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Why it’s time for Canada to introduce self-testing HIV kits

New cases of HIV are rising dramatically in Canada. And self-testing kits are nearly as easy to use as a home pregnancy test.

Self-test HIV kits are fast and discreet (Photograph by Gillian Mapp)

Christian Jasserand, 56, was on a work trip in the U.S. three years ago when he strolled into a drugstore and bought a self-testing HIV kit off the shelf for US$35. After he tried it back home in Toronto—with a touch of saliva and a few minutes of waiting—he wished he’d bought several.

“I thought, you can do this in the comfort of your home. You don’t have to go to a doctor’s appointment, or to a clinic, you do this on your own terms,” says Jasserand. It was a quick and efficient way of finding out he had tested negative for the virus. “It makes it much easier on a person.”

Seventy-seven countries, including the U.S., South Africa and Nigeria, have approved home self-testing HIV kits, using either a mouth swab or a drop of blood. Canada is not among them, despite the fact that the World Health Organization (WHO) gave its blessing in 2016 to self-test HIV kits as a tool in the quest to eradicate the virus. It’s also despite the fact that the Canadian company bioLytical Laboratories Inc. is the manufacturer of INSTI, a finger-prick self-test that WHO has assessed and pre-approved for use in UN agencies around the world.

Now, doctors, public health workers and leaders in HIV/AIDS organizations are saying enough is enough. They want Health Canada to approve self-test HIV kits.

“It’s totally doable,” says Nitika Pant Pai, a research scientist at McGill University Health Centre in Montreal and an associate professor in McGill’s department of medicine. “If you can do it in Africa, why can’t you do it in Canada?”


companies that make self-tests have walked away from Canada because the market here is too small or the regulatory process too cumbersome, says Sean Rourke, a psychiatrist and scientist at the MAP Centre for Urban Health Solutions at St. Michael’s Hospital in Toronto.

One stumbling block for approval from Health Canada has been the lack of a clinical trial in Canada showing how accurate and easy to use the kits are, and whether users will seek medical care if they test positive. So, Rourke raised the money for a 1,000-person clinical trial across five Canadian cities on INSTI finger-prick self-testing kits. Pant Pai is running the Quebec side of the trial. They expect it to be finished in February.

Once bioLytical submits the results to Health Canada, Rourke predicts the government will have everything it needs to approve the kits. “Hopefully, by early spring or summer, the first self-test kits will be available in Canada,” he says.

The pressure for access in Canada to self-test HIV kits is mounting because of several troubling trends. First, far from being an epidemic in retreat, new cases of infection are rising dramatically in Canada. In 2018, 2,561 people tested positive, a jump of more than 25 per cent from 2014. In fact, the new-infection figure for 2018 is among the highest in the past two decades.

The rate of infection in the general population is also rising. It hit 6.9 for every 100,000 Canadians in 2018, compared to a two-decade low of 5.8 four years earlier. True, the rate has dropped from much higher levels in the 1980s, when the number of infections peaked in Canada, but these rising numbers are the opposite of what’s happening in many other countries. Globally, the estimated number of new HIV infections has declined steadily since 2000, according to the 2019 report from UNAIDS, the United Nations organization leading the global effort to end the public health threat of HIV/AIDS.


Why are things going backwards here? One key reason is the 9,000 or so Canadians who are positive but don’t know it, and can spread the virus inadvertently, says Rourke. That comes to about 14 per cent of the 63,000 Canadians living with HIV, a stat that puts Canada at the back of the G7 pack, tied with the U.S., says Laurie Edmiston, executive director of CATIE, the Canadian AIDS Treatment Information Exchange in Toronto.

“We need to make it easier for people to be tested,” she says.

The global target (set by UNAIDS on the strength of mathematical projections aimed at ending the epidemic) is to have 90 per cent of those living with HIV know their status by this year, limiting those who don’t know to 10 per cent. The United Kingdom has met that goal and so have Botswana, Cambodia, Eswatini and Namibia. (There are two other targets: that 90 per cent of people living with HIV be on medication and 90 per cent of people on medication have suppressed viral loads. Canada, which endorses the plan, has missed the first two targets.)

And that’s where the self-test kit could turn things around.

“If you want to reach those who are undiagnosed, you’ve got to bring the test to the people,” Rourke says.

Today, almost all of the 1.5 million HIV tests done in Canada in a year are conducted the old-fashioned, sit-on-your-hands-and-wait way: a health professional draws blood and sends it to the lab, and you get your results in a week or so. Canada has approved a version of the INSTI finger-prick test that can be administered in a clinic, but it hasn’t taken off. Despite the one-minute result and more than 99-per-cent accuracy, in 2019, only about 55,000 of those tests were done in Canada, Rourke says.

Home tests could fill a big gap.

A few months ago, one of Jasserand’s friends was going through an HIV scare and needed to be tested. His doctor couldn’t give him an appointment for a week. The local clinic didn’t have an opening for even longer. It was a nightmare.

“I find it truly shocking and shameful,” says Jasserand, “that in Canada we haven’t introduced these kits yet when the rest of the modern world has done it and demonstrated that it’s a pretty good thing to do.”

The problem is not just getting swift access to a doctor or clinic. ACT, which was once known as the AIDS Committee of Toronto, recently did a survey asking why people were reluctant to get tested. Some said they hadn’t yet come out to their family doctors and were uncomfortable asking for health care related to their sexuality, says Tyler Morden, manager of ACT’s gay men’s health programs. Others reported being afraid of showing up at HIV-care or sexual health clinics for fear of outing themselves or running into friends or ex-partners.

“Self-testing would offer confidentiality and privacy,” Morden says. “It would also reach a group of people that we’re not seeing in our physical spaces where we’re offering testing today.”

The kits, which test for the presence of antibodies to the virus, are nearly as easy to use as a home pregnancy test. For the mouth swab, you take a sample of saliva from your gum, insert it into a tube of pre-mixed fluid, and then wait 20 minutes for the fluid to travel up the test stick. If you get no lines, the test isn’t working properly. If you get one line, it means you are HIV-negative. Two, and you are positive. The test manufacturer provides links to counselling and care and a how-to video.

The process for the INSTI blood test has more steps, with three tiny vials of fluid and a flat, dish-like device containing a small membrane. You prick your finger, put a drop of blood into the first vial, shake it four times, pour it onto the membrane and wait until the fluid disappears. Then you shake the second bottle—no blood needed—and empty it onto the membrane, waiting until it, too, vanishes. Same thing with the third vial. Within a minute, you will have either one dot that tells you the test is negative, or two, meaning positive. Again, the manufacturer provides links for further care.

