HIV Australia | Vol. 9 No. 3 | November 2011

JANE LOERNER and SEIICHI ICHIKAWA give an overview of HIV testing, treatment and prevention among gay and other men who have sex with men in Japan.

Japan is a country with low HIV prevalence by international standards. In 2009, less than 0.1% of the total population were estimated to be living with HIV.¹

Despite this, the yearly number of cases of HIV in Japan has been steadily rising, with dramatic increases observed among men who have sex with men since 2000.²

At the end of 2010, there were a total of 18,342 cumulative reports of people with HIV and or AIDS in Japan; this cumulative figure consists of 11,573 people with HIV and 5,330 people with AIDS. Additionally, there were 1,439 reports of people becoming infected through blood products prior to 1986.³ In 2010, 68% of new cases of HIV were acquired through male-to male sexual transmission, while heterosexual transmission accounted for 18% of cases.⁴ Gay men and other men who have sex with men are therefore deemed a priority population in terms of HIV prevention in Japan.⁵

Continued increases in Japan’s HIV rates, along with disproportionate rates of HIV among men who have sex with men have led gay community-based groups, through funding by the Japan’s Ministry of Health, Labour and Welfare (MHLW), to focus on capacity development activities around testing and treatment, and to support the development of awareness campaigns targeting gay men and other men who have sex with men.

Japan’s response to HIV is based around the provision of education, voluntary HIV counseling and testing, and access to high quality HIV treatments.⁶ While gay men and other men who have sex with men are designated as a priority group in relation to HIV policy, efforts to date have not slowed the steady increase in cases of HIV among this group. This article summarises recent HIV testing, treatment and prevention initiatives in Japan, particularly those that target priority populations of gay men and other men who have sex with men, and makes recommendations for future directions.

HIV testing

Japan’s HIV testing policy is based on the provision of free and anonymous testing at public health centres, but the majority of these centres only provide HIV testing for a two to three hour period one day per week.⁷ A few local governments have contracted volunteer based non-government organisations (NGOs) to provide rapid HIV testing services in the evenings and on weekends and non-anonymous HIV tests are also available at hospitals and clinics, but the cost is not fully covered by health insurance.

While there has been little research into the accessibility of HIV testing services, a survey conducted among men who have sex with men attending a community-organised HIV testing event in Nagoya found that 66.5% of respondents reported that HIV testing at public health centres is difficult to access due to limited available times for HIV testing is and lack of information on where to go for testing.⁸

In 2006, the MHLW provided funding through the Japan Foundation for AIDS Prevention for a five-year strategic research project that aimed to increase HIV testing rates and reduce AIDS diagnoses among the general population and men who have sex with men in the Tokyo and Osaka areas.⁹ One of the project’s aims was to increase gay and bisexual men’s awareness of gay-friendly HIV counseling and support services, using gay community campaigns produced by NGOs. This was accompanied by workshops for public health centre staff to increase their capacity to address the needs of gay and bisexual men. Community campaigns promoting HIV testing and the merits of early diagnosis were also conducted in 2010.

While the final results of all this work are yet to be published, the project has fostered a range of collaborations between local government and NGOs that work with gay and HIV-positive people. The project has also successfully collated a range of information on HIV testing, counseling and support services for men who have sex with men. Furthermore, the NGOs involved with the project were able to extend their outreach to previously unreached groups piloting new information tools, and support HIV testing projects.

A future priority is to increase the availability and capacity of gay-friendly HIV testing services around the country, which at this time remain variable in their capacity to provide non-judgmental HIV testing and counseling. We believe that improving the accessibility and sensitivity of public health centre HIV testing would benefit not only gay, bisexual and other men who have sex with men, but also other groups using HIV testing services, including sex workers, young people, foreigners and people who use drugs.

