HIV and Gay and Bisexual Men

Gay, bisexual, and other men who reported male-to-male sexual contact a are the population most affected by HIV in the United States. In 2018, gay and bisexual menb made up 69% of the 37,968 new HIV diagnosesc in the United States (US) and dependent areas.d Approximately 492,000 sexually active gay and bisexual men are at high risk for HIV; however, we have more tools to prevent HIV than ever before.

1980s. HIV/AIDS: Why was AIDS called ‘the gay plague’?

The early years of AIDS were a time of great fear and anxiety for gay men around the world.* The bulk of this was generated by the mysterious and lethal nature of this new condition. But there was another element that exacerbated the situation – the homophobia whipped up by irresponsible media. Central to this was the sustained use of the terms ‘gay plague’ and ‘gay bug’ when referring to AIDS.

Yet AIDS was never a ‘plague’ and the notion that it was somehow a consequence of a person’s sexual orientation was discounted just over a year after the disease was first identified. Nonetheless, media usage of the term increased rather than decreased in the face of this evidence.

The Oxford English dictionary defines a plague as either:

“A contagious bacterial disease characterized by fever and delirium, typically with the formation of buboes…”

Even in the earliest days of its manifestation, it was clear that the disease was not spread by the type of casual contact with which plagues are spread. On September 9th, 1983, the US Centers for Disease Control explicitly identified all major routes of transmission as well as ruling out the possibility of transmission through casual contact:

“…AIDS is caused by an agent that is transmitted sexually or, less commonly, through contaminated needles or blood…there has been no evidence that the disease was acquired through casual contact with AIDS patients or with persons in population groups with an increased incidence of AIDS. AIDS is not known to be transmitted through food, water, air or environmental surfaces.”

Nonetheless, this did not stop headlines such as The Star’s “Kiss of Death” (27th September 1985) or The Sun’s “It’s spreading like wildfire.” (1st February 1985). *

As for the ‘gay’ connection, there is no doubt that AIDS was first detected in gay men and, for a brief period, desperate researchers examined the so-called ‘gay lifestyle’ for clues as to causation. Sadly, this resulted in the creation of the acronym GRID – “Gay Related Immune Deficiency”. But GRID was only adopted from early 1982 until July 27th 1982, when the Centers for Disease Control realised, amongst other things, that there’s no such thing as a universal “gay lifestyle”.

Even references to Kaposi’s Sarcoma as “the gay cancer” in the gay media had tailed off by December 1982. (For example, ‘”Gay cancer” and poppers are not linked’, HIM Monthly, December 1982).

By 1983 it was clear that AIDS was a global issue that was affecting different groups in different countries. In France and Belgium, for example, the majority of cases were heterosexuals – many with links to Central Africa. At the same time, studies coming out of Africa were showing not only that AIDS had been around long before its emergence in the West but also that it was transmitted predominantly through heterosexual sex. *

And yet media usage of the terms ‘gay plague’ and ‘gay bug’ was only just beginning. For example, The Australian was one of the first newspapers to use the term (‘”Gay plague” epidemic sweeping US’, 17th July 1982). The following month the Philadelphia Daily News ran ‘”Gay plague” Baffling Medical Detectives’ (9th August 1982). In the UK it didn’t appear until nine months after the CDC had abandoned the term ‘GRID’ (“What killed gay plague man?” The Times, 27th March 1983). But then it continued relentlessly, with headlines such as the Mail on Sunday‘s “Britain threatened by gay virus plague” (6th January 1985) continuing into the late 80s.

So why did the media continue to call AIDS ‘the gay plague’ in spite of the evidence? I think part of the clue lies in what a journalist told one of my colleagues when I worked at the Terrence Higgins Trust in 1984 – “AIDS sells more newspapers than bingo.”

AIDS had everything – sex, celebrity exposes, moral enterprise, conspiracy theories and the opportunity to kick a group that was already marginalised from mainstream society. It allowed people to conclude that our ‘lifestyles’ actually generated AIDS as God’s punishment, and it was used to suggest that we were both a physical and moral threat to ‘innocent’ people. Not only were we immensely contagious we were also deliberately contaminating the blood supplies. The repeated use of the term ‘innocent victim’ simply reinforced this idea.

History should judge the media harshly when it comes to their coverage of AIDS. Whilst there were some intelligent exceptions to the rule, the likes of Rupert Murdoch’s newspapers stuck to their usual motto of “Never let the facts get in the way of a good story.”

1980s. HIV/AIDS: Why was AIDS called ‘the gay plague’?

Dr. Gay

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Why are gay men more at risk for HIV?

Dr. David explains what’s behind the higher rates of HIV among gay men.

One reason some groups and areas have been more affected by HIV/AIDS than others is because the HIV prevalence – the percent of the population that has HIV – is already high. In other words, the chances of coming in contact with the virus and thus also the risk of infection is greater.

A common misconception is that groups with higher rates of HIV are acting less responsibly. In fact, research shows that this is not the case. Groups more at-risk for HIV are generally found to get tested more frequently, use condoms more often, and take other precautions to protect against HIV as compared with other groups. The chance of being exposed to the virus is just greater in these social networks and so the response must also be greater.

Increased access to , along with earlier diagnosis, and use of PrEP has been shown to bring down rates of HIV even among areas with higher prevalence.

TRANSCRIPT:Dr. David: This gentlemen asks, “’Why are gay men more at risk for HIV?”Dr. Demetre: You have some questions? We know David: I’m a doctor. I’m trained for Leandro: We’re gonna give you what you David: The answer to this question is not about who you are, but it’s more about a numbers game. Since the HIV epidemic started in the 1980s gay men have been at a greater risk and represented more of the new HIV cases that we’ve known in this country and actually internationally as well. In this day and time, gay men still make up about 2/3 of the new HIV diagnosis. So whether you like or not, just because you’re having sex with other men you are going to put yourself in a pool where you’re having a greater chance of getting in contact with HIV. The other part of that is that when you do have sex, anal sex in particular, without a condom it’s going to be more at risk for HIV. So again, the point I would want to make, it’s not because of who you are, it’s not just because you’re gay. It’s because we live in a high HIV prevalent society among gay men and then also because some of the behaviors that we engage in may put us more at risk for HIV.

Why are gay men more at risk for HIV?

Men who have sex with men (MSM), HIV and AIDS

Explore this page to find out more about what factors put men who have sex with men at risk of HIVprevention programmestesting initiativesusing technologyaccess to antiretroviral treatmentbarriers to prevention and the way forward for men who have sex with men.

Globally, gay men and other men who have sex with men (referred to throughout this page as ‘men who have sex with men’ or ‘MSM’) are 27 times more likely to acquire HIV than the general population.1 New diagnoses among this group are increasing in some regions – with a 17% rise in Western and Central Europe and a rise of 8% in North America between 2010 and 2014.2

In 2017, men who have sex with men accounted for 57% of new HIV infections in Western Europe and North America, 41% in Latin America and the Caribbean, 25% in Asia and the Pacific and the Caribbean, 20% in Eastern Europe and Central Asia and the Middle East and North Africa, and an estimated 12% in Western and Central Africa.3

In around 25 countries, 15% of men who have sex with men, or more, are living with HIV.4 In Mauritania, its estimated that as many as 45% of men who have sex with men are HIV-positive, the country with the highest HIV prevalence among men who have sex with men in the world.5

Some nations have progressive attitudes and policies regarding homosexuality and the lesbian, gay, bisexual and transgender and queer (LGBTQ) community. In Latin AmericaWestern Europe, Central Europe and North America, many countries have made significant progress in recognising the rights of LGBTQ people and allow marriage or civil unions between people of the same sex.6 7

However, the majority of Africa, along with the Middle East and Russia, continues to ignore and abuse the human rights of men who have sex with men.8 Punitive laws that criminalise same-sex activity in 67 countries drive this population underground, elevating their risk of HIV and preventing them from accessing healthcare, including HIV services.9

Even in countries where same-sex activity is legal, other laws discriminate against LGBTQ people, and stigma and discrimination stop people from accessing HIV services and can lead to risk-behaviours that drive transmission.

Men who have sex with men (MSM), HIV and AIDS

Discrimination and homophobia fuel the HIV epidemic in gay and bisexual men

Perry N. Halkitis, PhD, MSSteinhardt School of Culture, Education and Human Development, New York University Over the last 30 years, efforts to prevent new HIVgay and bisexual men have been guided by paradigms that hold individuals responsible for their health behaviors. These approaches, rooted primarily in social-cognitive frameworks (Halkitis, 2010b), have resulted in maintaining new infections in the United States at a steady state for the last decade (Centers for Disease Control and Prevention [CDC], 2011b). In addition, the population of men who have sex with men (MSM) has continued to be the only risk category for which new infections are rising (Hall et al., 2008). In fact, gay, bisexual, and other MSM acquire HIV at rates 44 times greater than other men and 40 times greater than women (CDC, 2011a). More recently, with the game-changing breakthroughs in the biomedical arena, attention has shifted to these biomedical prevention strategies, which include preexposure prophylaxis (PrEP) for gay, bisexual, and other MSM (Grant et al., 2010) and vaginal microbicides for women (Abdool et al., 2010). In this biomedical approach, the early detection and treatment of HIV have been recommended policy for the last several years (CDC, 2006; Workowski & Berman, 2006) as a way to decrease community viral load. Yet even these medical advances are fraught with their own complications, not least of which are matters of uptake and adherence.

