What you love might kill you. Epidemiology, time trends and risk factors for sexually transmitted infections among men who have sex with men in Norway, 1992-2013.

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What you love might kill you

.

Epidemiology, time trends and risk

factors for sexually transmitted

infections among men who have sex with

men in Norway, 19922013

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© Irena Jakopanec, 2015

Series of dissertations submitted to the Faculty of Medicine, University of Oslo No. 1931

ISBN 978-82-8264-970-4

reproduced or transmitted, in any form or by any means, without permission.

Cover: Hanne Baadsgaard Utigard. Printed in Norway: AIT Oslo AS.

Produced in co-operation with Akademika Publishing.

The thesis is produced by Akademika Publishing merely in connection with the thesis defence. Kindly direct all inquiries regarding the thesis to the copyright holder or the unit which grants the doctorate.

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30%;*0%*1;)%%9/@f]O*%:)$;)%37739;<1*;@;3)%931%3';)%03:;*1:7*9*1(H*1:*();'</1$ informative speeches about STI and sexual health, given at a summer youth camp by Andrej Trampuž, 13>31%3';)%7930*1%1;7)@:*#*1:1$9%:%9#)%9:*1*1;%91/0%$*#*1%1$*1'%#;*3<:$*:%:%:1$ professor at the Charité, University of Medicine in Berlin. On another occasion, Andrej’s lecture about a '*%/$;9*7;3'9*#;9*((%9%$:%=%9/3'<:;3$%#*$%;3:;<$@0%$*#*1%K<;*;>:13;"%'39%0@'%//3> 0%$*#/:;<$%1;;;)%1*=%9:*;@*1-<"/-1=3/-1%#1$(3;*1=3/=%$*1793-%#;H'3#<:%$31 Hwith Brane Mozetič that I became more aware of LGBT agenda and vulnerability of 737</;*313' ;3K91%H>9*;%9H%$*;39H;91:/;391$1*0739;1;(@03=%0%1;#;*=*:;*1

Yugoslavia/Slovenia, recommended reading “To the Friend Who Did Not Save My Life”"@%9=& <*"%9;H )%9;(9*77*1(13=%/H>)*#);3<#)%$0%$%%7/@K#3O0%1;39*1;)*:793-%#;>:9%1/=:H7<"/*# )%/;)7)@:*#*11$:7%#*/*:;H/%$%7*$%0*3/3(*:;1$)%$3'H1$$%79;0%1;;;)% ;*31/1:;*;<;%3'<"/*#%/;)3';)%%7<"/*#3'/3=%1*K9%1/;%9"%#0%0@"3::H%1"/%$0@ '*9:;/%#;<9*1(37739;<1*;*%:*1;)%'*%/$1$7::*31;%/@%1#3<9(%$0@#9%%9*1%7*$%0*3/3(@K)%1 discussed Guibert’s book with my friend Amelia Kraigher, she told me about Lorca’s death. I never quite (3;3=%9;);K =1$$%#*$%$;3(3;3*0"">%*1^ffe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''*#*//@H;)*:9%:%9#)"%(1$<9*1(0@'%//3>:)*7;)%<937%193(900%'391;%9=%1;*31 7*$%0*3/3(@9*1*1(QH_]]cO_]]eRH39(1*:%$"@<937%1%1;9%'39*:%:%9%=%1;*311$ 31;93/QRH$<9*1(>)*#)>:":%$*1:/3K;*:*0739;1;;3:;9%::;);;)%'<1$*1('390@;>3 @%9'%//3>:)*7H:>%//:;)%#31;*1<;*313'0@>39.*1;)%:<##%%$*1(@%9:H#0%'93039>%(*1 1:;*;<;%3'<"/*#%/;)QRK$/@H;)%793(900%H1*0739;1;<937%1O>*$%*1*;*;*=%*1 %7*$%0*3/3(@%$<#;*1(1$"9*1(*1(;3(%;)%9)<1$9%$:3'%?7%9;:1$#.13>/%$(%$"@%$*#/ )0"%93'/3=%1*:79;3'7<"/*#)%/;):7%#*/*:;;9*1*1('39:H:%%0:;3"%#<99%1;/@ :;9<((/*1(>*;)'<1$*1(9%:3<9#%:K>3</$/*.%;3;)1.;)%'%//3>:H#339$*1;39:1$7930*1%1; %?7%9;:'39;)%*9=/<"/%(<*$1#%1$'%%$O"#.310@>39.K)%793(900%%1"/%$1$%1#3<9(%$ 0%;379%:%1;0@'*1$*1(:;:%=%9/*1;%91;*31/#31'%9%1#%:1$(<*$%$0@'*9:;:;%7:*1:#*%1#%H >)*#)>%9%13;:#/<0:@:;)%@0*();)=%"%%1>*;)3<;;)%*17<;3'//;)%:%>31$%9'</7%37/%K >3</$/*.%;3;)1.0@:<7%9=*:39H#)9*:0;*#7<"/*#)%/;)9%:%9#)%9H'390%9$%79;0%1;/%$%9; ;)%39>%(*11:;*;<;%3'<"/*#%/;)1$1%?7%9;%7*$%0*3/3(*:;9%"%1=*;:/1$K'%%/)<0"/% that I am in a way delivering “his” thesis. Since the very early days of HIV epidemic, Preben was one of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global struggle that I was to contribute with a small piece of research in Norway. Andrej’s jovial nature 1$*1;%//*(%1;)<03<9>%9%/>@:;)%9%;3:33;)%1@$%$/*1%71*#1$;3:;%%9;)*1(:;3>9$: 793'%::*31/>39.3')*()8</*;@K>:"/%;3/%91/3;'9303<9$%";%:1$0(9;%'</'39;)%;*0% )%;33.'930)*:"<:@:#)%$</%;3$*:#<::;)*1(:>*;)0%K )=%9%#%*=%$/3;3'=/<"/%#300%1;:'930%9':;$H13;"/%793'%::39;;)%%79;0%1;3' 300<1*;@%$*#*1%;1*=%9:*;@3':/3K1'39;<1;%/@H%9)::<''%9%$1##*$%1;;);#)//%1(%$ )*:"*/*;@;3#31#%1;9;%H;)3<()0=%9@(9;%'</)%9%0*1%$:3*1#9%$*"/@$%;%90*1%$;3:#9<;*1*A% ;)*::<009@K:*1#%9%/@)37%)%9%#3=%9:'<//@K >3</$/*.%;3;)1.01@3';)%#3//%(<%:;H>)3)=%#31;9*"<;%$>*;);)%*9.13>/%$(%H %1;)<:*:01$7%9:31/:<7739;;3;)*:>39.K)%@>%9%(9%;"<1#);3>39.>*;)I9%//@%1-3@%$ ;)%;%0;03:7)%9%;;)%$%79;0%1;H9%/?%$H37%1$%";%:1$>*//*1(1%::;3:)9%;)%.13>/%$(% 1$)%/7%#)3;)%9K1@#3//%(<%:0$%%''39;:;3:3#*/*A%>*;)0%*1;)%*9'9%%;*0%1$:)9%$ >*;)0%;)%*979*=;%7/#%:Q)<;:H7*#1*#:H:%:*$%1$:.**1(R;30.%0@%9/@H131O%:;"/*:)%$/*'%*1

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We identified a high sexual partners’ turnover and frequent concurrent sexual relationships with women 031(:;<$@79;*#*71;:K0739;1;793739;*313'Q_`KdiR*1;)%:;<$@9%739;%$<1793;%#;%$1/ *1;%9#3<9:%QR>*;)#:</39131@03<:79;1%9*1;)%/:;c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# #30"*1%$1;*9%;93=*9/;)%97@'39;9%;0%1;H;)*:;%90*:1;;%07;3':30% :#)3/9:;39%7/#%79%=*3<:/%:::7%#*'*#1$#/*1*#//@/%::#399%#;;%90Q1$ abbreviation for) “highly active antiretroviral therapy,” HAAH>)*#)*::;*//039% 79%$30*11;*1;)%/*;%9;<9% #31'*$%1#%*1;%9=/ #300%9#*/:%?>39.%9 %9%#;*/%$@:'<1#;*31 )<01*00<13$%'*#*%1#@=*9<: 0%1>)3)=%:%?>*;)0%1 0%1H>)3)=%:%?>*;)0%11$>30%1 131(313#3##/<9%;)9*;*: )%39>%(*1<9=%*//1#%@:;%0'39300<1*#"/%*:%:%: 39>%(*11:;*;<;%3'<"/*#%/;) 73:;O%?73:<9%7937)@/?*:I:)39;O;%901;*9%;93=*9/;9%;0%1;;39%$<#%;)%/*.%/*)33$ 3'*1'%#;*31';%973;%1;*/%?73:<9%H%*;)%93##<7;*31//@39;)93<():%?</ *1;%9#3<9:% 79%=/%1#%9;*3 9 79%O%?73:<9%7937)@/?*:I1%>79%=%1;*310%;)3$*1>)*#)7%37/%>)3$313; )=%;.%$*/@7*//;39%$<#%;)%*99*:.3'"%#30*1(*1'%#;%$ :%?<//@;91:0*;;%$$*:%:%: :%?<//@;91:0*;;%$*1'%#;*31: <1793;%#;%$1/*1;%9#3<9:% <1/*1.%$131@03<:;%:;*1( 39#:;:@

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(/ "/% ^K %/'O9%739;%$ #</;<9/ "#.(93<1$ "@ 7/#% 3' 9%:*$%1#% 3' 9%:731$*1( ;3 ;)% 1;%91%;O ":%$#93::O:%#;*31/:;<$@H_]]dH<17<"/*:)%$$;H1$;;*:;*#:39>@$;……….(%`_ "/%_K%?</*$%1;*;@*1;>3$*''%9%1; :<9=%@: *1;)% 737</;*313'in Norway, (2007, 2010). … ………(%`a "/% `K <0"%9 3' 0/% :%?</ 79;1%9: *1 ;)% /:; c 031;): "@ ;)% 9%739;%$ /%1(;) 3' :;%$@ 9%/;*31:)*7>*;)01Hk_a`]H1;%91%;:<9=%@3', 2007 (unpublished data). ……….(%`b "/%aK9%8<%1#@3':%?</79#;*#%:031(__b_0%1H>)39%739;%$)=*1(0/%:%?</79;1%9*1 ;)%/:;c031;):H<17<"/*:)%$$;'9301;%91%;:<9=%@3'*1_]]dQ<17<"/*:)%$$;RK…. Page`c "/% bK %=%/*1( :%? >*;) 0%1 ;3 $%$*#;%$ 79*09@ #9% 7)@:*#*1 "@:%?</ 39*%1;;*31H k_a`]H <17<"/*:)%$$;'9301;%91%;:<9=%@3'*1_]]dK………..(%`d "/%cK::<07;*31:1$.13>/%$(%"3<;Hk_a`]H<17<"/*:)%$$;'9301;%91%;:<9=%@3' *1_]]dK………KKK(%`f "/%dK7*1*31:"3<;:%?1$Hk_a`]H<17<"/*:)%$$;'9301;%91%;:<9=%@3'in 2007. …. ………(%a] "/%eK<0"%93':%?</79;1%9:*1/*'%9%739;%$"@131O#3)"*;;*1(Q_]]dR1$)%;%93:%?</

single men (2002). ………(%ae

"/%fK:%3'$9<(:031(Hk_a`]H<17<"/*:)%$$;'9301;%91%;:<9=%@3'*1_]]dK…. ………(%af #!1./ *(<9%^K(%1%9/*A%$(97)3';)%9%/;*31:)*7"%;>%%1#37*%:Q=*9//3$R1$a#3<1;:3=%9;)% =%9(%#/*1*#/#3<9:%3'<1;9%;%$*1'%#;*31K……….7(%^` *(<9%_K930*1'%#;*31;3#<9%J:@:;%0#)//%1(%:;3%''*#*%1;/@$%;%#;1$;9%;//*1'%#;%$K… page ^f *(<9% `K <0"%9 3' 1%>/@ $*(13:%$ (31399)3%H :@7)*/*: 1$ #:%: *1 39>@ 031( 0%1 >)3 )=%:%?>*;)0%1Hkaa_^H^ffÒ_]^`K………..7(%a^ *(<9%aK<0"%93'9%739;%$(31399)3%#:%:*139>@031(0%1"@:%?</;91:0*::*3193<;%Hk aeèH^ffÒ_]^`K……….7(%a_ *(<9% bK <0"%9 3' 9%739;%$ (31399)3% #:%: *1 39>@ 031( 0%1 >)3 )=% :%? >*;) 0%1 "@ 1;30*#/:*;%73:*;*=%HkêedH^ffÒ_]^`K………7(%a_ *(<9%cK%:;*1(0%;)3$:<:%$;3$*(13:%(31399)3%*10%1>)3)=%:%?>*;)0%1*139>@H^ffÒ _]^`HkêedK………7(%a`

