Editor's Note: In addition to being a Bilerico DC contributor, Dan O'Neill is chair of the HIV Prevention Working Group. HPWG is a program of The DC Center.
The gay community is now experiencing a rather devastating case of déjà vu; as recently it's become quite apparent that we are in the midst of a second major wave of the HIV/AIDS epidemic, at a magnitude that we have not seen for a couple of decades. A constellation of new data and recent national and local HIV/AIDS surveillance reports paints a very grim picture for current HIV incidence among men who have sex with men (MSM).
Many of us have seen the startling headlines, the District's 3% HIV prevalence figure that was emblazoned across TV screens and newspapers nationwide late last month; but we may not have considered what this means for us, as gay men - still the most disproportionally affected risk group for acquiring HIV.
Since 2000, the gay community has observed a steady increase in new annual incidence of HIV, after a brief decline in the late nineties due to the appearance of HAART and being saturated into submission with safer sex messages. However, the recent reports from the CDC and the DC Department of Health suggest that over the past couple of years, rates have once again skyrocketed within this risk group, a trend that is only now being noticed due to the inherent delays of reporting HIV/AIDS data.
For example, researchers responsible for the CDC's most recent HIV/AIDS Surveillance Report released last month made special note of the its most salient figure, a dramatic spike (26% increase) in new annual diagnoses of HIV in MSM since 2004. Importantly, new incidence from 2004-2006 increased, but remained relatively stable, showing between 17,000 and 19,000 new cases for each consecutive year. However, in 2007 something changed, resulting in a significant jump to nearly 22,500 new cases. Epidemiologists are quick to note that a significant increase in the number of MSM testing for HIV, as well as changes in reporting regulations and the addition of new, mature data sets (from Georgia) may have inflated this figure. Yet these same scientists also noted that such factors would only temper this increase slightly, indicating that it is not a mere statistical artifact.
Compounding the problem, the District's rate of new HIV/AIDS infections for 2007 (277 cases/100,000 individuals) is more than 13 times the national average (21 cases/100,000 individuals), according to recent data from the Kaiser Family Foundation. It is also important to note that the 3% HIV prevalence figure recently reported by the DC Department of Health is three times what is required for a "generalized" and severe epidemic. Jointly, these statistics indicate that whatever the risk currently is for MSM to acquire HIV, that risk becomes astronomically higher in the context of the District's modern epidemic.
Confirming this frightening supposition, the Whitman-Walker Clinic reported a 232% increase in actual (not estimated) new diagnoses last year, observing a dramatic upsurge from 80 clients testing HIV-positive for the first half of 2007 to 266 testing positive for the first half of 2008 - out of roughly the same number of total tests administered. Although the Clinic provides primary care and sexual health services to all underserved populations, its main client base is still largely comprised of gay men. Thus, one may conclude that this spike in new diagnoses was observed predominantly among MSM in the DC metropolitan area.
Altogether, these numbers suggest that the HIV epidemic, especially in DC, seems to have hit a 'tipping point' in the past couple of years, causing it to break free of its previously steady upward trajectory to now expand exponentially. And because many of these startling, new findings are already one-to-two years behind due to reporting delays, the reality of the current situation is likely far worse than what's been revealed.
Although many factors are to blame for this new epidemic of HIV, including the advent of the internet facilitating quick, anonymous sex; the gay community's raging crystal meth and bare-backing problem; and the lack of a coordinated domestic plan to fight HIV; gone from our memories, it seems, is a time when the gay community, like never before, rallied together to fight for survival, galvanized by the AIDS crisis. Perhaps it's because so many of those who would have passed on these memories of the devastation that AIDS caused died from the disease in the eighties and nineties. Or maybe it's because those who survived are so exhausted from practicing and preaching safer sex, that even they have succumbed to the recent phenomenon of HIV "prevention fatigue."
