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This forum grew out of an interest in having dialogues between researchers, providers and community members (these categories are not mutually exclusive groups). This would serve the dual purpose of giving research legs so that it can inform programs and helping ensure that program and life experience inform research studies. Another factor for calling this meeting was the high prevalence of HIV among men who have sex with men and are also injection drug users (MSM IDUs). In San Francisco, the prevalence of HIV among MSM IDUs is 35%. MSM IDUs make up 9% of the cumulative AIDS cases in California, and 6% of the cumulative AIDS cases in the US. Currently, the San Francisco Community Planning Group has listed MSM IDUs as a top priority for prevention programs and funding. Despite the high prevalence rates and interest in serving this population, there are few services, limited infrastructure and scant research specifically addressing MSM IDUs. Most of the funding is divided between MSM-specific and IDU-specific, as well divided between care and prevention, HIV+ and HIV-. As a result of this first informal meeting, CAPS is providing this Report Back on the forum, and a roster of participants to encourage ongoing discussion and networking among service providers, researchers and others working with MSM IDUs. NOTE: The ground rules of this meeting were that specific comments were not attributed to specific people. This Report is intended to be a summary of the different views and ideas from the forum; not every point made is included. This Report is not a consensus.

There have been many reactions to the release of preliminary data suggesting a significant increase in HIV incidence in San Francisco. Many are alarmed, some are saddened, and more than a few have a great deal of anger. The one reaction nobody has had is surprise. While a few don’t like the numbers and will argue about the analysis of them, there has been little shock that there appears to be a range of 750 – 900 new infections this year. That the majority of these infections are occurring in men who have sex with men (MSM) is also not surprising to most observers of or members of the San Francisco gay community. The increase in numbers is based on several realities: The AIDS epidemic changed forever when new treatments were unveiled in Vancouver in 1996. The perception of AIDS as a death sentence, already suspect among many gay men, is gone. If people see HIV as a death sentence, they make certain choices about risk. We know that when the perception of HIV becomes one of a chronic, manageable illness, people make different choices. The perception of HIV has changed on the streets and in the minds of MSM. Most HIV prevention efforts have not caught up with that change. Prevention and health education efforts, which rely on death or danger-avoidance for motivation, may no longer resonate with gay men. Studies indicate that high risk sexual behavior is increasing among MSM in San Francisco. Another factor contributing to the higher estimate of HIV incidence is that the population of gay men in San Francisco is larger than was previously thought. Because of recently improved data collection, such as survey work done for the Gay Men’s Health Study and some groundbreaking work with homeless gay men in San Francisco, we now know that gay men comprise between 15-20% of the adult male population of San Francisco. This is a significant increase from the data available in 1997. In San Francisco, one can look at gay men’s communities as being divided into three distinct groups, all of whom need HIV prevention. The first group is those who have eliminated high-risk behavior from their lives. These people have a thorough knowledge of HIV transmission and risk reduction techniques. They have chosen to eliminate risk based on personal decisions about their risk and need. Despite many years of risk reduction education and media, a second group of people have engaged in high-risk behavior throughout the epidemic. This has not changed. For these men, decisions about perceived risk are outweighed by their needs for identity, intimacy, pleasure, or other considerations. They know about risk, have made choices, and engage in behavior at the level of risk that they believe to be appropriate. A third group of MSM has increased their risk behavior recently. This group makes situational decisions about risk behavior. These decisions are based on their knowledge 3 and understanding of HIV transmission, the perceived risk of the behavior in question, and the stated or presumed HIV status of their partner. For nearly 20 years, we have conducted HIV prevention and education based on several theories, including cognitive learning theory. However, there are many issues that mediate people’s risk assessment and behavior. The behaviors in questions are basic, often urgent, and engaged in without complex cognitive analysis. A brochure can be informative on Tuesday morning; in a moment of intense passion on Friday night, a different analysis occurs. Substance use before and during sex is also a factor. Additionally, for some individuals chronic loneliness, isolation, and alienation lead to remedies, which may include highrisk behavior. The pursuit of pleasure in a society where discrimination can make life painful can be another motivation for pre-cognitive, high-risk behavior. There are many complicated and compelling reasons why a person chooses his own acceptable level of risk. In the era of HAART (highly active anti-retroviral therapy), many men make an assessment based on their firm belief that living with HIV is an acceptable option. Others make a determination about the potential for transmission from a given partner based on information (or perception) about his HIV status or viral load. The fact is, there is an increase in risk behavior amongst MSM in San Francisco. The AIDS epidemic has entered a new and complex era. It is time for prevention efforts to be based on these new realities. In the next section, we will outline an 11-point Action Plan to revitalize the HIV prevention programs of the City and County of San Francisco. No increase in HIV infections is acceptable, regardless of the reason. This new plan will allow us to break this epidemic by realistically equipping MSM to take control of their health.

Because of threats to government funding, community based organizations that provide HIV prevention programs diversify their sources of income by seeking non-governmental funding, including funding from foundations. This survey of foundations across the United States asked questions about the amount of money they spend on AIDS and HIV prevention, the types of prevention projects and populations their grants served, and the sources of AIDS information used by the foundation staff. The results were then compared to the types of projects known to be effective and to the populations most at risk for HIV infection. These organizations funded a diverse range of HIV prevention programs, with a total of 583 grants worth over $8.1 million. This represents almost a quarter of all AIDS-related funding by foundations in the United States.

• HIV prevention grants represented 52% of all AIDS-related grants
• The average HIV prevention grant was for almost $14,000, ranging from $750 to $1.4 million.
• Public policy, capacity building, outreach and technical assistance were among the most frequently funded HIV prevention programs.
• Some useful HIV prevention programs, such as condom distribution and needle exchange, were rarely funded. • Women and youth received 25% of the funding for HIV prevention.
• More grants targeted the general population than drug users, gay men or ethnic minorities, although these groups contain more people at risk for HIV infection.
• Print media, site visits and colleagues were the main sources of AIDS related information for funders.
• Better sources of information are available to help funders gauge the effectiveness of proposed programs.
• Several factors (such as using culturally relevant language, providing creative rewards for participants, designing flexible programs and creating a forum for open discussion) that make HIV prevention programs more effective are provided for use when evaluating programs.

[S]ubstance use plays a major role in the transmission of HIV disease-indeed, a much larger role than has been generally recognized. Clearly, our nation's drug control policies must recognize this inextricable linkage between drugs and HIV disease and be designed to address the two aggressively and simultaneously. -National Commission on AIDS, The Twin Epidemics of Substance Use and HIV, 1991[1] Because neither a vaccine nor a cure for HIV infection appears likely in the near future, planning is needed for the long term to limit the spread of HIV among drug injectors, their sexual partners, and their potential offspring. -National Research Council, AIDS: The Second Decade, 1990[2]

CAPS/UCSF PRC leading PrEP research!

Welcome to our new quarterly e-newsletter! This issue focuses on PrEP or pre-exposure prophylaxis. Read about our work on PrEP uptake and implementation in Oakland, Sacramento, San Francisco, Texas, and internationally. There are also CAPS updates to share, so take a look! In this issue:

1. The Trans Community and PrEP
2. Local black MSM and PrEP Access
3. Black MSM in TX and PrEP Use
4. iPrex Open Label Extension
5. International HIV/STI Programs for Transgender People
6. CAPS Technical Assistance
7. Mpowerment Summit 2016
8. Updates