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*(<9%dK<0"%93'9%:*:;1;%*::%9*(31399)3%%*:3/;%:'9300%1>)3)=%:%?>*;)0%1*1 39>@HkêedH^ffbO_]^`1$//*1'%#;%$*1;)*:;*0%7%9*3$K……….7(%a` *(<9%eK3;/1<0"%93'9%739;%$(31399)3%#:%:*139>@031(0%1>)3)=%:%?>*;)0%11$ #:%:>*;)#31#<99%1;39HkêedH^ffÒ_]^`K………..7(%aa *(<9%fK<0"%93'%9/@:@7)*/*:#:%:*139>@031(0%1"@:;(%3'$*:%:%'391$;3;/ 1<0"%9'39)%;%93:%?<//@*1'%#;%$0%1Hk^]àH^ff_O_]^`K………7(%ab *(<9%^]KH*1'%#;%$>*;):@7)*/*:1$#3*1#*$%1;*1'%#;*31:>*;)J^K39_K3;)%9H^ffbO_]^`H ke__K………..7(%ab *(<9%^^K<0"%93'$*(13:%$>*;)*1'%#;*31*1^ffbO_]^`*139>@H"@@%93'$*(13:*: 1$;*0%*1;%9=/"%;>%%1;)%$*(13:*:@%91$;)%%:;*0;%$@%93'*1'%#;*31Hk^^baK…K7(%ac *(<9%^_K<0"%93'H$*(13:%$>*;)*1'%#;*31*1^ffbO_]^`*139>@H"@@%93'$*(13:*: 1$#3*1#*$%1;3;)%9Hk^^baK………7(%ad

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)%;)%:*:*:":%$31;)%'3//3>*1(7<"/*:)%$77%9:K)%@>*//"%#*;%$"@;)%*99%:7%#;*=%301 1<0%9/K K'+,*H#)*00%9H 9-*"3=:.*H/3<01H=*;:/1$K%/'O9%739;%$:%?<//@;91:0*;;%$ *1'%#;*31:1$;)%*9#399%/;%:031(0%1>)3)=%:%?>*;)0%1*139>@J11;%91%;O":%$#93::O :%#;*31/:<9=%@K1'%#;*:_]^]I^]J_c^K K'+,*H39(%1H=*;:/1$K)%%7*$%0*3/3(@3'(31399)3%*139>@H^ffÒ_]]dJ7:; =*#;39*%:H'<;<9%#)//%1(%:K1'%#;*:_]]fIfJ``K K'+,*H 9-*"3=:.*H*/:%1H=*;:/1$K@7)*/*:%7*$%0*3/3(@*139>@H^ff_O_]]eJ 9%:<9(%1#%031(0%1>)3)=%:%?>*;)0%1K1'%#;*:_]^]I^]J^]bK K'+,*H 9-*"3=:.*H*/:%1H/@:;$H=*;:/1$K9%1$:*1*1'%#;*31:<9=%*//1#%$; 031(0%1>)3)=%:%?>*;)0%1*139>@H^ffbO_]^^K<"/*#%/;)_]^Ì^`JâaK )7;%9^ 79%:%1;:"9*%'3=%9=*%>3=%9;)%:;<$@737</;*31H:30%#)//%1(%:9%(9$*1( =*/"*/*;@3'*1'390;*3131031(1$:30%(%1%9/$%;*/:"3<; ;91:0*::*31H;91:0*::*31$@10*#:1$9*:.'#;39:H'3<1$;3"%::3#*;%$>*;) #8<*:*;*31 )7;%9_ 79%:%1;:;)%(%1%9/3"-%#;*=%:3';)%:;<$@H'3#<:*1(3139>%(*1 )7;%9` %?7/*1:;)%0%;)3$:<:%$;3#3//%#;1$1/@:%;)%:;<$@$; )7;%9a 79%:%1;:;)%0*19%:</;:3';)%:;<$@9%/;%$;3:7%#*'*#3"-%#;*=%: )7;%9b "@$*:#<::*313';)%'*1$*1(:H/*0*;;*31:1$1%>.13>/%$(%$$%$ )7;%9c :<009*A%:;)%0*1#31#/<:*31:1$9%#300%1$;*31:'3973/*#@H79#;*#%1$'<;<9% 9%:%9#)*1;)%'*%/$ 3//3>*1(#)7;%9:*?*:/*:;3'9%'%9%1#%:K)%7<"/*:)%$77%9:;);;)*:;)%:*:*:":%$<731#1"% '3<1$*1;)%77%1$*#%:;3(%;)%9>*;):<9=%*//1#%9%739;*1('390:'399%739;"/%*139>@K

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(15)

_^ E ^K^ %1>)3)=%:%?>*;)0%1:737</;*31 “')#)#.%'#)$+'.$#(.2”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

To begin any study with “men who have sex with men” (MSM) as a study population is to begin with 0.*1(1%9939K9%;*1(1%/<:*=%;%90:737</;*31*:1%7*$%0*3/3(*:;’s:)39;#<;1$93<() (%1%9/*A;*319;)%9;)1;1(*"/%$%'*1*;*31H:*;$%7*#;::30%31%>)3:%"%)=*3<90@/:;'39=%9@ "9*%'7%9*3$3';*0%1$*::30%;*0%:1%=%99%7%;%$K;*:;)<:9%/;*=%/@<1#%9;*1>)3:)3</$;)*:;%90 9%79%:%1;H%:7%#*//@H*'>%;9@;377/@*;(/3"//@K

79;'930men, who would describe their own sexual identity as “gay”39)303:%?</H;)%9%*:=9*%;@ 3'0%1H>)3)=%:%?>*;)0%1H"<;$313;1%#%::9*/@:)9%;)%:0%:%?</39*%1;;*31H:%?</39 (%1$%9*$%1;*;@H"<;>3</$"%/31(;39*:.(93<7'39:%?<//@;91:0*;;%$*1'%#;*31:QR$<%;3;)%*9 "%)=*3<9K@%91$9"//3O*&(<%A73*1;3<;13#31:%1:<:31:7%#*'*#$%'*1*;*31:%?*:;Q^RH"<;*;*: 7%9)7:<:%'</;;)*:73*1;;3793=*$%"9*%'3=%9=*%>3';)%;%90:>*;);)%*9Q<1/%::*1$*#;%$ 3;)%9>*:%R79373:%$$%'*1*;*31:J *.#*0#05J1Q*1$*=*$</R:3#*/#31:;9<#;3'>)*#)3';)%(%1$%9(93<7:7%9:31"%/31(:;3 Q;91:(%1$%9–7%9#%7;*313'"%*1(“trapped in a wrong body”)

41(+.#*00#+*J%93;*#39''%#;*31/$*:73:*;*31;3;)%:0%393773:*;%:%? 41(#*0#05J;)%>@7%37/%$%:#9*"%;)%0:%/=%:*1;%90:3';)%*9:%?</39*%1;;*31 41()#*+.#05J7%37/%>)3:%:%?</39*%1;;*313979#;*#%:$*''%9'930;)%$30*11;)%;%93:%?</ 79$*(0K)*:;%90%1#307::%::%?</39*%1;;*311$(%1$%9*$%1;*;@H*1#/<$*1(;)3:%>)3*$%1;*'@: "%*1(/%:"*1H(@H"*:%?</H;91:(%1$%939*1;%9:%?H399%39>30%1>)3)=%:%?>*;)>30%1 Q_RK

(16)

_{_} J0/%:>)3)=%:%?>*;)0/%:H9%(9$/%::3'>)%;)%93913;;)%@)=%:%?>*;)>30%139)=% 7%9:31/39:3#*/(@39"*:%?</*$%1;*;@Q`RK)*:#31#%7;*1#/<$%:0%1>)3:%/'O*$%1;*'@: )%;%93:%?</"<;)=%:%?>*;)3;)%90%1K 30%3';)%"3=%;%90:0@"%*1'/<%1#%$"@:3#*/1390:1$$%7%1$31;*0%*1)*:;39@1$#</;<9%K <01:%?</"%)=*3<9*:$*=%9:%QaR1$H:73*1;%$"3=%H1@*1$*=*$</#)3*#%:*1:%?</*;@0@"% *1;%90*;;%1;H;91:*%1;3931#%*1/*'%;*0%31/@K ^K^K_ 9%=/%1#%3':0%:%?:%?</"%)=*3<9 031(c`]]0/%:H>)3:%/*'%)*:;39*%:>%9%%?0*1%$"@*1:%@*1^faeH)303%93;*#7/@):"%%1 $%:#9*"%$;3"%8<*;%79%=/%1;031(79%$3/%:#%1;0/%:QcciRH"<;0<#)/%::Q^biR9%739;%$39/39 1/O(%1*;/#31;#;1$31/@ai9;%$;)%0:%/=%::%?#/<:*=%/@)303:%?</'39//3';)%*9/*=%:Q^RK1 *1$<:;9*/*A%$:3#*%;*%:;)%79%=/%1#%3')303:%?</"%)=*3<9*:%:;*0;%$;391(%"%;>%%1Ô^]iH $%7%1$*1(31;)%:07/*1(O/*'%;*0%=:K9%#%1;#31;#;K';)%/;;%9*:/*0*;%$;3/:;@%9HÒdi3'0%1 %1((%$*1)303:%?</#;*=*;@1$"%)=*3<9:;);9%*1#/<$%$Q^RK 3#*/%?79%::*313')303:%?</*;@0*();"%9%:;9*1%$*101@#</;<9%:>*;)/%(//@#9*0*1/*:%$:0%O :%?"%)=*3<9H7%9:*:;%1;)3037)3"*H$*:#9*0*1;*311$)<019*();:=*3/;*31H0.*1(;)%%:;*0;%: 039%$*''*#</;*1:<#):%;;*1(:1$$;:#9#%39<1=*/"/%K%=*%>3':;<$*%:31/*'%;*0%79%=/%1#% 0/%:%?>*;)0%1@*%/$%$'*(<9%:Òbi'39:;:*HcO^_i'393<;)1$3<;):;:*HcO^bi'39 :;%91<937%1$cO_]i'39;*10%9*#H>)*/%*':0%#;*=*;@>:9%:;9*1%$31/:;@%931/@H %:;*0;%:>%9%7793?*0;%/@)/'3'/*'%;*0%'*(<9%:QbRK 139>@H9%:%9#)3':%?</79#;*#%:<:*1(0*/%$131@03<:8<%:;*311*9%>:#31$<#;%$"@ 39>%(*11:;*;<;%3'<"/*#%/;)319%79%:%1;;*=%737</;*31:07/%3'^]]]]7%9:31:QêOc]1$ /;%9êOaf3/$R*1^fed1$9%7%;%$*1^ff_H^ffd1$_]]_K)%1:.%$*';)%@%=%9)$1@'3903' :%?</*1;%9#;*31>*;)7%9:313';)%:0%(%1$%9H`Kci0%1*1^fedHaKei*1^ff_HbKî*1^ffd1$ ^]Kdi0%1*1_]]_#31'*90%$K)%793739;*31:>%9%3":%9=%$;3"%)*()%9031(êO_a@%93/$0%1J bKei*1^fed1$âKî*1_]]_H"<;1;<9//@/3>%9*';)%8<%:;*31>:/*0*;%$;3:%?</*1;%9#;*31 >*;)01;);)77%1%$*1;)%/:;@%9J'930^Kbi*1^fed;3`Kei*1_]]_QcHdRUK 1;)%9%79%:%1;;*=%1;*31/:07/%3'^f;3_c@%9:3/$39>%(*1$3/%:#%1;:'930^ffa(“Young in

Norway” study)H>*;)'3//3>O<7:*1^ffc1$^fffN_]]]H:0%O:%?:%?</%?7%9*%1#%;1@;*0%*1;)%*9

