In the United States, HIV infection and AIDS have had a tremendous effect on
men who have sex with men (MSM). MSM accounted for 71% of all HIV infections
among male adults and adolescents in 2005 (based on data from 33 states with
long-term, confidential name-based HIV reporting), even though only about 5% to
7% of male adults and adolescents in the United States identify themselves as
The number of HIV diagnoses for MSM decreased during the 1980s and 1990s, but
recent surveillance data show an increase in HIV diagnoses for this group.3,4 Additionally, racial disparities exist with regard to HIV diagnoses within
the MSM population. A recent study, conducted in 5 large US cities, found that
HIV prevalence among black MSM (46%) was more than twice that among white MSM
The recent overall increase in HIV diagnoses for MSM, coupled with racial
disparities, strongly points to a continued need for appropriate prevention and
education services tailored for specific subgroups of MSM, especially those who
are members of minority races/ethnicities.
HIV/AIDS in 2005
(The following bullets refer to the 33 states with long-term, confidential name-based HIV reporting. See the
box, before the References section, for a list of the 33 states.)
- In the 33 states with long-term,
confidential name-based HIV reporting,
an estimated 19,620 MSM (18,296 MSM and
1,324 MSM who inject drugs) received a
diagnosis of HIV/AIDS, accounting for
71% of male adults and adolescents and
53% of all people receiving an HIV/AIDS
diagnosis that year.1
- The number of HIV/AIDS diagnoses among
MSM (including MSM who inject drugs)
increased 11% from 2001 through 2005.1
It is not known whether this increase is
due to an increase in the testing of
persons with risk factors, which results
in more HIV diagnoses, or due to an
increase in cases of HIV infection
- An estimated 231,893 MSM (207,810
MSM and 24,083 MSM who inject drugs)
were living with HIV/AIDS.1
Transmission Categories of Male Adults and Adolescents With HIV/AIDS Diagnosed During 2005
Note. Based on data from 33 states with long-term, confidential name-based HIV reporting. Because of rounding, percentages may not equal 100.
Race/Ethnicity of MSM Living With HIV/AIDS, 2005
Note. Based on 33 states with long-term, confidential name-based HIV reporting.
AIDS in 2005
(See the box, before the References section,
for AIDS definition. The following data are
from 50 states and the District of
An estimated 19,248 MSM (17,230 MSM and
2,018 MSM who inject drugs) received a
diagnosis of AIDS, accounting for 65% of
male adults and adolescents and 47% of
all people who received a diagnosis of
An estimated 7,293 MSM (5,929 MSM and
1,364 MSM who inject drugs) with AIDS
died, accounting for 60% of all men and
45% of all people with AIDS who died.1
Since the beginning of the epidemic, an
estimated 517,992 MSM (454,111 MSM and
65,881 MSM who inject drugs) had
received a diagnosis of AIDS, accounting
for 68% of male adults and adolescents
who received a diagnosis of AIDS and 54%
of all people who received a diagnosis
Since the beginning of the epidemic, an
estimated 300,669 MSM (260,749 MSM and
39,920 MSM who inject drugs) with AIDS
had died, accounting for 68% of male
adults and adolescents with AIDS who had
died and 57% of all people with AIDS who
- At the end of 2005, an estimated
217,323 MSM (191,362 MSM and 25,961 MSM
who inject drugs) were living with AIDS,
representing 67% of male adults and
adolescents living with AIDS and 52% of
all people living with AIDS.1
Risk Factors and Barriers to Prevention
Sexual Risk Factors
Sexual risk factors account for most HIV
infections in MSM. These factors include
unprotected sex and sexually transmitted
- Having anal sex without a condom
continues to be a significant threat to
the health of MSM.6 Unprotected anal
sex (barebacking) with casual partners
is an increasing concern. Not all the
reasons for an apparent increase in
unprotected anal intercourse are known,
but research points to the following
factors: optimism about improved HIV
treatment, substance use, complex sexual
decision making, seeking sex partners on
the Internet, and failure to practice
Some of these men may be serosorting, or
only having sex (or unprotected sex)
with a partner whose HIV serostatus,
they believe, is the same as their own.
