Need for Sustained HIV Prevention Among Men Who Have Sex with Men: Young and Minority Men at High Risk
Historically in the United States, HIV-related illness and death have had the greatest impact on men who have sex with men (MSM). Even though the toll of the epidemic among injection drug users (IDUs) and heterosexuals has increased during the last decade, MSM continue to account for the largest number of people reported with AIDS each year. In 1997 alone, 21,260 AIDS cases were reported among MSM, compared with 14,698 among IDUs and 8,112 among men and women who acquired HIV heterosexually.
Among white MSM, the estimated number of AIDS diagnoses each year (AIDS incidence) has been declining since 1993, reflecting in part the success of prevention programs in these communities. Yet, AIDS incidence among African-American and Hispanic MSM continued to increase until 1996, when new treatments began to have an impact on trends in these populations. The new combination drug therapies have now slowed the progression from HIV to AIDS in many people, resulting in fewer AIDS diagnoses among all populations - but, the declines have not been as significant among MSM of color as among white MSM.
These data highlight the need to design more effective prevention efforts for gay and bisexual men of color. The involvement of community and opinion leaders in prevention efforts will be critical to overcome cultural barriers to prevention, including homophobia. For example, there remains a tremendous stigma to acknowledging gay and bisexual activity in African-American and Hispanic communities.
Continuing Risk Among Young MSM
Abundant evidence shows a need to sustain prevention efforts for each generation of young gay and bisexual men. We cannot assume that the positive attitudinal and behavioral change seen among older men also applies to younger men. Recent data on HIV prevalence and risk behaviors suggest that young gay and bisexual men continue to place themselves at considerable risk for infection with HIV and other STDs.
Ongoing studies show that both HIV prevalence (the proportion of people living with HIV in a population) and risk behaviors remain high among young MSM. In a sample of MSM 15-22 years old in 6 urban counties, CDC researchers found that, overall, between 5% and 8% already were infected with HIV. Higher percentages of African Americans (8-14%) and Hispanics (2-11%) were infected than were whites (2-6%).
Only about half of U.S. states conduct HIV surveillance, but in these states, data show that substantial numbers of MSM are still being infected, especially younger men. In 1997, 47% of HIV diagnoses among adolescent males aged 13-19 and 53% of cases among men aged 20-24 were attributed to male-to-male sexual contact.
Research among gay and bisexual men suggests that some individuals are now less concerned about becoming infected than in the past and may be inclined to take more risks. This is backed up by reported increases in gonorrhea among gay men in several large U.S. cities between 1993 and 1996. Despite medical advances, HIV remains a serious, usually fatal disease that requires complex, costly, and difficult treatment regimens that do not work for everyone. As we work to develop better treatment options, we must not lose sight of the fact that preventing HIV infection in the first place precludes the need for people to follow these difficult and expensive regimens.
Need to Combat Other STDs
Studies among MSM who are treated in STD clinics have shown consistently high rates of HIV infection, ranging from nearly 4% in Minneapolis to a high of 31% in Houston. Scientists know that the likelihood of both acquiring and spreading HIV is 2-5 times greater in people with STDs, and that aggressively treating STDs in a community can help to reduce the rate of new HIV infections. Along with prompt attention to and treatment of STDs, efforts to reduce the behaviors that spread STDs are critical.
Prevention Services Must Reach Both Uninfected and Infected
While the number of AIDS cases is declining, the number of MSM living with HIV infection is growing. This increased prevalence of HIV in the population means that even more prevention efforts are needed, not fewer.
Research has shown that high-risk behavior is continuing in some populations of MSM, including those who are infected with HIV. For example, studies of HIV incidence among MSM treated in STD clinics show high rates of new STDs in HIV-infected clients, indicating that unprotected sex is common. As the numbers of gay and bisexual men living with HIV increase, greater efforts must be made to reach them with behavioral interventions that can help them protect their own health and prevent transmission to others.