/*=%:>:9%739;%$031(cK`i3'0%11$^Kbi)$;)*:%?7%9*%1#%*1;)%7:;^_031;):K1/@^K]i 9%739;%$"%*1(%?#/<:*=%/@;;9#;%$;3;)%:0%:%?QaRK031(;)3:%0/%:>)3)$:0%O:%?:%?</ %?7%9*%1#%;:30%73*1;HabK`i9%739;%$;)%@#<99%1;/@'%/;13:%?</;;9#;*31;37%37/%3':0%:%? QaRK )%%:;*0;%:3';)%79%=/%1#%3':0%:%?*1;*0;%"%)=*3<9:031(0%19%0*1#31;93=%9:*/1$ 9%'9<();>*;)0%;)3$3/3(*#/793"/%0:Q#31=%1*%1#%:07/*1(H779379*;%1%::3'*1#/<:*313' $*=%9:%*1$*=*$</:H#</;<9/#31;%?;:H$*=%9:%;%90*13/3(@RQ^HeRK)<:H13:*1(/%:;<$@>*//(*=%1%?#; %:;*0;%3':7%#*'*#:%?</"%)=*3<9K/:3H9%:%9#)3':%?</79#;*#%:*1(%1%9/737</;*31*:;*0% #31:<0*1(H#3:;/@1$/9(%/@$%7%1$%1;31:<''*#*%1;9%:731:%9;%>)*#)*:13;39*3<:/@$*''*#</;;3 #)*%=%*1;)*:;37*#K

(17)

_` ^K^K` *:;39*#/3=%9=*%>3':;9*:.737</;*31'39

3>;);>%$$9%::%$;)%$*=%9:*;@1$;%0739/*;@3':0%O:%?:%?</%?7%9*%1#%:H>%"9*%'/@ $%:#9*"%;)%39*(*1:3';)%;%90KThe term “homosexual” originated in a sexological discourse of 0*$O^f;)_{O#%1;<9@<937%H>)*/%}_{“gay” and “lesbian”}_{39*(*1;%$*1:<"#</;<9/#31;%?;:"3<;b]@%9:} /;%9QfRK )%%93':%?</9%=3/<;*31*1;)%%:;*1;)%/;%^fc]:1$^fd]:):/%$;3'390*1()303:%?</ :<"#</;<9%H*1>)*#)*1;*0#@>*;)0</;*7/%79;1%9:"%#0%1390Q^RK3(%;)%9>*;)3;)%9 %7*$%0*3/3(*#/9*:.'#;39:H;)*:/*'%:;@/%):/*.%/@7=%$;)%>@'39)*();91:0*::*313':%?<//@ ;91:0*;;%$*1'%#;*31:H*1#/<$*1(H:3;);)303:%?</0%1*1;)%1$%:;%91<937%>%9%;)% '*9:;$%:#9*"%$#:%:>*;)H>)*#):%%0%$;3$*:793739;*31//@''%#;;)%0*1;)%%9/@@%9:3' %7*$%0*#Q^]H^^RK)%;%9039*(*1;%$*1:#*%1;*'*#%1=*9310%1;:'391/@;*#/7<973:%:3'1$ :<9=%*//1#%*1;)%1*;%$;;%:1$>:/*.%/@<:%$'39;)%'*9:;;*0%*1^fee"@1;%//1$%;A.% Q^HfRwith its original meaning “men who have sex with men but do not identify as gay”>*;);)%7<973:% to distinguish this group from “gay” men.

$%7*#;%$1%7*$%0*3/3(*#/$%'*1*;*313';9*:.Q'39;91:0*::*31R(93<7H>)*#)*1#/<$%$ :;9*();39"*:%?</*$%1;*'*%$0%1>)3)$1/:%?>*;)3;)%90%1I*;>:;)<:#;%(39@$*:;*1#;*=%3' :%?</H9#%39:3#*/#/::*$%1;*;@K)%97*$(/3"/:79%$3';)%;%90H'*9:;;)93<()1(/*:)O$30*11; #3<1;9*%:H#3*1#*$%$>*;);)%9*:%3';)%1;%91%;1$##%/%9;*1(:#*%1;*'*#.13>/%$(%%?#)1(%*1;)% STI field and was probably aided by the fact that “gay “ was seen as inaccurate in many nonO%:;%91 #31;%?;:QfRK@;)%%9/@_]]]:H;)%;%90):"%%1;91:'390%$'930%?#/<$*1((@0%1*1;3*1#/<$*1( ;)%0H;)<::)39;%1%$into “men who have sex with men”K;9%0*1:$%";"/%Q"<;3'/%::

%7*$%0*3/3(*#/:*(1*'*#1#%R>)%;)%91$)3>;)*:;%90:)3</$/:3*1#/<$%;91:(%1$%97%9:31:QfH^_RH >)%;)%9*;*1#/<$%:$</;:31/@H>);:%?</79#;*#%:9%*07/*#*;under “sex”1$)3>3';%1Q31#%*1 /*'%;*0%GR:)3</$;)%@"%79#;*#%$;3'</'*/;)%#9*;%9*'39*1#/<:*313'Q^_RK

^K^Ka <99%1;$%";%31;%90

=*1(779%1;/*0*;;*31:H;)%;%90):"%%19%#3(1*:%$:793"/%0;*#:*1#%*;:%9/@<:%:H

when “there has bee1:%1:%;);>%/9%$@.13>will not work” QfR1$):H13;:<979*:*1(/@H

"%%1>*$%/@#9*;*#*A%$:*1#%H"<;*;/:3:%%0:;);it opened for “new possibilities for subjectivity” Q*K%K *$%1;*'*#;*31RQfRK

“…the term anticipates its own failure, yet consensus and even unexpected confirmation emerge.” $!!()$'

)*/%;)%;%900*();:%%0;3"%)%9%;3:;@1$*:"%*1(>*$%/@<:%$*1;)%:#*%1;*'*#/*;%9;<9%H;)*: $3%:13;*07/@*;:3=%9//##%7;1#%K/*0:)=%"%%10$%9%#%1;/@that “MSM” may 9epresent “a :3<9#%3'$*:#30'39;1$3''%1#%"%#<:%*;9%$<#%:(@0%1;3-<:;;)%*9:3#*/"%)=*3<9” and that the ;%90):"%%1<:%$73/*;*#//@:;33/;3“effectively deemphasize gay communities’ early role in 9%:731:%;3” Q^_RK)*/%9%0*1:#%7;*#/;);1@3;)%9;%90>3</$"%#307/%;%/@1%<;9/1$ ##%7;"/%;3//H0*1)<0"/%(9%%0%1;>*;)9%:;(%H>)3$%#/9%:;%90:

%7*$%0*3/3(*#//@:*07/*:;*#H:3#*//@0*:/%$*1(1$:%?3/3(*#//@-<:;:*//@Q^_RK)*:*:<1'39;<1;% "%#<:%>%#<99%1;/@/#.1@"%;;%9:<":;*;<;%:;);#1"%77/*%$(/3"//@K

(18)

_a 3>39.>*;)::;<$@737</;*31*:;3*1;93$<#%#31:;1;/@#)1(*1(390*::*1($%130*1;39H (9%;/*0*;;*31*1%7*$%0*3/3(*#/:;<$*%:K<9;)%9039%H:0%O:%?:%?</%?7%9*%1#%:9%13;>*$%/@ :3#*//@##%7;%$K)*:*:3';%1:;*(0;*A%$737</;*31>*;)/%(/1$:3#*/:1#;*31:1$9%:;9*#;*31: :;*//7%9:*:;*1(*101@79;:3';)%>39/$K)3<():30%0@3##:*31//@$%#/9%$*''%9%1;'*1$*1(:Q^`RH 9%*1(%1%9/13t “an easy to reach” populationand are frequently referred to as “hidden population”.

Though MSM represent “at risk” population with a certain “behavioural denominator”, ;)*:*:/9(%/@

)%;%93(%1%3<:(93<7K)*:9%:%9#)>39.>*//H)3>%=%9H*0;3$$9%::9*:.Q1$)%1#%"%)=*3<9/1$ $%03(97)*#R$*''%9%1#%:031(;9*:.'39*139>@K ^K_ ;)*#/1$/%(/:7%#;:3':%?<//@;91:0*;;%$*1'%#;*31:9%:%9#) “+'.$#)),)($*!)))$$#)*%%'$''"0)$%'$))$""$##!*('(0 #$#)*))$ 0)$%'+#))+)"/)$#$$)'$"$(-*!(2”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f]]QâR, “venereal diseases” >%9%#31:*$%9%$039%3'039/793"/%0*1 39>@K3$%91*:;*313';)%:3#*%;@*1;)%%9/@^f;)_{#%1;<9@*139>@):/%$;3*1#9%:%:*1;)%} 737</;*311$<9"1*A;*31K339/*=*1(#31$*;*31:H73=%9;@1$#93>$*1()=%#31;9*"<;%$;397*$ :79%$3'%7*$%0*#::<#):#)3/%91$/%793:@K;>:0*1/@;)%;)9%;3';)%:%$*:%:%:1$1 %?07/%3';)%1(/*:)<"/*#%/;)#;;);/%$to an establishment of a “Sunn)%;:/3=%1” (*! !),R*1êc]*139>@Q^bRK)*/%;)*:/>$*$13;:7%#*'*#//@0%1;*311@:H;)%9;*#/%W_^ >:(%1%9//@<:%$'39)3:7*;/*A*1(Q>*;)<:%3'73/*#%1$(*1:;;)%*9>*//H*'1%#%::9@R3'*1$*=*$</:H >)3>%9%#31:*$%9%$73;%1;*/:3<9#%3'*1'%#;*3139N1$#3</$13;''39$:<''*#*%1;#9%Q-<$(%$"@ $3#;39R;)30%K)%:%7%9:31:>%9%*$%1;*'*%$"@$*''%9%1;<;)39*;*%:H*1#/<$*1(0%$*#/7%9:311%/K 11(/*:)=%1%9%3/3(*:;31;)1<;#)*1:31H=*:*;*1(39>@*1êcfH%?79%::%$)*:#9*;*#*:0;3>9$: '39#%$)3:7*;/*A;*313';)%7;*%1;:H>)30*();)=%"%%1;.%1'930;)%*9)30%:"@73/*#%Q^cRK 1;)%'*9:;)/'3'^f;)_{#%1;<9@%''39;:'39%/*0*1;*1('3#<:%$31:#9%%1*1(3';)%'%0/%:%?</} >39.%9:Q::<0%$;3"%#39%(93<73';91:0*::*31;;)%;*0%RH>)3>%9%3"/*(%$;3(%;9%(</9

(19)

_b #)%#.:>*;)7)@:*#*1H>39.*1(;73/*#%:;;*31H*139$%9;3"%7%90*;;%$;3>39.Q^dRK)*:79#;*#% >::;377%$*1êed>*;)793)*"*;*313'793:;*;<;*31Q^cRK :;931(%9%07):*:31=3/<1;9@7;*%1;#337%9;*31*1$*(13:*:1$;9%;0%1;#0%31/@*1^f_` >*;)1%>/>79373:/H>)*#)>:*1*;*;%$"@;)%>%$*:)/>31=%1%9%/$*:%:%:%?%1%9*:*1 ^fêQêRK

In 1947, the STI specific law “Lov om åtgjerder mot kjønnssykdommer” Q,$#(*'(#()