Treatment

The standard of medical treatment for HIV available in Japan is high, with new antiretroviral drugs rapidly included into treatment regimen guidelines and made available at a minimal basic cost through health insurance. While health insurance is available to all Japanese residents, access requires legal residence status and is dependent on the payment of monthly health insurance premiums; people with low incomes and illegal foreign workers are precluded from accessing health insurance, and are therefore also unable to access subsidised HIV treatments.¹⁰

People living with HIV and AIDS also face high levels of social stigma and many people have concerns about employers and others finding out about their HIV status.^{11, 12} There have been a number of recent studies conducted regarding social isolation¹³, work-related issues¹⁴, and treatment issues¹⁵ faced by people living with HIV. In relation to HIV-positive gay and bisexual men, research regarding attitudes and behaviours relating to safe sex practices indicates the need for more targeted programs to reduce stigma and increase condom usage among these groups.¹⁶

A recent internet survey of people living with HIV investigated respondents’ experiences of receiving a positive HIV test. Of the 239 respondents, 49.8% stated that sex and sexuality-related issues were not adequately addressed by the medical professional providing the test result; only 48.5% were given follow-up information at the time of diagnosis (such as how to prevent HIV transmission; whether it was okay for them to have sex; how to prevent HIV transmission; whether it was necessary to disclose their status to sexual partners etc.).¹⁷

These results indicate a reluctance among health workers to discuss sex and sexuality related-issues with HIV-positive people. This highlights the need for more post-diagnosis support and counseling services for gay and bisexual men – and more training for health practitioners, particularly in regional areas as HIV counseling and support services are concentrated in the largest cities of Tokyo and Osaka.

Prevention

The first baseline behavioural study – providing data on gay and bisexual men’s HIV knowledge, HIV testing rates and condom use – was undertaken in Osaka in 1999, following a successful partnership between gay men, researchers and a local government health official. The results obtained were instrumental in informing HIV prevention activities in Osaka, and this model was repeated in other regions, funded through research grants from the MHLW. However, it was not until 2003 that the first specifically targeted prevention programs for men who have sex with men were funded through the provision of grants to fund community centres.

The first centres were established in Tokyo and Osaka in 2003, and there are now six centres operating in Nagoya (since 2004), Fukuoka (2006), and Sendai and Naha in Okinawa in 2009.

The establishment of community centres operated by NGOs and located in districts containing gay bars has been instrumental in facilitating networking between HIV prevention and support NGOs, gay commercial venues, community event organisers and individuals, but efforts were hampered by the lack of staff as most of the centres were only funded for one part time position (or less) per centre.

In March 2011, the MHLW announced a new policy initiative to fund HIV programs for men who have sex with men in six cities, including Tokyo, Osaka, Nagoya, Sendai, Fukuoka, and Okinawa. This funding will be used to conduct information outreach delivering condoms and publications to gay commercial venues, and conduct other prevention and support activities. While this is an encouraging new step, NGO capacity remains rather weak, with small numbers of staff (currently nine positions nationally).

To date, HIV prevention activities have been evaluated through surveys conducted at gay clubs and gay bars, and mobile phone RDS surveys; survey findings indicate some success in increasing condom use, HIV testing, and NGO activities (see Table 1). Behavioural surveys indicate that prevention activities need to be extended to older gay and bisexual men, and that school-based HIV and sex education is needed for young gay and bisexual men.

While a few local governments have included men who have sex with men in their HIV testing and prevention policies and plans, the vast majority do not have any targeted HIV testing and prevention programs or plans. In order to extend prevention activities nationally, it is critical that NGO capacities are scaled-up and that local governments implement initiatives that include men who have sex with men in developing local HIV policies.

Furthermore, a national coordinating body needs to be established, which includes representatives from national and local government to coordinate and direct the response in relation to gay and bisexual men. HIV policy is currently under review by the MHLW, with outcomes of the review expected in the next months.

Future challenges

This article has outlined initiatives which have attracted recent funding from the Ministry of Health, Labour and Welfare. There has been no commitment to maintain or scale up activities, and in view of the huge levels of government support needed for rebuilding efforts following the Northern Kanto tsunami and Fukushima nuclear reactor meltdown, there is a concern that resources will be diverted.

In view of the continued increase in HIV infections among men who have sex with men in Japan, improved coordination and funding to increase gay friendly HIV testing, to support gay community HIV prevention efforts and to support people with HIV, must be continued.

References

1 UNAIDS. (2010). Report on the global AIDS Epidemic. Available at: UNAIDS Report on the global AIDS epidemic 2010 www.unaids.org/globalreport/Global_report.htm (accessed25 October 2011).

