Pop quiz, no cheating allowed: if you had to guess, would you say that HIV and AIDS rates among gay men in the United States are A) declining, B) remaining stable, or C) rising?
The correct answer is C) rising, at an alarming 8% per year. HIV incidence -- that is, the proportion of a population infected -- among gay men in the United States rises by that amount every year since at least 2001. Overall, this incidence, at 15.4% cumulatively, is just slightly lower than the incidence among gay men in Sub-Saharan Africa. And there’s a good case to be made that the real numbers are actually higher; for instance, we know they’re higher in some major metropolitan areas, where the incidence among MSM (men who have sex with men) is one in five. In San Francisco, it may be as high as one in four.
Overall, the Centers for Disease Control and Prevention (CDC) estimates that between 400,000 and 500,000 gay men in the United States carried the virus in 2009, the most recent year for which data are available. Chillingly, gay and bisexual men are the only demographic to experience a rise in HIV infection rates.
These are astonishing facts. The AIDS epidemic is now over three decades old and has taken over 600,000 lives in the U.S. alone. That’s more casualties than were seen in the entire Civil War. It’s also noteworthy that new infections in the U.S. are numerically stable overall, at roughly 50,000 a year over the last decade or so -- a number seemingly impervious to public or private prevention efforts.
Considering the carnage AIDS has inflicted on gay men in particular, it’s urgent that we examine what, if anything, can be done to save lives and to prevent the widespread damage of another generation -- today’s young men. The fewer than 1% of Americans who are gay or bisexual men between the ages of 13 and 29 comprise 27% of new infections.
Public health experts have been concerned about the rising rates among MSM for years now, viewing the current epidemic as the second wave — the first having occurred in the 1980s. Today’s infections, they say, are affecting a new generation of men who didn’t live through the initial devastation of AIDS’ early days, when there were no drug treatments and a diagnosis was a death sentence. Public health messages about safe sex practices and testing targeted to gay men have waned in the intervening years, and now, some experts say, a new generation of at-risk men have to be educated about the disease.
There is no single reason why HIV rates have been rising again among gay men for at least a decade, or one tool that could hinder the process. The best we can do is identify contributing factors (with limited hard data), consider approaches to reach vulnerable demographics and help change behaviors.
Effective HIV therapy has been around since 1996, in the form of HAART (Highly Active Antiretroviral Therapy) drugs. These drugs reduced mortality rates, previously near 100%, by 50% to 80%, and gave HIV patients a new lease on life.
An unintended side effect was that the drugs also reduced the visibility of the disease within the gay community. The “gay ghettos” of large cities were no longer the sole mournful province of the walking dead. The sense of urgency around the epidemic began to fade, while indicators of unprotected sex, specifically the incidence of other sexually transmitted diseases, began to rise.
Roughly around the same time, Internet penetration of global and U.S. households rose incredibly fast, from 16 million in 1995 to 513 million in 2001. In another unintended side effect, the online revolution swept aside one of the main epidemiological tools that had been proven effective for tracking the disease: the closure or control of institutions such as bathhouses that had enabled the rapid spread of the virus in the early years.
The staggering death toll from the epidemic carried with it not just individual, but also communal loss. Absent reliable numbers on -- or even an agreed upon definition of -- gay men, it is impossible to exactly quantify these losses. One number (among several) that the CDC provides is just south of 300,000 fatalities since the beginning of the epidemic.
What can be said with certainty is that AIDS wiped out many of the best and brightest members of a generation -- a generation that gave the world Keith Haring, and Halston, and so many others besides. The catastrophic loss left this generation untethered from its history, bereft of mentors, adrift in the tides of a hostile society, and unsure of its future.
Around the turn of the century, something new appeared: crystal meth. Crystal -- also known as tina, crank, crack, and glass -- is a highly addictive, cheap and long-lasting stimulant. And it lends itself perfectly to sex. Crystal switches off that little switch in the brain that tells you that you really shouldn’t be doing something, and certainly not for two days, without pause or protection. It lowers inhibitions, creating arousal, euphoria and confidence. As such, there is a statistically significant correlation between crystal meth use, unsafe sex and HIV infection.
