Bay Windows - May 19, 2005
Ethan Jacobs, ejacobs@baywindows.com.

"That was just a metaphor for what occurred in so many communities over time. Men who have sex with men [who did not identify as gay] didn't think they were at risk because it was a gay thing. Black men didn't think they were at risk because it was a white gay thing. Women didn't think they were at risk because it was a male thing," remembers Kessler. "Today I think we still have that denial."

Gay and bi men, along with the other men who fall under the broad category of men who have sex with men (MSM), appear to be suffering from a particularly strong case of denial. Since 2000 the largest percentage of new HIV infections each year in Massachusetts has been among MSM. Statistics suggest prevention efforts among MSM are having an effect on reducing risk of infection: in 2003, the last year for which the state Department of Public Health has released statistics on HIV infections, the state saw the lowest number of new infections among MSM since 1996, the first year for which they have hard data. Yet that still represents 316 men who were infected in 2003 through same-sex contact, or through a combination of same-sex contact and IV drug use. The numbers suggest that, more than two decades into the epidemic, there is no magic bullet prevention strategy that will stop gay and bi men from putting themselves at risk for being infected with HIV.

No size fits all

According to Kenneth Mayer, research medical director at Fenway Community Health, a number of different factors influence gay and bi men to have risky sex, including drug and alcohol use, difficulty negotiating with partners, a dislike of condoms, psychological issues among many others. This makes it difficult to design prevention programs that address the needs of the whole community.

"The reasons why gay men have unprotected sex are complex, and it's not that one size fits all," says Mayer.

The latest research data Fenway has around MSM prevention shows how hard it can be to change behavior among gay and bi men. Last July, Fenway released data from Explore, a national four-year study that included more than 700 MSM from the Boston area. One group, the control, came in for counseling and testing twice a year. The other participated in 10 intensive counseling sessions on topics such as sexual behavior, drug and alcohol use, depression, and other factors thought to lead men to engage in risky sex, followed by regular follow-up sessions every three months for the duration of the study. Despite the hands-on, intensive counseling given to the experimental group, both groups became infected at nearly the same rate by the end of the study.

Mayer says the long-term prevention solution is a vaccine, and Fenway is currently recruiting for a vaccine study, but Mayer says such a vaccine is a long way off. A more promising short-term solution may be a microbicide that could be used in lube to kill HIV during sex without using condoms. Mayer says research on microbicides thus far has focused on vaginal rather than anal sex, but Fenway is currently recruiting men to take part in a study looking at differences in how men use lube with men during sex, to determine what sort of microbicide would be acceptable to MSM. Yet it will take time for researchers to find even an effective vaginal microbicide.

"Very optimistically in the next five years we'll know if any of these first generation of vaginal microbicides are working," explains Mayer.

Hard line vs. harm reduction

HIV prevention among gay and bi men has garnered more coverage from the mainstream media than in the recent past, in large part because of an alleged "superbug" strain of HIV in New York City and because of continued reports of rising crystal methamphetamine use among gay and bi men. The coverage has led people both within and outside the gay and bi male community to call for a "get tough" approach to HIV prevention, saying the community should not tolerate men who choose to have risky sex. Loudest among those voices has been activist and writer Larry Kramer, who last month published The Tragedy of Today's Gays, a transcript of a speech he delivered Nov. 7 at New York's Cooper Union. In the speech Kramer excoriates today's younger gay male generation for lack of political and community engagement, and he has particularly harsh words for those men who engage in risky sex.

"Hell, if you have time to get hooked on crystal and do your endless rounds of sex-seeking, you have too much time on your hands. Ah, you say, aren't we to have a little fun? Can't I get stoned and have the thrill of fucking without a condom one last time? Are you out of your fucking mind! At this moment in your history, no, you cannot," writes Kramer.

He also compares infecting someone with HIV through unprotected sex with murder, although he is careful to implicate himself as well. "Have you ever wondered how many men you killed? I know I murdered some of them," Kramer writes. He declined to speak with Bay Windows for the story but says his book represents his most current thinking on HIV prevention.

Yet according to HIV prevention specialists, any approach to HIV prevention that stigmatizes men who have risky sex could actually have a negative impact on prevention efforts. Benjamin Perkins, director of AIDS Action's Men's Action Life Empowerment (MALE) Center, a wellness center targeting MSM set to open in June, says such an approach may drive those most at risk for infection away from prevention services.

"Who's going to admit to having unprotected sex if they're going to be so stigmatized?" argues Perkins. "I think it's very seductive, the idea [of a 'get tough approach'], but I think ultimately in the long term it ends up causing more harm than good."

One method prevention workers have been using to reach men engaging in risky sex is to take a harm reduction approach, working with men to develop strategies for reducing their risk. While condom use is itself a form of harm reduction, the term also refers to a number of riskier strategies such as serosorting (only having sex with people of the same HIV status); strategic positioning (only topping if one is HIV negative); pulling out; abstaining from anal sex; and other strategies. Since 1996, when HIV drugs began significantly prolonging the lives of people living with HIV, prevention workers found that many men felt less of a sense of urgency about condom use.

"What has happened since '96 is that while the first line of attack is still barrier protection, people have developed other strategies, serosorting being one, strategic positioning [being another]," according to Stephen Morin, director of the Center for AIDS Prevention Studies (CAPS) at University of California Santa Barbara.