Although serosorting between MSM who
have tested HIV-positive is likely to
prevent new HIV transmission to persons
who are not infected, the effectiveness
of serosorting between men who have
tested HIV-negative has not been
established. Serosorting with condom use
may further reduce the risk of HIV
transmission. However, for men with
casual partners, serosorting alone is
likely to be less effective than always
using condoms because some men do not
know or disclose their HIV serostatus.8
- STDs, which increase the risk for HIV
infection, remain an important health
issue for MSM. According to the
Gonococcal Isolate Surveillance Project,
the proportion of gonorrhea-positive
test results among MSM increased from 4%
in 1988 to 20.2% in 2004.9 Rates of
syphilis among MSM have increased in
some urban areas, including Chicago, New
York, San Francisco, and Seattle.10-12 In the 9 US cities
participating in the MSM Prevalence
Monitoring Project, the rates of STDs
and HIV positivity varied by race and
ethnicity but tended to be highest among
black and Hispanic MSM.9 In addition
to increasing susceptibility to HIV,
STDs are markers for high-risk sexual
practices, through which HIV infection
can be transmitted.13
Unknown HIV Serostatus
Approximately 25% of people in the United
States who are infected with HIV do not know
they are infected.14
- Through its National HIV Behavioral
Surveillance system, CDC found that 25%
of the MSM surveyed in 5 large US cities
were infected with HIV and 48% of those
infected were unaware of their
- In a recent CDC study of young MSM,
77% of those who tested HIV-positive
mistakenly believed that they were not
infected.15 Young black MSM in this
study were more likely to be unaware of
their infection -- approximately 9 of 10
young black MSM compared with 6 of 10
young white MSM. Of the men who tested
positive, most (74%) had previously
tested negative for HIV infection, and
59% believed that they were at low or
very low risk.
Research has shown that many people who
learn that they are infected with HIV alter
their behaviors to reduce their risk of
transmitting the virus.16,17 Therefore,
increasing the proportion of people who know
their HIV serostatus can help decrease HIV
The use of alcohol and illegal drugs
continues to be prevalent among some MSM and
is linked to risk factors for HIV infection
and other STDs.18 Substance use can
increase the risk for HIV transmission
through the tendency toward risky sexual
behaviors while under the influence and
through sharing needles or other injection
equipment. Reports of increased use of the
stimulant drug methamphetamine are also a
concern because methamphetamine use has been
associated both with risky sexual behaviors
for HIV infection and other STDs and with
the sharing of injection equipment when the
drug is injected.19 Methamphetamine and
other "party" drugs (such as ecstasy, ketamine, and GHB [gamma hydroxybutyrate])
may be used to decrease social inhibitions
and enhance sexual experiences.20 These
drugs, along with alcohol and nitrate
inhalants ("poppers"), have been strongly
associated with risky sexual practices among MSM.21
Complacency About Risk
More than 25 years into the HIV epidemic, there
is evidence of an underestimation of risk,
of difficulty in maintaining safer sex
practices, and of a need to sustain
prevention efforts for all gay and bisexual
- The success of highly active
antiretroviral therapy (HAART) may have
had the unintended consequence of
increasing the risk behaviors of some
- Some research suggests that
the perceptions of the negative aspects
of HIV infection have been minimized
since the introduction of HAART, which
has led to a false understanding of what
living with HIV means and thus to an
increase in risky sexual behaviors.22,23 For example, some MSM may
mistakenly believe that they or their
partners are not infectious when they
take antiretroviral medication or when
they have low or undetectable viral
- Optimism about HIV treatments is
associated with a greater willingness to
have unprotected anal intercourse.25-27
efforts to practice safer sex present a
significant challenge. A 4-city study
indicates that years of exposure to
prevention messages and long-term
efforts to practice safer sex may play a
role in the decision of HIV-positive MSM
to engage in unprotected anal
- The rates of risky behaviors are
higher among young MSM than among older
MSM.28,29 Not having seen firsthand
the toll of AIDS in the early years of
the epidemic, young MSM may be less
motivated to practice safer sex.
MSM Who Are HIV-Positive
HAART has enabled HIV-infected MSM to live
longer. However, HAART's success means there
are more MSM living with HIV who have the
potential to transmit the virus to their sex
partners. This emphasizes the importance of
focusing prevention efforts on those who are
living with HIV.
