Sexual health is a fundamental determinant of health and wellbeing [1]. All persons—including
gay, bisexual, and other men who have sex with men (GBMSM)—have the right to enjoy
a safe and pleasurable sexual life with access to comprehensive information, affirmative
care, and an enabling legal and sociopolitical environment [1]. The COVID-19 pandemic
threatens to disrupt HIV programs and global progress toward UNAIDS 90–90-90 targets
[2, 3]. The unprecedented repurposing of health services and resources to address
COVID-19, along with necessary restrictive public health measures [4], present a spectrum
of psychological, sociocultural, structural, and biomedical concerns for sexual health
and HIV prevention [5]. In this Note, we draw on lessons learned from four decades
of the HIV response with GBMSM communities, and our respective programs of research,
to advocate carefully recalibrated, community-engaged approaches to reinforcing HIV
prevention in the COVID-19 pandemic.
Sex and Risk in a Pandemic
Sex in a pandemic is complicated. Key considerations for “safer sex” must address
the immediate risks of new coronavirus (SARS-CoV-2) transmission and potential exacerbation
of risks for HIV transmission. Sexual transmission of HIV, especially among GBMSM,
remains the leading driver of the AIDS epidemic [6]. The integral role of sexual health
in many people’s lives, and its sociocultural and political ramifications for GBMSM
and people living with HIV (PLHIV), suggests it is implausible to expect sexual contacts
to cease for months or years in response to social distancing and stay-at-home guidelines
[7] while awaiting new vaccines and therapeutics [4].
Among the core lessons to emerge from the HIV response is the failure of sex-negative,
stigmatizing, and ideologically driven approaches that defy science (e.g., abstinence-based
interventions) [8, 9]. SARS-CoV-2 presents very different transmission and infection
risks than HIV; nevertheless, unilateral proscriptions around sex fail to capture
the complexity of many GBMSM’s sexual lives. They also reflect a concerning disconnection
from the sociocultural meanings of sex for a community that has successfully struggled
against more than a century of criminalization and repression. The burden of recommendations
not to have sex with anyone outside of one’s household, and unilateral advice to avoid
new partners, are not equally distributed in the context of state-sanctioned heterosexuality
and the rights it confers in many parts of the world. In many countries, GBMSM are
fighting for their very right to exist. Calls to shut down sexual network apps used
by GBMSM in the context of the COVID-19 pandemic fail to account for their role in
promoting health and social support [10].
Fundamental Considerations for HIV Prevention in the COVID-19 Pandemic
Immediately following the first author’s December 2019 report on a UNICEF-sponsored
study of social and structural challenges for HIV prevention among adolescent and
young key populations in Southeast Asia [11], the study sponsor and our main partner
(Interagency Task Team on Young Key Populations) conducted a rapid survey with 113
respondents aged 18–29 years [12]. Half were MSM, 10% transgender people, and half
PLHIV. In addition to challenges in accessing food supplies (46%) and loss of income/employment
due to pandemic lockdowns (46%), participants reported disruptions in accessing condoms
(27%), HIV testing (26%), and PrEP (14%). While 80% reported receiving COVID-19 information,
over two-thirds (68%) indicated lack of information about measures for PLHIV. Among
the 51% (58/113) on antiretroviral medication (ARV), 22% reported one-week or less
and 29% a one-month supply; nearly all were unaware if they could access a multi-month
prescription [12].
Combination HIV prevention [13, 14] in the new pandemic must expand not only to address
COVID-19, but to foreground social determinants of health (SDOH), including intersectional
discrimination and syndemic burden among GBMSM that produce disparities across HIV
prevention and care cascades [15–20]. Pandemic burden is likely to be worsened for
GBMSM across intersections of race/ethnicity [16, 21], age [22–24], and immigrant/refugee
status [25, 26]. In low- and middle-income countries (LMIC), existing vulnerabilities
among GBMSM—as evidenced in our syndemic research on HIV risk in India [27, 28]—are
intensified in the pandemic amid overwhelmed healthcare systems [29, 30]. Finally,
lack of human rights protections, including in the U.S., more so in 70 + countries
that criminalize same-sex sexual behavior, fuel unstable housing, low-wage employment,
barriers in healthcare access, and violence victimization [31, 32], which exacerbate
vulnerability in the pandemic and across HIV prevention and care continua [33, 34].
Revisiting the HIV Prevention Cascade
The COVID-19 pandemic poses considerable threats across the HIV prevention cascade
[20]. First, HIV testing motivations and access may be reduced by stay-at-home and
physical distancing directives, travel restrictions, perceived risks of SARS-CoV-2
transmission in medical facilities, and clinic repurposing. We anticipate that GBMSM
will negotiate sex based on perceived HIV and COVID-19 risks (e.g., only having sex
with partners who have been distancing and are assumed to not have been exposed to
either). HIV testing may become further stigmatized, including by GBMSM and healthcare
providers, due to judgments about the profligacy of (same-sex) sexual activity in
the pandemic. However, this ignores different living configurations, sexual cultures
and meanings that form an essential context for understanding sexual activity among
GBMSM; it also elides situations in which sex is for survival (e.g., sex workers [35,
36]) and nonconsensual (including between people who share a residence) [37]. HIV
testing remains a cornerstone of prevention, facilitating access to counselors and
providers who can promote behavioral risk reduction strategies. Despite recent investments
and positive messaging around HIV testing (fast, easy, and accessible) highlighted
in the context of PrEP, testing remains a complex process for many GBMSM in the U.S
[38]. and globally [39–42]. This is particularly the case for those whose sexual practices
are stigmatized—such as GBMSM who combine sex and drugs [39, 40], and as evidenced
in our research with young GBMSM [11], including sex workers, in India [41] and Thailand
[42]—and amid structural barriers that limit access to testing [11, 38, 41].