#'!(((R$$9%::%$;)%1%#%::*;@3'9%:731:*"/%7)@:*#*1;3#31$<#;#31;#;;9#*1(*1;)% #:%3'1Q^dRK)*:/>0$%*;9%:731:*"*/*;@3'79%:<0"/@#31;(*3<:7%9:31;3##%7; $*(13:;*#793#%$<9%:1$;9%;0%1;K1:7*;%3';)%'39%0%1;*31%$#)1(%:H'39#%$;9%;0%1;>: 73::*"/%'397;*%1;:H>)39%'<:%$;3#337%9;%'<//@31:7%#*'*#0%:<9%:1$'<//@#307/%;%;)%*9 ;9%;0%1;K;>::;*//73::*"/%'39/3#/"39$:3')%/;);3<:%73/*#%'39)3:7*;/*A*1(79%:<0"/@ *1'%#;*3<:7%9:31:<1;*/^ffbH>)%1;)*:37;*31>:'*1//@9%03=%$"@;)%1%>300<1*#"/%*:%:%: 31;93/#;Q^dH^f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fb^H;)%39>%(*10*1*:;9@3'-<:;*#%>)*;%77%99%#300%1$%$$%O#9*0*1/*A;*313'#31:%1:</ )303:%?</#;:3'$</;7%9:31:39*(*1;*1('930;)%39>%(*1 %1%9/*=*/%1/3$%W_^`Q^f]`RH "<;;)%<:;*#%%79;0%1;1$39>%(*19/*0%1;9%-%#;%$;)*:79373:/K303:%?</79;1%9:)*7 >:;)<:"11%$*139>@'930^ced<1;*/^fd_H>)%1;)%9;*#/%W_^`>:9%03=%$Q_^RK31%;)%/%::H ;)%39>%(*1:@#)*;9*#::3#*;*31#31:*$%9%$:0%:%?39*%1;;*31;3"%0%1;/$*:39$%9<1;*/ ^fddK *1$*=*$</:1$:0%:%?#3<7/%:9*();:"%#0%'3#<:3'/*;*(;*31"%'39%;)%<937%1 3<9;3'<01*();:Q;R*1;)%^fe]:1$^ff]:Q_]RK <%;3;)%"3=%)*:;39@H;)%#;*1(3'>:1%*;)%97<"/*#H1%*;)%939(1*:%$Q<1;*/^fb]O*%:RK;*: ;)<:=%9@$*''*#</;;379%:%1;;)%:;*(09%/;%$:7%#*'*#//@;31$*1;)%7:;K%#1H 131%;)%/%::H"9*%'/@;3<#)<731:30%3';)%03:;*1;%9%:;*1(%;)*#/*::<%:*1;)%)*:;39@H;;*0%: #;*31:#300*;;%$*1;)%10%3'9%:%9#)H:>%//::%?</)%/;)K ^K_K_ "*;;%97;);303$%91%;)*#:J:@7)*/*:9%:%9#)*1^f;)_{1$%9/@_]};)_#%1;<9@ “##),)#*(0!)",)'*'.2” )%#<99%1;%;)*#/'90%>39.'399%:%9#)*:"<*/;31"*;;%9/%::31:1$01@/*=%:$%:;93@%$*1;)% 7:;K1;)%%9/@^f;)_{#%1;<9@H>%;1<9:%:>%9%"%*1(<:%$;3"9%:;'%%$*1'1;:3'>%/;)@'0*/*%:*1} 91#%Q1$%/:%>)%9%RK)%*1'390;*3131:@7)*/*:$*:%:%*1;)%""@>:'9%8<%1;/@"%*1(>*;))%/$ '930>%;1<9:%:$<%;3'%93';)%09%-%#;*1(;)%-3"K1$*''%9%1;%?7%9*0%1;:H*1=3/=*1($3#;39:H;)%

(20)

_c "3$*%:3';)%:%>%;1<9:%:>%9%"3;)%?73:%$;3;)%*1'%#;*31Q>)*#):30%%=%1;<//@#31;9#;%$R1$ <:%$:=%)*#/%:'39$0*1*:;9;*313'0%9#<9@;)93<()"9%:;0*/.*1;9%;0%1;%?7%9*0%1;:H>)*#) 01@;*0%:*1#/<$%$)*()/@;3?*#$3:%:1$>%9%7%9'390%$>*;)3<;#31:%1;Q__RKIn addition, Jenner’s success with vaccination against smallpox gave rise to the idea of “syphilisation”, proposed by French $3#;393:%7)O/%?1$9%<A*:O<9%11%K;0%1;;)%<:%3'7<:0;%9*/'930)9$#)1#9%:31 $*''%9%1;3;)%9"3$@79;:3'7;*%1;:*1)37%3'*1$<#*1(*00<1*;@H79#;*#%/:3#31$<#;%$31>%; 1<9:%:Q__H_`RK

139>@H793'%::399/*/)%/03%#.H#)*%'3'%90;3/3(@$%79;0%1;;*.:)3:7*;/%;H:/3H conducted “syphilisation” on 1075 patients in the period 1852Oêd]Q^cRK%/:3'39"$%0%9#<9@<:%*1 ;9%;0%1;3':@7)*/*:;)*:$%79;0%1;K'%$0*1*:;9;*313'73;%1;*//@%''*#*%1;0%9#<9@H;3?*1; 1@$3:%H>:/*.%/@*073::*"/%;3#)*%=%KCarl Wilhelm’s1%7)%>%:93%#.:<##%%$%$)*0: $%79;0%1;#)*%'*1êdb1$#31$<#;%$31%3';)%/31(%:;:;<$*%:3':@7)*/*:*1;)%>39/$QêfÔ^f^]RH *1#/<$*1("3<;_]]]7;*%1;:*1:/3K%#31;*1<%$>*;)0%9#<9@793)*"*;*31H"<;$*:#31;*1<%$ :@7)*/*:;*31K##39$*1(;3'39%0%1;*31%$%/;)>'930êc]H3%#.>:*173>%9;3$%;%90*1%;)% /%1(;)3'7;*%1;:’:;@*1;)%)3:7*;/K;;)%;*0%H;)%7339>%9%9%(9$%$:*0039/1$>%9%*1 039%$1(%9;3"%'39#%$/@)3:7*;/*A%$Q_aRKBoeck’s:;<$@9%:</;::<((%:;:;);=%9(%;*0%3' )3:7*;/*A;*31>:"3<;^]]$@:H^K_031;):/31(%9'39>30%1Q_bRK)%$339:;3;)%$%79;0%1; >%9%/3#.%$1$;)%$%79;0%1;>::<993<1$%$"@"39$'%1#%:1$"9"%$>*9%<1;*/^f`]:Q^cRK *1//@H;)%(93<1$"9%.*1($9<(9:7)%10*1%Q/=9:1R>:0$%=*/"/%;3:/3:@7)*/*:7;*%1;: *1^f^]Q_bRKBoecks’ '*1$*1(:1$;)3:%3')*::<##%::39:H9<<:(9$1$ -%:;/1$%#)3%$ *1;%91;*31//@Q_cRK1^f`_H>)%1;)*:>:)*()/@<11%#%::9@H<1%;)*#/1$37%1/@0/*#*3<:H;)%*$% 3':;<$@*1(L1;<9/#3<9:%3':@7)*/*:M(=%9*:%;3;)%13;39*3<:<:.%(%%:;<$@*1/"0HH*1 >)*#)c]]*073=%9*:)%$1$79%$30*11;/@*//*;%9;%9<9/'9*#10%9*#10%1>%9%/<9%$*1;3 #3//"39;*31<1$%97930*:%3''9%%0%/:H)%/;):%9=*#%:1$"<9*/*1:<91#%K;;)%;*0%3' %193/0%1;*1;)%:;<$@H`ff0%1>%9%*1'%#;%$>*;):@7)*/*:1$_]^>%9%#31:*$%9%$13;*1'%#;%$Q_dRK %(9$/%::3';)%3<;#30%$<9*1(;)%:;<$@H//c]]0%1>%9%/%';<1;9%;%$'39$%#$%:K)*/%;)% 9%:%9#)%9:7::*=%/@7%90*;;%$;)%*1'%#;*31;3:79%$;3;)%'0*/@0%0"%9:3'0%1*1<:.%(%%:;<$@H 3=%931%;)3<:1$*1$*=*$</:%193//%$*1 <;%0/%?7%9*0%1;>%9%*1;%1;*31//@%?73:%$;3H39 *13#</;%$>*;)H2%!!*"H2$#$''$H39 "$%!*(*'."%;>%%1^fac1$^faeQ_dRK )%"3=%)*:;39@*:$%:#9*"%$)%9%;3:;9%::;)%*0739;1#%3'$3#;39O7;*%1;#31'*$%1;*/*;@H9*();;3 7937%9*1'390;*31H7;*%1;#31:%1;*1//793#%$<9%:H9*();;303=%'9%%/@H9*();;3##%::*"/%$*(13:;*#: 1$;9%;0%1;Q*1:30%#3<1;9*%:H79*#%3')%/;)#9%:%9=*#%:39;9%;0%1;9%793)*"*;*=%'397339 7;*%1;:;3''39$31%R1$;)%patients’9*();;3)=%:%?<//*'%>*;)#31:%1;*1($</;:>*;)3<;1@ ::3#*;%$:;*(0K)%:%(3/:9%13;@%;(/3"//@#)*%=%$K

(21)

_d ^K_K` 3$%91793:%#<;*311$:;*(09%/;%$;3:%?</79#;*#%:1$*1'%#;%$ %:</;:3':<9=%@:<:*1(;)%%37/%*=*1(>*;);*(01$%?'930_]]eO_]^^:<((%:;%$;);039% ;)1)/'73:*;*=%79;*#*71;:9%739;%$=%9"/*1:</;:*1%1@H>1$1$0"*1$039%;)1 _]i>%9%7)@:*#//@::</;%$*1:;31*H%1@H*(%9*H>1$1$0"*Q_eRK )%9%*:$%#/*1%*11<0"%93'#3<1;9*%:>*;)O9%/;%$;9=%/9%:;9*#;*31:K90%1*H)*1H*-*H 0*"*H;)%%7<"/*#3'39%H;)%%7<"/*#3'3/$3=H.9*1%1$;)%1*;%$;;%:3'0%9*#)=% 31/@9%#%1;/@/*';%$;)%*9"1:H>)*/%3;)%9#3<1;9*%:#31;*1<%;3)=%;)%0Q_eRK 39>@>:;)%'*9:;#3<1;9@*1;)%>39/$;);*1;93$<#%$9%(</;*31:Q^fe^RH<1$%9>)*#))303:%?</: :*1$*=*$</:1$:(93<7"%#0%%1;*;/%$;3:7%#*/#9*0*1/793;%#;*31(*1:;$%93(;39@ 9%'%9%1#%:1$$*:#9*0*1;*31K)%/>3179;1%9:)*7>:7<;;379#;*#%*1^ff`1$39>@>:;)% :%#31$#3<1;9@*1;)%>39/$;3)=%##%7;%$:<#)9%(</;*313')303:%?</79;1%9:)*7K)*:/>>: 9%7/#%$"@1%>(%1$%9O1%<;9//>31099*(%31^:;1<9@_]]fQ_fRK ##39$*1(;3;)%1*;%$;*31: %1%9/::%0"/@9%739;'930_]^^H;)%9%9%0*1"3<;eb#3<1;9*%:*1 ;)%>39/$*1>)*#)#31:%1:</$</;)303:%?</#31$<#;*:7<1*:)"/%H*1;/%:;'*=%3';)%0>*;) $%;)7%1/;@Q`]RK ;91:0*::*31*::7%#*'*#//@#9*0*1/*A%$*1"3<;c]#3<1;9*%:Q:3'_]^_RQ_eRK1$%9%#;*31^bb3' ;)%39>%(*1 %1%9/*=*/%1/3$%Q`^RH*;*:#9*0*1/3''%1#%'397%9:31>)3.13>:;);)%39 she is infected with a “#300<1*#"/%$*:%:%H)A9$3<:;37<"/*#)%/;)” (the full list of these :7%#*'*%$ *1'%#;*31:*:9%(</9/@9%=*:%$RH;3%?73:%13;)%97%9:31;3;)%9*:.3'"%#30*1(*1'%#;%$K)% 7<1*:)0%1;*:<7;3:*?@%9:*079*:310%1;*''3<1$(<*/;@O;)%:0%'39;.*1(79;*139::*:;*1(*1 :<#)#;K179#;*#%1$9%:</;*1(*1#31=*#;*31H;)*:/>):"%%1<:%$0*1/@'39*1:;1#%:3' %?73:<9%K;*:%?73:<9%*;:%/';);*:7<1*:)"/%H%=%1;)3<();)%#;</;91:0*::*310*();13;)=% ;.%17/#%K <@*1(:%?</:%9=*#%:*:#9*0%*139>@<1$%99;*#/%W_]_*139>%(*1 %1%9/*=*/%1/3$%H %''%#;*=%31^1<9@_]]fQ`^RK*0*/9*1*;*;*=%>:%=/<;%$"@<:;*#%%79;0%1;1$9/*0%1; /9%$@*1^ffdH;>3@%9:"%'39%>%$%1"11%$;)%7<9#):%3':%?H"<;;)%79373:/>:$*:0*::%$K @/>H*;*:/:3793)*"*;%$;3'<9;)%939'39#%;3793:;*;<;*31K9*;*#:3';)%9%#%1;/%(*:/;*=%#)1(%:H >)*#)>%9%:<773:%$;379%=%1;)<01;9''*#.*1(H73*1;3<;;);:%?>39.%9:*139>@#113;)=% >39.#31;9#;:H:*#./%=%1$'390<1*31:K:9%1;*1(3<;7937%9;@;3793:;*;<;%:#3</$"%9%(9$%$: 7*07*1(H:%//*1(:%?</:%9=*#%:*139>@*:13>"%#30*1(1<1$%9(93<1$#;*=*;@Q`_RK)%.13>/%$(% 31:%?;9$%031(*139>@*::#9#%K ;*:#/%9;);*101@#3<1;9*%:93<1$;)%>39/$H/%(/#)//%1(%:9%0*1>)%1*;#30%:;3'<//9%:7%#; 3')<019*();:H/9%$@:<7739;%$"@*1;%91;*31/)<019*();:$3#<0%1;:K139$%9;3$$9%::;)*: *1#31:*:;%1#@1$7;;%91:3'"<:%H9%/;%$;3(%1$%9*$%1;*;@39:%?</39*%1;;*31Q1$3;)%9:;;<:RH *1;%91;*31/)<019*();:%?7%9;:0%;*13(@.9;H1$31%:*H*1_]]cK)%9%:</;*1($3#<0%1;H “Yogyakarta principles” is a :%;3'_f"*1$*1(/%(/:;1$9$:>*;)9%#300%1$;*31:;3(3=%910%1;:H 9%(*31/*1;%9(3=%910%1;/*1:;*;<;*31:H#*=*/:3#*%;@1$;)%Q``RK