Yet Morin stressed that those and other techniques do not reduce risk as significantly as consistent condom use. "The evidence of efficacy is all with barrier protection," says Morin, who adds that prevention workers tend to use a harm reduction approach for men who do not respond to the messages about consistent condom use. "I think agencies try to meet people at their model of the world, and if they fail on the first line strategy they try to come up with strategies that reduce harm."

Perkins says while harm reduction does not eliminate risk, the hope is that by encouraging men to think about protecting their health and the health of their partners, those men may eventually be willing to adopt safer sex practices. "Of course, these [harm reduction techniques] don't guarantee that you don't contract HIV, but what you do is at least build upon an impulse people have to protect themselves at some level," says Perkins. "It's really about identifying the health-promoting behaviors that the individual is engaging in and going from there and moving them to more health promoting behaviors."

The Centers for Disease Control has not endorsed some of the riskier harm reduction techniques, instead recommending that people avoid infection either by practicing abstinence, having a monogamous relationship with an uninfected partner, or using condoms. A spokesperson for the CDC said the agency will present a study on MSM prevention that looks at factors such as harm reduction and drug use at the 2005 National HIV Prevention Conference, to be held June 12-15 in Atlanta. CDC will not release the results of the study until it is presented at the conference.

Yet one major obstacle to people following through on engaging in health promoting behaviors is substance abuse, and in the gay male community, prevention workers have seen a particular link between crystal meth addiction and risky behavior. Russell Westacott, associate director of the Gay Men's Health Crisis' (GMHC) Institute for Gay Men's Health in New York, says that any prevention strategy which fails to address substance abuse as one of the underlying causes of risky behavior is doomed to be incomplete.

"There are very few gay-specific funded treatment services, which also makes it difficult when we're talking about a substance like crystal meth that is reported as being highly addictive," argues Westacott. "If we have no funded gay-specific treatment services to refer people to, it makes the work even harder because it just kind of takes away from that menu of options [for men seeking prevention services]."

It takes a village

One prevention strategy that has been shown to help reduce risk among young MSM is a community level intervention. Susan Kegeles, associate director of CAPS, developed an intervention in the late '80s and early '90s called the MPowerment Project, which attempts to build a community of young gay and bi men by holding social events and using those events to recruit volunteers to spread healthy messages among their peers. The theory behind the project is that there are few places for young MSM to meet beyond bars and clubs, and the volunteers work to create a community outside of those sex-charged environments where young men learn to care for themselves and each other and reinforce healthy behaviors. The community also tackles other underlying causes of risky behavior, confronting anti-gay stigma and helping young men learn how to negotiate with partners about safer sex.

"When we build this community then one of their big issues is to think about health and risk reduction," explains Kegeles. "You're getting these messages as a part of the community that it's important to take care of yourself and [that] you're responsible for the people you're having sex with."

She says research has shown that the MPowerment Project significantly reduces unprotected the rate of unprotected anal sex among both participants and among other gay men within the local community, suggesting that participants are taking the prevention messages with them when interact with men outside the MPowerment Project events. The evidence was strong enough that the Centers for Disease Control (CDC) listed the project in its compendium of prevention programs that have been proven effective.

Locally, prevention workers are using community level interventions to do prevention work among crystal meth users. Jon Vincent, a prevention worker at Fenway, will launch the community intervention program New Champions as part of the multi-agency Massachusetts Club Drug Initiative this July. As with the MPowerment Project, Vincent says the goal of New Champions will be to change community norms around engaging in risky behaviors when using meth and other drugs.

"It uses finding opinion leaders within social networks and encouraging them by training to spread information [about HIV prevention] among their friends," explains Vincent. He says the program will also feature community forums, support groups, and Web outreach. It will both encourage people to seek treatment for their substance abuse and promote harm reducing behaviors among those who do not or cannot quit.

"It's really part of what's expected of people, to get high on crystal and have unprotected sex with people for long periods of time," says Vincent. "It's hopeful and possible that the kind of preset plan that people have when they get high on crystal might change over time."

Morin says research shows that the key to prevention is changing the norms and create a community of mutual support among gay and bi men. "In terms of prevention strategies the ones that are the most effective strategies are the ones that change community norms. When the norms are such that people do communicate and check in and there's more condom use, you do have more HIV prevention," he says.

Big brother is watching

One obstacle to prevention has been obtaining federal funds at a time when the Bush administration has allegedly discouraged or intimidated health officials and scientists who are using federal funds to do work around HIV that explicitly targets the gay community. The New York Times reported in April 2003 that scientists working on AIDS research alleged that federal health officials warned them that the Office of Health and Human Services applies increased scrutiny of grants using phrases like "gay men" and "men who have sex with men."

Yet locally, prevention efforts have retained much of their federal funding. The MALE Center was funded with a five-year CDC grant, and Perkins explains that the Bay State has been relatively isolated from a federal crackdown in gay-specific prevention because the CDC uses local review boards to approve their programs.

"My sense is that Massachusetts is quite progressive when it comes to this stuff, which in many ways makes us fortunate. I think in other parts of the country where you have materials review boards that aren't so progressive it can be a real hindrance," he says.

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