NINETY-SEVEN THOUSAND, five hundred seventy-seven gay men—that’s how many “men who have sex with men” were newly diagnosed with HIV in the U.S. from 2001 to 2006. This just from 33 states, not including several with high incidence (Massachusetts, Pennsylvania, Maryland, California, and the District of Columbia). These figures also don’t include another 10,000 gay male intravenous drug users who also tested positive for HIV during that period. Think about it. More than 100,000 gay and bisexual men. The AIDS crisis never ended. In fact, it’s getting worse again.
The President’s Emergency Plan for AIDS Relief (pepfar), which has channeled some nineteen million dollars to fifteen of the hardest-hit countries since 2003, enjoys broad bipartisan support and has been hailed as a huge success. Thanks to pepfar, 1.5 million people with AIDS are now receiving anti-retroviral treatment, most of them in Africa. Five years ago only 50,000 Africans received such treatment. Despite ideological restrictions, such as the requirement that one third of prevention funds be used for abstinence-until-marriage programs, this Bush–Cheney initiative is widely viewed as a success. Renewal legislation currently before Congress, which would put three million more into treatment and fund prevention among men who have sex with men (MSM), has broad bipartisan support, including that of both Republican and Democratic presidential candidates.
The current administration’s record on AIDS in the U.S. has been dismal. Indeed since the Bush–Cheney administration took office, the country’s sexual health in general has declined dramatically. HIV and syphilis rates are up among gay men. HIV among gay and bisexual men under thirty rose 33 percent in New York City from 2001 to 2006. Nearly four in five of these newly infected young gay men are black or Latino. Nationally, according to the Centers for Disease Control (CDC), new infections among MSM jumped nine percent in this six-year period and twelve percent for black MSM. Most disturbingly, for black MSM age thirteen to 24, new infections nearly doubled during this time period (up 93 percent). For all MSM in this age group, new infections increased by a stunning twelve percent per year from 2001 to 2006.
The CDC will announce later this year that new HIV infections in the U.S. are closer to 60,000 per year than the steady 40,000 that the CDC had been reporting since the early 1990’s. It’s not clear whether this is due to an increase in new infections or more accurate reporting; it is likely a little bit of both. Either way, the domestic hiv/aids epidemic is even worse than we thought. About half of new infections in the U.S. are among MSM, however they identify (and most actually do identify as gay). Twenty-seven percent of new infections are black or Latino MSM, and 24 percent are white MSM.
Black Americans have been particularly hard-hit by HIV. Although African-Americans comprise only thirteen percent of the U.S. population, they account for 51 percent of new infections reported since 2001. Gay men continue to be hard-hit as well, making up fully 72 percent of new infections among male adults and adolescents in 2005, even though only about five to seven percent of male adults and adolescents are homosexual or bisexual men. Latinos and Native Americans are also disproportionately at risk for HIV, as are youths and women of color. AIDS is the leading cause of death for black women age 25 to 34.
The rise in HIV among gay men, and especially black gay men, must be seen in the broader context of declining sexual health, particularly among young adults. One in four teenage females has a sexually transmitted disease (STD); rates for black teen females are one in two. Last year, teen pregnancy increased nationally for the first time since the early 1990’s. Clearly we are failing to promote sexual health among young Americans.
Since its discovery over a quarter century ago, hiv/aids has killed over half a million Americans and infected at least 1.5 million in total. Since 1981 half a million gay and bisexual men have been infected in the U.S., and 300,000 have died from AIDS. Since 2001, at least another 100,000 gay and bi American men have been diagnosed with HIV. Worldwide, 33 million people are living with HIV or AIDS, with more than half of these in sub-Saharan Africa. In several southern African nations, twenty to 25 percent of adults are infected. Two and a half million people are newly infected around the world each year.
The U.S. response to the AIDS epidemic has been hampered by ideologically based rather than science-based approaches to public health. Prevention efforts have been encumbered by needless audits of AIDS service organizations. Anti-gay, sexist, and inaccurate abstinence-only programs have been promoted over comprehensive sex education. Restrictions on syringe exchange have also interfered with proven prevention strategies.
It is estimated that about a quarter of Americans who have HIV are not aware of it. This is a public health disaster: HIV-positive individuals who are unaware of their status cause fifty to seventy percent of new infections (Marks, et al., 2006). People who are diagnosed and in treatment are much more likely to practice safer sex to avoid infecting others.
