It would appear that much has changed in the past two decades, but not exclusively because of the disease. New social settings have been used by gay men to express their sexuality, and social and cultural elements have influenced the way their sexuality is expressed. Understanding how these changes have influenced sexuality is crucial to any discussion of HIV prevention. The many options for sexual expression that exist today further complicate the already difficult task of HIV prevention.
In the early years of the epidemic, there were between 8,000 and 10,000 deaths annually in New York City, almost exclusively among gay men. Fear gripped the gay community, and many responded by embracing safer sex or abstaining from sex altogether, approaches still practiced today. Others turned to the relative safety of relationships, and the new century has seen the growth of a vibrant movement claiming the right to marriage. But sex with occasional multiple partners remains a significant element of gay male sexuality. In response to the government shutdown of commercial sex establishments, there has been an explosion of private sex parties, and a new venue for sex with multiple partners has been introduced and embraced: the Internet. And as in the '70s, there remains a core group of highly visible individuals who embrace the use of illegal recreational drugs to enhance sexual activity.
In the 1980s, gay men widely adopted safer sex practices, but the number of new AIDS cases among MSM did not begin to decline until the advent of HAART (highly active antiretroviral therapy) in 1996. Today, new HIV/AIDS cases are actually increasing among MSM -- a 9% increase from 2001 to 2004, with the largest in increase occurring in 2004. And this year, a five-city CDC study of 1,767 MSM with a median age of 32 found high rates of infection: 25% tested HIV-positive. Alarmingly, 46% of African-American MSM tested positive, and 67% of those who did were unaware of their status.
A report from the Guttmacher Institute cites "prevention fatigue" (difficulty maintaining safer sex habits) and disinhibition (underestimating the consequences of HIV infection) as key barriers to control of the epidemic. Maintaining prevention can be difficult. Deciding to follow safer sex practices requires information, motivation, and time. Sticking to the decision requires constant reinforcement that safer sex itself does not provide. Behavioral modification does not generate visible results: time goes by uneventfully, a person tests negative for HIV, and the perception builds that the precautions may not be needed. Eventually the person may slip into episodes of unsafe behavior. Paradoxically, negative tests can reinforce the idea that safer sex is not needed.
Disinhibition is even more insidious. The success of anti-HIV medications in reducing progression to AIDS, prolonging life, and restoring quality of life for people with HIV has reduced fear of the virus. A common perception is that treatment will take care of an infection that does occur, and many people are unaware that progression to AIDS and development of HIV resistance still occur and that treatment comes with significant side effects and demands strict adherence. Viral load testing is also partially to blame for the more relaxed attitude toward HIV. "Undetectable" levels of HIV are taken as a license to have unprotected sex based on the assumption that when undetectable, there is a very low risk of the virus being transmitted. Efforts to counter this misinformation have achieved varying levels of success, and scare tactics do not work well in practice, especially for skeptical individuals.
Over all, it appears that as one group adopts safe sex practices, another comes along and engages in risky behaviors. This changing framework constitutes a challenge for HIV prevention, but targeted prevention programs have demonstrated some effectiveness. In the 1980s, white gay men were the focus of prevention efforts, and HIV incidence in that population declined. Over the last decade, ethnic minorities and young adults have been the focus of prevention efforts. While new cases in adolescent and younger adults are still growing, 12% fewer new HIV cases among those aged 25-44, the generation exposed to prevention measures in the last decade, were reported in 2004, compared to 2001. A similar drop occurred among African-Americans. The current focus of CDC prevention efforts is "prevention for positives" -- encouraging people with HIV to practice safer sex. The emphasis is now on HIV testing, since the CDC has found that the majority of new sexually transmitted infections involve people unaware of their HIV status.
Abstinence is a controversial concept with different definitions. For some, it means the total absence of any sexual activity; for others, it refers only to avoiding penetrative sex. The adoption of some form of abstinence may seem a direct response to the HIV epidemic, but in fact the practice has always has been one of the many ways in which men attracted to men dealt with sexual desire. Many gay men do not feel at ease in the gay scene, which generally caters to young, healthy-looking, attractive men. Some may have difficulty finding partners, and may eventually stop looking choosing to live as single, independent men. Abstinence is quite prevalent in older men, as it is in people with chronic diseases or disabilities; 31% of people living with HIV report they are abstinent. But abstinence is not an irreversible choice. Significant relationships can unexpectedly develop, and abstinence may be broken in anonymous settings.
In an article in Social Work magazine, Harvey Gochros, a support group facilitator who worked for years with HIV-positive people, describes the physical, social, and psychological factors that complicate the sexual activities of MSM living with HIV and that make abstinence an attractive option. Absence of willing sex partners is an important factor -- potential partners may refrain from getting involved with a person in precarious health, both to avoid the risk of infection and out of reluctance to assume the burden of caregiving. Economic factors can force people into living arrangements without a private space in which to engage in sexual activities, and physical ailments and side effects of medications can reduce sexual desire.
These obstacles are exacerbated by the negative societal attitude toward homosexuality, and in particular toward the sexuality of HIV-positive people, seen by some as inappropriate, irresponsible, or even criminal. These physical and social factors in turn influence psychological factors: people living with HIV may perceive themselves as unattractive and may experience guilt in connection with their status. Sexual experience can therefore be distressing, leading to abstinence or alternative sexual behaviors such as masturbation and viewing pornography -- ways to keep sexually active while avoiding rejection and post-sex guilt.