In response to these alarming health disparities among gay and bisexual men, there has been a call to broaden the prevention lens to examine the influence of multiple social and contextual factors influencing health behaviors (Halkitis & Cahill, 2011). The CDC recently delineated the significance of social determinants of health, stating that “while effective interventions that address individual risk factors and behaviors exist, to ensure good health in all communities requires a broader portfolio that looks at social and environmental factors as well” (CDC, 2010, p. 11). Despite clear evidence for the social determinants of HIV transmission and the beneficial effects of structural interventions (Adimora & Auerbach, 2010), there have been limited efforts targeting these social inequalities, which place gay and bisexual men at greater risk for the acquisition of HIV disease.

Of particular relevance to HIV prevention among gay and bisexual men are the social conditions that place us at heightened risk for acquiring HIV as compared to our heterosexual counterparts. In this article, consideration is given to the manner through which discrimination and homophobia, which may have been heightened because of the AIDS epidemic (Halkitis, 1999), perpetuate HIV vulnerabilities for gay and bisexual men. Such health vulnerabilities driven by homophobia are often exacerbated for gay and bisexual men of color, who are often further burdened by the social circumstances of racism and poverty. Since discrimination based on sexual identity is critical to the ideas being put forth, and since the HIV prevention needs of gay and bisexual men differ widely from those of non-gay or bisexual MSM (Halkitis, 2010b), the focus of this issue of the newsletter is on gay and bisexual men, and not MSM in general. This topic will be considered from the theoretical perspective of minority stress theory, with attention to (a) how clinicians can effectively address these social burdens with their clients, (b) the work of AIDS service organizations, and (c) policy in light of the National HIV/AIDS Strategy for the United States (Office of National AIDS Policy, 2010).

Prevention Challenges

A much higher proportion of gay and bisexual men have HIV compared to any other group in the US. Therefore, gay and bisexual men have an increased chance of having a partner who has HIV.

Stigma, homophobia, and discrimination affect the health and well-being of gay and bisexual men and may prevent them from seeking and receiving high-quality health services, including HIV testing, treatment, and other prevention services. These issues place gay and bisexual men at higher risk for HIV.

1 in 6 gay and bisexual men with HIV are unaware they have it. People who do not know they have HIV can’t take advantage of HIV care and treatment and may unknowingly pass HIV to others.

Some factors put gay and bisexual men at higher risk for HIV, including having anal sex with someone who has HIV without using protection (like condoms or medicine to prevent or treat HIV). Anal sex is the riskiest type of sex for getting or transmitting HIV. Receptive anal sex is 13 times as risky for getting HIV as insertive anal sex.

PrEP (pre-exposure prophylaxis) use among gay and bisexual men, especially Black/African American and Hispanic/Latino gay and bisexual men, remains low. According to a report pdf icon[PDF – 1 MB], only 19% of Black/African American gay and bisexual men and 21% of Hispanic/Latino gay and bisexual men took PrEP compared to 31% of White gay and bisexual men. If taken as prescribed, PrEP is highly effective for preventing HIV.

Gay and bisexual men are also at increased risk for other sexually transmitted diseases (STDs), like syphilis, gonorrhea, and chlamydia. Having another STD can greatly increase the chance of getting or transmitting HIV. Condoms can protect from some STDs, including HIV.

Socioeconomic factors such as limited access to quality health care, lower income and educational levels, and higher rates of unemployment and incarceration may place some gay and bisexual men at higher risk for HIV.

What CDC Is Doing

CDC is pursuing a high-impact HIV prevention approach to maximize the effectiveness of HIV prevention interventions and strategies. Funding state, territorial, and local health departments and community-based organizations (CBOs) to develop and implement tailored programs is CDC’s largest investment in HIV prevention. This includes longstanding successful programs and new efforts funded through the Ending the HIV Epidemic initiative. In addition to funding health departments and CBOs, CDC is also strengthening the HIV prevention workforce and developing HIV communication resources for consumers and health care providers.

The term male-to-male sexual contact is used in CDC surveillance systems. It indicates a behavior that transmits HIV infection, not how individuals self-identify in terms of their sexuality. This web content uses the term gay and bisexual men to represent gay, bisexual, and other men who reported male-to-male sexual contact aged 13 and older.b Includes infections attributed to male-to-male sexual contact and injection drug use (men who reported both risk factors).c HIV diagnoses refers to the number of people who received an HIV diagnosis during a given time period, not when the people got HIV infection.d Unless otherwise noted, the term United States (US) includes the 50 states, the District of Columbia, and the 6 dependent areas of American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, the Republic of Palau, and the US Virgin Islands.

A vivid 1983 reminder of initial AIDS scare

Even as the nation’s attention was directed toward gay AIDS victims, the virus was replicating in the bloodstreams of hemophiliacs and injection drug users. A government report from August 2016 found that between the start of the AIDS epidemic and today, nearly 700,000 people have died of AIDS in the U.S.

The AIDS Epidemic Arises

Though HIV arrived in the United States around 1970, it didn’t come to the public’s attention until the early 1980s.

In 1981, the Centers for Disease Control and Prevention (CDC) published a report about five previously healthy homosexual men becoming infected with Pneumocystis pneumonia, which is caused by the normally harmless fungus Pneumocystis jirovecii. This type of pneumonia, the CDC noted, almost never affects people with uncompromised immune systems.

The following year, The New York Times published an alarming article about the new immune system disorder, which, by that time, had affected 335 people, killing 136 of them. Because the disease appeared to affect mostly homosexual men, officials initially called it gay-related immune deficiency, or GRID.

Though the CDC discovered all major routes of the disease’s transmission—as well as that female partners of AIDS-positive men could be infected—in 1983, the public considered AIDS a gay disease. It was even called the “gay plague” for many years after.

In September of 1982, the CDC used the term AIDS to describe the disease for the first time. By the end of the year, AIDS cases were also reported in a number of European countries.

The HIV Test Arrives

In 1984, researchers finally identified the cause of AIDS—the HIV virus—and the Food and Drug Administration (FDA) licensed the first commercial blood test for HIV in 1985.

Today, numerous tests can detect HIV, most of which work by detecting HIV antibodies. The tests can be done on blood, saliva, or urine, though the blood tests detect HIV sooner after exposure due to higher levels of antibodies.

In 1985, actor Rock Hudson became the first high-profile fatality from AIDS. In fear of HIV making it into blood banks, the FDA also enacted regulations that ban gay men from donating blood. The FDA would revise its rules in 2015 to allow gay men to give blood if they’ve been celibate for a year, though blood banks routinely test blood for HIV.

By the end of 1985, there were more than 20,000 reported cases of AIDS, with at least one case in every region of the world.

HIV/AIDS in the 1990s and 2000s

In 1991, the red ribbon became an international symbol of AIDS awareness.

In that year, basketball player Magic Johnson announced he had HIV, helping to further bring awareness to the issue and dispel the stereotype of it being a gay disease. Soon after, Freddie Mercury—lead singer of the band Queen—announced he had AIDS and died a day later.

In 1994, the FDA approved the first oral (and non-blood) HIV test. Two years later, it approved the first home testing kit and the first urine test.

AIDS-related deaths and hospitalizations in developed countries began to decline sharply in 1995 thanks to new medications and the introduction of HAART. Still, by 1999, AIDS was the fourth biggest cause of death in the world and the leading cause of death in Africa.

HIV Treatment Progresses

In 2001, generic drug manufacturers began selling discounted copies of patented HIV drugs to developing countries, leading to several major pharmaceutical manufacturers slashing prices on their HIV drugs. The following year, the Joint United Nations Programme on HIV/AIDS (UNAIDS) reported that AIDS was by far the leading cause of death in sub-Saharan Africa.

In 2009, President Barack Obama lifted a 1987 U.S. ban that prevented HIV-positive people from entering the country.

The FDA approved pre-exposure prophylaxis, or PrEP, for HIV-negative people in 2012. When taken daily, PrEP can reduce the risk of HIV from sex by more than 90 percent and from intravenous drug use by 70 percent, according to the CDC. A major study completed in 2019 showed that over 750 gay men on an anti-viral treatment did not transmit the virus to their partners. „Our findings provide conclusive evidence that the risk of HIV transmission through anal sex when HIV viral load is suppressed is effectively zero,“ the paper, published in Lancet, stated.