Second, absent HIV testing and diagnosis, GBMSM cannot be provided relevant risk information
about HIV and COVID-19 in their communities. HIV testing also serves as a critical
conduit for PrEP, or ARV initiation for those who test HIV positive [14, 20]. In contrast
to the limitations of abstinence models, including in a pandemic, interventions that
promote sexual decision-making and risk reduction strategies are paramount. Beyond
the question around why anyone would seek out sex in a pandemic lurks its corollary:
“why would anyone want to initiate PrEP in a pandemic?” Yet, this is contrary to the
realities of worsening SDOH in the pandemic, which may increase risks for HIV transmission—and
the need for PrEP [37]. PrEP access and initiation challenges persist based on insurance
status [43], geography and racial disparities [44, 45]. In our 2016 study with GBMSM
in Toronto, lack of insurance coverage and pervasive stigma within and outside gay
communities were key barriers to PrEP uptake [43]; both are likely to worsen with
the economic and social impacts of COVID-19.
Third, the current disruption to health systems and daily life may impact many GBMSM’s
PrEP adherence, and clinical monitoring. The slow roll-out of PrEP, especially for
racialized GBMSM [45] and those in LMIC, is further threatened by potential ARV stock-outs
[46] that may aggravate tensions in the context of resource (and ideological) constraints
that pit prevention against treatment. Moreover, COVID-19 raises questions about what
‘safer sex’ means in the era of successful combination prevention, including PrEP
and U = U (Undetectable = Unstransmittable) [47]. Earlier discussions about ‘going
back’ to condoms if PrEP should fail to deliver may need to be revisited in the context
of global treatment disruptions and condom shortages due to the pandemic [46, 48,
49].
Finally, beyond challenges along the prevention cascade, limitations of the cascade
model itself may need to be re-evaluated. In addition to critiques of what is sometimes
approached as a ‘one-size-fits-all’ model predicated on linear steps, with all roads
leading to PrEP [43], adherence may be threatened by supply chain disruptions, constrained
clinic access, and lockdowns in response to COVID-19 [12, 46]. Pandemic stress [18,
50] in the absence of psychosocial support and health promotion programs may further
threaten PrEP adherence. Some GBMSM may decide to discontinue PrEP due to reduced
sexual activity or increased challenges and risks in using PrEP in the pandemic (e.g.,
attending clinics for required bloodwork). Providers need to be supported by clinical
practice guidelines and health insurance companies to respond to these realities by
making accommodations where possible (e.g., negotiating monitoring requirements, providing
longer-term prescriptions) [3, 18] and, importantly, maintaining open lines of communication.
Research Directions
Rapid research, including mixed methods and collaborative approaches, with diverse
GBMSM is needed to understand sexual health and broader mental health amidst COVID-19
[3, 7, 18]. The impact of public health-recommended behavioral changes (physical distancing,
stay-at-home), curfews and border lockdowns, and community closures (LGBT + community
centers and bars) are crucial topics for inquiry. Investigations should further address
the impact of emergency changes in the availability and provision of sexual health
screening, access to medication for treatment and prevention, and disruptions across
HIV prevention and care continua [3, 7, 47]. The pandemic also demands rapid implementation
science approaches to translate innovations in HIV prevention and sexual eHealth services
into routine practice—remote HIV and sexual health counseling and home HIV/STI testing
[51, 52], and virtual PrEP prescribing, monitoring, and adherence support [53]—along
with accelerated research on long-acting injectable PrEP [54, 55]. Structural interventions,
such as guaranteed income and healthcare coverage, may decrease reliance on survival
sex and ensure PrEP affordability. However, public health interventions are not neutral,
and engagement with diverse GBMSM communities is necessary to support acceptability
and uptake [56–58].
Conclusion: Community Mobilization and Survival
Marginalized communities tend to experience lack of confidence and mistrust in the
face of public health responses developed without community representation, fueled
by ongoing disparities in healthcare access in the absence of human rights protections
[32, 59, 60]. Lessons learned from successful HIV behavioral and policy responses
[61–63] indicate that community-engaged [64, 65], strengths-based [66], and positive
psychology approaches [67] that promote solidarity and pride [33, 34] may be most
effective in reenergizing HIV prevention—as a basic human right and a strategy for
community survival. Community mobilization that builds on individual and community
strengths among GBMSM and PLHIV in response to emergent challenges for HIV prevention
[68] can best promote health in the context of COVID-19 and preparedness for future
pandemics.