Men who have sex with men (MSM) have been disproportionately represented throughout the HIV/AIDS epidemic in the United States. MSM and their communities are credited with making major reductions in and sustaining relatively low levels of risky sexual behavior for many years during the 1980s and perhaps into the 1990s. Indicators since the mid-1990s, however, suggest a potential resurgence of HIV infections among MSM in the United States.

• Distinguishing between epidemics
  Before the widespread use of effective antiretroviral treatments, HIV/AIDS in the United States was viewed largely as an AIDS epidemic. Death rates were relatively high and the incidence of risky sexual behavior was relatively low among MSM, who were in danger of acquiring a terminal disease that progressed to death within several years. Since HAART became available in the mid- 1990s, HIV/AIDS has come to be viewed more like a chronic disease. Although HIV treatments are not effective for, adhered to, or tolerated by everyone over time, many promising new drugs are being developed, so a relatively low incidence of AIDS deaths may continue in the future. The HIV epidemic now faces challenges that other preventable chronic diseases (e.g., heart disease, diabetes) similarly rooted in behavior choices have faced for decades. The challenge for prevention is that people appear to be more likely to knowingly put themselves at risk for a disease if morbidity and mortality from that disease are relatively distant outcomes.

  Many MSM, HIV-negative as well as HIV-positive, acknowledge that their risky behavior has increased as a result of the availability of HAART. Gay and bisexual men report that HIV treatments relieve their worries about unsafe sex. For some MSM at some times, other needs (e.g., physical stimulation, emotional connection) may be equally or more important than preventing HIV infection.

• Current biomedical preventions
  The shift from an AIDS epidemic to an HIV epidemic in the United States poses a scientific challenge for assessing and subsequently disseminating effective vaccines and microbicides. Research indicates that the willingness to participate in vaccine trials may be associated with risky sexual behavior and, further, that MSM participants who perceive that they are in the vaccine arm of a clinical trial (compared to MSM who perceive that they are in the placebo arm or who are unsure) report higher rates of risky sexual behavior during the study. Similar results were reported from a feasibility study of a hypothetical microbicide product for rectal use.

• Paradigm shift for prevention
  HIV prevention strategies for MSM, by and large, have not changed to reflect the dramatic shift in the epidemic. A shift in HIV prevention is needed on two main fronts.
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  Tandem biomedical and behavioral prevention are needed. It is believed that early generations of available vaccines and microbicides will be less effective than condoms -- estimated to be approximately 90 percent to 95 percent effective -- so condom use will continue to be the prevention standard and a primary component of prevention messages. More behavioral research is needed to develop effective multicomponent prevention messages in preparation for a partially effective vaccine or microbicide. As a simple example, how might the following multicomponent message translate into behavior at the population level? "Used correctly, product X may be protective against HIV infection 50% of the time during anal sex, and condoms may be protective against HIV infection 95% of the time."

  Behavioral interventions are needed to reduce the risk for HIV infection in the era of an HIV epidemic. Thus, research is needed to develop multicomponent prevention messages that incorporate effective behavioral strategies that MSM may already be using. One example is "Use a condom unless you are in the context of 'negotiated safety' (i.e., an HIV-concordant primary partnership in which partners are periodically tested for HIV, agree to no risk behavior outside the partnership, and participate in ongoing reassessment of this agreement)." Multicomponent messages may dilute the primary message and prevention standard (i.e., always use a condom); however, acknowledging effective strategies with specific guidelines may not only provide options directly but may also enhance the credibility of message senders and indirectly increase condom use. In addition, behavioral research is needed to assess entirely new approaches to HIV prevention in a chronic disease epidemic.

These new approaches could be described as a shift from disease prevention in an AIDS epidemic to health promotion in an HIV epidemic. Rather than a single, specific disease prevention program, broad health promotion and healthy lifestyle programs may be beneficial. Broad health promotion programs would address HIV prevention in the context of other important health issues (e.g., substance use, depression, personal safety), promoting a general approach to health decision-making in one's life. In fact, there is evidence that health behaviors may be linked; that is, broad health promotion or healthy lifestyle programs may work to prevent chronic diseases and other health concerns.

"As responsive scientists, prevention specialists, and health officials, we must heed the call for change and work alongside MSM communities for a successful shift in HIV prevention that reflects the epidemiologic shift that has become a reality," the report concluded.

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