At the end of 2019, some 38 million people were living with HIV/AIDS worldwide, and 940,000 people died from AIDS-related illnesses that year, according to WHO. Sub-Saharan Africa remains the most severely affected region, accounting for nearly two-thirds of the world’s current HIV cases.

HIV testing initiatives

Two of the most effective ways to encourage HIV testing among men who have sex with men is to permit home-based testing and provide community-based testing.

Community-based testing is HIV testing carried out at local pop-up clinics or mobile vans in an area that men who have sex with men feel comfortable in. This removes the need to test in clinics where men who have sex with men may experience discrimination and mistreatment.55 Home-based testing has the benefit of the person testing for HIV being able to avoid identification by healthcare workers.56 The privacy of conducting an HIV test alone at home makes this an appealing option for many men who have sex with men. One study in Brazil found that 90% of men who have sex with men participants would use self-testing kits, although concerns included receiving the result alone and being able to read the result properly.57

Another study conducted in Australia found that HIV self-testing doubled frequency of testing among men who have sex with men at high risk of HIV, and quadrupled the frequency among non-recent testers, compared with standard care. It also showed that the availability of self-testing kits did not reduce the frequency of facility-based HIV testing.58

A study conducted in Myanmar on self-testing found the majority of men who have sex with men expressed a preference for this type of testing compared to testing carried out by community-based organisations.59

HIV self-testing should be made more widely available to help increase testing and earlier diagnosis. Men who have sex with men should be educated about the use of self-testing kits, to heighten their confidence in using one as an alternative to testing at regular healthcare settings.

For example, an HIV self-test kit vending machine designed with the input of gay men has been installed at various gay venues in the UK, including saunas, bars, clubs, pharmacies, university campuses and train stations. The first machine was installed in Brighton, and eight times more men took up testing via the vending machine compared to testing offered by community outreach workers at the same venue during the same period.60

Due to the preference for anonymity when it comes to accessing healthcare, some studies have shown that technology, messaging, and social media have helped to provide HIV prevention information to men who have sex with men.

In the Philippines, the smartphone app ‘LoveYourself’ was developed to mirror the popular mobile game Pokémon Go. Targeted at men who have sex with men, gay men and transgender women, it sends users to locations with condom dispensers in a bid to reduce stigma and increase condom use. Around 3,500 people downloaded the app within the first month of its launch. Future additions to the app are planned so that it becomes a ‘one-stop shop’ for people’s sexual and reproductive health. These include a ‘sex diary’ to help people track their sexual behaviours, and push notifications that remind people when to go for HIV testing.73

China’s Blued is one of the biggest dating apps in the world for men who have sex with men and has over 40 million users. The app is linked to 200 HIV testing sites operated by the Chinese government and community-based organisations and enables users to book an appointment through it. In 2016, Blued began promoting HIV testing to its users in Beijing, Chengdu and Qingdao. The number of people testing for HIV at sites promoted by Blued rose by 78%, compared to the previous year.74

A UNAIDS-supported project to address the vulnerabilities of gay men and other men who have sex with men in Egypt helped to achieve significant growth in reach and geographical coverage of related services from 2013. Innovations included outreach to men in slum areas through community-based organisations and awareness outreach and prevention services for the female sexual partners of men who have sex with men.

Online outreach proved to be particularly effective for the project, as police action against this population had intensified, making street outreach more challenging. Following online outreach, meetings are arranged with participants to deliver condoms and lubricants; the project also facilitates access to good-quality, stigma-free health services and psychosocial and legal support.

In the period 2014-2015 in Alexandria, the project reached around 1,000 people, distributed more than 3,100 condoms and packs of lubricant, and facilitated 300 visits to project services. In Gharbya governorate, to which the project was expanded in 2015, nearly 300 people were reached and over 500 preventive packages distributed.75

These types of programmes should be further explored as an avenue to engage men who have sex with men in the HIV response and their own healthcare.76

A study from South Africa found that sending text messages to men who have sex with men over a period of time encouraged men to test for HIV.77 The Adam’s Love organisation based in Thailand targets men who have sex with men and transgender women through an HIV educational website, eCounseling platforms and integrated social media networks. Since its launch in September 2011, Adam’s Love has had more than 2.8 million website visitors. Nearly 17,500 individuals received real-time counselling at Adam’s Love eCounseling platforms and were successfully linked to relevant clinical services, for example, HIV and sexually transmitted infection testing, treatment, and care and post-exposure prophylaxis (PEP).78

Technology is also being used to provide better data on particularly hidden groups of men who have sex with men. For example, researchers studying HIV testing rates in Tokyo have partnered with a gay dating app because around two-thirds of men who have sex with men in the area are not open about their sexuality. Previous research had taken place in ‘traditional’ MSM venues, so only reflected a minority of men who have sex with men there.79

Präsentation Regenbogenbus Nürnberg Juli 2015

Dererste „Transgender Day of Visibility“ (Internationaler Tag der Sichtbarkeit von Trans*-Personen) am letzten März-Mittwoch in Nürnberg war ein voller Erfolg. Rund 65 Personen sind aufdem Community Gedenkort Magnus-Hirschfeld-Platz amSterntor erschienen. Das Bündnis gegen Trans- und Homophobie in der Metropolregion Nürnberg hat diese erste Demonstration für mehr Trans* Sichtbarkeit organisiert. Zahlreiche Menschen aus Vereinenund Gruppen der queeren Community waren ebenfalls vertreten, um ihre Unterstützung mit Plakaten kundzutun. In teils sehr emotionalen Redebeiträgen wurden auch persönliche Geschichten übermittelt. …+++ Hier geht es zum vollständigen Bericht mit Bildergalerie auf der DOKU-Seite +++

SeitJahren heimlich in Planung, in diesem Jahr werden die exklusiven Verträge unterzeichnet: Der Nürnberger Lederclub eröffnet zum Ende des Jahres in einer alten Fabrikhalle am Kohlenhof in derNürnberger Innenstadt ein NLC-Motorrad-Museum! Eigentlich hätte die Eröffnung schon pünktlich zum 35jährigen Jubiläum des Vereins stattfinden sollen, doch Corona hatte alle Planungen um ein Jahrverschoben. Wie unser Informant aus dem engsten Planungskreis berichtet, wird auch die AIDS-Hilfe Nürnberg einen Teil der Räume mieten, weil deren Platzkapazitäten in der Entengasse in ihrem Haus inder Altstadt nicht mehr ausreichen. …. Zum vollständigenGAYCON Aprilscherz 2021 sowie die Ausgaben der letztenJahre auf derDOKU-Seite!+++

HIV in the gay and bisexual population

In the now historic document, which recently reached its 30th anniversary, the CDC (1981) reported five cases of Pneumocystis carinii pneumonia in young gay men who otherwise should have been healthy. I first became aware of this phenomenon as I sat on the beach reading The New York Times the summer before my freshman year at Columbia University. With bewilderment and fear, I read Robert Altman’s (1981) account of “doctors in New York and California [who] have diagnosed among homosexual men 41 cases of a rare and often rapidly fatal form of cancer.” In the following years, I witnessed the eruption of the disease, which in its early years was given the name GRID (gayrelated immunodeficiency disease) because of its omnipresence in the gay population (Shilts, 2007; Weeks & Alcamo, 2010).

Two generations later, GRID has evolved into what we have come to know as HIV/AIDS. However, despite the fact that the disease no longer remains confined solely to gay and bisexual men, the reality is that this segment of the population is the one most affected by this epidemic. In the seminal 1998 American Psychologist article, Walter Batchelor warned that “AIDS still attacks homosexual and bisexual men in great numbers” (p. 854). It is truly alarming that 30 years later, HIV/AIDS continues to be predominantly a gay and bisexual disease in this country (Halkitis, 2010b). This burden becomes abundantly clear when we consider the epidemiological data. Despite the fact that gay and bisexual men constitute approximately 2–4 percent of the U.S. male population 18–44 years of age (Chandra, Mosher, Copen, & Sionean, 2011), MSM, primarily gay and bisexual men, account for more than 50 percent of all AIDS cases and all HIV infections and 57 percent all new HIV infections (CDC, 2011b).

Discrimination and homophobia as causes of HIV

Despite increased visibility, acceptance and recent sociopolitical advances, gay and bisexual men continue to live in a society that privileges heterosexuality while denigrating nonheterosexual relationships, behaviors and identities (Herek, Gillis, & Cogan, 2009). As a result, our population continues to face stigma rarely encountered by our heterosexual counterparts. Oppressive social structures and inequalities affecting gay and bisexual men have been implicated in perpetuating not only the HIV epidemic but also rates of anal cancer, Hepatitis B, human papillomavirus (HPV) and lymphogranulma vernreum (LGV) infections, syphilis, gonorrhea and Hepatitis C (Wolitski & Fenton, 2011).

