By Jeffrey Levi and Chris Collins
Much of the rhetoric at this year's International
AIDS Conference was about achieving an "AIDS-free generation." This
new optimism reflects the tremendous progress that has been made in both the
science of HIV and our ability to translate that science into meaningful
prevention and treatment programs, but if the United States is going to be part
of that AIDS-free generation, we are going to need to refocus our attention on
the domestic epidemic among gay men.
Gay men in the U.S. represent the largest proportion of new HIV
infections. Young men who have sex with men (MSM) are the only risk group
for which HIV incidence appears to be increasing.
For gay men of color, the crisis is especially
dire. Between 2006 and 2009, the CDC estimates that HIV incidence increased by 21
percent among young people (13 to 29 years old), driven by a 34-percent
increase among young MSM, which in turn was driven
almost exclusively by a 48-percent
increase among young African-American MSM. In spite
of similar risk behaviors, black gay men are
at greater risk of infection than any other risk group, in part because of lower rates of HIV and STI diagnosis and
treatment. The severe racial disparities that characterize the HIV epidemic in
the U.S. are one of the most important equality issues for the LGBT community.
Yet these data run counter to the prevailing
perception of the epidemic within the gay community -- that is, that things
were bad in the 1980s and early 1990s, but once effective treatments came
online in the mid 1990s, the crisis passed. How could this be?
First, it is clear that a younger generation of
gay men have not been reached with the prevention message. The gay community
has been appropriately praised for the tremendous reduction in risky behavior
that occurred in the early years of the epidemic. The early mobilization of the
LGBT community against HIV, a mobilization that occurred in a hostile political
climate and initially with little government support, resulted in an 89-percent
decline in the estimated HIV transmission rate.
Today we are in danger of seeing that progress
reversed. One indicator of the problem is the estimate by the Centers for
Disease Control and Prevention that some 20 percent
of HIV-positive Americans are unaware of their infection, and nearly half of
new HIV infections originate in individuals who are unaware that they have HIV.
Second, scientific advances in treating HIV have
led the public at large and many in the gay community to consider HIV a
treatable, "chronic" disease. And indeed it is -- if people are
diagnosed early, and if they have access to quality and sustainable care.
But the data suggest otherwise: The CDC estimates
that only 28 percent
of those with HIV are actually successfully treated, meaning that their HIV is suppressed. This is an avoidable problem
if more people know their status and we take advantage of the opportunities
provided by the Affordable Care Act to expand access to health coverage for all
Americans, including the estimated
24 percent of people with HIV who lack insurance. And while we offer the message of hope that an HIV diagnosis is not
a death sentence, we must reinforce the primary prevention message: avoiding
HIV infection in the first place.
Third, the LGBT community's attention to HIV has
declined. By the late 1980s the "professionalization" of the HIV
response resulted in waning interest by LGBT organizations in HIV advocacy and
mobilization. HIV was left to the growing number of national and local AIDS
organizations that took up the cause.
But in mainstreaming HIV as the larger public
health challenge that it is, the gay-specific voice has diminished. That's been
a missed opportunity to reinforce the self-caring approach that supported so
much of the early HIV prevention efforts among gay men. That is not to say that
the larger LGBT agenda is not relevant to the fight against HIV. Indeed, it is
central: We have solid evidence that higher-risk behavior among gay men is
strongly associated with feelings of stigmatization because of sexual
orientation and the legacy of family and societal discrimination. So the fights
against discrimination, bullying, and hate crimes and for same-sex marriage all
validate LGBT people and their relationships and have the potential for
bringing a "whole health" approach to HIV prevention among gay men.
But these struggles need to be united, not fragmented. And HIV prevention must
resume its appropriate place in the larger LGBT agenda.
So what is to be done? Our organizations recently
released an issue brief, titled "Ending the HIV
Epidemic Among Gay Men in the United States," that
outlines a comprehensive agenda that includes taking full advantage of the
Affordable Care Act to assure HIV testing, care, and treatment are readily
available for all who need them. It also calls for reforms in the health system
toward a "whole health" approach to meeting the needs of LGBT people
-- from mental health and primary care to HIV prevention interventions for
HIV-positive gay men. Among the goals are assuring access to early treatment to
decrease a person's HIV viral load, which will improve their health outcomes
and reduce the likelihood that HIV will be passed on to others. We also need to
scale up HIV testing among gay men and remobilize the LGBT community so that we
repeat the successes of the 1980s in changing the course of the epidemic.
This is not a small agenda, and it is one that
will require a realigning of resources and priorities inside government and in
the community. But the lives of another generation of gay men hang in the
While the focus on gay men is but one element of
a national response to HIV (as demonstrated in the comprehensive approach taken
by the Obama administration's National HIV/AIDS Strategy), rising HIV incidence
among gay men poses the greatest threat to achieving the national goal of
creating an AIDS-free generation.
Collins is vice president and director of public policy at amfAR, The
Foundation for AIDS Research. His email is firstname.lastname@example.org
This op-ed originally appeared on The
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