A sombre and moving opening to the MSMGF Pre-Conference as delegates killed in the shooting down of flight MH17 were honoured by a minute’s silence and tributes from plenary speakers, including Don Baxter and incoming President of the IAS, Chris Beyrer. Beyrer in particular pointed out that the tragedy highlighted the strong coalition that drives the HIV response, with researchers, activists and policymakers travelling together and losing their lives on the flight. Beyrer went on to encourage strong engagement at the conference, highlighting developments in biomedical prevention in particular. However, he acknowledged the risk of leaving behind vulnerable populations, particularly men who have sex with men in countries which feature violent suppression of homosexuality. Achieving basic coverage of HIV prevention in these contexts remains extraordinarily difficult.

Michel Sidibe, Executive Director of UNAIDS, emphasised how the violation of human rights of men who have sex with men and transgender people in many countries poses such a threat to the HIV response, fuelling stigma, discrimination and violence and preventing people from accessing HIV prevention and treatment. Sidibe implied that it is difficult to see how we could achieve bold global targets without fighting to protect the rights of all people affected by HIV and by encouraging peace, security, equality and health. Sidibe concluded by saying, ‘no more to exclusion, bigotry and AIDS.’

My colleague, Peter Aggleton, from the Centre for Social Research in Health, UNSW, gave a plenary presentation in which he argued that the current fixation on scientific solutions to HIV often appears to neglect the ways that people live and behave, failing to harness the creativity and passion of affected communities. Taking something of a risk at a conference with MSM in the title, Aggleton highlighted his role with others in creating the category ‘men who have sex with men’ to help describe a range of homosexually active (or not so active) men. Peter said that those ‘experts’ never realised the force that the label MSM would gather around itself, making invisible complex cultures, practices and identities. Aggleton highlighted the ways in which the professionalisation of the field, including the community sector, often distances activists and educators from the communities with which they work. He concluded that we need to remember the anger and passion that kept the concerns of gay, bisexual and other ‘MSM’ central to the response to ensure that biomedical strategies like ‘test and treat’ and PrEP are critically evaluated rather than unquestioned and imposed.

The final plenary speaker, Kene Esom from African Men for Sexual Health and Rights, argued eloquently for a nimble range of diplomacy, activism and engagement, both loud and public as well as quiet and behind the scenes, to challenge violence, educate policymakers and advocate for the rights of LGBTI people so that HIV prevention can gain purchase in more countries in Africa.

Fabulous plenary session in more way than one this morning. The first three speakers spoke passionately about the inclusion of marginalised populations in the response to HIV, reminding us that strategies that are developed without the full participation of affected communities are likely to fail.

Dr Paul Semugoma from Uganda highlighted how many countries are failing to provide adequate access to prevention and care for men who have sex with men, resulting in higher rates of HIV among most MSM populations, particularly in the developing world. Prejudice and homophobia remain major barriers to effectively working with MSM, and Semugoma argued we need to "fight stigma with data" to counter misinformation. Dr Semugoma argued that donors should insist that countries' HIV strategies address MSM and paid tribute to activists who have suffered and died trying to achieve rights for MSM, including the late David Kato.

Cheryl Overs (Monash), founder of the Global Network of Sex Work Projects, sounded a warning note about rolling out new prevention and testing technologies without adequate consultation with and protections for sex workers. She suggested that developments such as PrEP and rapid testing could be used to coerce sex workers into having unprotected sex, with the industry seeing a market opportunity to use new technologies to sell unprotected sex. Overs reminded the conference, to much applause, that although the US decision's to allow entry of HIV-positive people into the country is long overdue and welcome, people who admit to being current sex workers or injecting drug users remain barred from entry. This means that the conference is failing to represent affected populations, undermining the response.

This criticism, summed up in the slogan, "No drug users? No sex workers? No International AIDS Conference", was taken up by Debbie McMillan. As McMillan put it, as an African American transgender woman, former drug user and sex worker who has been incarcerated, her chances of avoiding HIV were slim - but that does not mean she could not or cannot address HIV, which she now does as a counsellor. McMillan criticised the continuing US ban on federal funding for needle and syringe programs, despite the overwhelming research showing their beneficial effects - as she put it, "I don't need the research to know this is true." Debbie's testimony of growing up in poverty, wrestling with her sexual identity, doing sex work, becoming drug addicted and being incarcerated was powerful, and starkly illustrated the inequities faced by many in the US. McMillan spoke convincingly about the value of non-judgmental drug treatment programs, specifically designed for LGBT people, that helped her manage her addiction, come to terms with being a transgender woman, and fire her enthusiasm for activism.