These structural conditions, which take the form of discrimination and homophobia (Wolistki & Fenton, 2011; Wolitski, Stall, & Validiserri, 2008), are further compounded by racism and economic disparities for gay and bisexual men of color. Exposure to and experiences of homophobia have been implicated in substance abuse, risky sexual behaviors, negative body image, suicide attempts, increased stress and limited social support among gay and bisexual men (Halkitis, Fischgrund, & Parsons, 2005; Mayer, Bradford, Makadon, Stall, & Goldhammer, 2008; Wolitski, Stall, Valdiserri, 2008). Moreover, experiences with homophobia have been shown to interfere with the ability of gay and bisexual men to establish and maintain longterm same-sex relationships, which protect against HIV acquisition (Diaz, Ayala, Bein, Henne, & Marin, 2001). The experiences of homophobia may exert their effects on sexual risk taking indirectly by exacerbating mental health burden (Halkitis, 2010b; Johnson, Carrico, Chesney, & Morin, 2008).

Experiences with oppression and homophobia, which tend to pervade family, school and community settings, are especially relevant for gay and bisexual young men, who are in the process of establishing their personal identities. Unlike other marginalized groups (e.g., immigrants) who grow up with people like themselves and who receive the support of their families, gay and bisexual youth frequently have more complicated and often abusive family dynamics (D’Augelli, Hershberger, & Pilkington, 1998; Pilkington & D’Augelli, 1995). In a seminal study, Ryan, Huebner, and Sanchez (2009) showed the powerful effects of homophobia perpetrated by family members. These researchers compared lesbian, gay and bisexual (LGB) young adults who were rejected with those who were supported by their families. Rejected LGB youth were 8.4 times more likely to have tried to commit suicide, 5.9 times more likely to report high levels of depression, 3.4 times more likely to use illegal drugs, and 3.4 times more likely to have risky sex. For young gay and bisexual men, this form of nonacceptance starts in childhood and adolescence within the contexts of families.

The effects of discrimination are likely moderated by numerous factors, including the intensity of the discriminatory experience, the duration over which these experiences occur, as well as the relationship between the victim and the perpetrator(s) (Raymond Chen, Stall, & McFarland, 2011). For example, the lifelong health risks may be even greater if the family victimization takes the form of sexual abuse; Mimiaga et al. (2009) demonstrated that gay and bisexual men with histories of childhood sexual abuse were more likely to report both unprotected anal intercourse, to derive fewer benefits from participation in prevention programs, and to be at an overall greater risk for HIV infection.

Recently our research team at the Center for Health Identity, Behavior and Prevention Studies (CHIBPS) at New York University documented the risks and resiliencies of young gay and bisexual men ages 13–29 in a study named Project Desire. Using Gilligan’s (1982) Listening Guide for Psychological Inquiry (see Camic, Rhodes, & Yardley, 2003), we recorded these young men’s fears, hopes, and dreams in relation to emerging adulthood, dating, sex and HIV. Some spoke very clearly about experiences of homophobia in their lives (Halkitis, Moeller, & Siconolfi, 2010a, 2010b). An 18-year-old Latino who was HIV-negative expressed how he experienced homophobia from his own sister:

Similarly, a 25-year-old Black, HIV-positive man described his family’s reaction to his coming out as follows:

These realities extend to school environments, which, as a microcosm of society, are often filled with victimization and oppression of those who do not present with heterosexual identity (Espelage & Swearer, 2008; Kosciw, Greytak, Diaz, & Bartkiewicz, 2010). In their qualitative study of masculinity, Phoenix, Frosh, and Pattman (2003) found that boys as young as 11 years of age have found it critically important to present themselves as masculine in order to avoid being bullied and labeled as gay. In fact, when it comes to traditional gender expression, boys tend to be watched very closely because of the high value assigned to hegemonic masculinity, which is the most honored way of being a man in our culture (Connell & Messerschmidt, 2005; Pascoe, 2007).

Unfortunately, the cultural perception of gay and bisexual males as less masculine may lead to their assertions of masculinity through engagement in unprotected sexual behaviors (Halkitis, Green, & Wilton, 2004; Harper, 2007). Scientific evidence shows that gay men’s doubts about their masculinity as well as endorsement of masculine characteristics are associated with frequent risky sexual behaviors, which increase exposure to HIV (Connell, 1995; Diaz, 1998).

Life experiences with oppression and homophobia often become internalized and can have detrimental effects on the development of positive sexual identity (Rowen & Malcolm, 2002). Positive attitudes toward one’s sexual identity have been shown to be protective against risky sexual behaviors (Rosario, Hunter, Maguen, Gwadz, & Smith, 2001), while elevated rates of internalized homophobia have been linked to exacerbated sexual risk taking and other health risks.

This is how a 25-year-old HIV-negative White male participant of Project Desire described his struggles with internalized homophobia:

Others nested their experiences of homophobia in relation to organized religion, as demonstrated in the comments of one 28-year-old HIV-negative Black man:

Gay and bisexual men experience homophobia throughout the course of their lives. Thus, it is critical that we consider the well-being of gay and bisexual men by using a life course perspective (Institute of Medicine, 2011). Last year at CHIBPS, we enacted a program of study named Project GOLD, which examines the life experiences, risk, and resiliencies of HIV-positive men 50 years of age and older (Halkitis, 2010a). Many of the men with whom we have spoken are long-term survivors of the disease, having lived with AIDS for over 20 years. Yet even those older men vividly describe how the experience of homophobia shaped their lives in the past and how it continues to affect their lives. Johnson et al. (2008) demonstrated that among 465 HIV-positive men, internalized homophobia was associated with unprotected receptive anal intercourse with partners who were HIV-negative or of unknown HIV status and was also associated with poorer adherence to antiretroviral therapy. A 51-year-old Latino man, who has been living with HIV for 24 years, described it as follows:

Another, a 53-year-old Black man living with HIV for 21 years, described his experiences in this manner:

The confluence of homophobia, racism, and economic inequalities

For gay and bisexual men of color, the effects of sexual orientation discrimination on HIV risk may be confounded and exacerbated by other powerful structural factors, including racism, lack of access to economic means, and poverty (Williams, Wyatt, Resell, Peterson, & Asuan-O’Brien, 2004). HIV in the United States has disproportionately affected racial/ethnic minorities and the poor for decades (Brooks, Rotheram-Borus, Bing, Ayala, & Henry, 2003; Karon, Fleming, Steketee, & De Cock, 2001). Thus, the synergistic social conditions of homophobia, racism, and poverty likely explain the even higher incidence of new HIV infections among racial ethnic minorities, particularly Black and Latino gay and bisexual men (CDC, 2011b). In a study of Latino men, Diaz et al. (2001) identified positive relations between risky sexual behaviors and the participants’ experiences of homophobia, racism, and financial instability. Mays, Cochran, and Zamudio (2004) revealed similar findings in a study of gay, bisexual and other MSM.

Poverty has been identified by the United Nations Population Fund (2003) as a critical factor in the spread and treatment of HIV. For many gay and bisexual men of color, economic inequalities add to the pernicious effects of oppression and homophobia. For example, in a seven-city study of HIV prevalence among young gay and bisexual men, Harawa et al. (2004) found prevalence rates of 16 percent for Black men, 6.9 percent for Latinos, and 3.3 percent for Whites, despite the fact that the White men reported potentially risky sex and drug-using behaviors with greater frequency. In this sample, however, such indicators of socioeconomic status as unemployment and lack of formal education were highly associated with HIV infection, suggesting socioeconomic inequalities suffered by the racial and ethnic minority men.

Perhaps the effects of economic standing on HIV prevalence among gay and bisexual men can also be understood in relation to contextual factors, particularly the roles played by residential neighborhoods (e.g., Frye et al., 2006). Certainly person-level variables interact with sociopolitical variables to shape HIV risk-taking behavior among gay men. Yet it is a likely hypothesis that those who have access to and navigate environments where there are high levels of gay presence are also likely to be exposed to HIV prevention messaging through publications and advertisements, as well as through interactions with other gay men in social venues. In addition, living in impoverished neighborhoods may bestow additional burdens on gay and bisexual men. According to Ellen, Mijanovich, and Dillman (2001), the impact of neighborhoods may be manifested through (a) short-term influences on behavior, attitudes, and access to health care, which affect immediate well-being; and (b) long-term effects associated with poor environmental quality and limited resources experienced over numerous years and known as “weathering.”

For those young gay men of color who are socioeconomically disadvantaged, access to gayrelated health resources may be more limited because their neighborhoods of residence tend to be outside the exclusive city center, where many gay cultural, health, and social establishments tend to be located (Halkitis, Moeller, & Siconolfi, 2009a, 2009b). In effect, risk may be exacerbated by the fact that these men must negotiate the reality of their sexual identities within residential neighborhoods that reject and stigmatize people with non-heterosexual identities (Mays, Chatters, Cochran, & Mackness, 1998; Mays, Cochran, & Zamudio, 2004). This situation is compounded by the lack of access to other services in poor communities where some African American men reside, increasing their likelihood of HIV seroconversion (Crosby & Grofe, 2001).

