HIV: a right of passage for gay men?

It’s taken two whole years, but US CDC has finally published data from the 2008 round of HIV and behavioural surveillance in gay men in 21 cities. Nearly one in five gay men is infected; in some cities (notably Baltimore) it is twice as high, at 38%.

Reacting to the report, CDC’s HIV prevention director Kevin Fenton said:

For gay community leaders, it is critical that together we engage and make HIV education, prevention, and testing of the highest priority. We must ensure that HIV is not a rite of passage for young MSM. We can rekindle a sense of urgency and action in the gay community to again embrace the work needed to drive down new infections. Now is the time to act.

But no-where in his lengthy blog post about the results does Dr Fenton say WHY HIV prevention is urgent, WHY young people should interrupt their sexual enjoyment by scrabbling for a piece of latex. He, like me, is part of a dinosaur generation that just assumes that everyone knows that HIV is a Bad Thing. Can the same be said of a generation that became sexually active after ARVs transformed HIV from a death sentence to an expensive annoyance, at least in the eyes of people who are not yet living with the boring round of blood tests, drug failures, to-tell-or-not-to-tell seductions that HIV infection brings? And we’re certainly seeing lots of infection in those groups: among teenagers not old enough to drink in most US states (18 and 19 year-olds) seven percent are already positive and because drugs are now keeping people alive, rates rise almost steadily with age.

Sadly, in the two years since the data were collected, CDC hasn’t yet managed to publish any results from the behavioural part of the survey, except to tell us a bit about testing. It’s not pretty. In Seattle and San Francisco, fewer than one in five gay men who tested positive for HIV in the 2008 survey said he didn’t know he was infected — the lowest proportion in the country. In Baltimore, close to three out of four who were actually positive said they thought they were negative or didn’t know their status (73%). That was UP from 62 percent three years earlier; the rate was 70% or more in another three cities.

For uninfected guys who think serosorting is a good way to stay uninfected, that should give pause for thought. You’re uninfected. You’re only going to bareback with someone else who is uninfected. You’re responsible enough to actually ASK about your partner’s status. Of those who tell you they’re negative and really believe it (because they’ve tested negative), one in 11 (9%) is infected with HIV. That might make you a bit more responsible. Now ask when his last negative test was. If he tells you it was less than a year ago, you should be OK, right? Not really. Among those who say they last tested negative within the last year, 7% (one in 14) was infected with HIV. People infected in the last year are more likely to have a lot of virus in their blood and semen than people infected longer ago. So in fact, that 7% may be among the most dangerous people to be having unprotected sex with (though of course people who were tested longer ago may also have been infected just recently).

Gay men who are also black, like Dr. Fenton, are especially likely to be infected (28% prevalence, vs 16% in white men), and especially likely not to know that they are (59% of black guys living with HIV didn’t know it, versus 26% of white guys). [I should note that these data come from men approached at gay venues such as bars, saunas, gyms etc. — places where people go to cruise. They therefore are likely to represent the higher end of the risk spectrum, though they may exclude some high-risk people who confine their cruising to the web.]

I don’t think that simply encouraging more testing will be enough to stop new infections. As we’ve seen, plenty of people who have recently tested negative go on doing risky things (otherwise they wouldn’t now be positive). And certainly not all of those new infections are the product of sex with people who believe they themselves are negative, although it is probably a disproportionately high percentage.

We’ll know more if/when we see the analysis of the behavioural data. But for now it seems mightily as though we have failed to explain to young, gay men WHY they should make a huge effort to avoid HIV infection in a post-AIDS world. In public health terms there are lots of reasons, notably cost and the danger of resistance. But at the individual level it’s frankly harder to make a case, especially when we’re simultaneously rightly concerned with “normalising” HIV so as to avoid stigma for those who are infected. “HIV’s just another virus: Don’t get it!”, is a mixed message that is not working so well. Until we make individuals believe that “HIV Sucks; Don’t get it!” it will probably hover somewhere between rite of passage and status quo. And it may be time to acknowledge that unless you’re a public heath nerd, or pay taxes somewhere where the state pays for treatment, that may not be such a bad thing.

Note: in an earlier version of this post I had included an image which I had randomly taken off Google images. The people in the image were not named, and I didn’t seek their permission to use it. One of them has contacted me to request removal of the image. I apologise without reservation for having used it. [But I still want one of those T-shirts.]

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This post was published on 24/09/10 in Men, women and others.

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  1. Comment by Miriam in Vancouver, 24/09/10, 11:48:

    Thanks for this great post. Disturbing stats, but I think you’re right about the mixed-messaging.

  2. Comment by Brian, 25/09/10, 02:59:

    I don’t know; a lot of people, including MSM, are devastated by the diagnosis.

    But the number of new diagnoses stays constant and rises in young MSM, and particularly young black MSM.

    Is it possible that is because the denominator is also rising? Even if the number of ‘gay’ young men is constant, it seems much easier for young men to have sex with men than it was when the number of new diagnoses in that subpopulation was smaller.

    The other issue with the young is that they are having sex with others who are young, who by virtue of being young and relatively sexually inexperienced, of all infected men are the most likely to be newly infected, and concomitantly most dangerous.

