Originally published in Prospect Magazine – 29th June 2008 — Issue 147
An HIV diagnosis in Britain is no longer a death sentence—thanks to costly new drugs. But as the spectre of death fades, so do the most visible reasons to avoid risky behaviour. Now the Aids prevention industry has a whole new set of problems
I’m in a bar in Soho. A message flashes up on the plasma screen on the wall behind me: “Tom, I want to nibble your biltong.” A guy leaning against the banisters makes a show of putting his mobile phone away while making eye contact with a cute blond boy at the bar. Cute blond blushes. Soon, they’re smooching in a corner. How Tom’s biltong fared that night I don’t know, but I can guess.
This is London’s gay scene in a world without Aids. Since treatment for HIV became available in the mid-1990s, Aids has all but evaporated in rich countries. Annual deaths among gay men in Britain have crashed from a peak of over 1,162 in 1994 to just 153 in 2007. “Aids? I’ve never met anyone with Aids,” says Tim, an engineering undergraduate who’s sitting under the plasma screen, nursing a nasty pre-mixed drink. When I ask how many of the guys around us might be infected with HIV, he looks shocked. “That’s not a nice thing to talk about. I don’t know, 4 or 5 per cent?” Actually, the government estimates that around 9 per cent of gay men in London are HIV-infected, against 5 per cent elsewhere. But we’re not looking at all gay men in London. We’re looking at guys in a pick-up bar at 1am on Friday night; I’m probably the only person here who will leave without being propositioned. Many of the men eyeing each other up are in their 30s; they’ve had plenty of time to get infected. My guess is that 25 per cent of the men in this room have HIV, possibly a lot more. In 2006, 2,640 gay men were diagnosed with HIV—making up nearly two thirds of the total diagnoses of HIV infections that were acquired in Britain.
You don’t have to be an epidemiologist to work out that if 2,640 people are diagnosed with an incurable disease and only 153 die, the number of people known to be living with the disease will rise. The number of gay men living with HIV in Britain is probably around 31,000.
But these days you never see a cadaverous looking 35 year old in an armchair surrounded by friends trying not to notice that his face is covered by the black splotches of Kaposi’s sarcoma, a cancer that feeds on people weakened by HIV. And as Aids disappears, so does the most visible reason to avoid unprotected sex. Just under half of gay men say they had some unprotected anal sex in the last year, up from under a third in 1996, when treatment became widespread. But if HIV isn’t fatal any more, does it really matter if lots more people get infected?
The relationship between HIV treatment and prevention in the gay community is not straightforward. Virology, psychology, drugs and gay activist ideology play their part. Let’s start with the virology. HIV is not very infectious. It is only easily transmitted when there’s a high “viral load”—lots of free virus in the blood or genital fluids—and that is usually only for the first couple of months after a person gets infected, and then, years later, once they get sick. That means that people who have unprotected sex with several people in a three-month period are far more likely both to contract and spread HIV than people who have the same number of partners over a longer period. And gay men are far more likely than straight people to have lots of partners at once. A recent study of people who go drinking and clubbing in nine European cities found that gay or bisexual men were four times more likely than even out-to-have-fun heterosexuals to have had five or more recent partners.
Even when there is lots of virus in the body fluids, HIV isn’t transmitted all that easily. It needs to get into the bloodstream of the uninfected person, usually through a small tear or lesion. And anal sex is a lot better at providing those tears than vaginal sex. Anal sex between men has another advantage, too, from the point of view of the virus. In any sexual pairing of an infected and an uninfected person, transmission is most likely if the infected person is insertive and the uninfected person receptive. That’s one of the reasons women get infected more easily than men, but don’t pass on the virus so readily. But gay men can take both roles in sex. So a man can be infected when he’s being a “bottom,” then go on to infect another guy when he’s being a “top.” That’s why HIV moves so quickly in gay communities.
Well-monitored antiretroviral treatment can now bring HIV in body fluids down below levels that are associated with heterosexual transmission. There was much excitement about this in the late 1990s—mathematical modelling showed that if behaviour stayed the same and infected people got treated, HIV transmission would trickle to a halt. But the models didn’t factor in the possibility that you need less virus to get infected in the more dangerous act of anal sex. They also forgot that humans don’t behave like mathematical models. Gay men who have lived for 15 years in the shadow of a fearsome and disfiguring plague are especially unlikely to behave like mathematical models. In fact, gay men breathed a collective sigh of relief, hit the dancefloor and threw their condoms to the winds. Well, not to the winds exactly—48 per cent of gay men in Britain still use condoms all the time, which is more than can be said for straight men. But in 1996, just like everywhere in the world where HIV treatment became available, the proportion using condoms started falling. And so our hopes that getting everyone on treatment would squash viral load and slash new infections have been dashed. Viral load may be lower, but risk is higher, so new infections are motoring along nicely. And because so few people are dying, the number of people with HIV is climbing. In the last decade, the number of gay men living with HIV in Britain has more than doubled, from around 14,400 in 1998 to over 31,000 today.