The confluence of neighborhood factors, socioeconomic factors and access to services not only exacerbates HIV risk but also the comorbid conditions of substance use, including injection drug use (Crosby & Grofe, 2001; Shafer et al., 2002), and mental health burden (e.g., Truong & Ma, 2006), which in turn elevate vulnerabilities. Frye et al. (2010) examined the relation between gay neighborhood presence and sexual risk taking of young gay men and found that gay neighborhood presence was positively associated with consistent condom use during anal intercourse. These matters are of particular concern in relation to homeless and unstably housed youth (Marshall et al., 2009), who may reside in a variety of different neighborhood environments including parks and public spaces, vehicles, shelters and hostels (Daly, 1996).

Conclusions

Taken together, the extant literature suggests that the perpetuation of the HIV epidemic in gay and bisexual men is not directed solely by person-level behaviors but is influenced by a range of contextual factors, rooted in cultural, historical, and political structures in this country. These findings suggest that HIV prevention efforts must be embedded within a larger framework of gay men’s lives, identities and health. A holistic approach to the well-being of gay men (Halkitis, 2010b; Safren, Resiner, Herick, Mimiaga, & Stall, 2010) should collectively consider the biomedical, psychological and social factors that create these health disparities in this segment of the population.

As noted by the Institute of Medicine (2011) and as supported by the ideas presented in this article, an approach to the totality of gay men’s health must consider the role that social structures play in compromising gay men’s health. Specifically, we must combat the homophobia and discrimination that gay and bisexual men face from families, communities, and society at large. We must understand that such oppression not only perpetuates the HIV epidemic but also compromises the overall wellness of gay and bisexual men. In the end, our best hope for eradicating the HIV epidemic in gay and bisexual men will arise from the combined strength of biomedical, social, behavioral and legislative interventions. Finally, for preventive efforts to be meaningful and effective, such approaches must understand the lives of gay and bisexual men, support us in development of strong and healthy identities, and help us in the creation of strong communities in which we will not only be cared for but also able to take care of ourselves and support each other.

About the author

Perry N. Halkitis, PhD, MS, is an associate dean for research and doctoral studies, a professor of applied psychology, public health and medicine, and the director of the Center for Health, Identity, Behavior and Prevention Studies at the Steinhardt School of Culture, Education, and Human Development at New York University (NYU). He is also an affiliate of the Center for AIDS Research and the Center for Drug Use and HIV Research, also at NYU. He is internationally recognized for his work examining the intersection of HIV, drug abuse, and mental health and is well known as one of the nation’s leading experts on methamphetamine addiction and HIV behavioral research.

He is lead editor of two volumes: „HIV + Sex: The Psychological and Interpersonal Dynamics of HIVSeropositive Gay and Bisexual Men’s Relationships“ (2005) and „Barebacking: Psychosocial and Public Health Perspectives“ (2006). His book „Methamphetamine Addiction: Biological Foundations, Psychological Factors, and Social Consequences“ was published in 2009, and he is currently working on a new manuscript examining the life experiences of gay men who are long-term survivors of HIV/AIDS. Author of over 120 peer-reviewed academic manuscripts, Dr. Halkitis’s research examines how sexual and drug-related risk taking, as well as mental health, are influenced by interpersonal, contextual, developmental and cultural factors.

Dr. Halkitis’s research has been funded by the National Institutes of Health (NIH), the CDC, the New York City Department of Health and Mental Hygiene, the New York State AIDS Institute, the United Way, the New York Community Trust and the American Psychological Foundation. He serves on the APA’s Committee on Psychology and AIDS, is a member of the advisory committee on HIV and STD prevention and treatment of the CDC and the Health Services Research Administration, and is a member of the College of Reviewers of the NIH Center for Scientific Review. He is the recipient of numerous awards from both professional and community-based organizations and is an elected fellow of the New York Academy of Medicine, the Society of Behavioral Medicine and APA. Dr. Halkitis received his PhD in 1995 from the Graduate Center of the City University of New York and is currently completing his MPH degree.

References

Abdool, K.Q., Abdool, K.S.S., Frolich, J.A., Grobler, A.C., Baxter, C., Mansor, L.E., Taylor, D. (2010). Effectiveness and safety of tenofvir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science, 329, 1168-1174.

Adimora, A.A., & Auerbach, J.D. (2010). Structural interventions for HIV prevention in the United States. Journal of Acquired Immune Deficiency Syndromes, 55, S132–S135. doi:10.1097/QAI.0b013e3181fbcb38

Altman, L.K. (1981, July 3). Rare cancer seen in 41 homosexuals. The New York Times, p. A20.

Batchelor, W. (1988). AIDS 1988: The science and the limits of science. American Psychologist, 43, 853-858. doi:10.1037/0003-066X.43.11.853

Brooks, R., Rotheram-Borus, M.J., Bing, E.G., Ayala, G., & Henry, C.L. (2003). HIV and AIDS among men of color who have sex with men and men of color who have sex with men and women: An epidemiological profile. AIDS Education and Prevention, 15(Suppl. A), 1-6.

Camic, P.M., Rhodes, J.E., & Yardley, L. (2003). Qualitative research in psychology: Expanding perspectives in methodology and design. Washington, D.C.: American Psychological Association.

Centers for Disease Control and Prevention. (1981). Pneumocystis pneumonia—Los Angeles. Morbidity and Mortality Weekly Report, 30(21), 250-252.

Centers for Disease Control and Prevention. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Morbidity and Mortality Weekly Report, 55(14), 1-17. 

Centers for Disease Control and Prevention. (2010). Establishing a holistic framework to reduce inequities in HIV, viral hepatitis, STDs, and tuberculosis in the United States (PDF, 2.83MB) [White paper].

Centers for Disease Control and Prevention. (2011a, September). CDC fact sheet: HIV and AIDS among gay and bisexual men (PDF, 2.80MB).

Centers for Disease Control and Prevention. (2011b). HIV surveillance report.

Chandra, A., Mosher, W. D., Copen, C., & Sionean, C. (2011). Sexual behavior, sexual attraction, and sexual identity in the United States: Data from the 2006-2008 National Survey of Family Growth (PDF, 603KB).

Connell, R.W. (1995). Masculinities. Berkeley, CA: University of California Press.

Connell, R.W., & Messerscmidt, J.W. (2005). Hegemonic masculinity: Rethinking the concept. Gender & Society, 19, 829-859. doi:10.1177/0891243205278639

Crosby, G.M., & Grofe, M. (2001). Study of HIV sexual risk among disenfranchised African American MSM (In Science to Community, No. 8). San Francisco, CA: UCSF CAPS and AIDS Research Institute.

Daly, G.P. (1996). Homeless: Policies, strategies, and lives on the street. London, England: Routledge.

D’Augelli, A.R., Hershberger, S.L., & Pilkington, N.W. (1998). Lesbian, gay, and bisexual youth and their families: Disclosure of sexual orientation and its consequences. American Journal of Orthopsychiatry, 68, 361-371. doi:10.1037/h0080345

Diaz, R.M. (1998). Latino gay men and HIV: Culture, sexuality and risk behavior. New York, NY: Routledge.

Diaz, R.M., Ayala, G., Bein, E., Henne, J., & Marin, B.V. (2001). The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: Findings from 3 U.S. cities. American Journal of Public Health, 91, 927–932. doi:10.2105/AJPH.91.6.927

Ellen, I.G., Mijanovich, T., & Dillman, K. (2001). Neighborhood effects on health: Exploring the links and assessing the evidence. Journal of Urban Affairs, 23(3-4), 391-408.

Espelage, D.L., & Swearer, S.M. (2008). Addressing research gaps in the intersection between homophobia and bullying. School Psychology Review, 37, 155-159.

Frye, V., Koblin, B., Chin, J., Beard, J., Blaney, S., Halkitis, P., Galea, S. (2010). Neighborhood-level correlates of consistent condom use among men who have sex with men: A multi-level analysis. AIDS and Behavior, 14, 974-985. doi:10.1007/s10461-008-9438-5

Frye, V., Latka. M., Koblin, B., Halkitis, P.N., Putnam, S., Galea, S., & Vlahov, D. (2006). The urban environment and sexual risk behavior among men who have sex with men. Journal of Urban Health, 83, 308-324.

Gilligan, C. (1982). In a different voice: Psychological theory and women’s development. Cambridge, MA: Harvard University Press.

Grant, R.M., Lama, J.R., Anderson, P.L., McMahan, V., Liu, A.Y., Vargas, L., the iPrEx Study Team. (2010). Preexposure chemoprohylaxis for HIV prevention in men who have sex with men. New England Journal of Medicine, 363, 2587-2599.

Halkitis, P.N. (1999). Redefining masculinity in the age of AIDS: Seropositive gay men and the “buff agenda.” In. P. Nardi (Ed.), Gay masculinities (pp. 130-151). Newbury Park, CA: Sage.