The final speaker, Gottfried Hirnschall (WHO), gave an overview of the achievements to date in promoting global treatment access for HIV, suggesting that while current targets are aiming for 15 million people on ART by 2015, we need to start thinking about bigger and bolder targets. Acknowledging the previous speakers, he noted the huge disparities in roll-out and access, particularly among stigmatised groups. For example, it is estimated globally no more than 10% of HIV-positive IDU have access to treatment. Hirnschall went on to discuss another hot topic - treatment guidelines and when to initiate treatment. He noted that even a compromise guideline to initiate treatment at ≤350CD4 with treatment as prevention for people in discordant couples (for example) would include 23 million people globally - which is why scale-up needs to be considered now. Hirnschall noted that none of this will work without universal access to HIV testing, and that it has become vital to broaden access to testing. He referred the audience to the WHO's new strategic policy framework for HIV testing and counselling, released today (download here). The framework emphasises that all countries trying to boost uptake of testing need to consider a range of approaches in addition to clinic-based testing, most notably community-based testing and self-testing. I think this framework will be a valuable tool as we plan for Australia to offer rapid testing in a range of settings, and consider the merits and risks of home-based testing.

This conference is a marathon. Day 4 and I am exhausted. So many people, protests and presentations to attend - it's quite overwhelming. One of the highlights for me yesterday was a packed oral poster session on PEP, PrEP and HIV testing held over lunch. The presenters only had 5 minutes each to present their key findings, and there was spirited discussion from the audience. A presentation by Antonio Urbina (St Luke's Roosevelt Hospital) reviewed the delivery of non-occupational post-exposure-prophylaxis (PEP) in emergency departments in New York City. 216 cases were reviewed. While apparently very successful (94% completed the course and only one person seroconverted), the audience questioned the intensity and length of the PEP regime - a 4 week course based on Combivir, which often causes nausea. There was debate about whether a shorter and better tolerated regime could be used. One of the other presenters in the session, Kristen Underhill (Yale) picked up on how negative experiences of antiretroviral drugs from a course of PEP can have lasting consequences. Kristen had conducted group interviews with gay and bisexual men in Rhode Island to explore the acceptability of HIV pre-exposure prophylaxis (PrEP). She found that men who had had a previous bad experience with PEP found the idea of PrEP very unappealing.

The other standout presentation was from Alex Carballo-Diéguez (HIV Center for Clinical and Behavioral Studies, NYC). Alex was reporting the results of his study of home HIV testing among 'high risk' HIV-negative gay men in New York City. A small group of men (n=32) was enrolled and given OraQuick oral fluid rapid test kits to use at home (the test has just been approved by the US FDA for sale over-the-counter). The men were encouraged to test themselves and their casual sex partners. Around 100 tests were performed. Telephone support/counselling was offered but rarely used. Five sexual partners tested positive for HIV during the study. Very few adverse incidents were reported. When quizzed by a member of the audience who was concerned about relying on a test with a longer window period than a lab-based HIV test, Alex noted, "Sometimes when looking for the optimal, we overlook the good enough." While debate will undoubtedly continue about the merits of home-based testing, I think this research illustrates that home testing can function pretty well as a harm reduction tool and, as Alex noted, can give gay men a greater sense of control over their health and HIV status. It's certainly motivated me to work with my colleagues in Sydney and Melbourne to do a similar study of home-based HIV testing.

DC is hotting up. The opening plenary last night was long and impassioned, with various speakers exhorting the audience to 'end AIDS now'. Michel Sidibé (UNAIDS Executive Director) summed up the push to maintain international funding levels and deliver treatment to those who need it when he said, "The end of AIDS is not free, it is not too expensive, it is priceless."

I'm stepping back to earlier in the day to consider a different but no less important issue: HIV testing. The whole push for 'treatment as prevention' will, of course, fail if people do not present for testing and find out their HIV status. Françoise Barré-Sinoussi, President-elect of the IAS, introduced a satellite session by the French NGO, Sidaction, titled "Confronting the hidden epidemic: HIV testing science and implementation". Professor Barré-Sinoussi noted that internationally many at-risk groups have poor access to testing, and there is a need to diversify testing to engage people and make it more efficient, using a variety of methods such as community-based testing, self-testing and outreach. The session had a particular focus on undiagnosed infection and engaging hard-to-reach groups, particularly in France. I felt that many of the observations had relevance for Australia.

Virginie Supervie (U943 Inserm) presented a mathematical model of the French HIV epidemic and undiagnosed infection. For the statisticians among you, she used a modified back-calculation method based on the number of new HIV cases over time. No, I don't know what that means either. The model indicates that there are 29000 people with undiagnosed HIV in France, 9000 of whom are men who have sex with men (MSM) and 9800 are French-born heterosexual people. Because the MSM population is relatively small, their prevalence rate is the highest, at 314 per 10000. This means it is much easier to find undiagnosed MSM through testing; huge numbers of heterosexuals need to be tested to find undiagnosed people. The analysis suggested that median time from infection to diagnosis is ~2 years and that 59% of undiagnosed people have a CD4 count below 500 i.e. they are undiagnosed but already eligible for ART. Supervie went on to talk about the broader French epidemic and reported that, because there is good access to ART in France (once people are diagnosed), they estimate that 56% of PLHIV are virally suppressed (as opposed to only 28% in the US). It would be interesting to know the figure in Australia - hopefully closer to the French figure than the US one.

