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Saturday 12 November 2016

Gay men's health - it's time to get angry!

Posted in: Health & HIV
By Shaun Robinson - 30th September 2013

Shaun Robinson
In a major speech on gay men's health, delivered on Friday, NZ AIDS Foundation boss Shaun Robinson highlights the health issues where gay and bisexual men are over-represented but which New Zealand's health system ignores.

I want to open a conversation with gay and bisexual men, about your health and about your rights and how that plays out in New Zealand's health system and in our society at this time.

HIV and AIDS have gone through three phases. The first was when HIV meant getting AIDS and then dying. That was an incredibly traumatic, compelling crisis phase, significantly and overwhelming affecting New Zealand gay and bisexual men. The community had to rally to address that phase.

Phase two was when treatment came to mean living with HIV. That was made possible by the work of clinicians, scientists, the drug companies and totally transformed the world of HIV.

A friend of mine, who has lived with HIV for over 20 years, says every day of living with HIV is a new horizon. Because every day is the first day that someone with HIV has lived as long as this.

So we are now in the third phase which is long-term health management.

In phase one there was a very clear line between HIV and other health issues. Understandably, because HIV was incurable: it led to AIDS and people died, and that is why it stood out from other health issues.

Today that line is becoming much more blurred. HIV is sitting alongside a whole lot of other issues which affect gay and bisexual men - and other people living with HIV - some of which are approaching incurable and lead to death. And HIV does not now [inevitably] lead to death. So that hard line between HIV and other health issues has disappeared. We now hear people say that we need to now be looking at a more holistic view of the health of gay and bisexual men.

But there is something that lies under the surface of these three phases: in my view that is significant health inequality for gay and bisexual men. There is a bunch of conditions including cancers, serious STIs, Hepatitis C, cardiovascular disease and many more which are doing serious harm and in some cases killing gay and bisexual men in New Zealand and around the world... and which dramatically over-impact on people living with HIV and fundamentally over-impact on gay and bisexual men. These are significant health burdens that affect gay and bi men.

In a way by fighting the phase one crisis of HIV and AIDS we kind of got lulled into a false sense of security that these other things didn't matter, that they weren't so important. And they probably weren't at that time. But in fact they've been sitting there underneath that crisis throughout the last thirty, forty, fifty years... in fact forever.

The other really significant thing is that these issues are largely ignored by the New Zealand health system. And in saying this I acknowledge that many individual clinicians go out of their way and in their own time do work to try to understand, address, quantify and deal with these issues that affect gay and bi men's health.

But, as a system, the New Zealand health system essentially ignores them. It doesn't even count the number of gay and bi men affected by many of these health issues, even though there is clear evidence that they overwhelmingly impact on gay and bisexual men. There is no research, there is no support for gay and bisexual men to make informed choices about their health unless their own health professionals have gone out of their way to do this. But as a health system... no support.

Let's just go through a few statistics to make my point.

Syphilis. 83% of the cases in New Zealand are gay and bisexual men. It's an accelerating epidemic that's gone up ten-fold in the last decade. And 18% of men who have sex with men who have syhpilis also have HIV. So this is overwhelmingly a disease which is impacting on gay and bisexual men. And often there are no symptoms, often you don't know you have it.

Gonorrhoea. It does more than just burn when you pee. Overall the national rate of gonorrhoea has increased by 35% in the last year. But ano-rectal gonorrhoea has increased 114%. Now we don't know, we don't bother to even count, whether this is of the same dimensions as syphilis. But the fact that ano-rectal gonorrhoea has gone up 114% is something of an indicator. And anecdotally, from some of the small-scale work that has been done around outbreaks of gonorrhoea, I think it is reasonable to say that around 80% of gonorrhoea is also impacting on gay and bisexual men. It is a gay and bisexual men's disease in New Zealand.

The scary thing about gonorrhoea is that there are now forms of gonorrhoea that are incurable. In fact we had an outbreak in Auckland last year of a strain of gonorrhoea that was highly treatment-resistant. So it's not just overseas, it's right here.

Hepatitis C. I had an interesting conversation yesterday with the needle exchange people because hepatitis C is a sexually transmitted disease, especially for gay and bi men. In fact what is happening around the world is that it has been so exclusively defined as a blood to blood infection and associated with intravenous needle use that when gay and bisexual men have been turning up with hepatitis C infections clinicians have not been believing that they are not drug users.

But microscopic blood to blood transmission during sex is passing on hepatitis C. This is an epidemic that is being quantified in other parts of the world and it is killing gay and bisexual men. Having survived phase one [of the HIV epidemic] people are dying in phase three because we don't know, we don't count, we don't see this as a specific gay and bisexual men's issue. In Australia it is estimated that between 500 and 1,000 gay and bisexual men who are living with HIV also have hep C. If you have HIV there's a 400% increased chance of getting hep C. And so far this year we've already had the highest annual number of new hep C diagnoses in this country... and it's not even a full year yet. And once again, no specific information gathered within the health system for gay and bisexual men.