Although many MSM reduce their risk
behaviors after learning that they have HIV,
most remain sexually active.17 Most
HIV-infected MSM believe that they have a
personal responsibility to protect others
from HIV, but some engage in risky sexual
behaviors that may result in others'
contracting HIV.30-32 Interventions to
reduce the risk for transmission, some of
which were tested with MSM, are available
for persons living with HIV.33,34
During the past decade, the Internet has created
new opportunities for MSM to meet sex
partners.35 Internet users can
anonymously find partners with similar
sexual interests without having to leave
their residence or having to risk
face-to-face rejection if the behaviors they
seek are not consistent with safer sex.36
The Internet may also normalize certain
risky behaviors by making others aware of
these behaviors and creating new connections
between those who engage in them. At the
same time, however, the Internet has the
potential to be a powerful tool for use with
HIV prevention interventions.
Social Discrimination and Cultural Issues
MSM are members of all communities, all
races and ethnicities, and all strata of
society. To reduce the rate of HIV
infection, prevention efforts must be
designed with respect for the many
differences among MSM and with recognition
of the discrimination against MSM and other
persons infected with HIV in many parts of
- Social and economic factors, including
racism, homophobia, poverty, and lack of
access to health care are barriers to
HIV prevention services, particularly
for MSM of minority races or
ethnicities. Black and Hispanic men are
more likely than white men to be given a
diagnosis of HIV infection in the late
stages of infection, often when they
already have AIDS, suggesting that they
are not accessing testing or health care
services through which HIV infection
could be diagnosed at an earlier stage.37
- The stigma associated with homosexuality
may inhibit some men from identifying
themselves as gay or bisexual, even though
they have sex with other men.38,39 Some
men who have sex with men and with women
don't identify themselves as gay or bisexual.40 Research among black men has shown
that even if these men do not identify
themselves as gay or bisexual, they do not
engage in risky behavior more often than the
men who do identify themselves as gay or
bisexual.41 This research suggests that
elevated rates of STDs and undetected or
late diagnosis of HIV infection may
contribute to higher rates of HIV infection
among black MSM.
- Black and Hispanic MSM are less likely
than white MSM to live in gay-identified
prevention programs directed to
gay-identified neighborhoods may not
reach these MSM.
- For Hispanic MSM, unique cultural
factors may discourage openness about
homosexuality: machismo, the high
value placed on masculinity; simpatia,
the importance of smooth,
nonconfrontational relationships; and
familismo, the importance of a close
relationship with one's family.43,44
- Although Asians/Pacific Islanders and
American Indians/Alaska Natives
accounted for less than 2% of the AIDS
cases in MSM reported nationally during
1989-1998, these groups accounted for
noteworthy proportions of cases in
certain metropolitan areas.38 Also,
HIV infection among American Indians and
Alaska Natives may be underestimated
because not all surveillance systems
recognize American Indian or Alaska
Native as a race/ethnicity.45
Combinations of Risk Factors
There is growing recognition that combinations of individual, sociocultural, and
biomedical factors affect HIV risk behavior among MSM.46 Childhood sexual
abuse, substance use, depression, and partner violence have been shown to
increase the practice of risky sexual behaviors. Further research has shown that
the combined effects of these problems may be greater than their individual
effects.47 Therefore, MSM with more than 1 of these problems may have
additional risk factors for HIV infection. The expansion and wider awareness of
this type of research, which shows the additive effect of various psychosocial
problems, will result in more precise prevention efforts.
Differences Within the MSM Population
Even though MSM constitute a group at risk
for HIV, not all MSM are at risk for HIV.
Analyzing the context within which
individuals of the larger MSM community live
and socialize may be a promising method for
developing and focusing HIV interventions. A
recent large-scale HIV vaccine efficacy
trial looked at combinations of demographic
characteristics and risk behaviors to help
identify MSM at greatest risk.48 This
study of more than 5,000 HIV-negative MSM
found that older men with large numbers of
sex partners, young men who used "party"
drugs, and older men who used nitrate
inhalants were most likely to contract HIV.
The appreciation of differences within the MSM community will aid in the
development of successful HIV prevention interventions.
To reduce the incidence of HIV, CDC
Revised Recommendations for HIV Testing of
Adults, Adolescents, and Pregnant Women in
in 2006. These
recommendations include the routine HIV
screening of adults, adolescents, and
pregnant women in health care settings in
the United States. They also include
reducing barriers to HIV testing. In 2003,
Advancing HIV Prevention
initiative comprises 4 strategies: making
HIV testing a routine part of medical care,
implementing new models for diagnosing HIV
infections outside medical settings,
preventing new infections by working with
HIV-infected persons and their partners, and
further decreasing perinatal HIV
Given that a large number of HIV-infected
MSM are unaware of their infection, HIV
testing is an important strategy for this
population. Many of these men have
previously tested HIV-negative, so CDC
recommends that all sexually active MSM be
tested for HIV at least once a year.49
MSM who engage in high-risk behaviors (e.g.,
unprotected anal sex with casual partners)
should be tested more frequently.