(22)

_e ^K` %?<//@;91:0*;;%$*1'%#;*31:3'7<"/*#)%/;)*0739;1#%*1 “$'!).(+#'!((2)(%'"'.()(!!+')*1)(($#'.()0$'$"1)( )')'.()0(.%!(2” 9<:H9/ )%)*:;39*#/;%90+#'!((9%'%99%$;39;)%9:)39;/*:;3'$*:%:%:K30%79373:%;);;)% %?79%::*319%793$<#;*=%;9#;*1'%#;*31:QR$%O:;*(0;*A%::<#)#31$*;*31:1$*:039%779379*;%'39 *1'%#;*31:H'39>)*#):%?</;91:0*::*31*::;*//$%";%$Q`aRK3=3*$<11%#%::9@#31'<:*31>*;) 9%:7*9;39@;9#;*1'%#;*31:H#<99%1;/@H;)%;%90::%?<//@;91:0*;;%$$*:%:%QR1$:%?<//@ ;91:0*;;%$infection (STI) are used interchangeably in the literature, though “infection” is preferred

over “disease”H:*1'%#;*31:0@9%0*1>*;)3<;779%1;:@07;30:–7%901%1;/@39;/%:;'39/31( 7%9*3$:3';*0%K*:'9%8<%1;/@10%$:%79;%/@;31$H"<;*1;)*:>39.>*//<:%;%90 :%?<//@;91:0*;;%$*1'%#;*31H>)*#)*1#/<$%://73::*"/%7;)3(%1:H*1#/<$*1(K )%;3;/1<0"%93'$*:;*1#;:%?<//@;91:0*;;%$39;91:0*::*"/%7;)3(%1:13>%?#%%$:`bQ`aR1$ *1#/<$%::30%3';)%7;)3(%1:;);3##<931/@=%9@99%/@*139>@H'39%?07/%79:*;%:Q)'*( %*(1$'$%)((R39:)*(%//3:*:K)%%7*$%0*3/3(*#1$#/*1*#/%=*$%1#%*::<((%:;*1(:30% 1%>/@*$%1;*'*%$7;)3(%1:0*();"%:%?<//@;91:0*::*"/%Q;91:0*;;%$"@#31;#;3'0<#3<: 0%0"91%:Q`bRRH;)3<()*1:30%H131:%?</93<;%:3';91:0*::*3179%$30*1;%Q`aRK)%/*:;>*// 7%9)7:1%=%9"%%?)<:;*=%H:>%)=%/%91%$;);1%>7;)3(%1:–;.%:1%?07/%H#11$ $3%0%9(%K;>3</$"%"%@31$;)%:#37%3';)*:>39.;3'3#<:31//3';)%0H"<;"%/*%=%*;*:1%#%::9@ ;3793=*$%"9*%'$%:#9*7;*31:3'3'7<"/*#)%/;)*0739;1#%1$;)%*9%7*$%0*3/3(*#/1$#/*1*#/ #)9#;%9*:;*#:*10%1K;0@"%3'*1;%9%:;;3'*9:;;.%/33.;;)%(/3"/"<9$%13'K ^K`K^ /3"/"<9$%13'

are among the world’s most common diseases, with an an1</*1#*$%1#%%?#%%$%$31/@"@$*99)%/

$*:%:%:H0/9*H1$/3>%99%:7*9;39@*1'%#;*31:Q`cRK39/$>*$%H;)%%*();03:;79%=/%1;9% *1'%#;*31:>*;)J'%$#"%!!*"H(('$#$''$H!".)'$")(H '$"$#(+#!(H(%1*;/)%97%::*07/%?=*9<:HH)%7;*;*:=*9<:QRH1$)<01 77*//30=*9<:QRI//3'>)*#)#<:%H%=%1>*;)3<;H03:;#30031#31$*;*31:/%$*1(;3 )%/;)#9%#31:</;;*31:Q`cRK )%;3;/1<0"%93'1%>#:%:3';)%'3<9:031($</;:H(%$^bOaf@%9:H>:%:;*0;%$;3"% afeKf0*//*31(/3"//@*1_]]eK';)%:%H^]bKd0*//*31>%9%#:%:3'2)'$")(H^]cK^0*//*313'2 $#$''$H^]Kc0*//*313':@7)*/*:1$_dcKa0*//*313'2+#!(K/%:##3<1;%$'39_ccK^0*//*31 39bì3';)%1%>#:%:K3079%$;3_]]bH;)*:>:1^î*1#9%:%*11<0"%93'#:%:K1$$*;*31H; 1@73*1;*1_]]e*;>:%:;*0;%$;);^]]Ka0*//*31$</;:>%9%*1'%#;%$>*;)2)'$")(H`cKa 0*//*31>*;)2$#$''$H`cKa0*//*31>*;):@7)*/*:1$êdK]0*//*31>*;)2+#!(4785K )%:%1<0"%9:9%=%/(9%;7<"/*#)%/;)793"/%01$:;1$'3973;%1;*/:%9*3<:)%/;)#31:%8<%1#%: '39;)%*1'%#;%$(/3"//@H*';)%*1'%#;*31:9%13;;9%;%$31;*0%K)*/%*;0@"%#)//%1(*1(;3(%; 039"*$*;@%:;*0;%:'39//H:%?<//@;91:0*;;%$#)/0@$*/$*:%:%:1$;9*#)3031*:*:9%9%739;%$

(23)

_f ;3"%031(b]03:;#30031:%8<%/%3'//$*:"*/*;@#<:*1($*:%:%:1$*1-<9*%:H>*;)(/3"/ 79%=/%1#%3'_Kbi'39#)/0@$**10%11$^Kai'39;9*#)3031*:*:QèRK 1;*/_]]fH039%;)1c]0*//*317%37/%)=%"%%1*1'%#;%$>*;)1$1%9/@`]0*//*317%37/%)=% $*%$3'O9%/;%$#<:%:K;;)%%1$3'_]^^H1%:;*0;%$à0*//*317%37/%>%9%/*=*1(>*;)H >)*#)/:39%79%:%1;%$]Kei3'$</;:(%$^bOafK1;)%:0%@%9H^Kd0*//*317%37/%$*%$'930Q _ai$%#/*1%#3079%$>*;)_K`0*//*31*1_]]bRQ`fRK)*/%;)%(/3"/1<0"%93'1%>/@*1'%#;%$>:_]i /3>%9*1_]^^Q_Kb0*//*31R;)1*1_]]^H;)%"<9$%13'%7*$%0*#=9*%:#31:*$%9"/@"%;>%%1#3<1;9*%:H 9%(*31:1$737</;*31:''%#;%$Q_eRK 0739;1;:;%7:)=%"%%10$%;379%=%1;039;/*;@'930:*1;)%7:;$%#$%H9%:</;*1(*1$%#9%:% 3'039;/*;@$<%;31%?#/<$*1("@a`Kbi"%;>%%1^ff]1$_]^]K1'39;<1;%/@H$%;):$<%;3 N>%9%:;*//031(/%$*1(#<:%:3'$%;)1$@%9:3'/*'%/3:;$<%;379%0;<9%039;/*;@*1 _]^]Qa]RK)*/%$%;)9;%:'%//'3903:;3';)%$*:%:%:*1;)%7:;$%#$%H(%:;1$9$*:%$$%;) 9;%:'930N*1#9%:%$K1^ff]HN>:91.%$`b;)_{03:;#30031#<:%3'$%;)(/3"//@H} "<;*;03=%$;3"%;)%c;)*1_]^]Qa]RK1$$*;*31H:@7)*/*:*:1<0"%9`c;)_{:/%$*1(#<:%3'} 79%0;<9%039;/*;@(/3"//@*1_]^]Qa]RK /3"//@HN*:;)%`c;)_{/%$*1(#<:%'39@%9:/*=%$>*;)$*:"*/*;@*1_]^]H91(*1('930^}:;_*1 3<;)%91:<"O)91'9*#;3^`^:;_{*1%:;%91<937%QèRK} )3<()(9%;9%(*31/=9*"*/*;@%?*:;:*1039;/*;@1$039"*$*;@$<%;3H/9(%793739;*313' ;)%0*:;9%;"/%1$//9%79%=%1;"/%*1'%#;*31:O3';%1>*;):*07/%H*1%?7%1:*=%*1;%9=%1;*31:Q`cRK )*/%;)%9%*:13=%9//$%#/*1%*19;%:*101@)*()O*1#30%:%;;*1(:Q<:;9/*H91#%H;)%1$ RH*1#9%:%:031(9%3":%9=%$*1;)%%93'#–“reOemergent epidemics” Qa^RK*0*/9;3 H3;)%9:9%$*:793739;*31//@''%#;*1(*101@#3<1;9*%:H*1#/<$*1(<937%11*311$;)% <937%1#3130*#9%QNRQa_RK3'9%/%=1#%'390@"%*$%1;*'*%$:JH(31399)3%H :@7)*/*:H)%7;*;*:H)%7;*;*:H*1;%:;*1/79:*;%:Q03%"%1$'!"!RH*1;%:;*1/"#;%9* Q%:7%#*//@!!R1$/@07)3(91</30=%1%9%<0Q RQ_fRK:/3;3';)%03##<931/@:739$*#//@ *139>@H;)%$%;*/%$$%:#9*7;*313'//3';)%0>3</$"%"%@31$;)%:#37%3';)*:>39.K ^K`K_ #;%9*/*1'%#;*31:*10%1 “+#(((+!$())'%'()0)''#6)($"#.$)"!)2# )$+'222#$"$'(.%!(0 #$"$'!%0#$"$').%$222#)$)(+) #!))'.$*)$"#2“ 3<*:%9$*11$%/*1%QêfaO^fc^R 3<*:%9$*11$%/*1%$*$13;/*=%/31(%13<();33":%9=%;)%(9%;#30%O"#.3'"#;%9*/*1'%#;*3<: $*:%:%:H1$;)%*9*079%::*=%#7"*/*;@;3$%=%/371;*"*3;*#9%:*:;1#%':;%9;)1>%)<01:$%=%/37 1%>1;*0*#93"*/$9<(:K1'39;<1;%/@H>%13>'#%793"/%0::<#):0</;*7/%$9<(9%:*:;1; (31399)3%%=3/=*1(*1;31<1;9%;"/%$*:%:%K 1;)%'3//3>*1($%:#9*7;*31:3':%/%#;%$:%?<//@;91:0*;;%$"#;%9*/*1'%#;*31:H>*//"9*%'/@$%:#9*"% ;)%*99%/%=1;7;)3(%1%:*:1$03:;79%=/%1;:@07;30:3'*1'%#;*31*10%1K

