Walt Senterfitt asks this critical question and submits his thoughts as part of our mobilization to collect input for the 2009 Gay Men's Health Agenda.
Walt is a 64-year-old epidemiologist in Los Angeles, living with HIV for more than 22 years, and is Board Co-Chair of CHAMP (Community HIV/AIDS Mobilization Project). He's been an AIDS activist for 25 years, one aspect of his lifelong struggle for social justice for everyone.[Click here to read previous input into the 2009 Gay Men's Health Agenda. Please feel free to comment there - or you could send in a full post of your own here. We will be happy to publish it! The feedback we receive will be featured in the closing plenary of the upcoming National Gay Men's Health Summit and will be a means of moving the community forward in the new year around issues that are important to all of us.]
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The long-delayed release of the CDC's new HIV incidence estimates for the United States coincided with the opening of the International AIDS Conference (IAC) in Mexico City. These two events had one striking common theme: gay and bisexual men and other men who have sex with men (MSM) are the core of the epidemic in the US and in many other parts of the world and must be at the core of the response in order to end AIDS.
The majority of new HIV infections (more than 57%) are among gay, bisexual and other MSM. [See below about terminology] Gay men are 10 to 30 times more likely to get HIV than are heterosexual men and the population at large, in the US and worldwide.
The resources dedicated to HIV prevention and research among gay men, however, are not proportionate to their centrality in the epidemic. Prevention money is not following the epidemic. Furthermore, the total "pot" for HIV prevention is way too small, and shrinking. Thus, the CDC reports that fewer than 8% of gay and bisexual men surveyed in 15 cities received group-level HIV prevention services and only 15% received individual-level interventions, i.e. 85-92 % of all MSM at risk for HIV are not receiving the currently most effective prevention support.
If the CDC study had reached all gay and bisexual men, including those in small towns and rural areas as well as those who would be afraid to participate in such a survey, the true number of gay men not being reached with effective prevention would no doubt exceed 95%! This critical failure affects MSM of all races and ethnicities, but is most dire among Black, Latino, American Indian and Asian and Pacific Islander gay men whose risk of acquiring HIV is several times higher than the already sky-high risk for white gay men.
Estimated Number of New HIV Infections, by Transmission Category, 2006
Source: CDC HIV/AIDS Facts, August 2008 (http://www.cdc.gov/hiv/topics/surveillance/resources/factsheets/incidence.htm)
The Government's Non-Response
Why is there such a gap between the epidemic and the government's response? For starters, there is a scarcity of accepted interventions for gay men that, in turn, is caused by a historic underinvestment in research on HIV prevention among MSM. Only four of the 30 "best-evidence" prevention interventions in the CDC's current updated "Compendium of Evidence-based Interventions" and only four of the 17 packaged "DEBIs" (shorthand for a CDC project called Diffusion of Effective Behavioral Interventions) are directed at MSM. State and local health department and community-based organization prevention programs are strongly encouraged, if not outright required, to use these interventions in their federally-funded programs.
A strong legacy of fear and resistance abounds in the federal government and, therefore, in academic research to honest and open discussion of sex and sexuality in federally funded research, messaging and programming – and that is most especially true for homosexuality, transgenderism and all other forms of "non-normative" or diverse sexuality. While this taboo is broadly cultural, it owes its specific foundation in HIV prevention to the "Helms Amendment" which forbids the use of any federal prevention program and evaluation dollars for anything that might be considered "promoting" sex or sexual behavior outside of heterosexual sex within marriage. Though somewhat ameliorated by legislative compromise and judicial decisions, this provision – originally known as "no promo homo" – remains on the books as Section 2500 of the federal Public Health Service Act (42 U.S.C. Section 300ee(b), (c), and (d)) and is enforced by the Centers for Disease Control and Prevention (CDC).
While there is not such a clear legal restriction on using federal money for research into homosexual behavior and identity and prevention interventions for MSM, there have been periodic Congressional efforts to impose such limitations. As a result, National Institutes of Health (NIH) program announcements and peer review panels have effectively self-censored in such a way as to effectively hamper this critical research.
"De-gay-ifying" HIV/AIDS
There has also been a consistent tendency over at least the last 15 years within much of the AIDS community itself – and certainly by the media and other institutions of civil society enlisted in the struggle against HIV/AIDS – to "de-gay-ify" HIV/AIDS. For example, messages stress that HIV is an "equal opportunity virus" and that anyone can be at risk, emphasize children and women at risk, and stress that HIV/AIDS is, in its majority, now an epidemic in communities of color (while simultaneously neglecting to stress that those most disproportionately impacted in communities of color are gay and bisexual men).
This direction in messaging was in part well intended, to combat the widespread assumption that if you are not a white gay man, AIDS is not your problem and you are not at risk. It was also meant to get beyond the intensified stigmatization of gay men and focus on the behaviors that put one at risk. This approach has been embraced by many HIV positive and other gay men who fear the added stigmatization of having "gay" remain widely associated with "HIV/AIDS" in public consciousness. Even from the start though, this approach was a capitulation to rather than a confrontation of societal stigma and prejudice against gay people, against transgender people, against all people who are sexually "non-normative." And it didn't work. Homophobia still is rampant, dollars have gone elsewhere, and, alone among the exposure categories, HIV infection rates among gay men are rising.
HIV transmission and the AIDS epidemic are not just about the behavior. They are also about the social and structural context of the behavior, about the vulnerability and resilience of communities and populations, about individuals living in communities having the awareness, tools and support to protect themselves and their partners. Homophobia is itself a major risk factor, as well as part of the risk context or vulnerability, for HIV transmission among MSM and, indirectly, for sexual transmission from men to women.