To make things even easier, Pant Pai developed an open source mobile app called HIVsmart! to guide people through the test and link them to health care and counselling if they test positive for the virus. The app has already been translated into several languages and can be used on tablets or smartphones.

While the home tests are considered highly accurate, health professionals advise people who test positive with them to have a traditional lab test done to confirm the diagnosis and to seek appropriate medical care.


Another driver behind the push to get self-testing approved is that it matters when you start treatment. Combination antiretroviral therapy, which was discovered in 1996, greatly lengthened the life-expectancy of people with HIV. But doctors used to hold off treatment until the infection had fully taken hold, meaning people’s immune systems were in rough shape before they got medication. Today, patients get the drugs immediately. Instead of being a death sentence, HIV is considered a chronic disease akin to diabetes that requires daily medication.

As well, a person who is HIV-negative can take a daily prescription of PrEP, or pre-exposure prophylaxis, to prevent getting HIV. It’s another reason to have access to testing.

“We don’t hear or talk about AIDS anymore, because AIDS has really gone away for the most part,” Rourke says. “As long as people get access to the medication.”

Not only that, but once a person’s viral load is under control with medication, that person cannot infect another.

It adds up to an opportunity Canada has never had before. If self-test kits are finally approved for drug-store shelves and if more Canadians living with HIV gain access to medication, it’s a whole new world.

“We can end the HIV epidemic,” says Rourke. “Other countries have targets for 2030—we can do this in three to five years.”


PrEP Users With Commercial Insurance Persist on Regimen Longer Than Medicaid-Insured Individuals

Daily oral pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV infection when used appropriately. Clinical studies have concluded that daily oral tenofovir/emtricitabine (TDF/FTC) use can reduce the risk of acquiring HIV through sex by about 99%.

However, research has also demonstrated that poor adherence to PrEP can result in reduced efficacy and can also lead to HIV-drug resistance if an individual becomes infected while using PrEP.

Since adherence is a key element of the PrEP regimen, investigators with the US Centers for Disease Control and Prevention’s Division of HIV/AIDS Prevention conducted a new study to estimate PrEP persistence among cohorts of individuals with commercial or Medicaid insurance. Their findings were published in Clinical Infectious Diseases.

The study team analyzed data from the IBM MarketScan Research Database focusing on individuals aged 18-64 years who initiated PrEP between 2012-17. In total, the team studied 11,807 commercially-insured and 647 Medicaid-insured persons with PrEP prescriptions.

In order to determine PrEP persistence, the team calculated the time period that each individual continued to fill their prescriptions until there was gap of more than 30 days.

From there, Kaplan-Meier time-to-event methods were used to determine estimates of the proportion of individuals who persisted with PrEP at 3, 6, and 12 months following initiation of the regimen.

According to the results, commercially-insured patients persisted for median time of 13.7 months (95% CI, 13.1-14.1), compared with 6.8 months (95% CI, 6.1-7.6) among Medicaid patients.

The investigators also designed Cox proportional hazards models to determine characteristics associated with non-persistence.

The characteristics of being female, younger in age, residing in a rural area, and black race were linked to shorter persistence of PrEP.

The study team adjusted for covariates and found that female sex [hazard ratio, 1.18; 95% CI, 1.56-2.11) and younger age (18-24 years: HR, 2.38; 95% CI, 2.11-2.69) predicted non-persistence.

The lack of persistence in females could be a concerning topic. In 2017, 19% of new HIV diagnoses occurred in women. According to the authors of this report, an estimated 176,670 women have indications for PrEP in the United States yet only 2% have been prescribed TDF/FTC.

Some barriers to PrEP for women have been identified as low HIV risk perception. The team points to the need for more research on the relationship between pregnancy and PrEP use.

One notable limitation of this research is that persistence was based upon prescription fill records, but an individual may not be adherent to medication just because they filled their prescription.

Overall, the study found that more than half of commercially-insured persons who initiated PrEP persisted with it for 12 months, compared with a third of those with Medicaid.

“A better understanding of reasons for non-persistence is important to support persistent PrEP use and to develop interventions designed for the diverse needs of at-risk populations,” the authors concluded. “PrEP will only be effective in preventing new HIV infections if it is used adherently and persistently by persons at risk of acquiring HIV.”


HIV PrEP could also lead to big reductions in gonorrhoea, Dutch study finds

At least a third of the benefit of PrEP is due to more HIV and STI testing

A PrEP programme targeting 5% of gay and bisexual men in the Netherlands would not only cause big reductions in HIV incidence, but would lead to even greater reductions in gonorrhoea.

In the ’base case’ of the model, gonorrhoea would almost be eliminated, with 2027 only having 3% of the infections seen in 2018, the year the model assumes the PrEP programme was started.

As with all modelling studies, its findings should not be regarded as predictions, but as a test of the assumptions fed into the model; the question it asks is: “If we were able to create these conditions, what might happen?”

Its most important finding is probably that, even if a PrEP programme results in a 75% rise in the likelihood of condomless anal sex in gay men, it would nonetheless lead to falls in gonorrhoea, due to more STI testing and treatment. The idea that PrEP might lead to a rise in STIs in itself is not upheld, unless condom use falls almost to zero.

A lot of the benefit of PrEP is due to PrEP users testing for HIV and STIs more regularly. This study suggests that a third to a half of the benefit of PrEP programmes is due to more testing, with the rest due to PrEP’s direct effect against HIV.

The model

Researchers at the Dutch National Institute for Public Health and the Environment (RIVM) built a model based on their most recent (2017) data for HIV prevalence and diagnoses, gonorrhoea incidence, and current condom use within the Dutch gay community. They also factored in the 2017 costs for PrEP drugs and antiretroviral therapy (ART) as well as the three-monthly testing and monitoring a PrEP programme would entail.

In their ‘base case’ they assumed that 75% of Dutch gay and bisexual men eligible for PrEP would start taking daily PrEP on 1st January 2018. (This didn’t happen, of course; but the model follows what might have happened if it had.) Dutch eligibility criteria are as follows:

  • At least one casual condomless sex partner in the last six months;
  • A diagnosis of rectal or urethral gonorrhoea in the last six months; or
  • A steady partner who has HIV and has a detectable viral load.

