Since January 1, 2011, I have diagnosed one new HV patient a week. They have all been men under 40, and more than half had no health insurance. What makes this most worrisome was that many were in the twenties.In the current issue of the Journal, Levy et al. describes some of the issues associated with the emerging and evolving HIV epidemic in Israel. They not only documented that the absolute number of HIV infections has been increasing over the past decade, despite wide access to HAART, but that the preponderant number of those recently infected and newly diagnosed were MSM. Particularly concerning was the finding that 29% of the men were infected with HIV that was resistant to at least 1 of the antiretroviral classes, and coinfection with syphilis was common.In my practice nearly half of the men diagnosed with HIV had a concomitant syphilis infection. Several contracted a strain of HIV with one or more major mutations. “These findings call to question some of the recent optimism about “treatment as prevention”, which presumed that if expanded efforts at increasing HIV testing and linkage to care could be undertaken, and individuals could be promptly treated, that the AIDS epidemic could be brought to a halt.”That doesn’t seem to be true. The data suggests that a subset of these infected men may be engaging in unsafe sex.Why?The current school of thought states there is a low risk for transmitting HIV to HIV negative partners if the patient is on medication which effectively suppresses the virus. One explanation for the increase in transmission is that a subset of HIV positive men are not compliant with their medications due to depression, drugs or forgetfulness. Also co-infection with a sexually transmitted disease can possess sufficient concentrations of resistant HIV in the genital tract secretions to transmit to uninfected sexual partners. “This study is not the first to document that some individuals are newly infected with resistant virus  and that syphilis is increasingly common in HIV-infected MSM [28, 29], but the combination of these factors and their association with an expansion of a national HIV epidemic heightens the acuity of the concern that a new generation of MSM could face an AIDS epidemic with constrained therapeutic choices.”
Why is this happening?Therapeutic optimism is only part of the explanation. Since the earliest days of the epidemic, affective disorders, like depression, as well as substance use, have been associated with unprotected sex and multiple partners [30, 31]. For some, early life experiences, ranging from sexual abuse to homophobic violence, may result in decreased self-efficacy and lowered self-esteem . The use of disinhibiting drugs and unprotected sex may serve a depressed MSM as ways to “self-medicate” in an adverse environment [33, 34]. These conditions not only tend to co-occur, they synergistically interact to enhance the risk of engaging in unprotected sex and becoming HIV-infected . Thus, attenuating the spread of HIV among MSM requires the scaling up of evidence-based programs that not only encourage HIV testing, linkage to care, and treatment, but also engage providers in the provision of culturally competent care to sexual and gender minority patients . For example, drug treatment programs that are tailored to substance-using MSM have been shown to be more effective than those that do not acknowledge the participants’ sexuality . Unfortunately, many MSM who engage in practices that put them at risk for HIV and other sexually transmitted infections (STIs) report that they are not always comfortable disclosing their behaviors to their medical providers [38, 39], creating multiple missed opportunities for slowing the epidemic every day around the world.The last patient I diagnosed with HIV had been my patient for over five years. He was very distraught to learn he was HIV positive, and so I encouraged him to see a therapist. When the therapist called to confer with me, he asked if I knew the patient had a crystal meth addiction. I did not. Even after five years of treating this man, he denied ever using drugs whenever I asked.
“The Israeli study holds a mirror to the future of the epidemic in this population, suggesting that MSM should not assume that their partner is HIV-uninfected, and if he is infected, it is unwise to assume that his medication will make him noninfectious.