HEALTH
HIV Prevention: Whose Job Is It?
by Dan Wohlfeiler, M.P.H.
In recent years, community-based HIV prevention programs have been blamed for the increasing rates of HIV infections in the gay community. Critics have accused AIDS agencies of issuing simplistic messages and "Pavlovian dictates" that cause men to have sex that puts them or others at risk for HIV.* I suspect that many of these criticisms come from over-inflated egos seeking to promote themselves and their own agendas. Some come from frustration at new infections. While there are plenty of reasons to criticize prevention agencies -- trust me, I worked in one for years, and made plenty of mistakes -- some of this blame also masks painful questions about who’s responsible for the course of the AIDS epidemic in the gay community.
It’s easy to blame AIDS agencies for new infections, although it is difficult to find any data, which support that claim. The idea that responsibility for ending the epidemic is shared by many different people and institutions is difficult for some people to grasp. All of us are responsible for stopping AIDS, but new reports show that too often, a growing number of us are shirking our role.
Are You Having Safer Sex?
More of us are having unsafe sex and with more partners, and more of us are getting infected. There is no one reason why people are having unsafe sex. Different people give different explanations: Unsafe sex feels better. My partner is responsible for protection. New treatments make AIDS no big deal. People don’t really get sick from HIV. Others never had the economic, psychological, or emotional resources necessary to protect their own health.
There’s been a hue and a cry that many of us have an inalienable right to intimacy, which for some of us means exchanging semen. No one would dispute that sex without latex can be much, much more intimate. But how intimate do you need to be, with whom, and when? Does it mean the same to you to not wear condoms with your lover as with the guy you met last Thursday whose name and HIV status you didn’t know, or the guy you’ll trick with tonight ? Or with five, ten, or twenty more guys this year? Isn’t taking care of each other also part of intimacy? Gay liberation was about the freedom to have sex, to break rules, to have no limits. And we can have most of that. We don’t have to be prudish -- we just need to be prudent.
Let’s Not Forget Businesses
While it’s important that AIDS service organizations and public health departments take a leadership role in reducing infections let’s not forget the role businesses can play. Our society holds tobacco companies responsible for contributing to the health risks of their customers. Public health advocates are attempting to do the same for gun manufacturers and alcohol companies. We expect these companies to minimize risk, and to encourage their customers to be responsible. Why should it be any different for bar and bathhouse owners, circuit-party organizers and Internet providers?
These companies all make plenty of profit helping people find new partners and lovers. They can also help reduce the number of new HIV infections that occur each year by distributing condoms and making sure there are plenty of (non-Pavlovian, but encouraging) safe sex facts and messages available. Bars can help make sure customers don’t drive off drunk, and bathhouse owners can make sure they don’t come in drunk or tweaked out on speed.
The pharmaceutical industry has invested plenty in marketing their HIV medications. Would it be too much for them to contribute to the community's prevention efforts as well? Marketing strategies that make HIV treatment look like a vacation only exacerbate misconceptions about what it is really like living with HIV.
Most gay newspapers give only slight discounts to prevention agencies for advertising. Can’t we expect them to give fair coverage and more reasonable advertising rates to prevention programs? It might even benefit the newspapers financially if readership grew from better coverage of sex and sexual health in our community, and the factors that promote -- and discourage -- risk.
Where’s the community in our community-based organizations?
Many of us, as individuals and local business owners, founded our AIDS prevention agencies. We created them, we supported them, we were them. We knew what the problem was -- that we were getting sick and dying -- and we created prevention organizations as the solution.
But then we expected these organizations to take over, and we get angry when they don’t meet our expectations as new infections continue. In one notable case, Dan Savage -- a founder of Gay City in Seattle -- argued publicly for the organization's funding to be taken and sent to Africa when the agency had failed to bring down the rates of new infections.
Sure, AIDS agencies need to assume responsibility for listening to the community, responding to our wants, and mobilizing our resources. They need to be careful that they don’t fall prey to the forces that turn many grassroots efforts into bureaucracies and become too top-heavy. They need to be careful that their responsiveness to funders doesn’t overwhelm their responsiveness to us. They need to maintain roles for volunteers to assume real leadership, not just stuff envelopes.
But, to paraphrase an unlikely source, let’s ask not what our AIDS agencies can do for us, but what we can do for our AIDS agencies and to stop the epidemic.
When was the last time you volunteered? There is no way for the small prevention staffs to maintain the kind of AIDS prevention many people in the community are demanding. Compare Coca-Cola’s advertising budget to AIDS prevention’s, and then ask why prevention messages aren’t as effective as they could be.
You don’t even need to set foot in an agency. The important thing is to do something to reduce not only your own risk -- but someone else’s as well. Once while doing outreach, a young man told me that every time his roommate went out cruising he left condoms and lube on his bed. That’s effective AIDS prevention. That kind of day-to-day involvement and caring was how we reduced infections by historic amounts in record time in the early 80’s.