Gay men are getting quite sophisticated at managing risk. Consider “serosorting.” That means “barebacking,” or having unprotected anal sex, with people of the same HIV status as yourself. This works for men who know they and their partners are positive. It’s a lot riskier if you think you are negative. And testing levels in Britain are among the lowest in the wealthy world—43 per cent of gay men in Britain have never been tested for HIV, and nearly half of those whose last test was negative haven’t had a check-up for over a year. “For negative people, it’s not serosorting, it’s sero-guessing,” says Yusef Azad, head of policy at the National Aids Trust.
Most men who know they are infected have their viral load monitored, keeping it down with treatment if need be. So it is almost certainly undiagnosed early infections that are powering the proliferation of HIV among gay men in Britain. Can anything be done about that? Yes. But it means challenging orthodoxies both in the Aids industry and in the medical profession. That early spike in infection often has symptoms—flu, a sore throat and a body rash. And yet a recent study in the British Medical Journal showed that 43 per cent of the people who recalled having symptoms of primary HIV infection never went to health services at all, and half of those who did were not diagnosed with HIV. That’s partly because sexual health services have moved out of general practice into specialised clinics. “It was the right thing to do and it worked,” says Valerie Delpech, an HIV epidemiologist at the Health Protection Agency. “But now GPs have lost all their sexual health skills.”
Early diagnosis rattles another skeleton in the Aids industry closet: contact tracing. HIV spreads in bursts, like fireworks. Our best bet for controlling the bursts is to ask newly infected people who they have had sex with, find the partners and offer them HIV tests and care services. But any involuntary disclosure of HIV status is anathema to some of the “survivors” who still control much of the HIV prevention industry, people who lived through the discrimination and rejection that an HIV diagnosis used to promise. This frustrates public health officials, who use contract tracing to curb other infectious diseases.
The history of Aids has left us with other dilemmas. One is a fear of appearing to be judgemental about particular behaviours. Gay men have more sex partners than heterosexuals. That’s not a judgement, it’s a fact. But the HIV industry is squeamish about pushing the “stop screwing around” message. Azad says that it is a hard sell. “For centuries, gay men have been told not to have sex. We’re tired of it.” But he does think the gay community should start talking more about the danger of sex with several partners in a short timeframe. “It’s the engine that’s driving HIV.” But a “just say no” message will be counterproductive, he says. Besides, reducing sexual risk may involve giving up other nice things too. Gay men are more likely than straight men to smoke and to take drugs, not just booze and dope but also the “love drugs.” One in five use each of Viagra, ecstasy and cocaine. Two in five inhale poppers, or amyl nitrate. On the plus side, poppers help to relax your anus; on the minus side, they make you bleed more easily—not good if you or your partner has HIV. At the extreme is crystal meth (”Tina,” to her friends): a viciously addictive drug that fuels rough, impersonal sex and wrecks lives. At least one world-famous Aids researcher, Ramon Torres, spent time in a homeless shelter after getting addicted to crystal meth. All of these drugs are used more by HIV-infected than uninfected men.
Some think this risky behaviour boils down to post-traumatic stress in those who lived through the carnage of the Aids years. Others associate it with a search for shared identity in a world in which gay men still feel embattled. Gay marriage has changed attitudes and boosted morale. “But there are still only 20 streets in the whole of Britain that I can walk down holding my partner’s hand,” claims Yusef Azad. “There’s almost an internalised homophobia, a feeling that we deserve ill health. We need to try and re-establish healthy norms among gay men.”
On the throbbing dancefloor of Fabric, healthy norms seem a long way away. It’s the May bank holiday weekend, time for “Matinee,” the all-night rave that is one of the rites of spring for gay men in London. This is body fascism at its best; by midnight most people are stripped to the waist, displaying gym-sculpted torsos now gilded with dance-induced sweat. I know that most people won’t leave the warrens of this club until they’re completely spent, well past dawn. Some will faint from dehydration, there may be an overdose or two, and there may be some passing around of viruses. Many of the larger gay clubs have medics on site to reduce the risk of the first two, but there’s not much they can do about the third.
I’m here with Brazilian friends; we’ve been laughing about the footballer Ronaldo, lately found in a motel with three transgender prostitutes. “Another one for our team,” says Alessandro. He says it’s far easier to get away without using condoms in Britain than it is in Brazil. “In Brazil we have condoms on the radio, condoms on television, condoms on posters. So you feel guilty if you don’t use one. But here, nothing. So it’s easy to go out and have fun, to just forget.”
Here’s another problem for HIV prevention: it is not only expensive to keep HIV in the public eye, it is also pretty dishonest. Roughly four out of five heterosexuals diagnosed with HIV in Britain in 2006 imported the virus from sub-Saharan Africa or elsewhere. These tend to be well-established infections and so less infectious. Unless you’re having sex with a new import, the risk of getting HIV in heterosexual sex in Britain is extremely low. The days of the “everyone is at risk” campaign are rightly over.