Anal cancer. This has been mentioned as being one of the key new thresholds in the care of people living with HIV. It's more of a risk to gay and bisexual men than cervical cancer is to women. Gay and bisexual men are 20 times more at risk of getting anal cancer than the general population is, and men who live with HIV are 100 times more at risk of getting anal cancer than the general population. It is a cancer that is significantly on the increase and in Australia it is now as common as prostate cancer. In the decade to 2009, 156 Kiwi men were diagnosed with anal cancer, that's about 20 per year, Given the risks it's pretty reasonable to assume that the majority of those were gay and bisexual men, but again we don't really know because we don't bother to count.

Anal and genital warts. These are caused by another strain of HPV, which is the virus which is also responsible for most anal cancer. It's not an insignificant issue. People require surgery to deal with anal warts. It's not something that can be brushed aside. Again, the evidence is less clear here, but given the susceptibility to HPV for gay and bisexual men the likelihood is that there is an elevated risk for men who have sex with men. And the only study that gives us any information on that shows us that it was the 4th most common STD for gay men around 2002.

Heart disease. This is a major killer of people living with HIV. When you consider that 80% of the people living with HIV in New Zealand are gay and bisexual men this is a significant risk. It is now as common as prostate cancer and bowel cancer in Australia. In New Zealand we can only assume that that is the same because there is absolutely no data.

And it goes on and on and on. Gay and bisexual men are more prone to alcohol and drug abuse, to depression, mental health issues, suicide, bone density problems... and a whole range of other STIs.

What can we actually do? There are lots of things. Knowledge about these health risks is a key step in making informed choices. Getting early treatment... if you find you are suffering from these health issues and to prevent yourself from being exposed to them. Sexual health testing will pick up a lot of these issues, an anal health examination annually will take you a long way. Taking your health seriously and doing the check-ups that are needed to identify these issues is something everybody can do.

We are lucky that, in terms of anal cancer and genital warts, because there is a vaccine that is proven effective if young gay and bisexual men get it early enough before they've had sufficient exposure to a large number [of strains of HPV]. Australia has brought in vaccination for all boys and we are really hoping that it is going to be made available to young gay and bisexual men in New Zealand in the near future. There is also potentially some protective or therapeutic effect from the vaccine from older gay and bisexual men, it depends on how much exposure you have had to the dozens of different strains of HPV. It's is worth noting that the vaccine is available fully funded if it is prescribed in a hospital setting, so that is something at least.

Have safe sex. Condoms are highly protective against syphilis, gonorrhoea, hepatitis C and of course HIV and they halve the risk of anal cancer. There's even evidence that regular condom use will increase the ability to clear HPV and early signs of anal cancer. So condoms are a good idea.

And maintain the best health you can. Stop smoking... given the elevated risk of cardiovascular disease for people living with HIV giving up smoking is a good idea. Eat well and try to maintain good general health.

And my last point: be a bit bloody angry. Be a bit pissed off about this. In phase one the health system world-wide only really responded because gay men were dying in their thousands, because gay men with their supporters, acted up and forced these issues. For gay and bisexual men in New Zealand recognition of the health issues affecting you is about where issues of Maori health and women's health were in about 1970.

Here are some of the things we don't bother to count that affect gay and bisexual men overwhelmingly more than others in the general population. Anal cancer... we don't count it. Heart disease... we don't count it. Hep C... we don't count it. Syphilis... we do have some information now. Gonorrhoea... we don't count it. Drug and alcohol issues... we don't count them. Mental health... we don't count it. Suicide... we don't count it. Bone density... we don't count it.

We just don't see how many gay and bisexual men are affected by these diseases, health issues, these risks, even though we know they are there. Is that a health system that is paying you attention? I don't think so.

In fact, world-wide, institutional homophobia is alive and well. The fact that UNAIDS could come out this week and say that the end of AIDS is on the horizon and not mention at all that the epidemic is continuing to go up amongst gay and bisexual men all around the world proves my point. In the last two world AIDS conferences less than 17%, that's less than 1 in 5, of the papers discussing issues around HIV and AIDS addressed gay and bisexual men. How can that be? And should this be? Is it because gay and bisexual men are less human than anybody else? Well, I think we got over that a little while ago!

In New Zealand is being a gay man or having anal sex illegal? No. We've signed up to saying that everybody has the right to the enjoyment of the highest available standard of physical and mental health. We signed up to that in 1978. Now we're in the age of marriage equality and yet we do nothing to address the very high health risks of gay and bisexual men. It's a sign of an unresponsive and immature health system.

In phase one of HIV it took people stamping their feet to get the health system to respond. In phase three is that what it is going to take as well? 

- Shaun Robinson. Executive Director, NZ AIDS Foundation.

[ transcript]

Shaun Robinson - 30th September 2013

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