Monday, September 27, 2010 marks National Gay Men's HIV Awareness Day, a new addition to the growing list of CDC-sponsored efforts that draw attention to the terrible toll this disease continues to have on high-risk communities. Sadly, I fear this day will come and go without notice, but I hope I am wrong.
As highlighted in the recent National HIV/AIDS Strategy, the plight of gay and bisexual men has taken a turn for the worse over the past decade. Once again, we have reached a tipping point in the course of this epidemic with the imminent rise of another major wave of new HIV infections on the horizon - the likes of which we have not seen since the early nineties.
Nationally, MSM are 44-86 times more likely to be infected with HIV than their heterosexual counterparts, for gay and bisexual men account for 53 percent of new infections, despite comprising an estimated 2 percent of the total population. HHS Secretary, Kathleen Sebelius even noted recently "in some U.S. cities, it is estimated that nearly half of gay African-American men are HIV-positive."
While many factors are to blame for this new epidemic of HIV among gay men (including a growing complacency around the disease and the threat it still poses to one's health; the advent of the internet, facilitating quick and often anonymous sex; and, until recently, the lack of a coordinated domestic plan to fight HIV); gone from our memories, it seems, is a time when the gay men rallied together to fight for our survival - galvanized by the death and destruction that HIV/AIDS inflicts on our community. Thus, as our communal urgency around the disease has waxed and waned; so has our perceived need to protect each other and ourselves.
In D.C. the picture is especially grim. The recent National HIV Behavioral Surveillance (NHBS) study revealed that at least 14 percent of local gay men surveyed tested positive for HIV, with prevalence as high as 25 percent among African-Americans. That said, only 57.4 percent of those sampled reported using a condom at their last anal intercourse. Considering our community's history with HIV/AIDS, we should know better; yet for whatever reason, HIV/AIDS continues to remain an undeniably "gay disease," begging the question: How have we, a community so impacted by this epidemic over the past three decades, backslid so terribly in preventing its spread?
Perhaps it's because so many of those who would have passed on memories of the devastation have since died from the disease; while others may say it's because we've been so distracted lately by numerous other LGBT civil rights issues - from same-sex marriage to the repeal of DADT. Or maybe it's because those who have survived are so exhausted from practicing and preaching safer sex that their decades of restraint have finally given way to HIV "prevention fatigue."
Regardless of the reason, today we find a new generation of gay men that have experienced their sexual debut after the advent of highly-active antiretroviral therapy 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. Today, when just one young gay man dies, it's a tragedy. Sadly, back then it was commonplace. As a result, the new generation remains apathetic toward this disease, partly out of ignorance about what it was like back then. Well, they may soon find out, if something isn't done to stem HIV's alarming resurgence.
Yet despite the bleak situation the gay community currently faces, we now have a much broader arsenal of information and technology to protect ourselves than ever before. Knowledge is power; but this knowledge does us little good if we're unwilling to educate ourselves and our fellow gay men. As such, in recognition of National Gay Men's HIV Awareness Day, following are 6 important, often-overlooked, facts that all gay men should know about this disease and the new epidemic we now face.
- Newly infected individuals who are still within their "window period" (< 3 months since being infected) are both most infectious (likely to transmit the virus to someone else) and unlikely to test positive for the virus: In a perverse twist of fortune, HIV is most likely to be transmitted by newly infected people, who will likely continue to receive false-negative results from antibody screening tests, until they seroconvert. In the early stages of HIV infection, the virus expands rapidly, seeding throughout one's body, as his/her immune system has yet to mount an appropriate response. Only when this robust response occurs, producing HIV-specific antibodies, will a screening test identify someone as positive. In the meantime, one's viral load becomes astronomically high, dramatically increasing the chance of transmitting the virus, while at the same time being missed by our increasingly sensitive HIV tests. Thus, at times when people may feel most safe, they may be at most risk of infection. So close those windows!