Halkitis, P.N. (2010a, September 8). For HIV-positive men, 50 is the new 40 (and the new 60). Chelsea Now, 4(30), 17-18.

Halkitis, P.N. (2010b). Reframing HIV prevention for gay men in the United States. American Psychologist ®, 65, 752-763. doi:10.1037/0003-066X.65.8.752

Halkitis, P.N., Fischgrund, B.N., & Parsons, J.T. (2005). Explanations for methamphetamine use among gay and bisexual men in New York City. Substance Use & Misuse, 40, 1-15.

Halkitis, P.N., Green, K.A., & Wilton, L. (2004). Masculinity, body image, and sexual behavior in HIV-seropositive gay men: A two-phase behavioral investigation using the Internet. International Journal of Men’s Health, 3, 27-42.

Halkitis, P.N., Moeller R.W., & Siconolfi, D. (2009a, April). Young men who have sex with men (YMSM) HIV prevention project: Findings from the quantitative survey of 18-29 year old YMSM. Report prepared for the New York City Department of Heath and Mental Hygiene.

Halkitis, P.N., Moeller R.W., & Siconolfi, D. (2009b, April). Young men who have sex with men (YMSM) HIV prevention project: Findings from the quantitative survey of 13-17 year old YMSM. Report prepared for the New York City Department of Heath and Mental Hygiene.

Halkitis, P.N., Moeller R. W., & Siconolfi, D. (2010a). Young men who have sex with men (YMSM) HIV prevention project: Findings from the qualitative interviews of 18-29 year old YMSM. Report prepared for the New York City Department of Heath and Mental Hygiene.

Halkitis, P.N., Moeller R.W., & Siconolfi, D. (2010b). Young men who have sex with men (YMSM) HIV prevention project: Findings from the qualitative interviews of 13-17 year old YMSM. Report prepared for the New York City Department of Health and Mental Hygiene.

Hall, H. I., Song, R., Rhodes, P., Prejean, J., An, Q., Lee, L.M., the HIV Incidence Surveillance Group. (2008). HIV incidence surveillance group: Estimation of HIV incidence in the United States. Journal of the American Medical Association, 300, 520-529.

Harawa, N.T., Greenland, S., Bingham, T.A., Johnson, D.F., Cochran, S.D., Cunningham, W.E., Valleroy, L.A. (2004). Associations of race/ethnicity with HIV prevalence and HIV-related behaviors among young men who have sex with men in 7 urban centers in the United States. Journal of Acquired Immune Deficiency Syndromes, 35, 526-536.

Harper, G.W. (2007). Sex isn’t that simple: Culture and context in HIV prevention interventions for gay and bisexual male adolescents. American Psychologist, 62, 806-819. doi:10.1037/0003-066X.62.8.806

Herek, G.M., Gillis, J.R., & Cogan, J.C. (2009). Internalized stigma among sexual minority adults: Insights from a social psychological perspective. Journal of Counseling Psychology, 56, 32-43. doi:10.1037/a0014672

Institute of Medicine. (2011). The health of gay, bisexual, and transgender people; Building a foundation for better understanding. Washington, D.C.: National Academies Press.

Johnson, M.O., Carrico, A.W., Chesney, M.A., & Morin, S.F. (2008). Internalized heterosexism among HIV-positive gay-identified men: Implications for HIV prevention and care. Journal of Consulting and Clinical Psychology, 76, 829–839. doi:10.1037/0022-006X.76.5.829

Karon, J.M., Fleming, P.L., Steketee, R.W., & De Cock, K.M. (2001). HIV in the United States at the turn of the century: An epidemic in transition. American Journal of Public Health, 91, 1060-1068.

Kosciw, J.G., Greytak, E.A., Diaz, E.M., & Bartkiewicz, M.J. (2010). The 2009 National School Climate Survey: The experiences of lesbian, gay, bisexual and transgender youth in our nation’s schools. New York, NY: GLSEN.

Marshall, B.D., Kerr, T., Shoveller, J.A., Patterson, T.L., Buxton, J.A., & Wood, E. (2009). Homelessness and unstable housing associated with an increased risk of HIV and STI transmission among street-involved youth. Health & Place, 15, 783-790.

Mayer, K.H., Bradford J.B., Makadon, H.J., Stall, R., & Goldhammer, H. (2008). Sexual and gender minority health: What we know and what needs to be done. American Journal of Public Health, 98, 989–995. doi:10.2105/AJPH.2007.127811

Mays, V.M., Chatters, L.M., Cochran, S.D., & Mackness, J. (1998). African American families in diversity: Gay men and lesbians as participants in family networks. Journal of Comparative Literature, 29, 73-87.

Mays, V.M., Cochran, S.D., & Zamudio, A. (2004). HIV prevention research: Are we meeting the needs of African American men who have sex with men? Journal of Black Psychology, 30, 78-105. doi:10.1177/0095798403260265

Mimiaga, M.J., Noonan, E., Donnel, D., Safren, S.A., Koenen, K.C., Gortmaker, S., Mayer, K.H. (2009). Childhood sexual abuse is highly associated with HIV risk-taking behavior and infection among MSM in the EXPLORE study. Journal of Acquired Immune Deficiency Syndromes, 51, 350-348.

Office of National AIDS Policy. (2010, July). National HIV/AIDS strategy for the United States (PDF, 1.20MB).

Pascoe, C.J. (2007). Dude, you’re a fag: Masculinity and sexuality in high school. Berkeley, CA: University of California Press.

Pilkington, N.W., & D’Augelli, A.R. (1995). Victimization of lesbian, gay, and bisexual youth in community settings. Journal of Community Psychology, 23, 34-56. doi:10.1002/1520-6629(199501)23:1 3.;2-N

Phoenix, A., Frosh, S., & Pattman, R. (2003). Producing contradictory masculine subject positions: narratives of threat, homophobia and bullying in 11–14 year old boys. Journal of Social Issues, 59, 179-195. doi:10.1111/1540-4560.t01-1-00011

Raymond, H. Fisher, Chen, Y.-H., Stall, R. D., & McFarland, W. (2011). Adolescent experiences of discrimination, harassment, connectedness to community and comfort with sexual orientation reported by adult men who have sex with men as a predictor of adult HIV status. AIDS and Behavior, 15, 550-556. doi:10.1007/s10461-009-9634-y

Rosario, M., Hunter, J., Maguen, S., Gwadz, M., & Smith, R. (2001). The coming-out process and its adaptational and health-related associations among gay, lesbian, and bisexual youths: Stipulation and exploration of a model. American Journal of Community Psychology, 29, 133–160. doi:10.1023/A:1005205630978

Rowen, C.J., & Malcolm, P.J. (2002). Correlates of internalized homophobia and homosexual identity formation in a sample of gay men. Journal of Homosexuality, 43, 77-92. doi:10.1300/J082v43n02_05

Ryan, C., Huebner, D., & Sanchez, J. (2009). Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics, 123, 346-352.

Safren, S.A., Reisner, S.L., Herrick, A., Mimiaga, M.J., & Stall, R.D. (2010). Mental health and HIV risk in men who have sex with men. Journal of Acquired Immune Deficiency Syndromes, 55(Suppl. 2), S74-S77.

Shafer, K.P., Hahn, J.A., Lum, P.J., Ochoa, K., Graves, A., & Moss, A. (2002). Prevalence and correlated of HIV infection among young injection drug users in San Francisco. Journal of Acquired Immune Deficiency Syndromes, 31, 422-431.

Shilts, R. (2007). And the band played on: Politics, people, and the AIDS epidemic (20th anniversary ed.). New York, NY: St. Martins Griffin.

Truong, K.D., & Ma, S. (2006). A systematic review of relations between neighborhoods and mental health. Journal of Mental Health Policy and Economics, 9, 137-154.

United Nations Population Fund. (2003). The impact of HIV/AIDS: A population and development perspective (PDF, 927KB).

Weeks, B.S., & Alcamo, I.E. (2010). AIDS: The biological basis (5th ed.). Boston, MA; Jones and Bartlett.

Williams, J.K., Wyatt, G.E., Resell, J., Peterson, J., & Asuan-O’Brien, A. (2004). Psychosocial issues among gay and non-gay-identifying HIV-seropositive African American and Latino MSM. Cultural Diversity and Ethnic Minority Psychology, 10, 268–286. doi:10.1037/1099-9809.10.3.268

Wolitski, R.J., & Fenton, K.A. (2011). Sexual health, HIV, and sexually transmitted infections among gay, bisexual, and other men who have sex with men in the United States. AIDS and Behavior, 15(Suppl. 1), S9-S17. doi:10.1007/s10461-011-9901-6

Wolitski, R.J., Stall, R., &. Valdiserri, R.O. (Eds.). (2008). Unequal opportunity: Health disparities affecting gay and bisexual men in the United States. Oxford, England: Oxford University Press.

Workowski, K.A., & Berman, S.M. (2006). Sexually transmitted diseases treatment guidelines, 2006. Morbidity and Mortality Weekly Report, 55(RR11), 1-94.