Seventy-five per cent of men fitting these criteria would total about 5.5% of the Dutch gay male population, or about 11,000 people on PrEP. For comparison, this is one person per 1556 of the entire Dutch population; when the English PrEP IMPACT study fully recruits, its 26,000 participants will represent one person per 2153 of the English population.

It was assumed that PrEP users stop taking it if an annual check-up finds they no longer meet any of the criteria, while gay men meeting the criteria steadily join the PrEP-taking population up till 31 December 2027. The model examined what would happen to HIV and gonorrhoea diagnoses over those ten years, and to the resultant cost and cost-effectiveness of the PrEP programme.

The model simulated four different scenarios. The first is as described above. In the second, a 75% increase in the likelihood of any one man having condomless anal sex on any one occasion of sex was assumed once people started PrEP. (This is not the same as a 75% rise in condomless sex across the board: in practice, once run through the model, it means that an average of eleven occasions of condomless anal sex every three months increases to 13 occasions.)

In the third, there was a cap of 5000 on the number of PrEP prescriptions available, or 2.5% of the entire Dutch gay male population. In this, it was assumed that eligible men start PrEP on a first-come first-served basis, rather than further criteria operating.

In the fourth scenario, the 75% increase in the likelihood of condomless sex was combined with a 5000-place cap.

“In the era of generic drugs, the cost of HIV testing and medical monitoring in PrEP is higher than the cost of PrEP drugs.”

As already mentioned, the model assumed daily PrEP. The cost of PrEP drugs in the model ranged from €30 to €50 a month. One interesting aspect of the model is that, based on the current costs of tests and staff time in STI clinics, the cost of testing and monitoring is actually higher than the cost of PrEP, at €150-€163 every three months. In other words, the total cost of PrEP ranges from €240 to €313 every three months. It was not assumed that STIs were all diagnosed or treated at sexual health clinics; the cost of diagnosing and treating them was shared between sexual health centres, primary care physicians, and other hospital settings, and varied accordingly.

Other inputs included the cost of ART in those who acquire HIV if they do not take PrEP. This is €2641 every three months for the most frequently used regimen in the Netherlands. The cost of HIV care varies: it is higher immediately after infection and then falls again until people become ill, the likelihood of which is derived from current HIV statistics.

The impact of the PrEP programme in terms of quality-adjusted life-years (QALYs) saved was measured over a ten-year time horizon, from 2018 to 2027. As is usual in cost-effectiveness studied, the crucial figure is the ICER or incremental cost-effectiveness ratio, which is the amount of money the intervention (i.e. providing PrEP) costs per person, as compared with not making the intervention (i.e. not providing PrEP). Because it’s acknowledged that health improvements are worth spending money on, PrEP is not necessarily expected to save money: for the purposes of this study, an ICER of less than €20,000 per person was deemed to be cost-effective.

The effectiveness of PrEP, for the purposes of this model, was 86%, in line with its effectiveness in the PROUD study.

The four models were run many times to produce various different permutations of scenarios. This resulted in a range of costs, and different degrees to which the models were either cost-saving or cost-effective.

In sensitivity analyses, the parameters were stretched further, to produce ‘best and worst case’ scenarios. Effectiveness was varied from 97% to 64% (the upper and lower bounds of the 10% confidence interval in the PROUD study). A further analysis was done assuming an effectiveness of zero: the reason for doing this was to measure the impact solely due to the increase in HIV and STI testing caused by PrEP, independent of its intrinsic efficacy. Other assumptions that were varied were that the probability of condomless anal sex tripled (up 200%); that there was an 80% reduction over time in the cost of HIV treatment; and that only 50% of qualifying men offered PrEP started it rather than 75%.

The results

When all these inputs were fed into the cost-effectiveness model, the base case scenario produced a 61% reduction in the overall number of HIV infections over the ten years, and a 69% decline in the incidence rate by 2027 relative to 2018. HIV incidence would decline from one infection per 342 per year in 2018 to one per 1075 by 2027, and the total number of new infections averted would be 3486.

Importantly, due to the prevention of secondary infections, HIV incidence would fall by nearly as much in gay men in general as in men taking PrEP. In fact by 2027 HIV incidence would be higher in men taking PrEP than in men not taking it, because they would be the more at-risk group. There would remain a very high-incidence subgroup of men who fitted the criteria for taking PrEP but chose not to take it; but even among them, HIV incidence would fall from 2.2% a year (one infection in 45 men a year) to 1.2% a year (one in 83).

“A lot of the benefit of PrEP is due to PrEP users testing for HIV and STIs more regularly.”

The most striking result, however, and the one that is novel to this study, is that gonorrhoea rates would plummet, by a lot more than HIV. In the base case scenario annual gonorrhoea incidence in men starting PrEP would be 0.782% a year, or one case per 128 a year. But by 2027 it would be 0.023%, or one case per 4348 men a year – a 97% decrease in annual incidence. The incidence of gonorrhoea would drop so much it would mean a considerable drop in the number of men on PrEP, because STIs would nearly disappear as a reason to take it, leaving condomless sex as the main criterion. As a result the number on PrEP would nearly halve, from 11,000 to 6000.

On balance, PrEP would save money; the total cost of the PrEP programme would be €3.7m lower than not doing it. However, it was only cost-saving in 52% of the times the model was run (it was cost-effective 97% of the time). As mentioned above, testing and monitoring, at a cost of €39m over the decade, ended up being considerably more expensive than the cost of PrEP drugs (€22m).

In the risk compensation scenario, interestingly, HIV incidence fell even further than in the standard scenario, down to just one infection per 1191 people a year, or a 70.5% reduction between 2018 and 2027, and a total reduction of 63% in the number of infections over ten years.

Why, seemingly counter-intuitively, did HIV fall slightly more even if condom use also fell? The reason is that more people would both start and stay on PrEP in this scenario (there would be 11,600 PrEP users in 2018 and 7300 in 2027) and the effect of more people staying on PrEP would outweigh the effect of fewer people using condoms.

“Due to the prevention of secondary infections, HIV incidence would fall by nearly as much in gay men in general as in men taking PrEP.”

In the risk-compensation scenario the fall in gonorrhoea cases would still be considerable, but nothing like the 97% in the base case; it would be about 73%, down to one case per 472 men per year in 2027 from one per 128 in 2018.

Because there would be more people on PrEP, the programme would cost more, at €45.5m for monitoring and €25.5m for the medication; because of this, the PrEP programme would cost money, at €3.8m more than not doing it. It would be cost-effective, on average, only 73% of the time, and cost-saving 23% of the time.