Many people with HIV are diagnosed too late to benefit from early medical care. This is especially true of people from other countries. In New York City, immigrants diagnosed with HIV are a third more likely than native-born people to be diagnosed with AIDS. This means that they’re being diagnosed several years—often a decade—after becoming infected. Half of Americans living with hiv/aids do not receive regular HIV-related care, and half of those who are eligible for antiretroviral treatment do not receive this treatment (Collins, 2007). Lack of access to treatment and care are most pronounced in Africa and other parts of the developing world, where even basic pain relief medications are often not available to millions of sick and dying people.
Key Issues in the 2008 Election
1. A National AIDS Strategy
The United States requires pepfar recipients to have a national AIDS strategy, yet 27 years into the epidemic, we have never had one. Numerous government and private studies have pointed to the need for better planning of U.S. hiv/aids policy and programming. In 2004, the Institute of Medicine determined that federal financing of AIDS-related health care “does not allow for comprehensive and sustained access to quality HIV care” in the U.S. Our failure to bring down new infection rates also has a fiscal as well as a human cost: a 2005 study (Holtgrave) found that failure to meet the CDC’s then goal of reducing HIV infections by half would lead to eighteen billion dollars in excess expenses through 2010.
The next administration should develop and implement a national AIDS strategy that engages multiple sectors in strategy development; is comprehensive across federal agencies; sets timelines and assigns responsibility for implementing changes; identifies targets for improved prevention and treatment outcomes and reduced racial disparities; and mandates annual reporting on progress.
Barack Obama committed himself to creating and implementing a national AIDS strategy last fall. John McCain had not yet done so as of this writing, despite repeated outreach from AIDS activists since summer 2007. However, gay rights and AIDS activists, including Log Cabin Republicans, were still pushing the Republican nominee and the GOP platform committee to endorse a national AIDS strategy. The plan has bipartisan support in Congress, in part because its supporters deliberately chose language that could be embraced by a broad swath of politicians (details to be filled in later, hopefully under a more science-friendly administration).
2. HIV Prevention: Sex Education and Clean Needles
Preventing people from contracting HIV is the best way to stem the tide of the epidemic and to reduce its impact nationally and globally. By focusing predominantly on treatment, we will not be able to keep pace with the disease. Currently only four percent of the federal budget dedicated to HIV and AIDS goes to prevention efforts. Since 2001, federal funding for prevention has declined nineteen percent when adjusted for inflation. We cannot continue funding at such low levels if we ever hope to eradicate domestic hiv/aids.
For the past eight years, the Bush–Cheney Administration has focused its prevention efforts on areas that have been proven to be ineffective. Millions of U.S. tax dollars have gone to fund abstinence-only programs that we know don’t work. Study after study, including many commissioned by the government, have shown that abstinence-only education does not delay the onset of sexual intercourse. All it does is promote outdated gender stereotypes, anti-gay bias, and ignorance about HIV and AIDS. It is clear that comprehensive sex education and the widespread availability of condoms are the only means to ensure that young people learn about healthy sexual behaviors.
We must also utilize evidence-based methodologies when addressing HIV infection among injection drug users. Providing clean needles to intravenous drugs users has proven effective, dropping infection rates by forty percent in Rhode Island from 2000 to 2004 and by 78 percent in New York City from 1990 to 2002. This has occurred without an increase in drug use or crime, defying opponents’ predictions.
Prevention must target communities most at risk for infection, particularly gay/bi men, people of color, women, youths, substance users, prisoners, and low-income Americans. We must address the root causes of the AIDS epidemic among black people, including the lack of affordable housing, high levels of poverty and unemployment, and the impact of incarceration (Fullilove, 2006). Other biomedical advances must be encouraged and funded, such as vaginal and rectal microbiocides, and pre- and post-exposure prophylaxis.
In the area of prevention, the differences between the two major party nominees are stark. Obama supports an end to federal funding for abstinence-only education, a redirection of funds toward comprehensive sex education, and an end to the federal funds ban for syringe exchange. McCain supports abstinence-only programs and has not taken a clear position on syringe exchange. Obama is the lead sponsor of the Microbiocides Development Act, which would support research and development of new technologies that could prevent infections among women.
3. The entry ban for people living with HIV/AIDS
For the last 21 years, U.S. policy has banned HIV-positive non-citizens from entering the U.S. and barred those already living here from attaining most types of legal status. These policies violate the human rights of immigrants and travelers and undermine public health. Highly skilled workers who have full health insurance through their employers cannot seek legal permanent residence in the U.S. if they have tested positive for HIV, unless they have a heterosexual spouse or child who is an American citizen or lawful permanent resident. While opposite-sex spouses can constitute such relatives, same-sex partners cannot. Thus, this policy discriminates in particular ways against gay and lesbian people. The U.S. entry ban undermines public health inside the U.S., as immigrants and visitors avoid seeking HIV testing and treatment for fear of jeopardizing their ability to stay here.
