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Sex Stories: What Does WHO PrEP Endorsement Mean for US?

by Kait Scalisi | Jul 25, 2014 | News

Earlier this week, the WHO released its latest guidelines on HIV prevention, diagnosis, treatment, and care. The guidelines focus on five key groups who both are at the highest risk for getting HIV and receive the least care. The groups include:

Men who have sex with men (MSM).
Sex workers
Prisoners
IV drug users
Trans* individuals

The guidelines are meant to be adapted for each country’s unique setting. However, the groups, regardless of where you are in the world, remain the same. In other words, in both the developed and developing world, these five groups are the ones most likely to get HIV and not receive treatment for it.

Reasons for this exist at almost every level. Individuals in these groups tend to mistrust healthcare providers and establishments based on past negative experiences. Additionally, they experience higher rates of violence, poverty, and mental illness. As a result, the WHO recommends an overall HIV strategy that is comprehensive and intersectional. Health sector interventions are one part of said strategy and PrEP is just one of such intervention.

More specifically, the WHO views PrEP as an additional HIV prevention choice for MSM. The recommendation moved from provisional due to persistently high rates of HIV among MSM as well as evidence that is “strong” and “high quality.” Given that the WHO estimates PrEP could produce a 20-25% global reduction in HIV incidence in this population, it is no surprise they moved forward with recommending it.

Given the major concern that this recommendation will reduce condom use, it is also worth noting that the study on which the WHO made the recommendation actually showed an increase in condom use among PrEP users. This, of course, can be a false result given that we know many people prefer to answer surveys with the most socially acceptable answer.

Ultimately, I feel that much of the fear expressed by US public health and healthcare providers comes from a deeper fear and shame of talking about sex. “Use a condom. Every time.” has become almost standard. At this point it is easy and routine. The new recommendation, however, shifts how a conversation about safe sex will need to happen. In other words, it requires actually having a conversation about sex that goes beyond “Are you sexually active?” Determining whether PrEP is the best HIV prevention choice calls for an inquiry into patients’ sexual history, repertoire, preferences, etc. Since comparisons between PrEP and contraception abound, it is worth noting that such a conversation rarely happens for something as established and relatively well-accepted as birth control options. Healthcare providers receive little to no training on how to broach these topics. Additionally, as the report mentions, “PrEP does not fit well in current (US) models of care, which do not include frequent, regular clinic visits.” Taken together a cycle forms:

Healthcare providers receive minimal training about sexual health.
Healthcare providers are at risk of offending, traumatizing, or generally just having a poor response to MSM.
MSMs develop a mistrust of healthcare providers and share minimal information. Or their mistrust is confirmed upon hearing about another negative experience. They may avoid treatment completely.
There is an apparent lack of need for more comprehensive sexual health training.
No training is created and sex continues to be ignored and mishandled by healthcare.

It is exciting to see the WHO take a strong harm-reduction stance around this issue. While the recommendation is not without potential negative consequences and difficulties, it provides one way to meet people where they’re at and offer a different kind and level of prevention. Ultimately, the more tools we have to prevent HIV, the better we will be able to target campaigns, outreach, and programs to groups that will be a best fit. Like with most things in life, a one size approach will not fit all. The clearer HIV prevention efforts get on their target audience the more effective they can be in reaching their goal.

Other Sexual Health News This Week

Institutional Summit Calls for Action Against Sexual Assault on College Campuses (Madame Noire)

Training For a Triathlon Commonly Leads To Urinary Incontinence and Other Pelvic Floor Disorders (Prevention)

President Obama to Sign Order Barring Federal Discrimination Against Sexual Orientation, Gender Identity Monday (NY Daily News)

Rochester, NY Extends Protections for Gender Identity and Expression (Human Rights Campaign)

10 States Join Indiana’s Appeal of Federal Judge’s Same-Sex Marriage Ruling (IndyStar)

Transgender Inmates Pushing Policy Changes (WLBZ2)

State Agencies Launch LGBT Data-Collection Effort (Capital New York)

Important Dates

Proposals for the following conferences are due in July. Click on each title for more information and to apply.

Playground: A Sex-Positive Inclusive Event for All Communities. Proposals due by 31 July 2014.

The following conferences take place in August. Click on each title for more information and to register.

National Reproductive Health Conference, Aug 2-6, Orlando, FL.

Woodhull Sexual Freedom Summit, August 14-17, Alexandria, VA. Look for SHR writer Kait Scalisi who is volunteering at the conference.

National Sexual Assault Conference, August 20-22, Pittsburgh, PA Be sure to check out “Sexual Violence in ‘The Scene’:Lessons from and Challenges Within BDSM/Kink Circles” presented by Aida Manduley from SHR’s partner organization, The CSPH.