Capping the programme to 5000 places meant it cost less, but also produced fewer savings in HIV treatment and monitoring. Annual HIV incidence only fell by 56% between 2018 and 2027 (with 48% fewer cumulative infections over ten years) and gonorrhoea by 75%. The programme would on average save money, in the order of €10.7m over ten years, but largely because it would spend less money on testing and therefore on ART.

Finally, capping the programme to 5000 and assuming a 75% increase in the likelihood of condomless sex would result in the lowest fall in annual HIV incidence (52%), the lowest fall in the cumulative number of HIV infections (46%) and a much smaller fall in annual gonorrhoea cases (28% reduction). The programme would on average save €5.2m but almost as many people would be on PrEP at the end as at the beginning.

As mentioned earlier, one sensitivity analysis assumed that PrEP had zero effectiveness, so that the model isolated the effectiveness of more HIV and STI testing. Under this scenario 1219 HIV infections were still averted over ten years, compared to not offering even ‘placebo PrEP’, so to speak. However this is less than half of the 2530 infections averted in even the capped-and-risk-compensation programme, and one-third as many as in the largest (11,000 plus risk compensation) programme.

If PrEP was 96% effective, the programme would be cost-effective in 97% of the model runs and cost-saving in 63% of runs.

If the likelihood of condomless sex per act increased by 200% (i.e. threefold), this would work out as an increase from 11 to 15 occasions of condomless sex a month per person. Under this scenario, even though more HIV infections would be prevented, more people would remain on PrEP by 2027 and the total costs of the PrEP programme would exceed the costs of HIV treatment and monitoring so much that it would, on average, no longer be cost-effective, with an average ICER of €58,558 per QALY gained. The same would happen if the cost of HIV drugs fell by 80% (though this is a counterfactual scenario in that it would had to have happened from the beginning of 2018 onwards).


This study shows that the cost of PrEP programmes is quite sensitive to other changes. In particular, a fall in HIV treatment costs, by the same extent as PrEP drug costs, could make PrEP uneconomical, as could a large increase in condomless sex.

It is arguable, however, that with condom use already quite low in people eligible for PrEP, the impact of further falls may be limited; small further falls in condom use may actually have the paradoxical effect of increasing the overall impact of PrEP, by making more men eligible for PrEP and therefore preventing more HIV infections than otherwise would have happened.

In terms of the cost of ART, it could be argued that they are unlikely to decrease by as much as PrEP costs in that patented, full-cost combination-therapy drugs are likely to form at least part of ART for the foreseeable future.

The study also shows that in the era of generic drugs, the cost of HIV testing and medical monitoring in PrEP is higher than the cost of PrEP drugs. This suggests that savings should be sought by means such as screening for HIV, STIs and kidney function being done at home, or perhaps less frequently.

The study’s most striking findings are twofold. Firstly, even if PrEP had no biological efficacy, the increase in HIV testing that a PrEP programme entails would reduce HIV infections by a third to a half by itself.

Secondly, under nearly all scenarios in this model and especially in scenarios where further falls in condom use are contained, the increase in STI screening due to the PrEP programme results in falls in gonorrhoea (and presumably other bacterial STIs) that are quite dramatic.


Denmark changes 1988 health legislation to allow gay men to give blood

Denmark changes 1988 health legislation to allow gay men to give blood
Photo: Mads Claus Rasmussen/Ritzau Scanpix
Denmark is to change its rules for blood donation from March, introducing a long-awaited provision allowing gay men to give blood.

The rule change was initially announced by former health minister Ellen Trane Nørby in August 2018, and the policy has been continued by the new government, DR reports.

Denmark has not allowed men who have had same-sex relationships to give blood since 1988, when the AIDs epidemic was at its height in the country as well as globally.

Parliamentary consensus has held for several years that the rules are now outdated and discriminatory.

They are now set to be changed in March, albeit with the requirement that men may not have had same-sex intercourse within the last four months prior to giving blood.

That was confirmed in a letter sent by Minister of Health Magnus Heunicke to a number of parliamentary committees, DR writes. That exact date the change will come into effect is currently unconfirmed.

No parliamentary vote is required to implement the rule change, since it is a legal provision bekendtgørelse in Danish) which the minister is able to change unilaterally.

“The introduction of blood donation for MSM [men who have sex with men, ed.] is a positive move. With the four-month probation period, Denmark will be among the most progressive countries in the world with regard to blood donation for MSM,” the minister writes in the parliamentary notice.

Blood Donation in Denmark (Bloddonorerne i Danmark) an association for blood donors in the country, backed the ministry decision.

“A permanent ban made sense at the time in was implemented. The situation today is different, with very reliable testing. We have supported calls for this very strict rule to be changed without it affecting patient safety,” the organization’s general secretary Flemming Bøgh-Sørensen told DR.

The four-month waiting time could be reconsidered in future, Bøgh-Sørensen added.

“There is no research supporting (that length of time). So we see the change as a step in the right direction but would welcome further relaxation of the rules at some point,” he said.

Charity AIDS-Fondet (The Danish AIDS Foundation) also welcomed the change.

“It was time for this to happen. It is quite right to modernize legislation that for many years has been somewhat stuck in an old reality,” director Andreas Gylling Æbelø told DR.


Are Dating Apps Making Gay Men Miserable?

New research explores the motivations and outcomes of using gay dating apps.

A new study of gay men’s use of dating apps raises questions about whether the technology intended to make our (love) lives easier may be getting in the way of happiness. In a recent study published in Psychology & Sexuality, researchers from the U.K. explored the motivations and outcomes associated with using various gay dating apps among a sample of 191 gay and bisexual men.1 The researchers were interested in better understanding the conflicting research to date that points to both the positive and negative consequences of using gay dating apps, such as Grindr.

It wasn’t long ago that individuals within the LGBTQ community were at the forefront of online dating, adopting it earlier and more frequently than their heterosexual counterparts. To many in the LGBTQ community, the opportunity to find dates online provided increased safety by knowing a potential date’s sexual identity before asking them out, allowed users to connect outside of the bar scene, and made it possible to connect with people across geographic boundaries. While online dating may have started out with a focus on seeking romantic relationships, many have expressed concern that the advent of smartphone dating applications that allow users to see others based on proximity has put a greater focus on more superficial sexual relationships.