New HIV Infections (HIV Incidence)

HIV incidence refers to the estimated number of new HIV infections during specified period of time (such as a year), which is different from the number of people diagnosed with HIV during a given year. (Some people may have HIV for some time but not know it, so the year they are diagnosed may not be the same as the year they acquired HIV.)

According to the latest estimates from the Centers for Disease Control and Prevention, approximately 36,400 new HIV infections occurred in the United States in 2018. a Annual infections in the U.S. have been reduced by more than two-thirds since the height of the epidemic in the mid-1980s. However, CDC data indicate that the progress has stalled in recent years, at about 38,000 new HIV infections each year between 2014 and 2018.

The latest estimates indicate that effective HIV prevention and treatment are not adequately reaching those who could most benefit from them, and certain groups such as men who have sex with men (MSM), transgender persons, African Americans, and Hispanics/Latinos continue to be disproportionately affected. Additionally, the highest rates of new HIV infection continue to occur in the South.

Notes

a Unless otherwise noted, the term United States (U.S.) includes the 50 states, the District of Columbia, and the 6 dependent areas of American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, the Republic of Palau, and the U.S. Virgin Islands.b The term male-to-male sexual contact is used in CDC surveillance systems. It indicates a behavior that transmits HIV infection, not how individuals self-identify in terms of their sexuality. This web content uses the term gay, bisexual and men who have sex with men.c This includes infections attributed to male-to-male sexual contact and injection drug use (men who reported both risk factors)d Hispanics/Latinx can be of any race.e This page uses the regions defined by the U.S. Census Bureau and used in CDC’s National HIV Surveillance System:

Midwest: IL, IN, IA, KS, MI, MN, MO, NE, ND, OH, SD, WI

South: AL, AR, DE, DC, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV

West: AK, AZ, CA, CO, HI, ID, MT, NV, NM, OR, UT, WA, WY.

Anfang der 1980er-Jahre: die ersten Fälle

Im Sommer 1981 waren die Mediziner der US-Seuchenüberwachungsbehörde „Center for Disease Control“ alarmiert: Fünf bislang gesunde homosexuelle Männer im Raum Los Angeles infizierten sich mit der seltenen Lungenerkrankung Pneumocystis-Pneumonie (PCP), die normalerweise nur Menschen mit einem schwachen Immunsystem befällt.

Fast parallel dazu trat in New York City das Kaposi-Sarkom, eine Krebserkrankung, ungewöhnlich häufig auf. Die Vermutung lag nahe, dass die Mediziner eine neue Krankheit entdeckt hatten. Sie hatte zu dem Zeitpunkt zwar noch keinen Namen, aber viele Symptome.

Da anfangs vor allem Homosexuelle von den seltenen Erkrankungen betroffen waren, vermuteten Wissenschaftler einen Zusammenhang. Das Syndrom bekam den Namen „Gay-Related Immune Deficiency“ (GRID).

Doch schon bald mussten Forscher den Namen, der übersetzt so viel bedeutet wie „Schwulenbezogene Immunschwäche“, durch einen anderen ersetzen. Denn es tauchten immer mehr heterosexuelle Patienten auf.

Erst im Sommer 1982 nannten Mediziner den Immundefekt „Acquired Immune Deficiency Syndrome“ (auf Deutsch: Erworbenes Immunschwäche-Syndrom), kurz Aids. Auch in Deutschland diagnostizierten Ärzte die Erkrankung das erste Mal bei einem Patienten.

1982 wussten Forscher bereits von 14 Ländern, in denen die Krankheit aufgetreten war. Sie hatten erste Vermutungen, dass ein bestimmtes Virus den Immundefekt mit den vielen Krankheitsbildern auslöst.

Bald gab es erste Hinweise auf ein Virus als Auslöser

New HIV Diagnoses Among Gay and Bisexual Men in the US and Dependent Areas by Race/Ethnicity, 2018

* Black refers to people having origins in any of the Black racial groups of Africa. African American is a term often used for Americans of African descent with ancestry in North America.† Hispanics/Latinos can be of any CDC. Diagnoses of HIV infection in the United States and dependent areas, 2018 (updated)HIV Surveillance Report 2020;31.

New HIV Diagnoses Among Gay and Bisexual Men in the US and Dependent Areas by Age, 2018

Total may not equal 100% due to CDC. Diagnoses of HIV infection in the United States and dependent areas, 2018 (updated)HIV Surveillance Report 2020;31.

From 2014 to 2018, HIV diagnoses decreased 7% among gay and bisexual men overall. But trends varied for different groups of gay and bisexual men.

HIV Diagnoses Among Gay and Bisexual Men in the US and Dependent Areas, 2014-2018

* Black refers to people having origins in any of the Black racial groups of Africa. African American is a term often used for Americans of African descent with ancestry in North America.† Hispanics/Latinos can be of any race.‡ Changes in subpopulations with fewer HIV diagnoses can lead to a large percentage increase or CDC. Diagnoses of HIV infection in the United States and dependent areas, 2018 (updated)HIV Surveillance Report 2020;31.

Gay and Bisexual Men With HIV in 50 States and the District of Columbia

It is important for gay and bisexual men to know their HIV status so they can take medicine to treat HIV if they have the virus. Taking HIV medicine every day can make the viral load undetectable. People who get and keep an undetectable viral load (or stay virally suppressed) can live a long and healthy life. They also have effectively no risk of transmitting HIV to HIV-negative sex partners.

* Includes infections attributed to male-to-male sexual contact only. Among men with HIV attributed to male-to-male sexual contact and injection drug use, 12 in 13 knew they had HIV.† Had 2 viral load or CD4 tests at least 3 months apart in a year.‡ Based on most recent viral load CDC. Estimated HIV incidence and prevalence in the United States 2014–2018 pdf icon[PDF – 3 MB]HIV Surveillance Supplemental Report 2020;25(1) CDC. Selected national HIV prevention and care outcomes pdf icon[PDF – 2 MB]. (slides).

A LURKING VIRUS

When the AIDS plague finally took hold in the U.S., it surged through communities that the straight world preferred not to see.

It took a few tries. The virus lurked in tropical regions of central Africa, and made several incursions into the American continent before becoming a global pandemic. HIV likely killed a young man in St. Louis in 1969died from AIDS in 1976 after he likely contracted the virus while traveling in Africa.

It was not until the late 1970s when the HIV strain that started the North American pandemic had made its way to the United States, via Zaire and Haiti. By then, the sexual revolution was in full swing and HIV was spreading silently among gay male populations in large American cities. Men who have sex with men were, and still are, disproportionately impacted by HIV because it transmits much more easily through anal sex than through vaginal sex.

The first official government report on AIDS came on June 5, 1981, in the Morbidity and Mortality Weekly Report, a government bulletin on perplexing disease cases: “In the period October 1980-May 1981, 5 young men, all active homosexuals, were treated for biopsy-confirmed Pneumocystis carinii pneumonia at 3 different hospitals in Los Angeles, California. Two of the patients died.”

In NBC Nightly News’ first report on AIDS in June 1982, Robert Bazell reported that “the best guess is some infectious agent is causing it.”

In a 1983 appearance on NBC’s „Today“ show, activist and Gay Mens Health Crisis co-founder Larry Kramer asked host Jane Pauley, „Jane, can you imagine what it must be like if you had lost 20 of your friends in the last 18 months?“

THE ‚GAY PLAGUE‘

After the Stonewall Riots in 1969, LGBTQ activists across the country made significant civil rights advances and secured some municipal and state-level protections against discrimination in public employment. Roughly two dozen states had decriminalized sodomy by 1980, and some activists were already talking about the next frontier: legal recognition for marriage.

Almost at the exact time that HIV cases first began to pop up in Los Angeles and New York, the LGBTQ civil rights struggle faced a reactionary backlash led by figures like Anita Bryant and Rev. Jerry Falwell, whose “Moral Majority” inveighed against giving rights to gay people.

On March 22, 1980, a year before that first MMWR report, evangelical Christian leaders delivered a petition to President Jimmy Carter demanding a halt to the advance of gay rights. “God’s judgment is going to fall on America as on other societies that allowed homosexuality to become a protected way of life,” Bob Jones III predicted, according to UPI.

As the anti-gay reaction gained steam across America with the election of Moral Majority ally Ronald Reagan, activists found their demands for attention for a growing medical crisis were ignored. The march for LGBTQ civil rights ground to a halt — after more than a dozen states repealed sodomy bans in the 1970s, just two jurisdictions, Wisconsin and the Virgin Islands, decriminalized sodomy in the 1980s.

In 1982, Larry Speakes, press secretary for Reagan, laughed when asked about whether the president was tracking the spread of AIDS.

“It’s known as gay plague,” the journalist asked. Some people in the room chuckled.