Sandrine Fournier (Sidaction) reported on an innovative community-based, outreach testing strategy to engage gay, bisexual and other MSM in the Paris area. The Flash Test program offered rapid HIV testing (using the INSTI test) to MSM at 39 gay venues, beats, NGOs, general practices and health centres during a one week period. Intensively publicised with the tagline, "Et toi, tu sais?" (And you, you know?), the aim was to engage men who had not tested for a long time (or ever) and to make testing easy and attractive. Over a hundred health care workers and activists were trained to work in the program. 556 tests were performed during the week, identifying 7 new HIV diagnoses. The locations that were rated as most attractive by MSM were gay venues (because it was convenient and social). Cruising areas were found to be difficult places to recruit. NGOs found they had increased attendance at their sites during the test period; GPs were not particularly proactive at offering tests, but it was difficult for them to offer appointments during the testing period. The success of the project means that Sidaction is considering promoting an Annual Testing Week in France. In Australia, we seem a long way off such a project - we don't even have one rapid test licenced yet!

A highly topical subject, and one that is sure to get more attention in Australia in the coming months, is home-based testing for HIV. Tim Greasen (EPS Maison Blanche) reported on a survey of over 9000 French MSM about attitudes to self-testing and the use of HIV home test kits ordered online. Greasen noted that the US has leapt ahead of other countries in liberalising access to testing with the recent FDA approval of the OraSure home test kit, but the US has had a version of home HIV testing for 16 years (!), using a system in which people send in dried finger prick specimens for testing at a lab, backed up with telephone results and counselling. As in Australia, home HIV testing is not legal in France, but there is suspicion that MSM in particular are ordering test kits over the internet. Greasen's survey of MSM found low numbers who had ordered home test kits (~1% of MSM), but a whopping 87% were interested in the idea, citing convenience, rapidity and anonymity as the main attractions. Men who more secretive about their same-sex activities and had never tested (or had not tested for a long time) were more interested in home testing. There was no association with suicidality (a concern of those who worry about men testing by themselves). Among the 69 men who had used a self-test, who tended to report more HIV risks, 62 tested negative, 3 tested positive (1 result was subsequently disconfirmed), and 4 were uncertain of the test result. Greasen noted that in France there is a perception that HIV testing is 'owned' by health professionals and there is resistance to citizens controlling their own health. However, he still thought (when quizzed by me) that home rapid tests are likely to become available in a year or so, backed up by telephone counselling (as in the US). It will be very interesting to see how this debate is taken up in Australia, in advance of Melbourne 2014.

In the US, 60% of new HIV infections are among the 2-5% of adult men who are gay, bisexual or other men who have sex with men (MSM), and rates of HIV diagnosis among MSM are increasing in many countries. It therefore seemed fitting that my warm-up to AIDS 2012 involved attending a pre-conference hosted by the MSM Global Forum. The early plenary speakers, including US Congresswoman Barbara Lee, former Australian High Court judge Michael Kirby and Dr Kevin Fenton (US CDC), highlighted the challenge of delivering effective HIV prevention and treatment when MSM in many countries are faced with hostile laws, violence and homophobia. The rights of MSM and transgender people are often precarious or non-existent and work to counter prejudice and protect these populations is vital but bruising work. 

It’s anticipated that much of the debate at AIDS 2012 will relate to developments in HIV prevention science, notably the preventative benefits of antiretroviral drugs when HIV-positive people are treated effectively (treatment as prevention) or when HIV-negative people take antiretrovirals (pre-exposure prophylaxis or PrEP). Kevin Fenton in particular spoke about how treatment as prevention and PrEP, when combined with existing strategies (such as condoms, treating STIs and so on), could dramatically reduce the sexual transmission of HIV among MSM, if targeted and implemented well. However, many in the field are uncertain about how to integrate, target, deliver and evaluate these strategies. 

A session on new prevention strategies featured Dr Robert Grant, lead investigator of the iPrEx trial of PrEP. Dr Grant echoed Kevin Fenton’s comments about implementation, admitting that despite the recent FDA approval of Truvada for use as PrEP, debate continues in the US about how best to target PrEP to MSM, how to facilitate access to those who will benefit most, and how to support those taking PrEP so that protection is maintained (PrEP’s efficacy is much higher among people who maintain a detectable level of the drug). Dr Grant raised some interesting issues about promoting effective PrEP use. He said that potential users should be told the realities of taking PrEP, rather than focusing on hypothetical risks. He said that potential users should be told that PrEP is highly effective if drug levels are maintained, but it is not as easy to take as you might think e.g. remembering to take pills, having to have regular HIV tests. Dr Grant argued against ‘intensive counselling’ or banning people from PrEP who report illicit drug use, saying this unnecessarily limits access and is not justified by the experience in trials. 

Dr Grant argued that MSM who have unprotected anal sex are generally still motivated to protect themselves from HIV and PrEP can help them. This point was echoed by Bruno Spire (from INSERM in France), saying it had been a motivation to set up the IPERGAY trial of intermittent PrEP dosing, currently enrolling gay men in France. In response to questions about how to justify the cost of PrEP, Dr Grant made the point that PrEP is cost-effective when you think of it as a short-term use of antiretrovirals to prevent HIV infection, life-long treatment and a higher risk of comorbid conditions. It will be interesting to see if this pragmatism about PrEP will be taken up in Australia.