Regardless, today we find a new generation of gay men that have experienced their sexual debut in the late nineties or beyond and never endured the fear and suffering of those who lived and died only decades before them. They never attended weekly funerals or experienced the pain of having their social circles decimated over night. At the peak of the AIDS crisis, for example, the San Francisco Gay Men's Chorus saw its numbers decline by more than half within a year's time, in which only 210 singers survived to read the 257 obituaries of those who did not. Today, when just one, young gay man dies (whether AIDS-related or not), it's a tragedy. Sadly, back then it was commonplace.
I believe this second wave of new HIV infections may be upon us because we, as gay men, never really addressed the fundamental questions of how gay culture fueled this epidemic the first time around:
How were the behaviors that favored the spread of HIV among gay men initially created and how could they be curbed beyond the technological quick fix of donning a condom or downing a handful of PEP after that condom breaks?
Is it possible to modify these behaviors in a way that would not compromise the gains we have made through gay liberation over the past decades?
How might we move towards the creation of a sustainable gay culture, in which our homosexuality is celebrated in a way that does not destroy us in the process?
It's not that surprising that we never acknowledged the need to answer these questions and fundamentally change our behavior the first time around, since engaging in such a public discourse would seem to play into the hands of anti-gay forces, only confirming their misconception that HIV was an exclusively "Gay Disease," resulting from our "degenerate" behavior. We were put so much on the defensive during the eighties and nineties that we never fully acknowledged that, in a lot of ways, HIV actually is a "Gay Disease."
We ramped up the use of condoms in order to prevent HIV transmission while also maintaining the "gay sex positivity" that defined much of who we had become in the latter half of the twentieth century. But getting gay men to finally use condoms and practice safer sex was a monumental task that seemed to gain traction only when our lives appeared to be in imminent danger. Unfortunately, that perception seems to have gone to the wayside, as we are now seeing rates of new infection similar to those observed in the early-to-mid nineties. And that begs the question: why have gay men back-slid so terribly in our practice of safer sex?
Although condoms and other modes of 'playing it safe(r)' are an essential part of combating the epidemic, they remain insufficient strategies for tackling the problem, if not reinforced by an underlining cultural sea change in our value system. For as long as I can remember, gay sex (under any circumstance) has been de facto tainted or diseased, always requiring a condom. Framed in this way, condom use is not an altruistic act of empowerment that one does out love for himself and, at a higher level, for his fellow gay men; rather, it's something one does because he'd be an idiot not to in the face of such terrible risk. Thus, it only follows that as the perceived risk of infection waxes and wanes, so will the use of condoms.
Yes, disease is transmitted at the individual level; however, it is amplified to epidemic proportions at the cultural or societal level, especially within groups that:
engage in very infective modes of transmission,
have already high prevalence of the disease, and
have highly fluid rates of partner change.
Condoms only help to minimize this first factor, by reducing infectivity. However, gay men must collectively address the second two factors, if we are to ever lose our "high risk" classification. Without addressing these underlining reasons as to why gay culture facilitates further spread of HIV, I fear we are destined to have history repeat itself.
It is now clear that the sense of community among gay men forged by the HIV/AIDS crisis in decades past desperately needs to be revived, if we are once again to turn the tide on this epidemic. But this time around, we need to raise the bar with respect to the value we place on our relationships and how we interact with each other, especially in bed. We need to probe deeper (pun intended) when it comes to the questions we ask each other about sex.
"You been tested?" said in the breathless throes of getting it on, will no longer suffice. We need to follow up with: "When were you last tested?" and "How many people have you had sex with since?"... "What types of sex have you had?"... "Did you use a condom?"..."Did you know the serostatus of those sexual partners?".. etc. And we need to answer those questions honestly.
Above all, we must acknowledge (although it is still said otherwise, in courtrooms and in bedrooms across America) that damn it, we're worth it; our gay lives and our gay relationships are worth protecting. This is a critical first step in stopping the spread of HIV within our community, and puts the onus squarely on us, both individually and collectively, to make that change. We have done it before; and now we need to do it again - for each other!