While there is nothing wrong with such relationships, the dominance of apps catering to sexual relationships may be making it more challenging for individuals seeking longterm relationships or friendships within the LGBT community. Consequently, researchers have begun examining how an individual’s specific goals and reasons for using gay dating apps may play a crucial role in determining whether the use of gay dating apps has positive or negative consequences for their overall wellbeing.

Most of the men in the study were single at the time of participating (60.2 percent), while 21 percent reported that they were in an open relationship and 18.8 percent reported that they were in an exclusive relationship. Participants completed an online questionnaire in which they answered questions about their sense of belonging within the LGBT community, their self-esteemloneliness, life satisfaction, and their overall frequency and intensity of using various gay dating apps. For example, they were asked how often they logged into gay dating apps and their primary motivation for doing so, from which they could select the following options: to make new friends, to meet people to have sex with, to find someone to date, to kill time, or to connect with the gay community. Participants could also enter their own reason for using gay dating apps if none of the provided responses were suitable.

The participants in the study reported logging into gay dating apps frequently, with 71.2 percent logging in at least once per day, with the majority of participants logging in 2 to 4 times per day. Just under half of the sample indicated that their primary use for the apps was to meet people for sex. The second most frequently cited reason was to find someone to date, however, this was only selected as a primary reason by 18.9 percent of the participants in the study. The least frequently cited reason for using gay dating apps was to build a sense of connection with the LGBT community.

When looking at all the participants in the sample together, the frequency with which men logged onto the gay dating apps was associated with greater loneliness, reduced life satisfaction, and a reduced sense of connection to the LGBT community. However, given the varied reasons for using gay dating apps, the researchers wanted to see if these associations were the same for individuals who wanted to use the apps primarily to find sexual partners compared to those using the apps for other reasons.

Men in the study reporting that they use gay dating apps primarily to find sexual partners reported higher levels of self-esteem and life satisfaction, as well as lower levels of loneliness when compared to men who indicated their primary use for gay dating apps was any of the other reasons unrelated to seeking a sexual partner (e.g., to make friends, find a relationship, connect with the gay community, etc.).

Thus, the question of whether using gay dating apps has negative or positive associations with the well-being of their users really appears to depend on the users’ goals and motivations for using the apps in the first place. This makes sense—if the apps are primarily designed to connect users for brief sexual encounters, then those using the apps to find sex partners will likely be the most satisfied with the outcomes. On the other hand, men seeking relationships, friendships, or community may not be best served through such apps and therefore may experience frustration upon using gay dating apps, which may contribute to reduced well-being. Of course, the findings could also suggest that individuals with lower self-esteem and overall satisfaction with life tend to use the apps differently, perhaps being more likely to seek out relationships rather than casual sex encounters. Additional research would be needed to determine the precise direction of the associations found in this study.

However, the research still tells us something important. There’s nothing wrong with the gay dating apps in so far as they provide the service that they are most often used for: connecting individuals looking for sexual encounters. However, this study also points to a need for more apps to enter the market targeted at gay men who are seeking other types of relationships, including friendships, long term romantic partners, and community building. Building apps and platforms specifically for this purpose may create a more balanced experience for gay and bisexual men seeking different types of relationships. Indeed, many men may opt to use both types of apps, one to satisfy their desire for sexual encounters and another to seek out long-term partners and friends.

The study did not use terms like gay/straight/bisexual, but rather asked men about their attractions and included male participants who were either sexually attracted to men only (90.1 percent) or sexually attracted to both men and women (9.9 percent).


Karen L. Blair Ph.D


We have what it takes to tackle HIV spike, but delay is not an option

Recognizing 25 new HIV cases in Boston among injection drug users is a chilling reminder of history repeating itself (“Officials scramble to halt HIV spike,” Metro, Jan. 9). These cases join the 182 individuals in Massachusetts who were diagnosed between 2015 and 2019.

If we forget lessons learned about HIV-prevention strategies, we do so at our own peril. The HIV/AIDS epidemic mobilized colleagues in public health, medical care, research, and community advocacy. Effective strategies included education about safer sex, access to condoms, harm reduction for IV drug use, and availability of HIV testing.

As the spike in HIV coincides with the opioid epidemic, we don’t need to reinvent any wheels. We have a public health infrastructure, practice-based evidence, health resources, and activist groups prepared to address this double epidemic. Boston-area organizations such as Fenway Health, Victory Programs, and Healing Our Community Collaborative have provided critical support for promoting prevention strategies and are linked with resources to address and treat opioid use.

Time is not on our side. The time to act is now. A powerful slogan of the early days of the HIV epidemic asserted that “Silence = Death.” As we prepare to address the compounded opioid/HIV epidemic, we are reminded that our inaction can result in needless harm.

Author: Elizabeth Sommers


Gay Men Are Dying From a Crisis We’re Not Talking About

No one’s really grappling with the meth disaster.

Credit…Daniel Kaesler/EyeEm, via Getty Images


LOS ANGELES — I came of age as a gay man in Greenwich Village during the late 1980s when the AIDS epidemic was raging. I watched my friends and lovers die left and right. At the peak of the crisis, I was attending a funeral every other weekend. Elected officials all across the country turned a blind eye as tens of thousands of young people died.

After a decades-long fight for solutions, H.I.V. is manageable today thanks to preventive medicine like PrEP; medications that reduce the viral loads of H.I.V.-positive people; and a better understanding of how to manage the virus. H.I.V. went from an inevitable death sentence to a manageable chronic disease. But it took far too many deaths to get there.

Today, the gay community is facing another crisis that we’re not talking about and that elected officials are once again ignoring. Crystal methamphetamine has become a popular temptation for gay men, leading many to addiction. The drug, which can change the chemical composition of the brain in chronic users, is extremely addictive. And just like during the AIDS epidemic of the 1980s and ’90s, resources are paltry, government support is virtually nonexistent and an aura of denial surrounds the crisis.

Gay men are more likely to try meth than straight men. One explanation for this could be that gay men struggle with acceptance in ways straight men don’t have to. Growing up gay and being forced to keep that a secret for fear of family rejection or neighborhood bullying can create huge insecurities and issues with intimacy.

My best friend was rejected by his family for being gay and was beaten in the streets of his hometown in Mexico. He had to flee to the United States for refuge. As he grew older, he became more and more desperate to belong to a community. He sought out men on gay apps, and he ended up falling for a handsome young man who was addicted to meth. The young man fostered my friend’s addiction. The initial drug use was about acceptance and remaining relevant in an overly sexualized culture. Now, despite recent interventions by me and other people, my friend is overcome by the daily ritual of obtaining and using crystal meth. He’s a different person than the one I had known for over 25 years.