(24)

_^] ^K`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`>%%.:K)%9%*: 73::*"*/*;@3'%@%*1'%#;*31Q*1#/<:*31#31-<1#;*=*;*:R;)93<()#31;#;>*;)*1'%#;*=%(%1*;/$*:#)9(%: Qa`RK )/0@$*%$313;/>@:793$<#%#/*1*#//@779%1;*1'%#;*31:K)/0@$*/*1'%#;*31:'3//3>:%/'O /*0*;%$#<;%#3<9:%1$9%:3/=%*1;3/3>O(9$%7%9:*:;%1;*1'%#;*31H>)*#)0@/:;'39@%9:H$<9*1( >)*#)%?#%9";*31:0@3##<9Qa`HaaRK/;%91;*=%/@H;)%"#;%9*9%#/%9%$"@;)%*00<1%:@:;%0K A*;)930@#*1::*1(/%O$3:%;9%;0%1;3'#)3*#%0.%:;)%;)%97@3'(%1*;/;9#;*1'%#;*319%/;*=%/@ :*07/%Qa`RK ^K`K_K_ 31399)3% (('$#$''$Q(313#3##*R*:$*7/3##3#<:H9%/;%$;3(('"##)(Q0%1*1(3#3##*RH;)% %;*3/3(*#/(%1;3'"#;%9*/0%1*1(*;*:QabRK 10%1H03:;#30031*1'%#;*31>*;)(313#3##<:*:#<;%1;%9*39<9%;)9*;*:H%=*$%1;';%91*1#<";*31 7%9*3$3'<:<//@_Ob$@:K)%:@07;30:*1#/<$%$@:<9*H##3071*%$"@0<#3*$390<#37<9</%1; $*:#)9(%H>)*#)*103:;7;*%1;:"%#30%:7<9</%1;>*;)*1$@K*;)3<;;9%;0%;H:731;1%3<: 9%:3/<;*31<:<//@'3//3>:*1'%>031;):K307/*#;*31:*1#/<$%%7*$*$@0*;*:H#<;%39#)931*# 793:;;*;*:H73:;%9*39<9%;)9*;*:H>)*#)0@/%$;3:;91(<9*1$<9*19@<9(%1#@H:%0*1/=:#</*;*:1$ infections of Cowper’s and Tyson’s glan$:QacRK

%#;/*1'%#;*31:9%'9%8<%1;031(1$01@9%:@07;30;*#H)3>%=%9:@07;30:Q*1'%>%9 ;)1^]i3'*1'%#;%$R0@91(%'9301/79<9*;<:H$*:#)9(%H9%#;/"/%%$*1(H;33=%9;793#;*;*:>*;) :%=%9%7*1H;%1%:0<:1$#31:;*7;*31K*0*/9/@H3=%9f]i3'7)9@1(%/*1'%#;*31:9%:@07;30;*#H ;)3<()7)9@1(*;*:39;31:*//*;*:):"%%11%#$3;//@9%739;%$K731;1%3<:9%:3/<;*313'7)9@1(%/ (31399)3%*1'%>>%%.:):"%%1$%:#9*"%$QadRK )*/%<9%;)9/*1'%#;*31:9%99%/@:@07;30;*#*10%1Q^O`iRH:@07;30;*#7)9@1(%/1$9%#;/ *1'%#;*31:9%/*.%/@*0739;1;*1(31399)3%;91:0*::*31H:;)%:%0%199%/@:%%.0%$*#/;;%1;*31 1$;9%;0%1;QacRK1;9%;%$*1'%#;*310@7%9:*:;'39#31:*$%9"/%7%9*3$:1$*1#9%:%;)%9*:.3' $*::%0*1;%$*1'%#;*31H*1#/<$*1($%90;*;*:O9;)9*;*::@1$930%H%1$3#9$*;*:1$0%1*1(*;*:K 1;)%7:;$%#$%:H(9$</:%/%#;*313'1;*"*3;*#9%:*:;1;(313#3##*;)93<()#)9303:30/ 0<;;*31:Q/3>O/%=%99%:*:;1#%;37%1*#*//*1:1$;%;9#@#/*1%:R1$7/:0*$:;);0%$*;%)*() 9%:*:;1#%/%$;3*1%''%#;*=%1%::3'7%1*#*//*11$;%;9#@#/*1%*103:;9%:K39%%?7%1:*=%1;*"*3;*#:

(25)

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(26)

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symptomatic disease (“lenti” –/;K:/3>RQbeRKO_):/3>%97;)3(%1*#*;@1$:/3>%9$*:%:%

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(27)

_^` 13$%:H;)93;1$0<:#/%7*1H9:)1$0/*:%%;#KH$%13;*1(#<;%9%;93=*9/:@1$930%K)%:;(%3' #/*1*#//;%1#@Q:@07;30;*#39#)931*#*1'%#;*31R'3//3>:H>)*#)#1=9@'930'%>>%%.:;3 ;>%1;@@%9:39039%<:<//@>*;)1339'%>:@07;30:1$$<9*1(>)*#);)%=*9<:*:"/%;3%''*#*%1;/@ :79%$031(;)%737</;*31H*::;*//0-397<"/*#)%/;)#)//%1(%QbeRK

While some individuals (i.e. “lon(Oterm nonprogressors”) remain healthy for many years without having 9%#%*=%$1@;9%;0%1;H*1;)%=:;0-39*;@Q3=%9f]iR3'O*1'%#;%$7;*%1;:793(9%::*31;3– :%%$%'*1*;*31'<9;)%9"%/3>O*:*1%=*;"/%H*(<9%^Qc]Hc^RK1@79;*#</9*1$*=*$</X:$*:%:%#3<9:% 0@H)3>%=%9H=9@#31:*$%9"/@K)3:%>*;))*()%:;=*9/"<9$%1:Q#<;%H1$97*$ 793(9%::39:R9%03:;#31;(*3<:Qc_RK #!1.E<!*.(#6!.,"+ 0".(0#+*/"#,03* +,#/?2#.((+@*H+1*0/+2. 0"2.!(#*#(+1./+ 1*0.0 #* 0#+*<(1(#*;HQ_{((+1*0?((/,.T@:.} (#* +,#/,.)+ ,(/):/+*.54#/<%9:*317<"/*:)%$31_]J`]H^`%#%0"%9_]^_K3 #37@9*();K*;)7%90*::*31<1$%9;)%9%;*=%30031:]^K]1*=%9:/<"/*#30*1%$*#;*31Qc^RK ):)*()';/*;@9;%1$:<9=*=/3'7;*%1;:*1''/<%1;#3<1;9*%:>*;)3<;;9%;0%1;<:%$;3"%`O b@%9:';%9;)%$*(13:*:QbfRK)%/*'%%?7%#;1#@*::*(1*'*#1;/@793/31(%$*'#30"*1%$1;*9%;93=*9/ ;)%97@Q#R*:*1*;*;%$%9/@I3''%9*1(1%91390/8</*;@3'/*'%H793=*$%$/31(;%90(33$$)%9%1#% *:0*1;*1%$Qc`RK*1#%;)%=*9<:*1=9*"/@9%77%9:';%9;)%#%::;*313':<779%::*=%;9%;0%1;H 79%:<0"/@'930#%//=*9/9%:%9=3*9:H;)%*1'%#;*319%0*1:*1#<9"/%QbeRK )%*1*;*/:<9=%*//1#%$%'*1*;*313'1#:%*1#/<$%$039%;)1$3A%137739;<1*:;*#*1'%#;*31: 1$:%=%9/#1#%9:H793=*$%$3;)%9*00<13$%'*#*%1#@#<:%:>%9%9</%$3<;K)%$%'*1*;*31>:/;%9

(28)

_^a "93$%1%$;3*1#/<$%/"39;39@#31'*90;*313'1$$$*;*31/*1$*#;39$*:%:%:K)%%1;%9s’'39 *:%:%31;93/QR$%'*1*;*31'930^ff`*1#/<$%$aj_{#%//#3<1;<1$%9_]]N00}`_39aj /@07)3#@;%7%9#%1;(%3';3;//@07)3#@;%:*:/%::;)1^aiH9%(9$/%::3'#/*1*#/:;;<:H;3"% *1$*#;*=%3'K)%:%"*3/3(*#/#9*;%9*>%9%13;*1#/<$%$*1;)%<937%1#:%$%'*1*;*31QcaRK *:(9%%0%1;9%0*1:31>)%1;3:;9;;)%;9%;0%1;*1$*(13:%$7;*%1;:K)*/%;)%9%*:(/3"/ consensus that any HIV+ person with CD4 counts less than 350 cells/μl should be treated, it remains #31;93=%9:*/>)%;)%9#*:*1$*#;%$*1:@07;30;*#O*1'%#;%$7%9:31:>*;)a#3<1;:"3=% 350 cells/μl, or whether it is more advisable to defer treatment and monitor CD4 count QcbRK

139>@H73:*;*=%1;*"3$@;%:;#<99%1;/@1%%$:;3"%#31'*90%$>*;);>3*1$%7%1$%1;;%:;:*1 ;)%9%'%9%1#%/"39;39@K*''%9%1;;%:;:Q1;*"3$@H1;*"3$@1$1;*(%1H1<#/%*##*$ 07/*'*#;*31;%:;:QR%;#KR$*''%9##39$*1(;3:%1:*;*=*;@H:7%#*'*#*;@1$"*/*;@;3$%;%#;1%9/@ *1'%#;*31K3<9;)(%1%9;*31#30"*1%$;%:;Q1;*"3$@1$7_a1;*(%1R#1"%73:*;*=%:%9/@:^O 2 weeks after the exposure, greatly shortening the “window period”H>)%1;)%1;*"3$*%:0*();13;@%; "%$%;%#;"/%Qc_RK33/*1(:%9'39#1"%#3:;O%''%#;*=%0%;)3$3'*1#9%:*1(;)%:%1:*;*=*;@3' ;)%;%:;*1(Qc_RK 0%;%#)1*8<%*:/:3<:%$*1<1/*1.%$131@03<:;%:;*1(QR:%9379%=/%1#%:<9=%@:*1>)*#) 9%:*$</"/33$:07/%:;.%1'391@$*(13:;*#7<973:%:9%;%:;%$';%9;)%@)=%"%%1*99%=%9:*"/@ <1/*1.%$1$131@0*:%$'930;)%*9:3<9#%K1;)*:*1:;1#%H%?7/*#*;#31:%1;*:13;3";*1%$*1;)% QccRH>)*/%*;*:1%#%::9@*1;)%%;)%9/1$:QcdRK*''%9%1;737</;*31(93<7:0@"%;9(%;%$>*;) Q1%>O"391:H#/*1*#:<:%9:H*1;9=%13<:$9<(<:%9:H;;%1$*1(=%1<%%;#KRK139>@H): 13;"%%1$%%0%$%7*$%0*3/3(*#//@1%#%::9@1$):1%=%9"%%1<1$%9;.%1QcdRK 1</@_]^_H;)%33$1$9<(:$0*1*:;9;*317793=%$97*$)30%;%:;H>)*#)//3>:<:%9: ;3;%:;;)%0:%/=%:'39*1'%#;*31;)30%K30%;%:;:9%0*1#31;93=%9:*/7<"/*#)%/;);37*#K 3:;O%?73:<9%7937)@/?*:QR):793=%1;3"%)*()/@%''%#;*=%*19%$<#*1(;)%9*:.3'#8<*9*1( *1'%#;*31H*'*1*;*;%$:331';%9%?73:<9%1$#31;*1<%$'39_e$@:QceRK1</@_]^_H;)%33$1$ 9<(:$0*1*:;9;*317793=%$3'$*/@39/;%13'3=*91$%0;9*#*;"*1%'3979%O%?73:<9%7937)@/?*: Q9R;379%=%1;*1'%#;*31*1)*()O9*:.*1$*=*$</:*1;)%H"<;:<#);)%97@9%0*1:)*()/@ #31;93=%9:*/'39)%/;)@*1$*=*$</:QcfRK ^K`Ka 7*$%0*3/3(@3'031(1$#3O*1'%#;*31: “$+*'!!!#((#)$!+)*#)')-%)$'%'.'(! () #.$*'##' #( #$)$'"$+)!"2” 1$9K3<(/: )%*1*;*/$%#/*1%3':031($<%;3:'%9:%?79#;*#%:*1;)%$=%1;3';)%%7*$%0*#Q: >%//::)39;%9:<9=*=/3';)3:%>*;)R>:'3//3>%$"@13":%9=%$*1#9%:%:*1#%;)%/;%^ff]:*1 *1$<:;9*/*A%$1;*31:Q^RK9*%;@3'#<:%:'39;)*:<1%?7%#;%$*1#9%:%)=%"%%1:<((%:;%$Qd]R1$ >%:)//%?7/39%:30%>)*#)0@"%77/*#"/%;3*139>@K