But the main reason a second wave of the HIV/AIDS epidemic is materializing and has failed to elicit much awareness or action in the gay community, is one of choices. Many LGBT rights groups have mainstreamed themselves, choosing topics (such as marriage, bullying or military service) that, while certainly worthy and urgent, make for an easier sell to the rest of society than getting high, sick or fucked. Those things, less telegenic than a man in uniform or a couple walking down the aisle, have somewhat receded from view.
This mainstreaming, as Joseph Huff-Hannon wrote about on AlterNet, is on the one hand an entirely logical response to pervasive societal and governmental discrimination. (Remember George W. Bush winning a close presidential election in 2004 on the backs of anti-gay referenda in several battleground states). On the other, it represents an abdication of solidarity with the most vulnerable segments of the community and our painful recent history. Off-the-record conversations with the leaders of several LGBT advocacy groups confirm this shift in emphasis.
One of the epicenters of HIV in the United States is Washington, DC, the city that played host to the XIX International AIDS Conference this July. A compact, media-saturated city of transients, where imperial architecture rubs shoulders with extremes of deprivation, the District is perhaps the country’s most suitable laboratory to measure and counteract this second wave.
Enter Daniel Fredrick O'Neill, a 31-year-old med student who moved to DC from Indiana in 2006. Working in clinics and general practices with high caseloads of HIV- and AIDS-positive gay men, and living the life of a young gay man in the big city himself, O’Neill quickly realized that the specter of HIV was prevalent in the District.
At first glance, O’Neill is an unlikely HIV activist. Too young to have experienced the devastation of the first wave and therefore free of the emotional and psychic scars it left in its wake, he could have chosen any number of other paths. As a diabetic, it would have been only natural for him to become active in that (also overlooked) field. But, as is sometimes the case, life intervened.
Working on the front lines of the forgotten epidemic, O’Neill quickly realized the gravity of its scope, and the inadequacy of the response to it. He saw little organization or impetus, and what efforts existed were balkanized into closely guarded bureaucratic fiefdoms.
DC is an anomaly within the United States. As the seat of the federal government, it has limited home rule, and is otherwise governed directly by Congress. And while Congress has its virtues, public health policy without ideological constraints is not among them. For instance, the so-called Helms Amendment, which was passed in 1987, prohibits the disbursement of any federal funds to "promote or encourage, directly or indirectly, homosexual sexual activities” -- a bit of a problem when it comes to stopping the progress of a disease spread largely or even mainly through gay sex.
O’Neill found that the Helms Amendment impeded the production of educational materials that would be appropriate for and acceptable to gay men. So O’Neill set out to do something about it.
The result is FUK!T [warning: extremely graphic], launched under the aegis of the D.C. Gay and Lesbian Center, a multimedia-supported effort to bring condoms and lubricant, neatly packed in kits by volunteers, into the hands of gay DC residents where they live, shop and play. Not for the faint of heart, the associated campaign uses adult-movie actors to demonstrate how these things work.
Publicly and privately funded, FUK!T -- and its more restrained twin, TOOLK!T -- are able to avoid the strictures of federal prudery. Produced by and for gay and bisexual men, the materials speak the language of the gay community, allowing them to start conversations. Hundreds of thousands of these kits have been distributed since 2009, free of cost. The contrast with similar campaigns in New York City -- specifically an infamous ad from the Bloomberg administration that infuriated the gay community, known colloquially as the Ass Cancer Spot -- is stark. In DC, the audience was engaged, whereas in New York it was horrified.
The beauty of this is that, in the tradition of the early days of the epidemic, the DC initiative grew out of the gay community itself, as did path-blazers like New York City’s Gay Mens’ Health Crisis. Historically, the LGBT community has learned that it can’t rely on the government to safeguard its interests; often enough, it has done the opposite. The result has been a network of independent institutions -- civil society at its best.
This loose network, responsive and nimble as can be, is the key to securing the health and well-being of the LGBT community.
In terms of the bigger picture, it’s likely already too late to stop this second wave of HIV and AIDS. There has always been a time lag of several years between infection and diagnosis, so the numbers we see today are reflective of events several years ago. But if the LGBT community realizes what is happening under its very nose, and uses our tools, experience and style, it can reverse the trend.
Daniel O’Neill’s experiment in DC, and others like it, show it can be done, and the catastrophic infection rates tell us it must be done. Who will protect us if we don’t protect ourselves? The answer is simple: no one.