There are many stories like this. The truth is, using meth can create a twisted sense of camaraderie among users.

Hookup apps like Grindr make finding meth — as well as men to use it with — fast and easy. Users sprinkle capital T’s, referring to meth’s street name, Tina, or diamond emojis throughout bios and user names. Meeting a stranger from the internet for the first time is stressful for anyone — especially for someone who might struggle to form deep connections. Using meth can create an instant, false sense of intimacy and trust, allowing a cheap escape from the problems of our daily lives. In the moment, it seems euphoric; the drug is associated with enhanced sexual pleasure, after all. In reality, it’s ruining countless lives.

There are many underlying reasons gay men start using meth — and those reasons must be addressed.

It’s an unfortunate reality that certain insidious practices and beliefs are upheld within gay male culture that put all of us in danger of adopting risky behaviors. We put intense pressure on one another to be thin, hot and have a lot of sex. Plus, while society is significantly more accepting than it was even 10 years ago, many gay men still struggle with discrimination, violence and our own internalized homophobia, which means drugs can be an escape for many. And meth use greatly increases the risk of getting H.I.V. and other sexually transmitted diseases.

This isn’t a new issue. I’ve watched gay men suffer from meth addiction for over 20 years — and it’s only getting worse. One of my closest friends started using the drug a couple of years ago. Previously a successful businessman, he has now lost his friends, family and business. He spends his days searching for meth. Ten years ago, I lost a partner to crystal addiction. He relapsed after two years of sobriety and eventually died on the street.

No one in the gay community is immune to the impact of crystal meth addiction. If we want to continue growing as a community, we must immediately provide funding and support for gay men who are addicted.

At the network of community health centers I lead in South Los Angeles, an overwhelming majority of patients we treat in our substance abuse programs are addicted to crystal meth. Because meth addiction disproportionately affects gay men, it hasn’t risen to the level of priority and intervention of other addictions.

Elected officials, gay leaders, health care centers and community centers must develop funding and programming to respond to this crisis. Universities and research institutions must begin intervention studies that can inform community-based practice.

Countless gay men suffer from this crippling addiction — and we cannot lose even more of our family members. It’s time to talk openly about the crisis so we can organize the will and the resources we need to address it.


Mr. Mangia runs a network of community health centers in Los Angeles.



PrEP’s unexpected side effect: reduced ‘HIV anxiety’

Use of the HIV prevention drug is associated with lower levels of anxiety about contracting HIV. But for gay men who remember AIDS, the specter of HIV is a hard ghost to shake.
Illustration of two men reaching for a bottle of PreP.

A new study has found that use of pre-exposure prophylaxis, or PrEP, reduces HIV anxiety in gay and bisexual men.Col McElwaine / for NBC News

When HIV first tore into America’s gay male community in the early 1980s, quotidian questions of sex, love, lust and trust transformed into weighty decisions with potential life-or-death consequences.

The decision to stop using condoms with a serious partner? Only as reliable an HIV-prevention method as your partner’s fidelity. A single instance of cheating? An indiscretion that carries the risk of an incurable and deadly disease. A random hookup? A nagging sense that, perhaps, this time was the time.

Todd Faircloth, 52, remembers those days well. In 1987, when gay men were still dying from AIDS in large numbers, Faircloth moved to New York City from North Carolina to start his big, gay life. He was just 17.

“I didn’t know anyone that lived past the age of 30, I didn’t anticipate anyone was going to live that long,” Faircloth, who now lives in Georgia with his husband, said. “It got to the point where people just assumed they all had a death sentence over their heads.”

He said he endured “hundreds” of AIDS funerals with a lot of dark humor, but still, “it was really scary to be out there.”

Amidst all the death, the human immunodeficiency virus caused understandable fear and anxiety among gay men, and Faircloth said this even influenced the relationships people entered into. “If you meet someone, you got with them, you were more likely to want to stay with them, not because you wanted to be with them, but because you’re scared to go back out,” he said.

Today, more than three decades after Faircloth moved to New York, HIV is controllable with medication and need not lead to death. In addition to condoms, first approved to stop HIV in 1987, people at risk of acquiring HIV today can take medications like Truvada to prevent the virus’ transmission, namely pre-exposure prophlyaxis (PrEP), and post-exposure prophylaxis (PEP), which are taken before and after sex, respectively, to prevent HIV transmission. And for those who already have the virus, treatment as prevention, or TasP, makes it impossible to transmit the virus in sex when taken regularly, according to the Centers for Disease Control and Prevention.

One unintended benefit of this new array of pharmaceutical prevention options, according to a new study, is a reduction in “HIV anxiety.” Anxiety about HIV transmission, which the study’s authors describe as a “common” experience of gay and bisexual men — especially those who, like Faircloth, lived through the darkest days of the AIDS epidemic — can compromise their “emotional well-being and create barriers to HIV testing.”

Fifteen years ago, if the condom broke, I would be freaking out about it, and there really wouldn’t be anything you could do for three to six months except just passively hoping you don’t get HIV.


“For many men, fear of HIV transmission led to anxiety about sex with other men, even in situations where transmission was impossible,” the authors note. Half of respondents worried about whether their sexual encounters were “safe,” and thought about HIV before sex, while a full quarter of study respondents, all of whom were HIV-negative, reported thinking about contracting HIV during sex. And the study found that taking PrEP “was independently associated with lower levels of HIV anxiety.”

The study suggests that this PrEP-associated reduction in HIV anxiety could “be promoted as part of demand creation initiatives to increase PrEP uptake,” a key goal of the U.S. government as it seeks to end the HIV epidemic by 2030.

A sea change

Tim Petlock, 49, a gay man living near Dallas, said that so much has changed since he came out as gay in the early 1990s.

“Fifteen years ago, if the condom broke, I would be freaking out about it, and there really wouldn’t be anything you could do for three to six months except just passively hoping you don’t get HIV” Petlock told NBC News, referring to the monthslong window of early HIV tests.

“Now, you can go to treatment the day after to reduce the risk,” he said of post-exposure prophylaxis, or PEP. And today’s HIV tests can tell if a person is infected in about seven days. “You know that much sooner, whether you’ve got it or not, so it does kind of change the calculus of the whole thing.”

Today, Petlock takes PrEP and said that he worries much less about contracting HIV than he used to. Now he’s more focused on avoiding sexually transmitted bacterial infections, such as syphilis and chlamydia, which are on the rise in America.