Invest in What Works Best for Communities at Risk
CDC's role is to provide communities with the best available science to guide comprehensive HIV prevention programs. As part of this process, CDC conducts an ongoing research synthesis process that seeks to identify the most recent and relevant scientific findings from around the world, both published and unpublished, and make them available to prevention program planners. CDC constantly combs the scientific literature, reviews domestic and international scientific databases, and speaks with colleagues around the world to identify effective interventions for all populations at risk, including MSM.
Many prevention interventions for gay and bisexual men have proven effective, as well as cost-saving, over the years. CDC will continue to work with communities to help develop these and other lessons learned into even more effective prevention programs.
Peer opinion leaders play a critical role in prevention for young gay men: In an intervention that attempted to change community norms, popular opinion leaders were trained to deliver AIDS risk-reduction messages to their peers who frequented gay bars. Three months after the intervention, fewer gay men practiced unprotected sex.
Social influences can be used to bring more gay men into prevention activities: One component of a community-level intervention for young gay men aged 18-29 used informal peer outreach and natural social networks to attract socially isolated men into safer-sex educational activities. New social events (such as safe-sex workshops) were created for young gay men who do not frequent gay bars or other venues where gay men tend to congregate. The intervention was successful in reducing rates of unprotected anal intercourse among participants.
Self-esteem and relationship factors are critical: A program providing group counseling sessions on assertiveness training, behavioral self-management, and relationship-building skills for MSM resulted in less unprotected sex among participants.
CDC will continue to provide surveillance data, biomedical and behavioral prevention research, evaluation of prevention programs, and technical assistance in communications and other aspects of prevention to communities so their prevention efforts - for all groups - are supported by the best science possible.
CDC Presentations Related to MSM
"HIV Testing Behaviors Among High Risk Populations: Why Do Persons Seek, Defer or Avoid Getting Tested for HIV in the United States?" Stan Lehman
"Social-Normative Factors Partially Explain the Association Between Younger Age and HIV Risk in Gay and Bisexual Men in the U.S.," Gordon Mansergh
"Adherence to Currently Prescribed Antiretroviral Therapies: Results from a Multisite Interview Project," Allyn Nakashima/Jeffrey Jones
"Does Measured Behavior Change Reflect Change in STD/HIV Risk?" Thomas Peterman
"HIV Risk Through Drug Use and Sexual Behavior in the U.S. Population," John Anderson
"Toward and Integrated Surveillance System for HIV/STD Risk Behaviors," Ron Fichtner
"AIDS Surveillance Trends in the United States: Declines in AIDS Diagnoses and Deaths Direct a Shift to Integrated HIV/AIDS Case Surveillance," Patricia Fleming
"Meta-Analysis of Sexual Risk Reduction Studies Among Men who have Sex with Men," Wayne Johnson
"Who is 'the Community' in Community Collaboration?" Kathleen MacQueen
"Negative Partner Reactions and Sex Roles: Influences on Male Condom Use," Janet Moore
"Substance Use and Sexual Behavior Among HIV-Seropositive Gay Men," David Purcell
"When Worlds Collide: Sex, Needles, and HIV Infection Among Young Injection Drug Using Men Who have Sex with Men," Greg Rebchook/Linda Valleroy
"Man-to-Man Sexual Health Seminars: Evaluation of an Innovative HIV Prevention Program for Men who have Sex with Men," Simon Rosser/Deborah Rugg
"Development of an HIV Intervention Studies Database for Providers and Researchers," Ellen Sogolow
"Effects of US-Based HIV Interventions on Safer Sex: Meta-Analyses, Overall and for Populations, Age, Groups, and Settings," Ellen Sogolow
"HIV Prevalence and Predictors of Unprotected Receptive Anal Intercourse for 15- to 22-Year-Old African-American Men who have Sex with Men in Seven Cities, U.S.A.," Linda Valleroy
"HIV Prevalence and Predictors of Unprotected Receptive Anal Intercourse for 15- to 22-Year-Old Men who have Sex with Men in Seven Urban Areas, U.S.A.," Linda Valleroy
"HIV Seroincidence Among High Risk Heterosexuals and Men who have Sex with Men in the United States Using a Dual EIA Testing Strategy," Hillard Weinstock
"HIV-Seropostive Men's Perceived Responsibility for Preventing the Transmission of HIV to Others," Richard Wolitski