You Can’t Always Get What You Want
Many of us want lots of carefree, unprotected, barrier-free sex with as many partners as we want. At the same time, we want HIV and AIDS to end. In our wishful thinking, some of us are forgetting the hard reality. We can’t have both.
Sexually active men are responsible for HIV prevention. And it’s the job of schools, families, government, and religious institutions to make sure that we raise generations of gay (and straight, ad infinitum) youth to value health, sex and one another. If we want to end new HIV infections in our community, and help assure that those future generations have a healthier future, we’re each going to have to do our part -- in our legislatures, workplaces, and bedrooms.
It’s really our choice.
(This article is a response, in part, to two recent articles that appeared on GayHealth.com: Safer-Sex Message May Spur Gay Men to Have Unsafe Sex and Reaching People Who Walk Away from Safer Sex. There is a link in the sidebar to these articles.)
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Dispelling HIV Treatment Myths
by Sarah Albert
20 years after the AIDS epidemic began, the rates of new HIV infections continue to increase -- especially in the African American and Latino/a communities and among men who have sex with men (MSM).
A recent study of MSM and barebacking conducted by the Centers for Disease Control and Prevention (CDC) found that approximately 14 percent of MSM intentionally seek out and have unprotected anal sex, and this does not even include MSM who have unplanned unsafe sex. While a feeling of greater intimacy and more physical stimulation were the primary reasons MSM gave for seeking out unprotected anal sex, 19 percent of the participants who had barebacked said that improved treatments caused them to have more unprotected sex.
"Way too many people out there are having unprotected sex because there are still over 40,000 new cases of HIV each year. And too many of those cases are among young, gay men," says Susan C. Ball, M.D., M.P.H., assistant director of the Birnbaum Unit HIV Care Center at New York Presbyterian Hospital. Regardless of whether or not HIV is a chronic disease, "it is still a big killer," she warns.
While treatments have advanced HIV care by prolonging, improving and saving lives, there are some misconceptions about what antiviral medications can and can’t do. Antiviral medications don’t cure HIV or AIDS. Here are some of the other common -- and dangerous -- HIV treatment myths.
MYTH #1
HIV medications prevent HIV transmission because a low viral load equals no risk of passing HIV between partners.WRONG!
According to the CDC study, 19 percent of MSM surveyed said that improved treatments caused them to have more unprotected sex. Some men may falsely believe having unprotected sex with an HIV positive man is safe because medications prevent HIV transmission.
"There is no doubt that a lower viral load corresponds to less risk. But we also know that viral loads often "blip" up -- even in people who are faithfully taking their medication and have steadily undetectable readings," says Dr. Ball. "No doctor would tell someone that unprotected sex is safe even if both partners have undetectable viral loads." The problem is you can't ever know when a "blip" is going to occur and this should be of concern when one is thinking of having unsafe sex, she adds.
Unsafe receptive sex has the highest incidences of viral transmission, explains Dr. Ball. "I tell patients that it only takes one virus. In people having unsafe sex with someone who is on medication, that one virus may be a resistant virus and while HIV is no fun either way you put it, having a resistant virus makes finding an effective regimen all the more difficult."
MYTH #2
I can have unsafe sex because I’m already positive and I take HIV medications so it’s not like I can get re-infected.WRONG!
Not only can you get re-infected, you can get infected with a drug resistant strain of HIV. "If you are having sex you can certainly receive a dose of virus from someone else. It is well known that resistant virus can be passed back and forth even in people who are taking medications," says Dr. Ball. As a result, you are not only putting your partners at risk by exposing them to HIV you are also putting your own health and treatment in jeopardy.
It's not just HIV you should be worried about. Forgoing condoms puts you and your partners at risk for sexually transmitted diseases (STDs). Several studies have found that STD infections are associated with HIV, and STDs may increase your risk of passing HIV between partners.
MYTH #3
Taking medications for treating HIV is as easy as taking daily vitamins.NOT LIKELY!
Talk to someone who is taking antiretroviral medications and you will likely rethink this notion. "I am grateful for having these medications because I don’t think I would be alive today without them. At the same time, I look at the pills everyday with some resentment," says John, a 27 year old producer in New York City. "I just get so sick of it, of feeling so dependent on medicine. And then there are the times when I am terribly sick from all of the pills."
The challenges of medication adherence go far beyond just remembering to pop pills everyday. For those taking dozens of pills daily there can be dietary restrictions and unpleasant side effects such as nausea and diarrhea. Others may have to set their alarms for the middle of the night to take their dose on time. "When I hear people say they don't care if they get HIV because it's treatable, I get so angry. I have to stay on these medications for the rest of my life," says John.
