The Vanguard Project, an ongoing study of HIV rates and risk factors in young gay and bisexual men in the Greater Vancouver area, saw its fifth birthday in May. There was little fanfare, but much to celebrate in the way of accomplishments and research contributions over the last five years.
In 1995, the Vanguard Project took over where the Vancouver Lymphadenopathy-AIDS Study (VLAS) left off. The VLAS, initiated in 1982, was a closed cohort of gay men recruited in two rounds.
"As the VLAS cohort aged, it became less representative. We weren't seeing any new infections, though these were occurring in the community," says Bob Hogg, the Vanguard Project's principal investigator. The Vanguard study is an open cohort of 15- to 30-year-old men who have sex with men, regardless of whether they self-identify as gay, bisexual or straight. As of March 2000, more than 1,000 participants had been recruited.
Participants see Mary Lou Miller, the project nurse, or a participating doctor or clinic once a year to complete a questionnaire, have an HIV test and provide a blood sample for storage.
The questionnaire collects a wide range of information on demographics,
family background, employment and income, health care, education,
social identity, relationships, general sexual history, sex with
men, paid sex, non-consensual sex, physical abuse, mental health,
institutionalization,
substance use, injection drug use, HIV testing, social support,
stress and self-esteem.
The Vanguard team has spent countless hours studying this data, looking for correlates, for clues. The bad news: a sizeable proportion of young gay and bisexual men are engaging in unprotected sex as well as other risk behaviours.
Why? Look at the answer from the flip side of the question
, suggests project coordinator Steve Martindale: "Many people
have good reasons to protect themselves. Others lack those reasons."
Among the factors that correlated with increased risk-taking behaviour
and therefore increased
risk of HIV infection were:
But it's not all bad news: While many Vanguard participants continue to engage in high risk behaviours, a recent comparison of sexual behaviour, unprotected sex and substance use in the Vanguard and VLAS cohorts suggests positive changes in the past 15 years. Young gay men in the 1980s were more than nine times more likely to report high-risk sexual behaviour (anal sex without condoms with casual partners) than in the 1990s, according to this analysis. Vanguard participants were having sex more often, with higher numbers of partners, but condom use was higher than in the earlier study. Most importantly, the incidence of HIV was much lower: over 42 months in the mid-1980s, the estimated cumulative rate of seroconversion was 21 per cent; only four per cent of the Vanguard cohort seroconverted.
"In a relatively short span of time, the gay community has seen a huge shift in sexual behaviours, which are notoriously difficult to change," says Martindale. "But that doesn't mean there's no longer cause for concern."
Unfortunately those at highest risk for HIV are the hardest
for Vanguard to recruit and follow up on - transients, sex trade
workers, transgendered people and street kids. The team does not
screen participants for follow-up availability and tries instead
to come up with creative ways to maintain
contact with participants who have no permanent mailing address.
For example, project staff were instrumental in setting up the Boys R Us drop-in centre three years ago, a program that provides food, coffee, safe shelter, counseling, health services, referrals, needles and condoms for male sex trade workers.
The Monday Health Project - which sets aside Mondays at the Downtown South Community Health Centre for gay-specific multidisciplinary health services - is another outreach project that has helped Vanguard keep in touch with some participants. "It's been a real lifeline, especially for some of the transgendered and street-involved people," says Martindale.
The Vanguard cohort is an invaluable resource for other HIV-related work. Currently, blood samples collected since mid-1997 are being tested for hepatitis C (HCV). Blood to blood contact such as needle sharing is known to transmit HCV, but there is some question as to how infectious the disease may be through sexual contact. Using VLAS blood samples, Centre epidemiologist Kevin Craib has found evidence of independent sexual transmissions of HCV among homosexual men, accounting for about half the cases in this population. Craib is now extending this research to include the stored blood samples of Vanguard participants.
In 1998-99, more than 300 men also took part in a two-phase
clinical trial to help test the accuracy of the rapid HIV test.
The test kits, which provide a preliminary HIV result in 15 minutes,
were subsequently approved
for use by health care professionals in Canada in March. Vanguard
has also helped publicize the Vancouver Vaccine Trial, a clinical
trial of the first investigational HIV vaccine to be tested in
large-scale populations.
Vanguard is a project of the BC Centre for Excellence in HIV/AIDS.
It is funded by a grant from Health Canada's National Health Research
and Development Program. The Vanguard team has published four
papers in academic journals, and has a number of others in press.
They have made
dozens of presentations at national and international conferences,
including the upcoming International Conference on AIDS to be
held in July in Durban, South Africa.
For more information, contact:
Bonnie Devlin
Vanguard Project Coordinator
608 - 1081 Burrard Street
Vancouver, BC, Canada, V6Z 1Y6
Tel: (604)806-8306
Fax: (604)806-9044