MSM as a group continues to be the
population most affected by HIV infection
and AIDS. However, research shows that HIV
prevention efforts can reduce sexual risk
factors: one review found that among men who
received an HIV prevention intervention, the
proportion who engaged in unprotected sex
decreased, on average, 26%.50
CDC offers effective interventions for
These interventions can be tailored to
various audiences, such as African American
or Hispanic MSM. For example,
- Many Men, Many Voices, which is a
group STD/HIV prevention intervention
for gay men of color and men who have
sex with other men but do not identify
themselves as gay or bisexual
- Mpowerment, which comprises HIV
prevention, safer sex, and risk-reduction
messages in a community-building format for
- Popular Opinion Leader, which involves
identifying, enlisting, and training key
opinion leaders to encourage safer sex as
the norm in the social networks of MSM
- Healthy Relationships, which helps
develop the skills and self-efficacy of MSM
and other people living with HIV/AIDS
- Peers Reaching Out and Modeling
Intervention Strategies (PROMISE), which
uses peer advocates (including men who do
not identify themselves as gay) to help
people adopt practices to reduce or
eliminate risk factors for HIV infection
In 2006, CDC provided 54 awards to community-based organizations
that focus primarily on MSM. CDC also
provides funding through state, territorial,
and local health departments. Of these 54
awards, 63% focus on African Americans, 43%
on Hispanics, 13% on Asians and Pacific
Islanders, and 20% on whites (the
percentages do not add to 100% because some
of the organizations focus on more than one
racial/ethnic group). For example,
- An organization in Jefferson County,
Alabama, that provides a range of
services, including individual
counseling, community and street
outreach, and interventions for African
American men and Spanish-speaking men
- An organization in New York City that
provides HIV/AIDS-related services,
education, and research to Asian and
Pacific Islander communities
- An organization offering HIV/AIDS
services throughout Los Angeles and San
Bernardino counties and San Diego that
is committed to enhancing the health and
well-being of the Latino community and
other underserved communities through
community education, prevention,
mobilization, advocacy, and direct
|Understanding HIV and AIDS Data|
surveillance: Through a uniform system, CDC receives reports of AIDS cases from all US states and dependent areas. Since the beginning of the epidemic, these data have been used to monitor trends because they are representative of all areas. The data are statistically adjusted for reporting delays and for the redistribution of cases initially reported without risk factors. As treatment
has become more available, trends in new AIDS diagnoses no longer accurately represent trends in new HIV infections; these data now represent persons who are tested late in the course of HIV infection, who have limited access to care, or in whom treatment has failed.
HIV surveillance: Monitoring trends in the HIV
epidemic today requires collecting information on HIV cases that have
not progressed to AIDS. Areas with confidential name-based HIV infection reporting requirements
use the same uniform system for data collection
on HIV cases as for AIDS cases. A total of 33 states
(Alabama, Alaska, Arizona, Arkansas, Colorado, Florida,
Idaho, Indiana, Iowa, Kansas, Louisiana, Michigan,
Minnesota, Mississippi, Missouri, Nebraska, Nevada,
New Jersey, New Mexico, New York, North Carolina,
North Dakota, Ohio, Oklahoma, South Carolina,
South Dakota, Tennessee, Texas, Utah, Virginia, West
Virginia, Wisconsin, and Wyoming) have collected
these data for at least 5 years, providing sufficient data
to monitor HIV trends and to estimate risk behaviors for
HIV/AIDS: This term is used to refer to 3 categories of diagnoses collectively: (1) a diagnosis of HIV infection (not AIDS), (2) a diagnosis of HIV infection and a later diagnosis of AIDS,
and (3) concurrent diagnoses of HIV infection and AIDS.
HIV/AIDS Surveillance Report, 2005.
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- Mansergh G, Marks G, Colfax GN, et al. "Barebacking" in a diverse sample of men who have sex with men.
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- Mansergh G, Colfax GN, Marks G, et al. The Circuit Party Men's Health Survey: findings and implications for gay and bisexual men.
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