Stable couple relationships are an important and often underestimated form of sexuality for MSM. The 2000 census counted 300,000 same-sex male households in the U.S.; this figure underestimates the number of stable homosexual relationships, since many gay couples maintain separate residences. The rising number of gay male couples and the campaign for same-sex marriage may be visible signs of a reaction to the HIV epidemic. Fear of infection may play a role, but increased acceptance of a gay identity may be more important. Of course, intimate relationships, whether between same-sex or mixed-sex couples, do not simply offer a means for sexual partnering but also offer shared identity and personal growth.
As there is no normative structure for same-sex relationships, gay men continually reinvent what it means to be together and renegotiate the rules for sexual conduct. One option is to form couples based on HIV status. This serosorting allows people living with HIV to find understanding in HIV-positive partners and spares them the need to coach HIV-negative potential partners to accept and respect their status. The other advantage for seroconcordant couples, whether HIV positive or negative, is that they can engage in unprotected sex with limited risk provided they practice mutual monogamy or have only safer sex with outside partners. Superinfection (infection with a second strain of HIV) has been reported, but rarely in people who have had HIV for over one year. Seroconcordant HIV-positive couples must decide for themselves if the risk of superinfection outweighs their desire for condomless sex.
Unfortunately, even monogamous couples can expose each other HIV. In one study, a third of couples interviewed had engaged in unprotected anal intercourse before they knew each other's serostatus or had had unprotected sex prior to the monogamous commitment but too recently to be detected by current HIV tests. On the other hand, serodiscordant couples must maintain safer sex practices even if committed to monogamy. According to a 2003 study published in AIDS Care, such couples experience higher distress than other couples, similar to couples coping with other chronic illnesses. This distress is the same for both the positive and the negative partner, showing that they face the challenge of HIV as one unit. The same study found that a high level of sexual satisfaction reduces the level of distress in serodiscordant couples, indicating how important sexuality is for the couples' overall well-being.
According to a 2003 study, more than half of the men in primary same-sex relationships also have non-primary sexual partners, but this does not automatically translate into unsafe sex. The HIV epidemic introduced the concept of safer sex negotiation, detailed discussions of sexual activities before the occasion arises. For HIV-negative couples the promise of monogamy is now also a commitment to protect the partner from infection and has its ritual of testing together for HIV and disclosing each other's HIV status. Slipping from a monogamous commitment cannot be overlooked, but requires responsible acknowledgment. Open couples need to define specifically the level of risk acceptable to both and the need to reveal to each other the details of their sexual experiences outside the relationship.
Sex with occasional outside partners and serial dating is common among MSM. Societal rejection of same-sex relationships can make it difficult to start and maintain a relationship, and there are ample opportunities for MSM to find casual sex partners, especially in large cities. A U.S. study of public sex environments (PSEs) -- parks, beaches, public bathrooms, truck stops, etc. -- and commercial sex environments (CSEs) -- bars, bathhouses, sex clubs, etc. -- found that half of the HIV-positive MSM surveyed had visited a PSE (50%) or a CSE (41%) in the previous three months, with 24% going to both. Interestingly, MSM who visited PSEs did not engage in more unprotected sexual activities than did those who did not visit PSEs, while visitors to CSEs had significantly more unprotected sex than non-visitors.
A European study found that between a quarter and a half of MSM use PSEs or CSEs and that the majority of users of both PSEs and CSEs are gay identified. The most common sexual activities in PSEs are mutual masturbation and oral sex, and less than 10% report unprotected anal intercourse. The type of activity varies according to situational constraints. HIV prevalence is twice as high among users of PSEs as in the entire gay population.
Most of the empirical evidence suggests that MSM tend not to disclose their HIV status to casual partners or negotiate safe sex in public and commercial sex environments. These are spaces where very little conversation occurs, and talking about HIV is considered a spoiler for the budding sexual adventure. The burden of initiating the conversation about disclosure is put on the HIV negative partner, and based exclusively on the perceived risk of the sexual activity engaged upon. Eventually, high-risk behaviors occur even when HIV status is disclosed and the partners are serodiscordant, but this behavior is not all about irrepressible sexual urges.
According to a 1999 study published in Sexualities, there are four powerful nonsexual factors that drive the engagement in sexual activities by gay men, including risky sexual practices: "(1) the need to validate one's sense of physical attractiveness; (2) the need to restore a wounded sense of masculinity; (3) the need to alleviate painful experiences of loneliness and social isolation; and (4) the need to get away, find relief or escape, at least temporarily, from difficult situations brought about by poverty, racism, interpersonal rejection, and AIDS." Thus the contextual elements of setting and motivation need to be considered when planning any prevention strategy.
There is a sharp divide between the pre-AIDS gay generation and their younger counterparts. The former share a profound experience of grief for the loss of countless loved ones and friends, nostalgia for a paradise lost, and resignation to the constraints of safer sex. Younger gay men entered the sex scene in an age when condoms, HIV testing, serostatus disclosure, and sex negotiation were part of the package; while they may feel cheated of the golden era of free sex, they nevertheless grew up on the concept of safer sex, since condoms, HIV testing, serostatus disclosure and sex negotiation were part of their entrance into the sex scene.
But the generation coming of age today, after the introduction of HAART, has had little exposure to the ugly realities of the epidemic, and may therefore be at greater risk of developing unsafe sexual habits. The success of HAART has, ironically, increased the danger that these young people will lapse into dangerous sexual practices.
Epidemiologic evidence and behavioral research have discovered wide variety in the ways MSM have responded to the challenges of the HIV epidemic and various prevention messages. Successful prevention requires open, accurate communication that acknowledges the right to sexuality in all individuals, at all ages, and in the presence of any medical condition. Every social, ethnic, and cultural group can be receptive to prevention messages that validate them by responding to their unique needs as well as to overall public health needs.
Nicola Di Pietro, M.D. is a Public Health and Social Science Researcher.