The International AIDS Conference stressed repeatedly the need to move the social and structural context, environment and interventions front and center. The CDC and the NIH have long given lip service to this dimension, but have devoted neither the money and other resources nor confronted the barriers to do so. There are no structural and social interventions whatsoever in the CDC's Compendium of Effective Interventions or DEBIs. There is nothing in the public portfolios of the CDC, NIH, SAMHSA (Substance Abuse & Mental Health Services Administration) or HRSA (Health Resources and Services Administration) that confront and target homophobia as a key barrier to ending the US HIV epidemic.
Mexico's Example
The IAC also highlighted the experience of the Mexican national health ministry and national AIDS program in targeting homophobia as a central priority in its HIV prevention response. The national AIDS program, CENSIDA, led by an openly gay and HIV positive physician, Jorge Saavedra, has for the last several years engaged in social marketing and community mobilizations against homophobia and has funded local campaigns.
The IAC was preceded by the First International March Against Stigma, Discrimination and Homophobia to the central national square in Mexico City. The march included tens of thousands of Mexicans from all sectors of civil society with Dr. Saavedra and the Mexican Minister of Health in the front rank. In his welcome to the opening ceremony of the Conference, the conservative Catholic President of the Mexican Republic, Felipe Calderon, called for a continuing national campaign to end homophobia. While Mexican activists in the trenches may be rightly skeptical of the hypocritical gap between rhetoric and reality, can you imagine George Bush saying this or HHS Secretary Leavitt in such a march?
Mexico is heavily Roman Catholic, socially conservative, and ruled by its most conservative national political party. If it can nevertheless recognize the fight against homophobia as central – and say so – why can't the United States?
Therefore, We Demand:
- That the agencies responsible for leading the federal government's response to the AIDS crisis take the lead in announcing and orchestrating as a public health priority an explicit, multi-faceted, multi-year campaign against homophobia, stigma and discrimination against sexual diversity.
- That this campaign be embraced and supported by state and local governments as well, and by media, non-governmental and private sector organizations with any relation to the fight against AIDS.
- That the campaign include social marketing and other appropriately targeted messaging as well as funding for innovative local and national community mobilizations, individual and group level interventions.
- That the lead agencies and community partners assess all current laws, policies and programs that explicitly or implicitly reinforce homophobia and stigma and/or act as barriers to effective anti-homophobia messaging and interventions, and change or propose changes to such laws and policies as soon as possible. This includes a careful review and, where necessary, revision of all current and future guidelines relating to HIV/STD/drug abuse prevention programs and a specific effort to repeal all vestiges in law of the original "Helms Amendments."
- That, affirmatively, promoting healthy expressions of diverse sexuality be recognized as a key requirement of advancing public health and should therefore be reflected as appropriate in all health-related publications and guidelines. This specifically includes guidelines, funding and curricula for adolescent and school health programs related to sex, sexual behavior and sexual identity.
- That the NIH, through the Office of AIDS Research and other mechanisms, and in coordination with the CDC, prioritize the development of social and structural interventions and strategies that will most effectively undermine public and private homophobia, stigma and discrimination. These must include the development of better measurement and evaluation tools for assessing progress against homophobia and stigma, for social and structural interventions in general, and for combination prevention packages or strategies.
- That this campaign against homophobia and for healthy sexual diversity must primarily be funded through new funding as part of a renewed and expanded national commitment to end AIDS, rather than by reducing funding of other effective programs and research.
- That this campaign recognize and reflect the multiple, interlocking social and structural strategies needed to combat the other root causes of the continued HIV epidemic, including, in particular, racism and xenophobia, women's oppression, transphobia, mass imprisonment, the "war on drugs," disempowerment of youth, and homelessness and other manifestations of poverty. Homophobia manifests quite differently in different communities and in combination with other forms of social oppression. Our response must be commensurately sophisticated and well matched.
| How to refer to men who have sex with other men, exclusively or some of the time is a challenge for which there is no easy solution. "Gay" came to be used most commonly, but only within the last few decades and many men, even many who readily identify as exclusively homosexual, have never or no longer embrace the term. For some it is too heavily associated with white men to be acceptable; yet other proposed terms such as "same gender loving" have not achieved widespread consensus either. For others, "gay" is too limiting or old-fashioned, when sexuality is much more diverse and fluid. For some, it implies a connection to a particular community or subculture they do not wish to embrace, or refers too much to an identity rather than a behavior. "Bisexual" is also problematic for many, even those who acknowledge having sex with both men and women. Many men who have sex with other men identify themselves as heterosexual, straight or other terms for culturally normative sexual behavior and identity. Because of this complexity and lack of consensus, and the desire to be behaviorally descriptive in discussing HIV risk and in targeting HIV prevention efforts, the CDC and community allies came up with the term "men who have sex with men" or MSM. This works for some purposes, but how many individuals identify themselves as an MSM? This term, while epidemiologically accurate and inclusive, is often criticized for leaving out the critical aspects of identity, culture and community in understanding sexuality and diverse sexual expression. Yet to simply say "gay" or "gay and bisexual" may mistakenly imply that the speaker assumes that all men who have sex with other men are essentially the same, and understand their sexuality the same way. For want of a better solution, we have used "gay," "gay and bisexual," "MSM" or "gay, bisexual and other MSM" more or less interchangeably in this article. We are quite aware, though, of the very important cultural and individual differences and contradictions in any such shorthand references and, more importantly, in figuring out how to reach and support everyone to whom this rubric applies. |
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