Sex Stories: How Higher Ed Is Failing Survivors of Sexual Violence

by Kait Scalisi | Jul 11, 2014 | News

A new report commissioned by Senator McCaskill, D-Mo. surveyed over 300 colleges and universities to assess how they report, investigate, and adjudicate sexual violence. It also looked at how schools coordinate with law enforcement around this issue.

To anyone who has been following sexual assault news, the results are unsurprisingly disheartening. But before we get there, lets talk about why the report was commissioned, how it was performed, and what it measured.

Twelve years ago, a report funded by the National Institute of Justice found that most colleges and universities were not using best practices to address sexual violence on their campus. Given the White House’s recent focus on this topic (see here, here, and here), it is not surprising that someone decided it was time to update these results and see if anything had changed in the last decade plus.

The information in the report is based on data from 2011-2012 school year. The following three samples of schools, representing more than 5.3 million students, were chosen:

A nationally representative sample of all four years schools receiving Title IV funding.
The 50 largest public four-year institutions.
The 40 private, non-profit four-year schools with 15,000 or more students.

Schools were contacted multiple times via telephone, e-mail, and regular mail. Response rates from the samples were fairly high at 67%, 98%, and 85%, respectively.

I already mentioned that the results were not very positive. However, what exactly did they find? Most schools surveyed are not incorporating best practices for any dimension of this issue. Specifically, colleges and universities…

lack knowledge about the scope of the problem. Though reporting of campus sexual assault is increasing, rates still hover around 5%. Additionally, the majority of campuses are not giving climate surveys which give more accurate estimates.
don’t encourage reporting. Of the nationally representative sample, only around half offer webs-based or telephone options for reporting. Additionally, 8% of schools do not offer confidential reporting.
do not provide sexual assault response training to faculty, staff, students, and law enforcement. This result varies greatly depending on the type of school. For example, a majority (~75%) of private, for-profit institutions and those with less than 1000 students offer no such training to students. There is also a gap in training for high-risk student groups such as those involved in Greek life or athletics. With regards to faculty and staff one third of schools in the nationally representative sample (group 1) train neither law enforcement of officials involved in the adjudication process.
are not necessarily investigating all reports of assault. Between one tenth and one fifth of schools conducted fewer investigations than the number of incidents reported to the Department of Education. Some schools, however, reported investigating more.
do not have an established system for working with law enforcement. Nearly three quarters of institutions in the national sample (group 1) do not have a protocol for how the various departments and law enforcement units should work together to respond to an incident.
aren’t providing adequate services for survivors. While most schools in all of the samples report using having a Sexual Assault Response Team (SART), those teams often lack not only adequate representatives but also a protocol for how to coordinate their response. Representatives missing from the SART include Sexual Assault Nurse Examiners, local prosecutors, and victim advocates.
do not follow requirements and best practices for adjudication. Some schools do not provide information about the adjudication process to students, many use the same process as for other student conduct issues (e.g. cheating), and follow different procedures for student athletes. Furthermore, between a quarter and one half of schools allow other students to participate in the process which has been shown to create conflicts of interests. Finally, schools are not providing effective punishments for perpetrators.
have not designated a Title IX coordinator.

Other issues that this report brings up:

Victims are confused over reporting methods and definitions.
Victims are worried about punishment for activities like drinking that often precede sexual assault.
Because schools do not understand the scope of the problem, they have less of a motivation to do anything about it.
There is an imbalance in the due process rights afforded to perpetrators and survivors. Often the imbalance favors the former group.

Overall, the schools needing the most improvement are those with less than 1000 students. It is easy to understand why this is so. First, smaller schools generally have fewer resources and more individuals doing multiple jobs. This makes something like training on sexual assault response burdensome. Potential concerns include cost and personnel. Who is going to pay for it? And who has the time to put together a program or attend it? Secondly, smaller schools tend to have very close communities. An event such as investigating a sexual assault, especially if students are involved in the adjudication process, can cause serious rifts. While these certainly are valid concerns, they do not make up for the fact that many of these schools are ignoring both the law and best practices and run the risk of hurting their students and their (fragile) reputations.

Though the report does not provide an abundance of new information for those working on this issue, what it does offer is solid evidence in support of the claims made by advocates. Like all studies, it has its faults. For example, many of the claims made in the media do not differentiate among the different groups studied. However, it was certainly time for an updated review of the current situation. A second benefit of the report is that it identifies specific areas where schools can improve. Some are more easily addressed than others; for example naming a Title IX coordinator versus effectively training all staff, faculty and students which involves changing ingrained assumptions about consent, rape culture, etc. Given that the public conversation around this issue is finally happening with some regularity, this report was released at a good time and will hopefully inspire not only more conversation but also some definitive change as part of the White House’s larger strategy.