Senator Obama expressed support for ending the HIV entry ban in a survey that Gay Men’s Health Crisis sent to him last year; Senator McCain declined to complete the survey. Both McCain and Obama support reauthorizing pepfar. The current pepfar reauthorization bill, stalled in the Senate due to objections by a handful of southern Republicans, would repeal the statutory HIV entry ban. While this is a promising development, in 1993 McCain voted to prevent people living with hiv/aids from entering the U.S. (Fullilove, 2006).
Most troubling, McCain has supported a number of draconian measures concerning those living with hiv/aids. In 1991, he voted to imprison HIV-positive health care workers who perform surgery. That year he also voted for an amendment, sponsored by Senator Jesse Helms, to test patients involuntarily for HIV before any surgical procedure.
McCain said this on the Senate floor in 2003: “The ethical implications of not doing everything in our power to slow the spread of this disease are severe. The most basic morality requires that we commit ourselves to combating hiv/aids everywhere.” McCain and Obama have united in support of reauthorizing pepfar, which funds prevention and treatment in Africa. Yet we still have questions and deep concerns about McCain’s positions on the domestic epidemic. Perhaps most troubling is that McCain’s key advisor on AIDS is the staunchly anti-gay Senator Thomas Coburn (R-OK).
4. Gay rights
Gay and bisexual men, who represent two or three percent of the U.S. population, comprise half of new HIV infections. While gay men of all races continue to get infected, black and Latino gay men are particularly devastated. This incredible health disparity is a national scandal. Increases are sharpest among young MSM, but we also see jumps in infection rates among gay men in their 30’s and 40’s.
Why is this? Possible factors include the rise of the Internet as a means of hooking up; increased use of crystal meth among gay men, which puts users at elevated risk for HIV, syphilis, and other STDs; aging and self-esteem issues; “AIDS fatigue,” or a sense of complacency since the advent of anti-retrovirals over a decade ago; the lack of positive images of gay men, particularly men of color, in popular culture; and the demonization of gay people in political discourse.
Cultural homophobia and the deployment of anti-gay bias toward political ends, as we saw in the presidential election of 2004, don’t exactly help the situation. Anti-gay bias is a public health problem that has negative public health outcomes, including increased risk of HIV infection.
Gay, lesbian and bisexual youth are more likely than their heterosexual counterparts to feel isolated, depressed, and suicidal, due in part to anti-gay harassment and bigotry. A growing body of research from the Youth Risk Behavior Survey and other data sets shows that gay-affirming interventions in schools and other social institutions, feelings of connectedness to a broader gay community, family support for gay youth, and HIV education correlate with health and resiliency, and make gay and bisexual youth less likely to engage in unsafe sex. It’s time for policy makers at the local, state, and national level to support sex education and pro-gay interventions in schools. This more than anything else will help turn the tide with gay men and HIV risk.
TWENTY-SEVEN YEARS into the AIDS epidemic, the situation is getting worse here at home, and we continue to fight AIDS with one hand tied behind our back. The GLBT community needs to reconnect with the AIDS movement and work closely with black and Latino organizations to address health disparities affecting all of our communities. We need to use all the tools in our arsenal, including sex education, condoms, and syringe exchange, to reverse the tide and bring down the rate of new infections. The science shows, unequivocally, that these approaches work. We need a renewed focus on the domestic hiv/aids epidemic, and to fully embrace science-based prevention, treatment and care. We need a president who will lead a domestic emergency plan for AIDS relief.
Collins, Chris. Improving outcomes: Blueprint for a national AIDS plan for the United States. Open Society Institute, 2007.
Fullilove, R. African Americans, health disparities, and HIV/AIDS. National Minority AIDS Council, November 2006.
Holtgrave, D. and S. Pinkerton. “Economic implications of failure to reduce incident HIV infections by 50 percent by 2005 in the United States.” JAIDS, 33, 2003.
Institute of Medicine. Public financing and delivery of HIV/AIDS care: Securing the legacy of Ryan White, 2004.
Marks, G., N. Crepaz, and R. Janssen. “Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA.” AIDS, June 26, 2006.
Sean Cahill manages policy and prevention for Gay Men’s Health Crisis in New York.