  3. Comment by Tucker, 25/09/10, 07:05:

    I agree that any attempt to “normalize” HIV is problematic (perhaps more so from a preventionist perspective), but I’m not convinced that many mixed-messages actually exist at the institutional level. Sex-ed and HIV prevention curricula don’t make a habit of normalizing HIV (they are much more likely to use subtle or not so subtle scare tactics). The so-called mixed-messages, in my opinion, emerge only when we examine all the many different messages about HIV from the many different media and institutions (ASOs, NGOs, CDC/health officials, schools, popular media ect…); but if we examine any topic as such we are going to find “mixed-messages.” And we are NEVER going to achieve a single, coordinated and agreed-upon messaging strategy for HIV/AIDS–in part because no such propaganda machine (or consensus) exists and in part because different people need different messages.

    Targeting HIV negative gay men for prevention campaigns is important, but at the end of the day we all know that it is impossible to reach all MSM for such campaigns and unfortunately, despite now more than two decades of work and millions of dollars, we have not seen epidemiological success. It’s my impression that prevention specialists often completely ignore the role that HIV positive men can and do play in prevention. Prevention workers assume that pos men are adequately counseled by medical professionals and case workers once they test positive and are enveloped into the health care system, but that isn’t the case.

    The fact that 14% of men who tested negative in the past year tested pos with the CDC is more reason to normalize regular, guilt-free, no-cost testing and to start using nucleic acid tests instead of anti-body tests, especially in high-risk groups.

  4. Comment by Daniel Reeders, 27/09/10, 01:58:

    Great post! But can you please post an example of one of these campaigns that says “HIV is just another virus: Don’t get it”?

  5. Comment by Breno B., 27/09/10, 11:29:


    Do you think that universal state-sponsored treatment, like in Brazil, encourage people to take risky behaviour?

  6. Comment by Songbird, 28/09/10, 12:31:

    I dunno. This is one of those articles that uses all the bad shift and rhetoric of the articles it is against to create… the same message.

    Did Larry Kramer write this?

    There are some things that never change in this kind of message — which includes the kinda “subtle” don’t fuck B/black men cant.

    People have been saying the messages that kept most of us negative aren’t working for the young guys because they don’t know how horrible HIV is!!! Well, shouldn’t young guys who are HIV + be encouraged to lead that kind of charge?

    No, because they are usually finding some kinda stable relationship with someone else who is Poz, thus not commenting on the rather salacious title. The virus has changed just as the treatment has changed. I am not saying that I think there is no big deal in seroconverting, I am in my 30’s, of course I feel it is a big deal. But when my young friend in his early 20’s seroconverted, he told me what my older friend in his 40’s told me the future of the virus would be when I was 20! — he told me, with a shrug, “It’s no big deal.”

    It made me want to cry.

    But that is where he is and how he sees it.

    He doesn’t even know how he got it… and he uses condoms, thinks it might have been oral, but no one ever thinks of creating dental health over as a safer sex issue. My point: HIV has changed because of the efforts of, well, all of us, in profound ways. I would rather we deal with reality first… people don’t die of HIV like they did of AIDS, sure HIV complications still occur, especially within communities of color (which becomes a healthcare issue, I believe)… what we need are voices. The young, gay and Poz are out there.

    Are they edgy, mundane? What do they think? People who are HIV negative (which admittedly includes myself) have no real right to this kind of thinking. We don’t know what it is like to be HIV +. We only know our fears and sometimes, what we see in our close friendships, but in the gay community, there is a very unspoken line placed between those that are positive and those negative.

    It is not a bad thing to not want to denigrate part of our own community for contracting a disease that ANY of us could get because I refuse to believe that ALL of us who are “negative” have “safer sex” all the time…. ugh. I have lost my point.

  7. Comment by matt, 10/10/10, 08:35:

    Isn’t it “Rite of passage” nor “Right of Passage” ? Also, is “passage” meant to be a bit freudian in this context (gay sex) ? If not, it is quite funny, in a not-at-all-funny kind of way. Sorry, just couldn’t resist.

    By the way, Wisdom of Whores is just superb – totally eye-opening


  8. Comment by thezak, 12/11/10, 08:58:

    How widespread is the strategy?… of
    “BEFORE we have sex let’s get tested TOGETHER
    for A VARIETY of STDs.”

    Do sexual health checkups reduce the ambiguity and can they be
    like anything else POTENTIAL sex partners do together?…

    If you needed surgery would you want the surgeon to wash
    before operating?…

    If you needed a blood transfusion would you want the blood tested
    before or after the transfusion?…

    see also

    “tested together” alerts

  9. Comment by Andrew, 22/02/11, 11:04:

    “should note that these data come from men approached at gay venues such as bars, saunas, gyms etc. — places where people go to cruise. They therefore are likely to represent the higher end of the risk spectrum”

    It should also be noted that fewer than half those approached agreed to be tested after they found out what the test was for, which could both explain the high number of people who were surprised at their status and could indicate that the actual infection rate, at least at those venues, is much, much higher.

    As for the notion that we need “more fear”…has it ever occurred to anyone in public health that newly diagnosed are just giving the reactions which get the best response? As one of those “immaculate infections” who thought they were doing everything right, I can assure you that the opposite response of “I’ll just take a few pills” doesn’t get a lot of sympathy. Screaming, crying and hysteria about how my life was over garnered responses which ranged from annoyance to sadism. (One nurse told me I’d be mentally incapacitated by neuroaids within 20 years, and responded to my surprise with “surely i’m not the first person to tell you this). People say things like “its no big deal” because freaking out about how you don’t want lipoatrophy doesn’t exactly make the situation any better, especially when half the time the person testing you has lipoatrophy. This doesn’t mean that young people are blind the the very obvious social, financial and physical implications of HIV.

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