On July 24, The Lancet 2012 Theme Series: Men who have sex with Men and HIV was officially launched. The main auditorium at the Washington Convention Center was packed. The session consisted of a series of presentations that combined research results and community-based information on the issues concerning Men who have Sex with Men (MSM) and the HIV epidemic in the U.S. as well as across the globe. I was instantly engaged. The first presentation sought to provide the answer to why the epidemic disproportionate amongst gay men, in comparison with other populations. The presenter compared sexual roles in heterosexual sex and gay sex, and discussed insertive and receptive anal intercourse with regard to the efficiency of HIV transmission. The answer seems to lie in the uniqueness of gay men and their versatility in terms of sexual roles. Gay men can be both insertive and receptive partners; this versatility sometimes occurs within a single sexual encounter, which in turn increases the efficiency of HIV transmission. With this answer in mind, the presenter proposed a hypothetical scenario: if this were not the case amongst MSM, what would the epidemic look like? The conclusion was that the incidence rates would not be nearly as disproportionate as they are currently. However, this was unfortunately just a hypothetical scenario. Changing an individual’s sexual role based on these results (as in a behavioral change intervention) would simply be absurd.
While individual sexual roles and preferences cannot be changed, there is some hope for addressing structural barriers, which are the main factors placing MSM around the world at risk. Stigma, plain hatred and discrimination against gay men are universal epidemics that are, to date, not susceptible to biomedical treatment. In the U.S., Black and Latino MSM face a dual stigma: societal and political; as such, they are less comfortable in disclosing their sexual identity. Criminalization (or social rejection in countries where homosexual behavior is no longer criminalized) of MSM identity and behavior, coupled with the stigma and denial of being part of a community at risk, means that men are missing out on basic prevention messages: “the message fails to reach them.” Sadly, most health providers are unaware of this plethora of issues and barriers that the so-called “hard to reach” MSM community faces. The factors that place MSM at risk seem pretty clear, yet as nations we keep wondering about the continuing disproportionate incidence rates of HIV infection in the MSM community.
In conclusion, no one approach is sufficient to turn the tide on HIV. In addition to promoting smooth transitions in the strategy of condom uptake testing linkage retention in care adherence, work also needs to be done at the political, societal, community and individual levels to address homophobia, stigma and discrimination towards the MSM community. There is a need to educate and train health providers in “Gay knowledge.” Maybe it is also time to better understand and potentially use in prevention work the factors that enhance resilience within the MSM community. These might be the ones that will help turn the tide on HIV.
Written by Bolivar X. Nieto