This chart shows absolute numbers of new HIV infections in the United States in 2006, broken down into high risk groups:
Click the picture for a larger view.
Source: CDC Fact Sheet – HIV and AIDS Among Gay and Bisexual Men, Aug 2009
While working in the prevention team of a Canadian AIDS service organisation, I was part of an inter-agency group that offered training to local social workers, nurses, shelter employees, etc on how to offer better services to sexual minorities.
To get the ball rolling in training sessions, I often start by saying:
Studies show that gay guys consistently use condoms with casual sex partners at rates way higher than do heterosexuals. In one study conducted at Toronto Pride in 2006, 75-80% of gay guys reported consistent condom use with casual partners. And even if that number is inflated, it’s still much higher than the rate for heterosexuals. Yet in Ottawa, gay guys still account for more new HIV infections than any other population and, in the US, gay men are the only group among whom HIV infections are currently on the rise.
If we are going to provide effective health services to men who have sex with men, it’s essential that we understand what’s going on. It seems totally illogical: gay guys use condoms more often, yet are infected with HIV more often. So as professionals who are paid to serve this community, I’m asking you: why?
Most people in the sessions feel genuinely perplexed by this question. They break into smaller groups and talk it all over and then we reconvene and usually the answers people come up with are variations of these:
– Maybe gay guys lie on those surveys because they feel embarrassed or they want to please the interviewer or whatever and so they say they consistently use condoms way more than they actually do.
– Maybe the condom breaks more often when gay guys are fucking. One reason could be that the butt doesn’t naturally create lube like the vagina so, unless they use a lot of lube and keep reapplying, there’s more friction in the ass, causing the condom to break more often.
– Maybe gay guys don’t know how to put a condom on correctly. Maybe they don’t squeeze the tip and so, when they orgasm, there’s no space for the cum and it bursts the condom.
– Maybe gay guys have sex drunk or high more often and so they thought they were using a condom or they thought they had used it correctly, but actually they didn’t or it slipped off or something.
– Maybe some gay guys even double up condoms, thinking it’ll make them twice as safe?
– Maybe the types of gay guys who go to Pride and the types of gay guys who answer surveys about condoms are also the types of gay guys who are more concerned with transmission and the types of gay guys who are more likely to use condoms. But maybe there’s also a whole cohort of men who have sex with men out there who don’t go to Pride and don’t answer surveys about condoms because they are too busy have non-stop condom-less sex at mass barebacking orgies.
I quite like that last answer by the way and I suspect there’s a grain of truth to it. I do think there’s a “survey crowd” out there covered in rainbow boas and pink triangle tattoos running from Pride parade to Pride parade leaving a trail of those little disposable golf pencils and multiple choice health questionnaires in their wake. I don’t think it’s sizable enough to skew the data in any serious way, but it’s a good visual nonetheless…
I enjoy participating in these sorts of training sessions and I really admire these folks who, despite their demanding workloads, are willing to come together and wrestle with tough questions so they can go back to their jobs better equipped to serve high risk populations like gay men. I also think their explanations of the seemingly illogical situation we find ourselves in – where the community that has one of the highest rates of condom usage also has one of the highest rates of HIV infection – reveal three interesting patterns:
1) A gap in understanding of basic epidemiology. Very rarely was it suggested that if a population has a high level of infection to begin with (prevalence), it stands to reason that they have more chance of passing that infection on to other group members (incidence). Or consider the same idea in reverse: if there was no HIV among a closed population to begin with (prevalence), there would also be no new infections (incidence) – even if nobody among them ever used condoms. A great policy change that health services could make is to ensure staff have time to remain up-to-date on emerging epidemiological research.
2) A gap in understanding of what determines health outcomes beyond individual, bio-medical factors. This isn’t to discount individual factors like getting tested or using condoms or the fact that unprotected anal sex is physiologically riskier than vaginal sex. But suggesting that the drastically higher rates of HIV among gay guys is due to dumb homos doubling up on condoms or forgetting to squeeze the tip when rolling one on represents health professionals grasping at bio-medical straws. Do we really think straight people use condoms correctly at rates so much higher than gay people that it explains why straight white dudes don’t even make it on to the graph above? Do we really believe that all gay guys have anal sex or that no straight people ever do? The answers above demonstrate how health systems depend too heavily on individual, bio-medical explanations without also accounting for community-level factors (like the fact that gay guys more often have multiple, simultaneous sex partners, whereas straight people tend to have multiple sex partners consecutively) or the role of structural factors in health outcomes. I’m amazed, for example, how rarely homophobia is mentioned as a possible factor in the mix. Doubling up on condoms? Apparently so. The fact that there are few places where gay men can publicly display affection and intimacy toward one another without fear of ridicule or violence? Apparently not.
3) A reluctance to look critically at the testing system itself. In most developed nations, a surprising number of HIV+ gay guys are still undiagnosed. In Ontario, Canada, epidemiologists estimate it is as much as 30%. The CDC estimates similar levels in the US. In an editorial in the May 30 2009 edition of The Lancet, a former UK government official describes the large number of undiagnosed HIV infections in that country as “appalling”. The author of the editorial writes: “There is no credible strategy to diagnose and care for those living with, but unaware of HIV in Britain today.” And a recent UK study showed that over 50% of recently HIV+ gay men leave UK sexual health clinics undiagnosed. In other words, undiagnosed infections are a major driver of high HIV incidence among gay men, yet a common reaction of testing staff is to look critically at their clients rather than at the institutions where they work. Again, it’s about the health structures, not about individual health professionals, who are generally well-intentioned but overworked and doing the best that they can.
Loud-mouth blogs are rarely considered a credible source of info. So I found it helpful when, in an August 2009 fact sheet about HIV and AIDS Among Gay and Bisexual Men, the US Centres for Disease Control and Prevention offered it’s own answer to why HIV incidence is so high among American gay guys despite their high levels of condom use as compared to heterosexuals:
Click the picture for a larger view.
What do you think?
Nico Little updates his personal blog regularly. You can follow it at www.ickaprick.com