“I know there’s some risk, but it’s likely not going to be life-altering,” he said.

Ghosts of the epidemic

While PrEP has been shown to reduce HIV anxiety in some gay and bisexual men, the unease has by no means dissipated among this population.

“When you are bombarded your adult life with HIV and seeing death, I don’t care how much we advance biomedical technologies — that emotional reaction to the disease is still going to be the same,” Perry Halkitis, dean of the Rutgers University School of Public Health and author of “Out in Time,” told NBC News. “I unfortunately think that the way we deal with HIV in this country still to this day is very rooted in the responses from AIDS.”

It got to the point where people just assumed they all had a death sentence over their heads.

One of the people for whom the memory of the epidemic’s darkest days is still fresh is Craig Lenti, a New York City-based media producer.

Lenti moved to Manhattan in 1996 at age 18 to attend college, one year after AIDS deaths peaked in the United States. He said he learned about homosexuality and AIDS at the same time, and during his late teenage years, AIDS was the top killer of young American men.

“They were always, for me, intrinsically linked,” Lenti said. “That was what I had in my head. That is what the media told me. And so from that point on, there really was no way of disconnecting those two concepts.”

For years, Lenti avoided taking an HIV test because of his fear that it would return positive.

To this day, Lenti said, it is hard for him to take an HIV test and to trust potential partners because of his fears from the epidemic’s early days.

“It was a foregone conclusion that I would become infected,” Lenti said of his thinking at the time. Yet despite all that worrying, he remains negative.

“I think the biggest fear that I had about HIV was not the fear of being sick. It was always the fear of dying alone,” Lenti said. “It’s just very hard for me to trust people, and I think you could argue that a lot of that stems from my fear of becoming infected, even though now there’s so many different ways to combat that.”

‘I don’t think it just changes overnight’

While Lenti no longer takes Truvada for PrEP because he suffered from its rare gastrointestinal side effects, he said he counsels many of his friends to take the daily medication.

“If you can take a pill that has a 99 percent effective rate, why wouldn’t you do that?” he said.

However, most at-risk Americans aren’t taking PrEP for a variety of other reasons — its high cost (a 30-day supply could cost $2,000), privacy fears and worries that the drug is dangerous (a misconception fueled in part by online ads widely criticized as deceptive). According to the CDC, PrEP is only reaching 18 percent of the 1.2 million Americans recommended to take it, and so HIV anxiety persists to this day for hundreds of thousands of gay men.

Levi, a 19-year-old college student in Ohio, is among the nearly 1 million Americans recommended to take, but not taking, PrEP. Because he’s a man who has sex with other men and is 28 or younger, he’s considered at high risk of contracting HIV, according to the CDC risk assessment worksheet for doctors (the worksheet is based on a point system and uses a variety of risk factors).

Levi is no stranger to HIV anxiety. He recalled a recent incident after he performed oral sex where he began to worry, “Do I need to get a test?”

“I spent the night basically in a hypochondriac fit running around looking if there are any sort of symptoms I should be looking for,” he said, telling an all-too-common tale. However, he needn’t have worried, as there is “little to no risk” of acquiring HIV through oral sex, according to the CDC.

Levi, who asked not to have his full name printed because he is still on his parents’ insurance and worries they would object to PrEP, said he’s just starting to think about taking the HIV prevention pill. He said the man he is dating is HIV-negative, and even though they plan to be monogamous, he doesn’t know if he can fully trust him, because the stakes are so high.

“Is there anything that I could even ask for?” Levi wondered. “Could you show me a paper or something? And could I even believe that?”

Levi’s struggle to answer this question is as old as the virus, Halkitis said.

“You have two sets of problems: a generation that has no clue and hasn’t seen death,” he said, “and a generation that is older that is completely bombarded.”

“I think there’s a whole negotiation morphing period going on right now as we get embedded in these technologies more and more,” Halkitis continued, referring to HIV prevention medications. “I don’t think it just changes overnight.”


Author: Tim Fitzsimons


Blaming Someone for Acquiring HIV Is Never Right

Blaming the Person Impacted Is Never Right, Whether It’s Sexual Assault or Acquiring HIV

Since I began writing this column, I have developed an interest in social media. I had always shied away from it, but my editor encouraged me to take an interest since it would provide me with a way to promote my own work, as well as the work of the magazine. I quickly became an enthusiastic user of Twitter, but Facebook always gave me pause. I believe in leaving the past in the past and I really have no interest in getting back in touch with anyone from the past that I’m not in touch with already. Since Facebook is another way the magazine is promoted and I like to see comments that are left about my work, I have established a “dummy” profile that gives me anonymity and lets me track A&U’s page. The comments are generally positive and supportive, but there was recently one about my October column that really got under my skin.

The column talks about a guy I was dating who raped me one night when I was eighteen. I divulge the fact that I was very high on drugs that night, we both were, but it is not offered as an excuse for a situation that clearly got out of hand. The author of this missive was kind enough to acknowledge that rape is wrong under any circumstances, but quickly goes on to blame me, the victim, for being high in the first place. He even acknowledges my early sexual abuse, but asks quite pointedly—and quite ignorantly—why all the drug use in the first place? I had obviously put myself at risk.

I’ll be quite clear, I was eighteen. I struggled with drug abuse well into my thirties, but at this time and place, New York City in the eighties, I was doing nothing that plenty of my brethren weren’t doing. It was still fun at that point; I didn’t expect there to be such a high price to pay. The price was giving up my power in this particular instance. Since he had penetrated me without a condom, I had to make a trip to a free clinic and wait weeks for the results of an HIV test. I got lucky this time, but years later received the opposite results as a direct result of poor decision-making due to my alcohol and drug use. I well know the potential costs of drug abuse——I don’t need a supercilious lecture on the subject.

I’m not alone. According to the NIH, LGBTQ individuals interviewed are twice as likely to have used illicit substances in the past year as their cisgender, heterosexual counterparts. A history of childhood sexual, physical, and emotional abuse, for me, increased my chances with the damage it did to my self-esteem. Yes, I did have a lot of fun, but much of it was to drown out the negative voices in my head. I was harassed daily throughout my school years for being gay, adding fuel to the fire. Is it any wonder that I turned to drugs and alcohol for solace? As a young man, I dreamed of a glamorous world of New York night clubs and bars. I thought I’d find myself, and perhaps I did, but I was also running away from a lot. It was the perfect storm.