- The Advent of PEP: Post-exposure prophylaxis (PEP) was initially developed for healthcare workers who were accidentally exposed to HIV, largely through needle sticks. As a result, it was found that if one followed a month-long regimen of anti-retroviral therapy, begun within 72 hours of the exposure, his/her chance of developing an infection was dramatically reduced. Thus, if the condom ever breaks or if you believe you may have been exposed to HIV, get yourself to the nearest clinic or department of health to begin PEP within 72 hours. This gift, however, is not to be abused, as it may breed resistance strains of HIV, if used indiscriminately. It is also quite costly and may have adverse effects on one's body. So be careful; but know PEP is there in case of emergency.
- The new ins and outs of HIV testing - What routine testing means for us: Stigma around HIV testing will never end, forever remaining a barrier, unless we routinely ask for the test and routinely expect it from our providers. Despite drastic changes in 2006 to the CDC HIV testing guidelines, shifting the recommendation from "opt-in" to "opt-out" testing and ending unnecessary written consent requirements, as well as the need for pre- and post- test counseling, many primary care providers still refuse to offer testing routinely to their patients. In high-risk communities, such as the District of Columbia, the CDC recommends that all individuals, age 13-64, receive a HIV test as a routine part of care - analogous to a blood pressure or cholesterol test. Yet sadly, most physicians still use arcane, risk-based approaches to profile patients and only test those they believe to be at risk. As a result, among those gay men who tested newly positive in the recent NHBS study, who had seen a doctor with in the past year, only slightly more than a third had been offered an HIV test by their healthcare providers. These cases are missed opportunities for early treatment and care. This has to change; so ask your primary care provider to routinely offer the test.
- You can do everything "right" and still become infected or everything "wrong" and not become infected: It's often difficult for us "non-sciency" types to get our heads around the probabilities that are associated with a particular risk behavior and the transmission of HIV. We tend to have a list in our minds of behaviors to avoid (i.e. unprotected anal sex, using oil-based lube, sharing needles etc.) and behaviors to follow (i.e. using condoms, knowing one's partner's status, etc.) and believe that acting accordingly necessarily means we will never become infected with HIV. And tragically, we'd be very wrong. Often I've heard gay men say that's it's only when one bleeds during anal sex that HIV transmission is likely. But that's just not true. Although, HIV is hard to transmit, one must remember that population level statistics never reduce to individual actions and moments in time. Every sexual encounter presents an opportunity for transmission, as there is no such thing as safe sex, only safer sex.
- Condoms 101: We have all seen the banana demonstrations and think we know how to use a condom. But bear with me, as there are a few pointers that many gay men often miss or forget. In particular... Always check to see if the condom has expired. Never tear a condom wrapper off with your teeth or sharp object. Never flip a condom over, if you begin to don it the wrong way. Only use condom-safe lube that is water- or silicon-based, never oil-based. Always use lube during anal sex. Know that the verdict is still out on using female condoms for anal sex. Be weary of being over-optimistic and using condoms that are too large. If you're not a "Magnum man," the condom is more likely to slip or break if you use an XL-size. Know that condoms are sexy. Don't believe me? Check out this NSWF educational website: www.DCFukit.org.
- Take action and have hope: For the younger generation of gay men, it's an accident of history that we are fortunate enough to be living in 2010, instead of 1980. If that were the case, well over half of us would be dead or dying within a few years. We're lucky; and we owe it to ourselves and the future generation of gay men to lower our prevalence of HIV; so we may one be able to live in less fear. If you lived through the eighties and nineties unscathed, share your story with younger gay men. They need to hear it. And finally, take action. One way to help is by volunteering for a HIV vaccine research study at one of many sites throughout the country. Currently, the NIH is recruiting 1350 MSM for a vaccine trial that could one day turn the tide on this epidemic. They need your help. Access the following link to find out how you can become involved: hopetakesaction.org.