(29)

_^b <99%1;/@H3<;"9%.:3':@7)*/*:H/@07)3(91</30=%1%9%<0Q RH)%7;*;*:=*9<:*1'%#;*31QR1$ 3;)%9*101@<937%1#*;*%::<((%:;)*()O9*:.:%?</"%)=*3<91$%?;%1:*=%:%?</1%;>39.*1( Qa_RK ;:)3</$"%13;%$;);*1#31=%1*%1#%:07/%:H;)%79%=/%1#%'*(<9%:9%3';%1%:;*0;%$031( ;)*()%:;9*:.QeRH;)<:/*.%/@3=%9%:;*0;*31K<%;3*1%=*;"/%$*''*#</;*%:*19%#)*1(1$ :#9%%1*1(%1;*9%737</;*313'H$%:#9*"%$79%=*3<:/@H;)%79%=/%1#%%:;*0;%:(*=%1"%/3>0*(); "%"*:%$K)%79%=/%1#%3'*1'%#;*31031(0%1>)3)=%:%?>*;)0%1*1:<9=%@:*1#7*;/#*;*%: *:31verage 13 times higher than that in the country’s general population Q_eRK1:07/*1(H>)*#)*: 01@;*0%:13;1;*31//@9%79%:%1;;*=%H:*;*:039%/*.%/@#31$<#;%$*1;)%#7*;/:H<937%1 countries where HIV prevalence is ≤1% in general population, reported the following prevalence among *19%#%1;@%9:J<1(9@aiHA%#)%7<"/*#biH>%$%1ciH;=*diH/3=%1*diH9%/1$fiH 39;<(/^]iH>*;A%9/1$^îH %901@^_iH 9%%#%^ìH7*1^ìH%;)%9/1$:âiH91#%^di Q_eRK%;>%%1_]]a1$_]]fH9%739;*1(9;%:*1*1#9%:%$*1;)%N'930`Kb;3aK^7%9 ^]]]]]0/%:Qa_RK101@#3<1;9*%:H*1#/<$*1(39>@H$;3179%=/%1#%031(9%13; =*/"/%39031*;39%$9%(</9/@K3079%$;3)%;%93:%?</7%37/%*1;)%:0%737</;*31:H)=% )*()%99;%:3'$</O1$0</;*7/%O=9*1;*1'%#;*31:Qa^RK <0177*//30=*9<:QR*:;)3<();;3"%;)%03:;#30031*1$%=%/37%$#3<1;9*%:Q^R1$;)% 79%=/%1#%3')*()O9*:.31#3(%1*#*1'%#;*31*:)*()%:;*1Qb_RK11%(;*=%H;)%79%=/%1#% 3'*:%:;*0;%$;3"%b]i*173:*;*=%HebiQ^Hb_RK031(;)%/;;%9H;)%*1#*$%1#%3'1/#1#%9 *:;>*#%:)*():#3079%$;31%(;*=%Qb`RK )%9*:.3'#8<*9*1(*1'%#;*31:%%0:;3"%)*()%9*1;)3:%__Oài3'H>)3#99@:;9*1:3' )*()9*:.31#3(%1*#73;%1;*/Qb_RK%#*793#//@H%?*:;*1(*1'%#;*31*:9*:.'#;39'39*1'%#;*31 Q%7*$%0*3/3(*#/:@1%9(@RK>*;))*()9*:.(%13;@7%:9%039%/*.%/@;3"%*1'%#;%$>*;)3;)%9 :H:<#):9%#;/*1'%#;*31>*;)!".)'$")(02$#$''$1$O_Qb_RK Q#<:*1( "#;%9*R0@%1)1#%;91:0*::*311$#8<*:*;*31031(Q^RK)%*1'%#;*31*1#9%:%: ;)%9*:.3'#8<*:*;*31"@;>3;3;)9%%'3/$:>%//:;91:0*::*31*1$<//@*1'%#;%$*1$*=*$</: QbdRK 1;)%<937%11*311$;)%<937%1#3130*#9%QNRH;)%793739;*313'#3O*1'%#;*31:*: )*()%:;031(>*;)Qfb–^]]iR1$ Q`b–^]]iR1$*:/3>%9'39:@7)*/*:Q_]–c]iR1$ (31399)3%Q_]–`biRQa_RK ^K`Kb 91:0*::*313'::3#*;%$>*;)$*''%9%1;:%?</79#;*#%: “#+'"((#)$+(-$'%%'$#)!+($#2” 39%*$/ ;)*#/1$/3(*:;*#/*::<%:79%=%1;$*9%#;%:;*0;%:3'%''*#*%1#@3';91:0*::*317%9:%?</#;K)% %:;*0;%:;)<:#30%'930/31(*;<$*1/#3)39;:;<$*%:H$3#<0%1;*1(;)%:%"%)=*3<9:Q^RH;)3<()*; :)3</$"%:;9%::%$;);:<#):;<$*%:'#%:%=%9/0%;)3$3/3(*#/793"/%0:Q;)%:3<9#%3'*1'%#;*31*: $*''*#</;;3*$%1;*'@9%;93:7%#;*=%/@1$9%/;*31:)*7:0*();13;"%0313(03<:RK>*//$$9%::'#;39: ;);7/@93/%*1*1'%#;*31%:;"/*:)*1(*;:%/'*1:<:#%7;*"/%737</;*31*1;)%1%?;#)7;%91$>*//

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_^c )%9%$*:#<::;91:0*::*"*/*;@–793""*/*;@'39:<:#%7;*"/%*1$*=*$</;3(%;*1'%#;%$$<9*1(:*1(/% :%?</#31;#;>*;)1*1'%#;%$*1$*=*$</Q`bRK 3079%$;3)%;%93:%?</7%37/%H;)%%:;*0;*313'7%9#;9*:.*1*:039%#307/%?13;31/@ "%#<:%9%(</99%/;*31:)*7:9%'9%8<%1;/@1310313(03<:>*;)79;1%9:3'<1.13>1:;;<:H"<; /:3"%#<:%#1;.%%*;)%9*1:%9;*=%399%#%7;*=%93/%Qd^RK @Q<1:7%#*'*%$R:%?</#31;#;H:@7)*/*:*:;91:'%99%$;3`]i3'<1*1'%#;%$79;1%9:QafRK 1:@:;%0;*#9%=*%>H;)%%''*#*%1#@3';91:0*::*31'399%#%7;*=%<1793;%#;%$1/*1;%9#3<9:% QR>:%:;*0;%$;3"%^KaiSJ]K_O_KbT7%9#;1$a]KaiSJcK]OdaKfT7%979;1%9Q*K%KH*99%:7%#;*=% 3'$<9;*311$'9%8<%1#@3':%?#;:R>*;)139*:.$*''%9%1#%3":%9=%$"%;>%%1)%;%93:%?</:1$ Qd_RK1:;<$@31â_d*1<:;9/*H;)%7%9O#;793""*/*;@'399%#%7;*=%>:^KaìSfbiJ ]Kae–_KebT*'%-#</;*313##<99%$*1:*$%;)%9%#;<0H1$]KcbiSfbi]K^b–^Kb`T>*;)7%1*: >*;)$9>/79*39;3%-#</;*31K )%%:;*0;%$;91:0*::*319;%*1;)%:0%:;<$@'39*1:%9;*=%*179;*#*71;:>)3>%9%#*9#<0#*:%$ >:]K^îQfbi]K]_–]K_aRH1$*;>:]Kc_iQfbi]K]d–^KceR*1<1#*9#<0#*:%$0%1Q]K^ci 9%(9$/%::3'#*9#<0#*:*31:;;<:RQd^RK1;)%9%=*%>H13;91:0*::*31%:;*0;%:7%9#;>%9%73::*"/% 1$;91:0*::*31%:;*0;%'39*1:%9;*=%7%979;1%9:)*7>:_^KdiSfbiJ]K_Oa`K`T1$#30"*1%$ *1:%9;*=%1$9%#%7;*=%7%979;1%9:)*7`fKfiSfbiJ__KbObdKaTQd_RK 31399)3%*:/*.%/@8<*;%%''*#*%1;/@;91:0*;;%$"@*1:%9;*=%399%#%7;*=%1/*1;%9#3<9:%QacRH #31:*$%9*1(;)%9*:.3'*1'%#;*31'390%1*1*1:*1(/%)%;%93:%?</*1;%9#3<9:%):"%%1%:;*0;%$;3"% ^fK]O_bK]iQd`RK;)%9H%''*#*%1;/@;91:0*;;%$"@1/*1;%9#3<9:%H*1#/<$%J:@7)*/*:H#)/0@$* Q*1#/<$*1( RH)%97%::*07/%?=*9<:1$)%7;*;*:QdaRK)%:%*1'%#;*31:0@9%:</;*1%*;)%9 :@07;30;*#39:@07;30;*#793#;*;*:H*1#/<$*1(*;#)*1(H7*1H#907:1$$*:#)9(%*11$93<1$;)% 1/#1/QdaRK 9/;91:0*::*31):"%%1%:;*0;%$;3"%]KaN^]]]'%//;*3#;:Q^RH"<;;)*:*:1<19%/*"/% %:;*0;%H:13;01@9%#39$:3':<#);91:0*::*31%?*:;1$*;*:;)3<();;);01@'#;39:H''%#;*1( 39/)%/;)H9%*1=3/=%$K )9@1(%/"#;%9*/*1'%#;*31:9%3':7%#*/*1;%9%:;H:;)%@9%'9%8<%1;/@:@07;30;*#1$0@H*1 ;)%":%1#%3'9%(</9;%:;*1(1$;9%;0%1;H7%9:*:;'39/31(%97%9*3$:QaaRK%#%7;*=%39/:%?>*;)3<; #31$301$<:%3'1/:%?;3@:>%9%*$%1;*'*%$:0-399*:.'#;39:3':@7)*/*:*1'%#;*31*1 0;#)%$#:%O#31;93/:;<$@*191#%QdbRK)9@1(%/#)/0@$*H$%;%#;%$*1î3'<:;9/*1H >:13;::3#*;%$>*;)7)9@1(%/:@07;30:1$7)9@1?>:;)%31/@/3#;*313';)%*1'%#;*31*1d]i QaaRK*0*/99%:</;:>%9%9%739;%$031(_^fd*1 %901@Q_]]fO_]^]R>*;)7)9@1(%/ #)/0@$*$%;%#;%$*1^KbiQ9%#;/*1eK]iR1$7)9@1(%/(31399)3%$%;%#;%$*1bKbiQ9%#;/*1aKciRK :0<#):èi3'(31399)3%*1'%#;*31:>%9%%?#/<:*=%/@7)9@1(%/QdcRK<9;)%9039%H31/@bKî3' >*;)7)9@1(%/*1'%#;*319%739;%$1@/3#/:@07;30:QdcRK *0*/9;3393O(%1*;/:%?H>)*#)*:93<;%3';91:0*::*31'39!".)'$")(0((' $#$''$H:@7)*/*:H#)1#93*$H(('"##)(1$9%:7*9;39@39(1*:0:H393O1/:%? Q9*00*1(R*:*07/*#;%$*1;)%;91:0*::*313'=9*3<:%1;%9*#*1'%#;*31:QddRH'39%?07/%!!0 '!"!0!"$#!!02.()$!)0"%.!$)'0'.%)$(%$'*"1$)%7;*;*:H>)*#)0@

(31)

