Labels Won't End HIV
The recent reports from the CDC couldn't be more clear. Gay men are acquiring HIV at rates far higher than other groups -- the current numbers show that 63% of all new infections occur among gay or bisexual men, even though they make up less than 4% of people in the U.S. And the infection rate has increased since 2006, when the CDC estimated that gay men accounted for 53% of all new infections. We must take action to get this number down and to help those who are newly infected learn their status and get the care and treatment they need.
In 2003, after learning about my own HIV infection, I became mobilized to do more to help my peers combat the HIV epidemic. After securing a position in HIV prevention, I found myself left wanting after hearing what messages were being sanctioned for dissemination to young gay men to help them make informed decisions about their intimate affairs. While immersed in trying to comprehend what my own diagnosis meant for me, I found myself having to simultaneously clarify public health information, which many found only partially helpful or confusing. The unfortunate result is that instead of using proven methods to keep themselves negative, many gay and bisexual men are using misinformed strategies that only serve to further divide gay men -- increasing HIV-related stigma and identity-related social isolation. Sexual health for gay men is complex, especially given the fact that HIV is very easily transmitted through anal sex. To achieve an AIDS-free generation, our community's health care messages must reflect the diversity of our lives and the ways in which we express our intimacy.
Evidence of how this plays out can be found on most online dating sites and apps. Amid the standard bare torso shots on sites like Adam4Adam or Manhunt, or apps like Grindr or Jack'd, visitors are almost immediately confronted with the advertiser's definition of desirability. Phrases like "no fems, fats, blacks, or Asians" and "no one over 40" are so common that many of us, including site owners and administrators, have become desensitized to their divisive and negative existence in a space that should be welcoming to all in our community. Thus some members of our community are marked as socially or sexually undesirable and immediately isolated. Insensitive and harmful statements such as these need to be addressed and done away with. Many of these sites were created as safe spaces for men to connect with one another without the constraints of the heterosexually dominated culture in which we live.
Even more pervasive and potentially harmful is the acronym "DDF," which stands for "drug and disease free," as if the two are inextricably linked. Some profiles go further and list the date of their last negative HIV test. While this could educate gay men about the importance of regular screening, it instead gives many a false sense of security with potentially inaccurate information. In reality, it discourages the discussions between HIV-negative and -positive gay men that could lead to more informed and protected sexual partnering. As a black gay man living with HIV, I wear many labels. But like everyone, I am not defined by any one of them. Unfortunately, our society often seeks to, and frequently succeeds in, separating us into categories that only distance and stigmatize us.
It is well established that stigma, whether from homophobia, racism, ageism, or HIV status, has a negative impact on our ability to slow the rate of new HIV infections, as well as the ability of those living with HIV to achieve positive health outcomes. How can we expect a person receiving messages that they are undesirable to feel empowered to negotiate sexual partnering? Or to question their medical providers when they feel invisible or feel they are already stigmatized by those providing their care? When someone is bombarded with images and messages that portray them as undesirable or "less than," even the strongest willed among us may eventually internalize those feelings. This explains, at least in part, why communities of color and the LGBT community have higher rates of depression and substance abuse than the general population. And these can worsen over time as age adds another dimension of separation and isolation.
Finding sexual partners has become as quick and convenient as ordering take-out for dinner. And many of us treat it with the same detachment. We list our partner preferences with little regard for the feelings of those who may be reading our profiles, and discount those who do not match our list of qualifying criteria with barely a passing thought. It may be tempting -- and easy -- to write off these interactions as insignificant, but the frequency with which individuals who do not fit the "Abercrombie" ideal are cast aside can take a significant toll on that person's self-concept. And placed within society's consistent messages about the low value of people of color and LGBT individuals, the impact of these interactions can be that much more severe.
Ageism in Public Health Messages
It is troubling when society stigmatizes individuals and communities. But when our public health messaging does the same thing, we have a serious problem. There has been significant concern raised in the public health community about the burden of the HIV epidemic borne by black gay and bisexual men. Many experts fear that highlighting this community may backfire, further stigmatizing black gay men and driving them deeper into the closet. It could foster a sense of the inevitability of HIV infection among black gay men that may decrease protective efforts. In fact, a recent study published in the Journal of Acquired Immune Deficiency Syndromes again highlighted that HIV incidence among black gay men may be higher, in part, because of their limited sexual networks and the enhanced opportunity to become exposed to HIV that results from them. But when it comes to older gay men, the messaging has already turned toxic. In fact, the CDC's own risk reduction recommendations for young people include explicit instructions to avoid "sex with older partners who may be more likely to be infected."
While it is true that the likelihood that a partner may have HIV increases with age, it is also true that older Americans are considerably more likely to know their HIV status, be in care, and have an undetectable viral load. In fact, when compared with those between the ages of 25 and 34, people with HIV aged 45 to 54 are 24% more likely to know their status and more than twice as likely to be virally suppressed -- significant factors in transmission risk.
With the growing knowledge of the role viral suppression plays in reducing HIV transmission, we have crossed the threshold where simple public health messages are sufficient for partner selection. Our community is better served by information that reflects the complexity of our lives and that doesn't oversimplify sexual negotiation into tidy categories. But beyond the usefulness of the CDC's questionable recommendation, the idea that any government-sponsored public health message would explicitly advise individuals to avoid sexual contact with a specific group is astonishing.
If it is acceptable to advise youth to avoid sexual contact with people above a certain age because HIV is more prevalent in that population, isn't it then acceptable to advise them to avoid sexual contact with African Americans or Latinos in general? Both groups have higher HIV prevalence than their white, Asian, and Pacific Islander counterparts. What about recommending that women avoid having sex with bisexual men, because they are more likely to have HIV than heterosexual men? For that matter, we could simply suggest that women avoid sex with men altogether, since sex between two women carries the lowest risk of HIV transmission.
The problematic nature of the CDC recommendations should be clear to anyone. The disproportionate impact of HIV on minority and marginalized populations is already cited by bigots and homophobes to excuse and perpetuate discrimination. For proof, one need only turn to the official regulations regarding blood donations, which forbid gay and bisexual men from giving. It is evident every time a legislator argues against gay marriage or expanding any LGBT protections based on the so-called destructive and unhealthy nature of their "lifestyle."
Targeting the Message
It is of course critical that we understand the nature of the U.S. HIV epidemic so that we know where best to target our prevention resources. The distribution of federal funding for HIV prevention has never adequately reflected the face of the epidemic.
Improvements in surveillance, along with recommendations made in the National HIV/AIDS Strategy, have done much to change that. But with these improvements, it is imperative that we use even more caution when creating public health messaging so as not to further stigmatize those communities where HIV has already taken a heavy toll due to stigma and discrimination.
Prevention messaging should always strive to empower individuals to make healthy decisions for themselves and their partners. We should never perpetuate messages that label any group as possible carriers of disease, even unintentionally. There are many ways to reduce the number of new HIV infections in our community -- from regular condom use to frequent HIV testing -- and none of them include avoiding sexual contact with any particular group. Individuals of all races, ethnicities, and ages can have perfectly healthy and satisfying sex lives, regardless of their HIV status. The point of public health messaging should be to help the public understand this fact and teach them how to achieve it.
Kali Lindsay is Director of Legislative and Public Affairs for the National Minority AIDS Council.
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