However, recent statistics suggest dramatic increases in risky sex (and other kinds of risky behavior) among older, white, and relatively affluent gay men in major cities -- traditionally the group for whom prevention efforts were most effective. Aided by the epidemic of crystal methamphetamine that has swept through the gay community, this new wave of infections poses troubling challenges for HIV prevention efforts.
It has always been hard to get a clear picture of where the epidemic is headed. The long asymptomatic period after infection and spotty surveillance efforts have usually meant that data reflect the epidemic of five to ten years ago. However, a variety of "secondary" markers suggest a resurgence of high-risk behavior.
For instance, because syphilis is transmitted in much the same way as HIV, we've often looked at rates of that disease to show us who is having unprotected sex. Among urban gay men, syphilis rates have more than tripled since 2000. In New York City, the rise in syphilis rates among gay men has been associated with increased average income, diagnosis in a private doctor's office (as opposed to a public clinic), increased age, and residence in one of the "gay ghettos" along the west side of Manhattan. The syphilis epidemics in other major cities, including Los Angeles, Chicago, San Francisco and Washington, DC, followed a similar pattern.
Measuring new HIV infections directly is harder, although a number of cities have reported increases in new HIV infections among gay men. However, looking at newly reported HIV cases, we can get some idea of where the epidemic is moving. One-third of newly reported HIV cases among gay men in New York City are in men over 40; 44% are in men in their 30s. The epidemic in gay men under age 30 largely affects men of color; over age 30, the disease affects a far greater percentage of white men.
Much of this resurgence may be related to the use of crystal methamphetamine, a highly addictive form of speed that has swept through the gay community. About 20% of gay men in San Francisco report some meth use, as do about 15% of gay men in New York. In Chicago, nearly one in five gay men who reported using meth said they took the drug weekly. Rates of use among whites were about three times that of African-Americans.
Use of meth is strongly associated with risky sexual behavior, and with HIV infection. Meth users have many more casual sex partners, and more episodes of unprotected receptive anal intercourse. In a recent study from the Los Angeles Gay & Lesbian Center, which offers HIV testing, nearly one-third of recent positive tests in gay men were associated with meth use.
Another key contributor to the spread of HIV in this population is depression. Gay men have much higher rates of depression than the overall population of men -- about 20% of gay men show some signs of depression, as compared to about 7% of all men. Depression has been strongly linked with unsafe sex in HIV-negative men. However, interestingly, the risk is concentrated not among men with the most serious kinds of depression, but among men with "dysthymia," or mild, chronic depression.
Traditionally, our HIV prevention programs (and, indeed, most kinds of health promotion campaigns) are based on giving people information, such as instructions on having "safer sex." However, if the epidemic is indeed experiencing a resurgence among relatively affluent, middle-aged white gay men, this presents us with some vexing questions; this population, it is safe to say, does not lack for information about how best to prevent HIV transmission. How, then, should health departments and AIDS organizations go about preventing the disease from spreading further?
One obvious answer is to develop programs to prevent meth use, and to treat meth addiction. Another is to concentrate on the development of meaningful mental health services.
However, more fundamentally, it is time for gay men to think about our communal behaviors and institutions.
Drug use, for example, has become highly normalized within the gay community. A 2001 study found that almost one in four urban gay men had recently used a stimulant drug, such as ecstasy, cocaine or methamphetamine, and almost one in five reported "multiple drug use." About 20% said that they had "frequent use" of these drugs. Are these levels too high? Given the strong association of methamphetamine with negative outcomes, should we single out this drug for prevention efforts? Or should we conduct more general programs that are designed to lower the overall rate of drug use? Is there some middle ground between complete prohibition and an "anything goes" attitude towards high levels of drug use? Are our institutions, such as nightclubs, websites and circuit parties encouraging addiction and HIV infection? This is a conversation that is urgently needed, and one that should not be shut down by our discomfort.
Finally, it is worth noting that many AIDS organizations have simply ceased to provide meaningful prevention services for gay men. The success of HIV prevention in the 1980s led prevention experts to focus on higher-risk populations. However, these data prove once again that HIV prevention requires more than a one-time intervention. To be effectively sustained, behavioral changes must receive ongoing support that is adapted to current challenges. At present, however, gay men are not receiving that support. If we want prevention efforts that meet our needs, we will need to vote loudly, with our voices and with our checkbooks. We too deserve lives without HIV.
Spencer Cox is the Founder and Executive Director of The Medius Institute for Gay Men's Health.