_^d 3##<9#30031/@031(:%?<//@#;*=%QdeRK)*/%*;*:<1#/%9)3>9%$*/@;)%:%9% ;91:0*;;%$*1;)%#;:3'7%1*/%O39/1$393O1/:%?H*;*:7/<:*"/%;);7)9@1(%/*1'%#;*31:0@)=% 93/%*113(%1*;/*1'%#;*31:QaaRH%:7%#*//@#31:*$%9*1(<:*1(#31$30*139/:%?0*();"%79#;*#%$ 99%/@031(K131%:;<$@H393O(%1*;/;91:0*::*31##3<1;%$'39_ci3'<9%;)9/(31399)3%*1 QdfRK@7)*/*:>:/:3::3#*;%$>*;)9*00*1(Qe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e^RK*:;*1(Q>*;)(/3=%:R>:/:3::3#*;%$>*;):@7)*/*: ;91:0*::*31Qe]RK 31%;)%/%::H#31$30<:%*17%1%;9;*=%1/:%?$3%:13;(<91;%%793;%#;*31'39"#;%9*/1$ 793;3A31:H>)*#)9%3';%1:79%$>*;)3<;7%1*/%7%1%;9;*31QdaRK)%<:%3':/*=:/<"9*#1;*1 *1:%9;*=%399%#%7;*=%7%1*/%O1/*1;%9#3<9:%39'*1(%9*1(N'*:;*1(*:>*$%:79%$79#;*#%031(H >)*#)0*();%?7/*1>)@9%;(9%;%99*:.'39#@;30%(/3=*9<:H1$039%9%#%1;/@ $*:#3=%9%$73:*:9#30O::3#*;%$)%97%:=*9<:*1'%#;*31:Qe_RK

Sharing semen (“cum play”) can include ejaculation over the anus, rubbing semen over the anus or using :%0%1:/<"9*#1;$<9*1(0:;<9";*3139'39$*(*;/1$7%1*/%7%1%;9;*31>*;)73;%1;*/9*:.'39 ;91:0*::*31Qe`RK'390of semen exchange called “felching’’ involves oral ingestion of semen from a partner’s anus following UAI Qe`RK

313#3##*:<9=*=%31/@:)39;;*0%3<;:*$%;)%)<01"3$@1$;91:0*::*31*:H/;)3<()<1/*.%/@H 73::*"/%/:3$*9%#;/@;)93<():)9%$3"-%#;H:<#):";);3>%/QabR391*1'/;"/%$3//QeaRK%1#%H :)9%$:%?</;3@:0@/:3"%0%1:3';91:0*::*31K 937)*/*Q“>;%9:739;:”39“(3/$%1:)3>%9:”R79#;*#%:0@;91:0*;)%7;*;*:H#@;30%(/3=*9<:H(%1*;/ )%97%:H#)/0@$*1$(31399)3%K ;:)3</$"%73*1;%$3<;;);3;)%9:%?</79#;*#%:H13;1%#%::9*/@*1=3/=*1(11/*1;%9#3<9:%H$3 #30%>*;)9*:.3';91:0*::*31H>)*#)*:$*''*#</;;3:#%9;*1K?07/%:)=%"%%1(*=%1*1:;<$@ 3':%?</79#;*#%:3': “nudging” (touching or rubbing of another man’s anus with the penis without a condom); “dipping” (partly inserting or briefly inserting the penis into the anus without a condom, followed by immediate withdrawal); and “docking” (pulling one’s foreskin over another man’s 7%1*:RQebRK:;)%<;)39:73*1;3<;H:30%3';)%:%79#;*#%:0@%?7/*11/*1'%#;*31:*1;)%":%1#% 3'9%739;%$1/:%?K

(32)

_^e ^Ka 91:0*::*31$@10*#:1$:%?</1%;>39.:

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/*.%/@;)10%0"%9:3';)%(%1%9/737</;*31;3"%#30%*1'%#;%$>*;)1KBecause the “core group” *:$%'*1%$79*09*/@31"%)=*3<9/(93<1$:H0%0"%9:9%13;7%901%1;QacRK)*:*:9%/%=1;'39 73;%1;*/%9$*#;*313'K/%9/@H1*1'%#;*31#113;7%9:*:;<1/%::1*1'%#;*3<:7%9:31;91:0*;:;)% $*:%:%;3:<:#%7;*"/%7%9:31K:3773:%$;33;)%9*1'%#;*3<:$*:%:%:H$%7%1$%1;31$*/@:3#*/ #31;#;:'39;)%*9;91:0*::*31H#31;#;:0*();"%'%>%91$)77%1*1;%90*;;%1;/@K;)%0;*#/ 03$%/::<((%:;;);(31399)3%79%=/%1#%#3</$$%#/*1%;3A%93H)$*;13;"%%1'39#39%(93<7 0%0"%9:;91:0*::*31H:;)%;91:0*::*31*:13;^]]i%''*#*%1;1$:731;1%3<:#<9%:$33##<9QacRK ;;)%737</;*31/%=%/H;)%:79%$3'1$%7%1$:<731;)%=%9(%1<0"%93'1%>#:%:3'*1'%#;*31 (%1%9;%$"@1*1'%#;%$7%9:31K)*:#1"%$%:#9*"%$*1;%90:3'9%793$<#;*=%9;%QR>)*#)H'391 H$%7%1$:<731;)%%''*#*%1#@3';91:0*::*31–;)%793""*/*;@3';91:0*::*31*1#31;#;"%;>%%1 1*1'%#;%$*1$*=*$</1$:<:#%7;*"/%31%–an “attack rate”Q"RH;)%0%19;%3':%?</79;1%9: #)1(%Q#R1$;)%=%9(%$<9;*313'*1'%#;*3<:1%::QR1$;)%793739;*313';)%737</;*31;);*: :<:#%7;*"/%Q%R:%?79%::%$*1;)%'390J

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)%)*()%9;)%=/<%3'H;)%(9%;%9;)%73;%1;*/'39;)%:79%$3';)%*1'%#;*31Q`bRK*1#%:%?</ #31;#;:9%31/@*1;%90*;;%1;H*;*:13;:<979*:*1(;3/%91;);03:;3'*1$<#%7339*00<1*;@*'1@; //1$=##*1%:#<99%1;/@%?*:;'3931/@'%>K139$%9'397;)3(%1;3>*;):;1$%9$*#;*31H/31( 7%9*3$3'*1'%#;*=*;@H3';%1031;):39@%9:*:1%#%::9@K1;*0*#93"*/1$1;*9%;93=*9/9%:*:;1#%9% /:3031(*0739;1;'#;39:;);0@73;%1;*;%;91:0*::*31:;)%@;@7*#//@793/31(;)%7%9*3$ 3'*1'%#;*=*;@Qd]RK $$*;*31//@H9%O#;*=;*31*1#:%3')%97%:=*9<:%:0%1:9%7%;%$*1'%#;*=*;@Q3';%179%#%$*1(#/*1*#/ :@07;30:R*1:30%*1$*=*$</:1$)%1#%039%:<##%::'</;91:0*::*31QecRH9%:</;*1(*1=%9@)*() :%93/3(*#/79%=/%1#%QbfRK@<:*1(#31$30:Q''%#;*1("RH/3>%9*1(1<0"%93':%?</79;1%9:Q#R1$ $%=%/37*1(=##*1%:Q%RH;)%%9$*#;*313'*:)@73;)%;*#//@73::*"/%K :>%)=%:%%1*1;)%79%=*3<:#)7;%9H$*''%9%1;:%?</79#;*#%:Q9%/;%$;393<;%3'%?73:<9%1$ *1;%1:*;@3'%?73:<9%R0*();"%::3#*;%$>*;)$*''%9%1;;;#.9;%:K)%;)%93913;;)%%?73:%$ *1$*=*$</>*//"%#30%*//>*///:3$%7%1$31#)9#;%9*:;*#:3';)%7;)3(%1Q%K(K=*9</%1#%3':;9*1R QedRK;:)3</$/:3"%:;9%::%$;);;)%"3=%'390</*:;33:*07/*:;*#;3*1#/<$%#31;#;7;;%91:*1 :3#*%;@H>)*#)9%H%:7%#*//@*1;)%#:%3'H13;91$3039)303(%13<:QecRK179#;*#%H;)%0%1 9;%3':%?</79;1%9:#)1(%*:/:3$*''*#</;;3%=/<;%H:;)%"%)=*3<90@(9%;/@=9@"@;*0%1$ *1#/<$%#31#<99%1;:%?</9%/;*31:)*7:>*;)$*''%9%1;7%37/%K%?</1%;>39.:H79;1%9#31#<99%1#@1$ 7;;%91:3'79;1%9:0*?*1(H:<#):91$30H::39;;*=%Q/*.%>*;)/*.%R39$*:::39;;*=%)=%"%%1<:%$ ;30;)%0;*#//@03$%/;)%%7*$%0*#QeeRK:79%$'930#39%(93<7:>*;))*()1<0"%93':%?</ #311%#;*31:(i.e. “high density networks”)H*1>)*#)9%0*1;*1%$%1$%0*#H;3/3>%99*:.*1$*=*$</:

(33)

_^f ;)93<()concurrent partnerships of “bridge persons”H3';%1*1=3/=*1(#/*%1;:3':%?>39.%9:3903"*/% 0%1H'39%?07/%0*(91;>39.%9:H;9<#.%9:%;#KQ`cHeeRK

)*/%)@73;)%:%:;);131Ogay homosexually active men might represent a group, “substantially less at risk than gay men” do exist Q^_RH9%=*%>3':;<$*%:310/%:0%O:%?"%)=*3<9*1/3>O1$0*$$/%O *1#30%#3<1;9*%:*1$*#;%:;);1<1%?7%#;%$/@/9(%793739;*313'*1=3/=%:*1)%;%93:%?</:%? 1$01@3';)%00@/#..13>/%$(%"3<;9*:.:3'<1793;%#;%$1/*1;%9#3<9:%1$>931('<//@ ::<0%*;;3"%/3>%9;)19*:.3'<1793;%#;%$=(*1/*1;%9#3<9:%QeRK<%;3"9*$(*1(H;)%"<9$%1 3'*:13;1<1*0739;1;1$*:3/;%$7<"/*#)%/;)793"/%0K139$%9;3*1;%99<7;;)% ;91:0*::*31H#39%1$"9*$(*1((93<7::)3</$"%;9(%;%$>*;)79%=%1;*31793(90:Q`cRK ^Kb 31*;39*1(3':%?<//@;91:0*;;%$*1'%#;*31:;91:0*::*31 “')#*"'(! %')"#'+'.''2” %1%%:#9;%: ''%#;*=%#;*31:*179%=%1;*1(;)%;91:0*::*313'031(*11@737</;*319%J=##*1;*31H>)%9% =*/"/%H0313(03<:9%/;*31:)*7:H;%:;*1(H;)393<()#31;#;;9#*1(H%''%#;*=%;9%;0%1;H/3>%9*1( *1'%#;*=*;@H$%#9%:*1(9*:.3'%?73:<9%Q#31$30:1$3;)%9"99*%9:RH1$=##*1;*31K )%*0:3';)%31(3*1(03$%91:<9=%*//1#%:@:;%0:9%;3'<9;)%93<9<1$%9:;1$*1(3' $*:;9*"<;*31*1;)%#300<1*;@*139$%9;3*1'39079%=%1;*31%''39;:39;3%=/<;%;)%%''%#;*=%1%::3' 79%=%1;*31*1;%9=%1;*31:Q^aRK #!1.F<.+)#* 0#+*0+1.;/5/0)"((*!/0+ ##*0(500*0.0((#* 0K30% :731;1%3<:#<9%:0@)3>%=%93##<9'39#%9;*1K 3$%91/"39;39@;%#)1*8<%:793=*$%''39$"/%$%;%#;*311$#31'*90;*313':1$9%*0739;1; 79;3':<9=%*//1#%:@:;%0:K1(%1%9/H;)%##<9#@3':<9=%*//1#%>*//$%7%1$)%=*/@31;)%03<1; 3'/"39;39@;%:;:7%9'390%$K)1(%:*1;%:;*1(#;*=*;@9%/*.%/@;3''%#;:<9=%*//1#%9%:</;:K)*:*: 79;*#</9/@793"/%0;*#>*;):@07;30;*#H*1>)*#)7;*%1;*:/%::/*.%/@;3:%%.0%$*#/::*:;1#% Q*(<9%_RK031(;)%$*(13:%$#:%:3'H31/@#%9;*1793739;*31*:3';%19%739;%$K)<:H*1:7*;%3' :731;1%3<:#<9%3':30%Hthe numbers in the surveillance system represent only the “tip of the