You hear stories about “bug chasers”; men who deliberately seek out HIV-infected partners for unprotected sex because they want to “poz up,” or get infected, so that they can stop feeling guilty about not using condoms. It makes for a good story, but these are the exceptions. Most of the new infections among the “survivor” generation are just a slipping of the guard. One friend told me that his own infection came in sex with an escort who wanted unprotected sex as a mark of intimacy. The very next day, another friend, a journalist, told me a similar tale. “Of course you use condoms, mostly. But if you’re fucking four guys in an afternoon, there’s usually one you want to mark out as special, and not using condoms is a way of telling someone they are special.” Who qualifies as special? “Oh, usually the guy who’s name you can remember.”
In this internet and mobile phone age, the post-Aids generation have far more opportunities to rack up the risks than ever before. They don’t have to scrape together the entrance fee to a club, or even the bus fare to Hampstead Heath. Log on to gaydar.co.uk and you can hook up with a partner in seconds, filtered by “dick size,” safer sex preference, body hair or any number of other things, including, of course, convenience to your current location. Gaydar is also a wonderful entry point for young men from abroad, who have more or less cornered the gay escort market. Since 2000, 28 per cent of gay men diagnosed with HIV in Britain have been foreign-born.
The post-Aids world is still dominated by those people who lived through the plague years, and who, in the words of Will Nutland of the Aids charity the Terrence Higgins Trust, are “popping pills, swigging and fucking.” Their behaviour establishes the norms for the post-Aids generation, and the Aids industry hasn’t caught up. “The successes we saw in the 1990s were driven by a sense of crisis, and we’re not living in crisis any more,” says Nutland. “But people are still reluctant publicly to say, ‘HIV is not a deadly disease. It’s a serious, manageable health condition.’”
Public health authorities fear this message undermines prevention efforts. “It’s a tightrope we’re walking between ‘you absolutely don’t want to get HIV’ and ‘you can live a long and healthy life with this virus,’” says the Health Protection Agency’s Valerie Delpech. The pharmaceutical industry doesn’t bother with the tightrope. It aggressively promotes antiretroviral drugs directly to consumers—the good-looking men in these ads show off their pecs while abseiling down a canyon against the sunset. It makes HIV look almost desirable—certainly not something you’d give up sex to prevent.
But living with HIV is not all abseiling down canyons at sunset. It’s about going to the clinic for viral load monitoring and taking toxic drugs, for the rest of your life, at an annual cost to the NHS of about £16,000 per person (which means an annual bill of about £1.2bn). And the virus is beginning to outwit some of the drugs we have developed, raising the prospect of strains of HIV that don’t respond to treatment. Plus, we don’t know what effects even the oldest drugs might have in the long term—many men who have been on antiretrovirals for over a decade have osteoporosis and failing livers; they’re suffering not from the infection but the remedy.
So what should HIV prevention look like in a post-Aids world? Criminalising transmission does not seem to be the answer—at best it discourages the early testing and contact tracing that might limit clusters of new cases. Gay men need to be getting tested regularly, and immediately if they suffer the “trinity” of symptoms of early infection. Condoms need to be sold as protection not just against HIV, but against nasty emerging infections such as LGV (lymphogranuloma venereum), a chlamydia-related disease which can leave half your colon in the operating room’s waste disposal. We are experimenting with chemical solutions too. We already give a short course of antiretrovirals to people who believe they have been exposed to the virus—a sort of morning-after pill, except it’s toxic and you have to take it for a month. And we are testing pre-exposure prophylaxis. There is a danger that this could lead to more resistant strains of HIV getting passed around. But if it works, it would be like an oral contraceptive—a pill every day and you can have as much unprotected sex as you like without getting infected with HIV.
All of this would work faster if the sex-and-drugs norms of the gay community shifted down a gear or two. That may well happen anyway. As the “survivor” generation ages out of the bars and clubs, as same-sex partnerships become more mainstream, clubs and parties may become less central to gay life. They won’t disappear, any more than getting plastered and getting laid have disappeared from the lives of young heterosexuals. But a sense of social alienation is part of the glue that binds young gay people into a “scene” where risky sex, risky everything, is normal. If gay men felt less alienated—if we talked more about same-sex relations in our families and schools, if we had more openly gay people in our boardrooms and sports clubs—we’d reduce the power of that glue.
Having worked in HIV for over a decade in developing countries, I shudder to think what will happen when the “post-Aids mentality” clashes with the imperfect health systems of poorer countries, where treatment can be intermittent and viral load bounces up and down. But in countries like Britain, the shift to a post-Aids world is manageable. The challenge for the gay community is to prevent the survivor generation’s attitude—”the plague is over, let’s party”—from becoming the norm for a world without Aids.