In Italy, a WHO recommendation, although questionable and relatively careful in its language, has become a clear return to the past: "key populations" in WHO language has become "risk groups" in Italy. All that was missing was statements like the disconcerting one: Iardino on the Fattoquotidiano, on casual sex and places of sexual encounter and the alleged "opposition" between therapies used for preventive purposes and condoms.
Meanwhile, there are no groups at risk. A fundamental "plus" is always missing from that expression, and we must ask ourselves why. The entire population is at risk, regardless of sexual orientation, but some subpopulations are more vulnerable than others for different reasons. Men who have sex with men (gay and bisexual men, to be clear) are one of them. And the data, both global and Italian, confirm this. New infections among homosexual and bisexual men have been increasing in the last three years in Italy, but national surveillance data shows no evidence of an increase among young gay men. It is true, if anything, that homosexual and bisexual men living with HIV are on average younger than straight men, and in this sense there is certainly a real risk of further spread in that age group.
Greater vulnerability exists and has various aspects, some of which don't even depend on a person's behavioral choices. Statistical aspects, because an already high percentage of people living with HIV in a small population increases the likelihood of exposure to the virus for each member of that population. Biological aspects, because anal sex itself is biologically more vulnerable than other types of sexual intercourse on a gradual scale of virus transmissibility for each individual sexual act. Psychosocial aspects, because it is widely demonstrated that social homophobia (hostility toward gay people) and internalized homophobia (the low self-esteem one has for being gay) decrease access to HIV testing and foster compulsive and self-destructive behaviors (called "minority stress"). To summarize, on average, a gay man must make a much greater and more persistent effort to manage risk and "control" his behavior than a straight man to achieve the same level of protection in terms of risk reduction, for reasons that are not even his fault. For this reason alone, men who have sex with men (whether straight, gay, or bisexual) deserve a little more attention in terms of prevention strategies shared between associations and institutions.
And yet, nothing. A complete void. The total indifference and lack of strategy on the part of institutions and many organizations (including mine for a long time) regarding HIV among gay and bisexual men has an insidious and persistent effect in this country, which I would summarize in four words: deliberate omission and criminal prudishness. On sex and HIV.
Arcigay was recently sued for distributing a flyer providing detailed information on risks and prevention measures. Some still call an image explaining how to properly wear a condom "pornography." Sex, pleasure, and "safersex" are not addressed explicitly and in detail in prevention campaigns, and institutions certainly don't. Funds transferred to the regions for HIV treatment only ever cover treatment, never prevention, much less targeted prevention for those most in need. The only national institutional information portal on HIV is shockingly inadequate and generic. In civilized countries, condoms are purchased and distributed by the state; in Italy, it's hard to even mention it in campaigns. Public funds aren't directed to prevention organizations; what little is allocated is hoarded by research institutions. General ignorance about HIV fuels discrimination and irrational phobias toward people living with HIV, even within the LGBT community. While throughout Europe, organizations offer and administer in-person HIV testing (community-based strategies), in Italy, corporations, bureaucracy, and regulatory backwardness hinder or slow down community-based strategies. There is no ministerial strategy to combat HIV, only recurring and unheard complaints from ministerial advisory bodies.
Prevention today could rely on different and effective tools, which is why it's called combined: condoms and lubricants, first and foremost, which remain a cornerstone. But also treatment for those already HIV-positive to reduce their infectious capacity to almost zero, or the PrEP recommended by the WHO, at least in certain conditions. Or the systematic provision of initiatives aimed at reducing social and internalized homophobia, as part of health promotion. Access points for HIV testing could be multiplied, allowing associations and those "inside" that community, familiar with its ways and language, to directly manage the provision, assisting the state in this.
The key message that should get across in this country isn't that all gay men need PrEP—which isn't true (put that way) and is in any case unsustainable—but that, to be effective, prevention must be targeted at every single technique, strategy, and communication, with data in hand, to identify the most appropriate solutions for each individual risk profile. To each his own, in short, because even gay and bisexual men (like everyone else) are at different levels of risk. And this should be done through dialogue with LGBT associations.
Instead, we find ourselves dealing with the insidious and disguised return of the homophobic and sexophobic use of HIV: that is, the infection is portrayed more or less unconsciously as a punishment for lewd, antisocial, and irresponsible behavior. Just like thirty years ago. If the state and institutions (and Iardino, who also holds an institutional role) are afraid of the words and realities of sex, they should at least provide the resources to associations to address it with their own language and their own ability to penetrate reality.
Otherwise, what are we talking about? A choice between PrEP and condoms? A sincere concern for gay health? But do me a favor…
Michael Breveglieri
National Secretary of Arcigay
