What are men who have sex with men’s (MSM) HIV prevention needs?
What do MSM need?
Men who have sex with men (MSM) are not a single homogenous group, but represent a wide variety of people, lifestyles and health needs. From middle class gay men, to homeless runaways, to injection drug users (IDUs) to incarcerated men, MSM have many different identities and associated risks for HIV and other infectious diseases. MSM refers to any man who has sex with a man, whether he identifies as gay, bisexual or heterosexual. Despite success in changing sexual behaviors, MSM continue to be disproportionately affected by HIV/AIDS. MSM account for the largest percentage of persons with AIDS in the US (53%), even as the percentage of AIDS cases among IDUs (25%) and heterosexuals (10%) has increased.1 In 1997, the prevalence rate of HIV for MSM in 4 urban communities was 17% overall, 29% for African-American MSM and 40% for MSM-IDUs.2 HIV is not an issue that exists by itself, but is woven into many aspects of men’s lives. Risk for HIV is embedded in many other core issues such as dating and intimacy, sexual desire and love, as well as alcohol and recreational drug use, homophobia, abuse and coercion, racism and self-esteem.3 HIV prevention programs must be informed by of all these elements
There is not enough sexuality education for young people in the US, and almost no samegender sexuality education. Like many teenagers, young MSM may only learn about sex through distorted media or pornographic images. In general, men in today’s society are pressured to prove their manhood through sexual activity and aggressiveness, while women receive messages on moderation and caretaking. Given this, many MSM face additional challenges learning about dating, intimacy and forming relationships, or about desire, sexual functioning and arousal. Discomfort with one’s sexuality and identity can lead to sexual risk taking.4 In Minnesota, “Man-to-Man: Sexual Health Seminars” are based on the sexual health model. This model assumes that if MSM are more sexually literate, comfortable and competent, they are more likely to be able to reduce risk in the context of sexual behaviors and relationships. The program uses comprehensive sexuality education, cultural specificity and empirical research to help MSM reduce HIV risk long-term. The program was effective in reducing internalized homonegativity and unprotected anal intercourse.5 HIV is not the only sexual health concern for MSM. Other sexually transmitted diseases (STDs) such as herpes and genital warts can negatively affect health and sexuality. Several states have seen an increase in drug-resistant gonorrhea among MSM, making it more difficult to treat.6
Homophobia, racism and self esteem
Homophobia and racism are prevalent in the US. Internal and external homophobia and racism can lead to low self-esteem, which can lead to increased risk behavior such as sexual aggression, difficulty negotiating safer sex, and drug or alcohol abuse. MSM of color are disproportionately affected by many social and health-related ills such as HIV. African American and Latino MSM are more likely than their White counterparts to engage in high-risk activities and to be HIV-infected. Social and cultural factors may limit the ability of MSM of color to protect themselves from HIV. A study of Latino gay men in urban centers found that men who reported high-risk behavior also reported significantly higher rates of financial hardship, experiences of racism and homophobia, incidence of domestic violence and a history of coercive childhood sexual abuse.7 Hermanos de Luna y Sol, an HIV prevention intervention for Latino gay/bisexual men in San Francisco, CA, deals with the common history of oppression among Latino gay men, including issues of homophobia, machismo, sexual abuse, racism and separation from family and culture.8 In Washington, DC, US Helping US (UHU) is a multi-modal prevention program for Black MSM that addresses the psychological and emotional stress that they may experience as racially and sexually oppressed minorities. UHU provides mental health services, community building and anti-homophobia social marketing.9
Alcohol and recreational drug use
The prevalence of drug use is higher among MSM than among heterosexuals,10 although decreases recently have been noted in all alcohol and drug use categories except amphetamines.11 In many areas of the US, gay bars–often sex-charged environments where alcohol and drugs are prevalent–are the only venues for MSM to meet and socialize with each other. Drug use may vary greatly by region and subculture. Substance use puts MSM at risk for HIV for several reasons: 1) MSM-IDUs are at risk if they share infected injection equipment; 2) substance use is associated with high risk sexual behavior; 3) background HIV prevalence rates are higher for MSM-IDUs and MSM who abuse drugs but do not inject, increasing the likelihood of transmission.12 Substance use can serve as a trigger or an excuse for unprotected sex. Some MSM have trouble having sex without getting high first; others prefer having sex while high, believing recreational drugs increase their libido. For some MSM, drug use provides a sense of community and bonding at gay clubs and circuit parties. A survey of MSM who attend circuit parties found that serodiscordant unprotected anal sex was more likely to occur among men who used amphetamines (speed), Viagra and amyl nitrites (poppers).13 For many MSM-IDUs, drug use, rather than sexual orientation, forms their personal identity. Many MSM-IDUs identify as heterosexual. Too often MSM-IDUs are missed in prevention programs that target MSM but leave out IDUs, or programs that target IDUs but don’t address sexual orientation. MSM-IDUs have high rates of HIV infection, high frequency of unprotected sex and high rates of poverty, addiction and its related social and physical ills.12 The Stonewall Project in San Francisco, CA is a harm reduction program for MSM who use speed. The project provides education and assistance and has been successful at reaching MSM of different sexual and social identities.14 Across the US, several cities have opened social centers for gay men where no alcohol is served and drugs are not allowed. One HIV prevention program for young gay men helps develop community centers where young men can socialize without alcohol.15
What is sexual risk?