2 National AIDS Surveillance Committee. (2010). UNGASS Country Progress Report: Japan (Report to UNAIDS – HIV/AIDS Trends in Japan December 2009). Available at: http://www.unaids.org/en/dataanalysis/monitoringcountryprogress/2010progressreportssubmittedbycountries/japan_2010_country_progress_report_en.pdf (accessed 21 October 2011).

3 National AIDS Surveillance Committee, HIV/AIDS in Japan, 2010. (2011). AIDS Prevention Information Network. Available at: http://api-net.jfap.or.jp/status/2010/10nenpo/gaiyou.pdf (accessed 26 October 2011) (in Japanese).

4 ibid.

5 Akino, K. (2008). Various policies for HIV/AIDS control after the revision of AIDS Prevention Guideline. in M. Kashiwazaki, (ed.). Challenging practices on HIV/AIDS in Japan, 2008, Japanese Foundation for AIDS Prevention, Tokyo. Available at: http://www.jfap.or.jp/english/ booklet/2008/data/1/003_akino.pdf (accessed 21 August 2011).

6 op. cit. (Akino, K 2008).

7 See HIV test search homepage www.kensa.org (in Japanese).

8 Kaneko, N., utsumi M., and Ichikawa S. (2007). HIV testing behaviour and HIV preventive behaviour among gay and bisexual men in tokai area. Japanese Journal of Nursing Research. 30(4): 194–43 (in Japanese).

9 See Strategic Research Homepage http://www.jfap.or.jp/strategic_study/index.html (in Japanese).

10 Tarui, M., Sawada, T., and Castro-Vazquez, G. (2004). Issues Concerning Human Rights and HIV/AIDS of Non-Japanese Workers, in Expert Meeting on HIV/AIDS and Human Rights in Asia-Pacific. Bangkok. Available at http://www.aidslex.org/site_documents/I010E.pdf (accessed 21 August 2011).

11 Yajima, T., Hasegawa, H., Ikushima, y., and Inoue, Y. (2008). Future and Long Life Series: Connected to society connected to people: Treatments, Work, Love, Future. PLACE tokyo, Japan Network of People living with HIV/AIDS. Available at: http://www.ptokyo.com/publications/booklets.php (in Japanese) (accessed 21 August 2011).

12 Ikushima, Y. and Wakabayashi C. (2009). People living with HIV/AIDS: Work, life, and community. In y. Ikushima, Editor. Study group on the support for HIV-positive people and others in regional areas. PLACE Tokyo, Japan Network of People living with HIV/AIDS. Available at: http://www.chiiki-shien.jp/resource.html#a_tool [in Japanese] (accessed 21 August 2011).

13 Yajima, T. et al. op. cit.

14 Ikushima, Y. et al. op. cit.

15 Ikushima, Y., Takaku Y., Nagano K., Hasegawa H., Yajima T., and Inoue Y. (2009). Future & Long Life Series: Thinking about treatments in the era of long-term HIV treatment. PLACE Tokyo, Japan Network of People living with HIV/AIDS. http://www.ptokyo.com/publications/booklets.php [in Japanese].

16 Inoue, Y., Yamazaki Y., Kihara M., Wakabayashi C., Seki Y., and Ichikawa S. (2006). The intent and practice of condom use among HIV-positive men who have sex with men in Japan. AIDS Patient Care and STDs, 20(11), 792–802.

17 Yajima, T., Takaku Y., Nagano K., Hasegawa H., Ikushima Y., and Inoue Y. (2011). The experience of 239 people with HIV about the experience of being informed about their HIV status. PLACE Tokyo, Japan Network of People Living with HIV/AIDS. http://www.ptokyo.com/publications/booklets.php (in Japanese).

Jane Koerner is a Research Associate in the Study Group on HIV Prevention Interventions among Men who have sex with Men, which is funded by the Ministry of Health, Labour and Welfare, and located at Nagoya City University. Jane has been working on HIV related issues in Japan for more than a decade.

Professor Seiichi Ichikawa is Head of the Study Group on HIV Prevention Interventions among Men who have sex with Men, and has been working with gay NGOs in conducting HIV prevention, support and research since 1998.

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