HIV Infections Up Among Gay Men, Especially African Americans

The incidence rate of HIV among men who have sex with men is rising to rates not seen since the early days of the epidemic, and African-American men are among those hardest hit, according to new study findings from the CDC released in a "special" edition of Morbidity and Mortality Weekly Report devoted to 20 years of the AIDS epidemic in the United States. At a press conference yesterday in Washington, D.C., Helene Gayle, director of the CDC's National Center for HIV, STD and TB Prevention, said that the study "has documented the dramatic impact HIV is having among gay and bisexual men of all races and the urgent need to expand our prevention efforts for these men, particularly in ... African-American communities" (CDC release, 5/31).

The report focuses on a follow-up study to the Young Men's Survey conducted between 1994 and 1998, which found a "high prevalence" of HIV in men who have sex with men ages 15 to 22 in seven U.S. cities -- Baltimore, Dallas, New York, Los Angeles, Miami, San Francisco and Seattle. Overall prevalence of HIV was 7.2% for the 3,492 men surveyed. The second phase of the study, which from 1998 to 2000 surveyed 2,942 men between the ages of 23 and 29 who have sex with men in six of the seven cities (excluding San Francisco), also found an overall 7% prevalence rate, but the rate among African-American men who have sex with men was 32%. The study also used a new blood test to determine the incidence rate of new HIV infections in the past year, which is also used as a measure of risk. The overall incidence rate was 4.4%: 2.5% among whites, 3.5% among Hispanics and 14.7% among African Americans (MMWR, 6/1). These rates "suggest" that there may be a "resurgent [HIV] epidemic" among men who have sex with men, particularly among black men who have sex with men, the Washington Post reports. In the early 1980s, during the initial years of the epidemic, the incidence rate among men who have sex with men was 18%. Between 1985 and 1990, that rate dropped to 3% from 5%, according to CDC epidemiologist Linda Valleroy, who headed the new study. Several studies throughout the 1990s showed an incidence rate of 1.6% to 3.5% among men who have sex with men. The new figures indicate that the HIV/AIDS epidemic among young men who have sex with men is "clearly on the upswing," according to the Post. Surgeon General David Satcher said that the prevalence rate among black men who have sex with men is "approaching Botswana's level of infection" (Brown, Washington Post, 6/1). "We tend to think about our rates in the United States as being so much less than what we are seeing in other countries, and that is true if we look at it overall," Gayle explained. However, the survey "show[s] that there may be populations in this country that have rates and potential for explosion analogous to what we have seen in other parts of the world," she added. Gayle and Valleroy said the rates were "alarming" and "of critical public health importance," but "cautioned" that the results "do not necessarily hold true" outside those cities studied. The sample size was "small" and researchers recruited men from gay bars and other "similar venues"; their "sexual practices and drug use may not mirror those of other gay men." CDC officials estimate that the incidence rate for black men who have sex with men may range anywhere from 7.9% to 27.1%. However, health officials stressed that even the lower 7.9% rate "suggested a resurgence" of HIV among young gay men. "The important thing about this is there is a significant and continuing HIV epidemic among men who have sex with men in these cities right now," Valleroy added (Altman, New York Times, 6/1).

The causes of the increase in HIV infections are not known, the Post reports, but some speculate that the success of drug therapies over the last five years has lulled many young people into viewing HIV as a "manageable, chronic disease" (Washington Post, 6/1). Peter Piot, director of UNAIDS, said that a "mix of complacency and sophisticated treatment may have undermined prevention campaigns" in the West. The developed world has shown a "clear failure" in prevention efforts and is "certainly not a model" for developing nations in Africa and Asia to follow, he added (Richmond Times-Dispatch, 6/1). "The sense that the worst is over has dangerously blinded the public. The disease is less visible -- there's less drama, yet it's more widespread," Mathilde Krim, founding chair of the American Foundation for AIDS research, said (Rose, New York Daily News, 6/1). "We are damned by our own successes. People don't perceive that you get infected and die within two months. All these posters that say you can climb mountains with AIDS. People feel it isn't too bad -- until they get infected," Phill Wilson, founder of the African American AIDS Policy and Training Institute, said (Cimons, Los Angeles Times, 6/1). The age of those being infected may also be a factor. "This is a whole new generation who didn't see people they knew, their friends and loved ones, withering away and dying," Marty Algaze, spokesperson for the Gay Men's Health Crisis, said (Delfiner, New York Post, 6/1).

The higher incidence rate among blacks is a "screaming emergency," Wilson said. The United States has "failed in developing prevention messages for young black men who have sex with men," he added. The country has been "reluctant" to mount prevention campaigns aimed at black men who have sex with men, partly because of a greater "broad social prejudice" against young black men, he said, adding, "We cannot ask someone to protect his life if you have not convinced him that his life is worth protecting" (Washington Post, 6/1). Homophobia has also contributed to the failure of prevention efforts, experts say. McCay Moiforay, who worked on the Baltimore portion of the survey, said black men who have sex with men have "more trouble gaining acceptance from family and friends" than in other cultures, which complicates talking about AIDS and learning how to protect oneself. The "lack of acceptance" has also led many men who have sex with men to continue relationships with women, putting their partners and children at risk (Bor, Baltimore Sun, 6/1).

Reaching these "hidden" black men who have sex with men "might be one of the most difficult challenges to date," Thomas Liberti, chief of the HIV/AIDS bureau for the Florida Department of Health, said (Suriano, Orlando Sentinel, 6/1). "There was a long-standing feeling that HIV was not a problem for communities of color. People thought of this as a white gay disease and not as a disease that was going to impact the African-American community," Gayle said (Marziani, Washington Times, 6/1). To change that opinion and reach more minorities, the CDC announced in January a new "strategic plan" to "targe[t]" those at highest risk of HIV infection, including minority men who have sex with men. The agency has already convened two meetings to "outlin[e] prevention priorities for men who have sex with men." Any such prevention programs "must address the stigma of homosexuality," which prevents many men from "accessing needed prevention and treatment services," Gayle said. The CDC donates nearly $400 million annually to state and local prevention programs and this year will include $12 million for community-based organizations dedicated to developing programs for minority men who have sex with men. An additional $3 million will go to national and regional groups to provide "training and technical assistance" to such groups (CDC release, 5/31).

The MMWR also examines the past 20 years of the AIDS epidemic more generally. Some of its other findings:

• As of December 31, 2000, 774,467 Americans were reported to have AIDS, 448,060 of whom have died.
  
• As of December 31, 2000, there were 322,865 Americans living with AIDS; 79% were men, 61% were black or Hispanic and 41% were infected through homosexual contact (MMWR, 6/1).