Having come through all that, I sometimes wish I had made better choices. But we don’t get do overs and those are the choices that I’m left with. I’m happy now; it took fifty years, but I’m there. I can’t waste time with regrets. I choose to live my life differently now. I have a few things to say to this judgemental person who wrote the commentary. Perhaps you did think I didn’t paint a clear enough picture of this aspect of my past. That’s fair. But also understand that I’m given a limited amount of column space each month to talk about the subject at hand. I chose to emphasize the actual rape, never expecting to be shamed for being its victim. People’s lives aren’t perfect; we all have struggles and substance abuse is a disease, last time I checked. I think one of the most important things to do when we’re tempted to judge someone else’s choices is to be gentle. We might not know the whole story. No one asks to be sexually assaulted and no one deserves it, regardless of the circumstances. Young women know all too well the tendency to blame the victim, far better than I do. Rapists are given shockingly forgiving sentences all the time in our legal system.

I never expected an otherwise gentle and kind man to rape me. The thought had never occurred to me. I didn’t love him, but I cared for him and had no indication that he could be violent. I did trust him however and he betrayed my trust. I hope this explains things a little more clearly.

Author: John Francis Leonard


Blaming Someone for Acquiring HIV Is Never Right

Partners must prioritize access in fight against HIV/AIDS, experts say

A  pharmacist dispenses anti-retroviral drugs at a hospital in Nairobi, Kenya. Photo by: REUTERS / Thomas Mukoya


SAN FRANCISCO — In July, researchers, advocates, policymakers, and others will gather in San Francisco and Oakland, California, for the International AIDS Conference, billed as the largest conference on any global health or development issue.

The last time that San Francisco held the conference was in 1990, when the city was considered the epicenter of the growing public health crisis.

“The [HIV] pandemic is not only not slowing down, but actually growing.”

— Marguerite Hanley, director, Tech4HIV

While the city still has one of the largest HIV-positive populations in the U.S., infection rates have plummeted, though new infections are on the rise in Oakland, particularly among racial and ethnic minorities.

Over the past 30 years, advances ranging from medical technology to policy implementation have reduced new infections and suppressed the virus for those already living with HIV. There is a lot of excitement about technological innovations already on the market and those that will be available in the near future, including preexposure prophylaxis, or PrEP, which could soon be available as implants instead of daily pills. But progress in the global fight against HIV has been uneven, with the San Francisco Bay Area serving as an example of the global inequities in the disease burden.

In the lead up to the AIDS 2020 conference, the conversation on existing and emerging HIV technology is shifting toward how to ensure that these products and services are scalable, affordable, and sustainable.

Partnering to go faster

Thanks to scientific advances, there are now more prevention and treatment options than ever before to tackle the HIV pandemic.

“Just because we have those approaches and tools available doesn’t mean they’re accessible to those who need them the most,” said Sara M. Allinder, executive director and senior fellow at the CSIS Global Health Policy Center, during a recent event hosted by CSIS on improving access to HIV technology.

The reasons for this inaccessibility range from inadequate financing to regulatory and guideline obstacles to inefficient delivery systems.

Drug companies can play an important role in providing access to medicines in low- and middle-income countries. For example, in low-income countries, Viiv Healthcare, which is focused on research and development of new medicines for HIV, issues voluntary licenses to generic manufacturers. However, as the company marked its 10-year anniversary last year, its chief executive officer said she was proud but not satisfied.

“We didn’t go fast enough,” said Deborah Waterhouse, CEO of Viiv, at the CSIS event.

Partnerships have been the key to success in overcoming the challenging regulatory approval process in countries with the greatest need. Last month, Viiv filed submissions to the U.S. Food and Drug Administration and the European Medicines Agency seeking approval to make dolutegravir, an antiretroviral medication used to treat HIV/AIDS, in a dispersible tablet that works for children. The commitment was made almost exactly a year after the Vatican hosted a convening on pediatric HIV with partners in a position to bring innovations to the markets that need them most.

Going beyond an analog response

Technology has driven some of the most important biomedical breakthroughs for HIV prevention and treatment. But the response to the HIV pandemic remains an analog response, with service delivery methods from the 20th century, according to the founders of Tech4HIV. The organization aims to engage tech companies in the fight against HIV in order to leverage nonbiomedical technologies in a more coordinated and streamlined way.

“The pandemic is not only not slowing down, but actually growing,” said Marguerite Hanley, director of Tech4HIV.

While emerging tech may play a role in the HIV effort, public health organizations need to start by taking advantage of off-the-shelf technologies already in existence, from relationship management software to cloud-sharing, she said.

“There are a lot of one-off examples of tech being used to help a local clinic or a particular software being involved to help one organization,” she said. “But there’s really no coordinated tech response.”

She said she sees AIDS 2020 as a unique opportunity to engage the tech sector, particularly groups based in the San Francisco Bay Area, to focus more on HIV prevention and treatment.

Moving from tools to systems

Like many efforts in global health, the fight against HIV/AIDS is too focused on the tools rather than what to do after those tools are available, said Mitchell Warren, executive director of AVAC, a nonprofit organization aimed at accelerating the development and delivery of HIV prevention options.

“We need to focus on the systems to take these innovations forward,” he said.

Despite the efficacy of oral PrEP, uptake around the world has been slow for a range of reasons. With the introduction of injectable PrEP, there is an opportunity to move from thinking product-by-product to system-by-system, Warren said.

For example, AVAC is leading a collaboration between Viiv, the Gates Foundation, and multilaterals including PEPFAR — the U.S. President’s Emergency Plan for AIDS Relief — to create the infrastructure through which any and all next-generation products can be delivered.

Innovation is rooted in the question “What if we could X?” said Charles Lyons, president and CEO of the Elizabeth Glaser Pediatric AIDS Foundation.

“As you’re what if-ing, you also have to ask: Would this thing be plausibly scalable, is it plausibly affordable, is it plausibly sustainable?” he said at the CSIS event.

If these innovations are not scalable, affordable, and sustainable, there will be no access, which renders innovation meaningless, Lyons said.

At the CSIS event, Warren, Lyons, and Deborah Birx, coordinator of the U.S. government’s activities to combat HIV/AIDS and U.S. special representative for PEPFAR, all emphasized the importance of engaging members of the community to ensure that innovations being developed actually meet their needs.

“We’ve learned that paper on a shelf doesn’t work,” Birx said. “The question is: Is the dialogue strong enough to get the insights quick enough to get that translated to the people we’re serving fast enough?”