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Connections: Sexual Health, Society, and HIV

on Sep 20, 2012 | HIV Sexual Health STDs/STIs | 0 comments

The XIX International AIDS conference was recently held in Washington, D.C. It had been 22 years since the International AIDS conference was held in the United States (mainly due to the unwillingness on the part of the United States to grant visas for HIV-infected individuals– only recently lifted).

Here 25,000 scientists, policy makers, health and education ministry officials, advocates, and activists from around the world were gathered with a renewed determination to stem the tide of this epidemic.  Medical advances, improved access to care, prevention initiatives, and revived determination were all good signs, but as a global culture we will need to shift our perspective to stop the spread of HIV.

Recent news of pre-exposure and post-exposure prophylaxis treatment has also been encouraging. Recently, the Food and Drug Administration (FDA) approved Truvada (emtricitabine and tenofovir disoproxil fumarate) for Pre-Exposure Prophylaxis (PrEP) to prevent the spread of HIV to high-risk, healthy individuals. Other similar preparations are under investigation and HIV therapeutic drugs are being developed for prophylactic use.  These drugs are very costly and require individuals to adhere to rigid compliance in order to be effective.

United States of America Secretary of State Hillary Clinton gave the plenary address and called for realization of President Obama’s determination to create an AIDS-free generation. With advances in treatment and prevention, she declared that we could see this within our lifetime.  This was certainly inspiring and there was much to celebrate, but will we really see an end to AIDS?

While we see great progress in halting mother to child transmission, we have not seen this in other populations.  While new infections have ebbed slightly, we still see an alarming rise in infection in groups with increased vulnerability due to poverty, stigma, and discrimination.  People of color, youth, and sexual minorities are much more likely to become infected than other groups.

Infections among gay and bisexual men, trans people and other men who have sex with men continue to climb globally.  While 60% of new infections in the United States are found in gay and bisexual men, only a fraction of the national prevention budget is directed at this group.  Also, transgender individual are an overlooked population at major risk for HIV risk, due in large part to continued stigma and discrimination.  This disparity in funding efforts represents the institutionalized stigmatization, heterosexism, and homophobia that exist in our culture as well as in our public health systems.  If we do not attend to this population as well as other marginalized populations such as sex workers and drug users, we will fail in our effort to stop the spread of infections.  The optimism is blunted when we look at these populations.

Over the last 30 years, where have we failed?  We know that HIV is still mostly spread by sexual behavior.  Yet, the disease is rather easily preventable through the use of condoms.  Condoms are reasonably inexpensive, potentially readily available, easy to use, and highly effective in preventing HIV and other sexually transmitted infections (and unintended pregnancy).  What a bargain!  So, why are they not used more?

Behavioral HIV prevention strategies and interventions have tried to get people to reduce risky sexual behavior and promote condom use.  While reasonably effective, there needs to be continuous implementation of these interventions, and they are costly. Investment in prevention strategies has always been difficult.

But a fundamental problem remains.  We remain a sexually dysfunctional culture.  We live in a culture that is still uncomfortable talking about sex and sexuality in a mature and honest fashion.  We continue to debate and hold back on providing comprehensive sexuality education.  It is very clear that what distinguishes the sexually health cultures from others is the existence of (or lack thereof) early and sustained comprehensive sexuality education.  When kids are educated early they grow up to be more comfortable with talking about sexuality, more likely to be sexually responsible, and have lower rates of sexually transmitted infections and unintended pregnancies.  They contribute to a cultural climate that is sexually healthy.  That climate then insists on comprehensive sexuality education and thereby creates a cycle of healthiness.  In most parts of the world, we are still caught up in a negative and unhealthy vicious cycle.

We need a broad sexual health approach to stem the tide of the HIV epidemic which emphasizes a positive and respectful approach to sexuality and sexual expression throughout the lifespan and that acknowledges sexuality as a basic and fundamental aspect of our humanness and that the pursuit of sexual pleasure is natural and desirable. A broad sexual health approach combats sexual coercion, shame, discrimination, and violence.  But a sexual health approach must go beyond venereology and on an individual level promote positive sexual identity and esteem, honest communication and trust between partners, the possibility of having pleasurable, fulfilling and satisfying sexual experiences, taking responsibility of the consequences of one’s sexual choices and their impact on others, and optimizing reproductive capacity and choice.  At the community level, it is achieved through access to developmentally appropriate, comprehensive and scientifically accurate sexuality education, clinical and preventative sexual health services, and respect for individual differences and diversity and a lack of societal prejudice, stigma, and discrimination.

We need to work together not only to address the sexual problems in the world -- but to advance the opportunity for everyone to lead sexually healthier lives which are pleasurable and satisfying.

Eli Coleman, PhD
University of Minnesota Medical School



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