“I don’t have it, do you?” Speakes snapped back, as the room erupted in laughter. „Do you? You didn’t answer my question. How do you know?“

In 1984, Health and Human Services Secretary Margaret Heckler announced the discovery of the virus that caused AIDS, the development of an AIDS test, and forecast that a vaccine would be available by 1986. But no vaccine ever came.

‚SEIZE THE FDA‘

After Heckler’s announcement, it took a year before Reagan publicly uttered the word “AIDS” until 1985, when over 12,000 Americans had died and the virus had begun to spread swiftly through hemophiliac populations and injection drug users.

In 1987, zidovudine, or AZT, became the first drug approved to treat AIDS. But the drug only seemed to slow the progression of the disease, and did not cure it or even prevent death. Patients were prescribed to take an AZT pill every four hours, night and day, forever. Today, we know that this amount of AZT is a toxic overdose.

In the face of government silence, and in the absence of a promised vaccine, AIDS activists began to organize to provide care for the patients who were falling ill. One such group was the Gay Men’s Health Crisis, founded in New York City in 1982, which is today the oldest HIV/AIDS service organization in the world.

But in 1987, activists were still frustrated by government inaction as bodies continued to pile up, and they founded the AIDS Coalition To Unleash Power, or ACT UP, in New York City.

Today, their actions and their activist art are legendary for speeding the government’s response to the AIDS crisis, allowing quicker testing and treatment of lifesaving experimental drugs, and drawing public attention to the deadly impact of homophobic public health policies.

“Our first demonstration [took] place three weeks later on March 24 on Wall Street, the financial center of the world, to protest the profiteering of pharmaceutical companies,” ACT UP wrote. In particular, the sky-high price of AZT: $10,000 per year.

Avram Finkelstein, one of the designers of the iconic ACT UP poster “Silence=Death,” wrote in guest post for the New York Public Library:

„In 1981, my soul mate started showing signs of immunosuppression, before AIDS even had its name. By 1984, he was dead, a year before Rock Hudson had been outed by the disease and died, and Reagan had uttered the word. This private devastation compelled me to form a collective with two of my friends.“

Finkelstein continued: „And in order to ’sell‘ activism in an apolitical moment, the poster needed to be cool, and to intone ‚knowing.‘ It needed to be both rarified and vernacular at the same time. It needed to give the impression of ubiquity, and to create its own literacy. It needed to insinuate itself into being. It needed to be advertising.“

ACT UP activist Douglas Crimp, writing in The Atlantic, said the October 1988 action „Seize the FDA“ was a turning point that “occurred for two interrelated reasons: 1) the demonstrated knowledge by AIDS activists of every detail of the complex FDA drug approval process, and 2) a professionally designed campaign that prepared the media to convey our treatment issues to the public.”

“ACT UP’s fundamental contention was that, with a new epidemic disease such as AIDS, testing experimental new therapies is itself a form of health care and that access to health care must be everyone’s right,” Crimp wrote.

1981

In 1981, cases of a rare lung infection called Pneumocystis carinii pneumonia (PCP) were found in five young, previously healthy gay men in Los Angeles.2 At the same time, there were reports of a group of men in New York and California with an unusually aggressive cancer named Kaposi’s Sarcoma.3

In December 1981, the first cases of PCP were reported in people who inject drugs.4

By the end of the year, there were 270 reported cases of severe immune deficiency among gay men – 121 of them had died.5

1982

In June 1982, a group of cases among gay men in Southern California suggested that the cause of the immune deficiency was sexual and the syndrome was initially called gay-related immune deficiency (or GRID).6

Later that month, the disease was reported in haemophiliacs and Haitians leading many to believe it had originated in Haiti.7 8

In September, the CDC used the term ‚AIDS‘ (acquired immune deficiency syndrome) for the first time, describing it as

a disease at least moderately predictive of a defect in cell mediated immunity, occurring in a person with no known case for diminished resistance to that disease.9

AIDS cases were also being reported in a number of European countries.10 11 12

In Uganda, doctors reported cases of a new, fatal wasting disease locally known as ’slim‘.13

By this point, a number of AIDS-specific organisations had been set up including the San Francisco AIDS Foundation (SFAF) in the USA and the Terrence Higgins Trust in the UK.14

1991

In 1991, the Visual AIDS Artists Caucus launched the Red Ribbon Project to create a symbol of compassion for people living with HIV and their carers. The red ribbon became an international symbol of AIDS awareness.51

On 7 November, professional basketball player Earvin (Magic) Johnson announced he had HIV and retired from the sport, planning to educate young people about the virus. This announcement helped begin to dispel the stereotype, still widely held in the US and elsewhere, of HIV as a ‘gay’ disease.52

A couple of weeks later, Freddie Mercury, lead singer of rock group Queen, announced he had AIDS and died a day later.53

Behavioural factors

Having multiple sexual partners is common among men who have sex with men, yet many men engaging in casual sex do not use condoms consistently. In 33 countries less than 60% of men who have sex with men had reported using a condom at last anal sex, and only 15 countries had rates higher than 80%.18

Data on other STIs among men who have sex with men are further evidence of inconsistent condom use.19 20

Access to HIV testing services among men who have sex with men is also varied. In several European and North American cities, men who have sex with men are approaching or have exceeded the 90-90-90 targets, with over 90% of men who have sex with men aware of their HIV status. Yet studies conducted in Kenya, Malawi and South Africa have found that only one in three HIV-positive men who have sex with men were aware of their status, and in Mozambique it was fewer than 10%.21 A study in India found that only 30% of a cohort of more than 1,000 men who have sex with men living with HIV were aware of their status.22

Not testing for HIV means that many men who have sex with men are unaware of their HIV status and may be unaware of the need to take protective measures to prevent onward transmission to others. Alcohol and drugs are a common part of socialising in some communities of men who have sex with men. Being under the influence of drugs or alcohol can make it more likely that people will have unprotected sex and a higher number of sexual partners, increasing the risk of HIV transmission. For instance, a study conducted in India among men who have sex with men found a link between alcohol, increased sexual risk behaviour and HIV acquisition.23 24

In Asia and the Pacific, and North America and Western Europe, evidence is growing that some men who have sex with men are participating in group sex most commonly known as ‘chemsex’ (also referred to as ‘party and play’ or ‘PNP’) under the influence of psychoactive and performance-enhancing drugs. The drugs being used, namely GHB (gamma-hydoxybutyrate), methamphetamine and methedrone, facilitate prolonged sexual sessions and usually involve multiple partners.25 Data from 2014 suggests around 3 in 10 gay men in the UK engaged in chemsex in the previous year.26

Healthcare professionals are particularly concerned with the high-risk behaviours that these drugs induce; a lack of physical inhibition and awareness often means a participant is exposed to multiple partners without protection or to shared drug taking equipment which increases the risk of HIV transmission. In cases where sexual activity is prolonged there is also a concern that participants living with HIV may forget to take ART medication, or that those who are HIV-negative will miss the 72-hour window to be eligible for receiving post-exposure prophylaxis (PEP) after suspected exposure to HIV.27

Men in this groups often become HIV-positive while still young. Estimates suggest that 4.2% of young men (under-25) who have sex with men are living with HIV. This is more common in countries where HIV prevalence among the whole men who have sex with men population is relatively high.28 One study carried out in Bangkok found HIV incidence was more than twice as high among men aged 18 to 21 years compared to men over 30 years of age.29

Where race intersects with age and sexuality, HIV risk can also be affected. For example, in the USA, young black men (aged between 13 and 24) who have sex with men are around three times more likely to have HIV than white men who have sex with men of the same age.30

Young men who have sex with men often find it harder to access HIV services, due to age of consent laws or unsociable opening times. HIV testing and status awareness in 2014 was lower among young men who have sex with men (36%) than among this group as a whole (43%).31

Data from more than 9,000 USA-based men who have sex with men who took part in an online survey found being young, from a black or ethnic minority, and having a low level of education were all significantly associated with not being aware of HIV status.32

Legal factors

As of 2019, 67 countries criminalised same-sex conduct, affecting the rights of men who have sex with men and other members of the LGBTQ community. In eight countries including Iran, Sudan, Saudi Arabia, Yemen and parts of Nigeria and Somalia, homosexuality is punishable by death.33 As a result, men who have sex with men are far less likely to access HIV services for fear of their sexual orientation and identity being revealed.

As of 2019, 32 countries restricted people’s freedom to express their sexual identity. Some have laws that ban content that ‘promote’ homosexuality or ‘non-traditional’ sexual relations. Around 41 countries have laws that restrict non-government organisations (NGOs) that work on LGBTQ issues.34 35

For example, Russia has an anti-propaganda law that it uses to prevent NGOs delivering HIV services to men who have sex with men. Its influence in the region is such that similar laws have also been introduced in Lithuania and Belarus and are also periodically being proposed, then challenged in Ukraine. Parliaments in Kyrgyzstan, Kazakhstan, Poland, Romania, Tajikistan, Azerbaijan, and Armenia have also attempted to pass anti-propaganda laws but none have been successful – yet.36