The perception of sexual risk for HIV varies among MSM and may change from one sexual situation to another. Throughout the HIV epidemic, MSM have engaged in sophisticated decision-making about what they consider to be risky.16 Some men decide for themselves it is OK to not use a condom if they are the top (insertive partner), if they are having oral sex or if their or their partner’s viral load is undetectable. MSM may make these decisions because the scientific evidence of HIV risk is cloudy, or simply because they are comfortable with some level of risk. HIV prevention programs should help MSM to make realistic and healthy choices based on factual information. MSM have engaged in a hierarchy of strategies for maintaining safer sex that are fluid and context-dependent. Most MSM are able to manage sexual risk with effective strategies such as monogamy with concordant partners, consistent condom use with repeated testing, condom use outside of relationship or abstinence. Other MSM use strategies that are not known to be effective (see above paragraph). A small minority of MSM choose to engage in known risk activities such as unprotected anal intercourse without knowledge of partner serostatus. Unprotected anal intercourse between an HIV+ and an HIV- man remains the greatest risk for HIV transmission among MSM. This has proven to be the biggest challenge for HIV prevention. The intimacy of skin-to-skin contact during intercourse is a powerful and important draw. Many MSM feel their sexual identity, as well as the hard-won goals of gay sexual liberation, are based on having sex–including anal intercourse–in a free and unconstricted manner. A majority of MSM consistently manage sexual risk, yet there is little understanding or research of men who are largely safe, and how their values of nurturance and caretaking, ethics, hopes for collective survival, or relations with friends and community help support them. Only recently have HIV+ MSM been targeted with messages and programs featuring “prevention altruism” that make use of MSM’s strengths. HIV prevention efforts need broader, more emotionally-resonant concepts that build on what is good in MSM’s lives.17
- Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. 2000;12.
- Catania JA, Osmond D, Stall RD, et al. The continuing HIV epidemic among men who have sex with men. American Journal of Public Health. in press.
- Seal DW, Kelly JA, Bloom FR, et al. HIV prevention with young men who have sex with men: what young men themselves say is needed. AIDS Care. 2000;12:5-26.
- Robinson BE, Bockting W, Rosser BRS, et al. The sexual health model: a sexological approach to long-term HIV risk reduction. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #ThPeD5613.
- Rosser BRS, Bockting WO, Rugg DL, et al. A sexual health approach to long-term HIV risk reduction among men who have sex with men: results from a randomized controlled intervention trial. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #WePeD4718.
- Altman LK. Gonorrhea shows its resistant side; disease control agency tells doctors of new recommendations. Milwaukee Journal Sentinel. October 2, 2000. p. 5G.
- Diaz RD, Ayala G, Bein E. Social oppression, resiliency and sexual risk: findings from the national Latino gay men’s study. Presented at the National HIV Prevention Conference, Atlanta, GA, Aug 29-Sep 1, 1999. Abst#287
- Díaz RM. Latino Gay Men and HIV: Culture, Sexuality, & Risk Behavior. NY:Routledge. 1998.
- Simmons R. Towards developing a comprehensive program for effective HIV prevention among racially oppressed gay men, bisexuals and MSM. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #TuPeD3839.
- Stall R, Wiley J. A comparison of alcohol and drug use patterns of homosexual and heterosexual men: the San Francisco men’s health study. Drug Alcohol Dependency. 1988;22:63-73.
- Crosby M, Stall R, Paul J, et al. Alcohol and drug use patterns have declined between generations of younger gay/bisexual men in San Francisco. Drug and Alcohol Dependence. 1998;52:177-182.
- Rhodes F, Deren S, Wood MM, et al. Understanding HIV risks of chronic drug-using men who have sex with men. AIDS Care. 1999;11:629-648.
- Colfax G, Mansergh G, Vittinghoff E, et al. Drug use and high-risk sexual behavior among circuit party participants. Presented at the XIII International Conference on AIDS, Durban, South Africa, July 2000. Abst #TuPeC3422.
- Stonewall Project. 415/502- 1999.
- Kegeles SM, Hays RB, Pollack LM, et al. Mobilizing young gay and bisexual men for HIV prevention: a two-community study. AIDS. 1999;13:1753-1762.
- Williams AM. Condoms, risk and responsibility. Presented at the HIV Prevention Summit, Half Moon Bay, CA, June 2000.
- Nimmons D. In this together: the limits of prevention based on self-interest and the role of altruism in HIV safety. Journal of Psychology & Human Sexuality. 1998;10:75-87
Prepared by Michael Crosby PhD and Pamela Decarlo, CAPS