in bysome • Boom of internet-based ‘hooking-up’ • Alsopracticedbyclosetedbisexuals/ non gay-identified MSM

  6. Key Barriers • Stigma, stigma, stigma • Le non-dit/le non-parlé (notsaid, notspoken) • Stigmaaround HIV remainsunchanged • Thisisreflectedamong MSM • Evenworseamong TW becausetheyoften do sex work and becausetheirrelationships are usuallyveryunequal • No servicestosupportdisclosure (e.g.couples HTC) • No substantialengagement of LGBT organizations in a renovation of HIV discussion • Somefocusedon HIV implementationonly (w/GF money) • Accusations of thegovernment (genocide) • Lack of broader, more rational gay community-leveldiscussionabout new needs and opportunities

  7. Role of New Technologies: TasP • HTLC+ (more peoplediagnosed and accessingtreatmentearlier) • Obviousfirststep, notyettaken • Impliessomeserviceexpansion and a media campaign • Probablywellaccepted, shouldbeimplemented • Earliertreatment (with CD4 over 350) • Wouldbeacceptable, esp. withserodiscordantcouples • Barriers • Healthserviceexpansionneeded; new protocolforserviceavailability and delivery • Couples are notwelldefined; legal barriers • Cultural barriers?

  8. Role of New Technologies: PrEP • iPrExstudy: 55% subjectsfromPeru • Ifrolledout –needforplanning & infrastructure • Acceptability • Lowamongstakeholders • PLH: competitionwithtreatment • Authorities: preconceptions – cost, notnecessary, riskcompensation • LGBT: notengaged! In some cases, oppositionwith no clearreasons • Manypeoplesaytheycould use it • Stigmastillplays a role: confusion w/treatment, disclosure, mixedmessagesaboututility • Whyitmightbeanoptionnow • Effective (accordingtoadherence) • Condom use isdecaying • global trendamong MSM

  9. Way Forward? • Government • Improvequality and consistency of programming • Seriousefforttoaddressstigma, notonly of HIV butalso of non-heterosexual sexualities • Bring MSM/TW HIV programming up-to-date: testing and accesstotreatment; addressneglecteddimensions • Society in General (incl. Academia) • Assumeits share of responsibility: confrontstigma; addressissues of sexual diversitybasedonevidence, commonsense and humanrights; fosterdiscussion • LGBT communities and organizations • Getout of the HIV closet (in variousways) • Getreadytoengage in cleardiscussion vis à vis the new context (sexual practices, sexual realities) • Focusonyoungerpeople – startacting as a community!

  10. Contracorriente (Undertow) 2010 Javier Fuentes Thanks!

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