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Are young gay men particularly affected by HIV and AIDS?Yes. In the UK, the USA and a number of other European countries, HIV and AIDS have affected young gay men more than any other group of people. In the UK and USA especially, the percentage of young gay men who have been infected with HIV and the percentage with AIDS are much higher than those among other groups such as heterosexual people or children. In the USA, it is estimated that nearly 300,000 men were living with AIDS at the end of 2002, and another 420,000 had died. Almost 60% of men diagnosed with HIV/AIDS in the USA were probably exposed to the virus through male-to-male sexual contact.1 In the UK, by the end of September 2004, more than 32,000 diagnoses of HIV had been in men who had probably become infected through sex with another man. Overall about 25% of all UK HIV diagnoses have been in young men under 29 years old. In 2003, there were 465 new diagnoses of HIV in men who were both under 29 and had had sex with men, comprising about 7% of the total number of new diagnoses.2 Despite the continuing impact of HIV & AIDS there are signs that awareness is waning among young people. For example, recent research with British teenagers has shown decreasing awareness of HIV & AIDS.3 The same pattern of increasing prevalence and decreasing awareness exists for STIs as a whole and many young people, including young gay men, may underestimate how likely they are to be exposed to sexually transmitted infections (STIs) including HIV. There is also evidence that in some places, even where they are otherwise well-informed about HIV and STIs, young people do not believe that they are vulnerable to contracting them.4 In the UK the numbers of young people with chlamydia, gonorrhoea and genital herpes has risen by more than 100% in the 1990s (PHLS, 2000). What needs to be done to prevent more young gay men becoming infected?The data on HIV infections show that there is a need both to sustain current prevention work with young gay men and to develop new approaches. It is important to do both, so that young gay men don't forget messages about HIV & AIDS or start to think that they are no longer relevant to them and to meet the needs which arise as circumstances change over time. For example, young gay men may need to get updated information about new testing arrangements in their area or new types of condoms. At the same time basic information needs to be provided all the time because new young gay men are beginning their sexual careers and may never have been reached with information, support and advice about HIV & AIDS or thought it was relevant to them. Good, effective prevention work with young gay men has the same basic elements as prevention work with any group or community. It involves:
Examples of effective interventionsA considerable amount of effective HIV prevention work has been carried out with gay men since the advent of HIV & AIDS in the early 1980s. Much of the work has involved groups and communities of gay men themselves. Many men have felt motivated to get involved because they have seen their friends and partners become infected with HIV. Others have felt that their particular needs have been ignored by mainstream health education and promotion. A good example of a particularly effective intervention is the Mpowerment project, which was implemented in California, USA (Kegeles et al., 1996). This project was based in a gay community and involved young gay men working in gay venues and the other community settings to initiate discussion groups and informal conversations with their peers to promote safer sex. They provided their peers with condoms and informed them about HIV prevention. Young gay men were involved in the management, design and implementation of the project, which helped ensure its relevance to other young gay men. The project successfully raised awareness about the risks of unprotected anal sex throughout the community and reduced unprotected anal sex among young gay men. Similar projects have been run in the UK like the 'Committed to youth' project in which health promotion services and the commercial sector came together to distribute safer sex information and condoms through special events in night clubs (McKevitt et al., 1994) Different types of intervention have been used with young gay men who do not use gay social and community venues and groups. Some of these young men do not, or cannot identify themselves as gay at all. For example, in Belgium a Flemish AIDS prevention organisation has developed a project which involves young gay men who have just 'come out' in working with other young men who are unsure or just finding out about their sexuality. In this project the young gay men are trained and equipped to run 'house parties' and other small events in community venues and people's homes at which young men can come to together to talk about their feelings and experiences. Safer sex materials and condoms are made available (Forrest and Reid, 2001). Special health services have also been developed which appeal to young gay men. In the UK a particularly successful service offers young gay men advice on a range of issues like bullying and coming out. The centre keeps in touch with young gay men through a newsletter and website5 and runs support groups, residential weekends and information about what a young gay man can expect from the gay scene in London. This project successfully appeals to young gay men by meeting a wide range of needs and combining health advice with more general support and the opportunity to meet other young gay men. Effective HIV prevention also needs to take into account an issue that causes some young gay men to be at particular risk of HIV. This is unprotected anal sex, which can be especially risky in terms of the transmission of HIV. Anal sex involves a man putting his penis into the anus or rectum of another man or woman. It is unprotected when he does not wear a condom. This is particularly risky in terms of HIV transmission because during anal sex it is easy to make small tears or cuts in and around the rectum through which HIV can pass. Why do some young gay men have unprotected anal sex even if they know the risks?Not all gay men have anal sex. Some don't like it or want to do it and others only do it rarely. Some research in the UK has suggested that about two thirds of men who have had any sexual experience with another man in their lives have never had anal sex at all (Johnson et al, 1994). When two men do decide to have anal sex there are a variety of reasons and circumstances when they might not use condoms, even though they know the facts about the risks of HIV infection. These reasons are not exclusive to gay men and can affect the choices heterosexual men and women make about using condoms too. If two men both think that neither of them have HIV or another sexually transmitted disease they might choose not to use condoms for anal sex. For many young gay men making a decision not to use condoms based on their knowledge about their own and their partner's HIV status is not really a realistic option. Research has shown that this is because when people are young they are very likely to have more than one sexual partner in a fairly short period of time and may well have sexual relationships with two people at the same time (Johnson et al., 2001). For some gay men not using condoms is bound up with trust or love. Some of them say that using a condom in the context of a monogamous relationship suggests that they have been unfaithful. Problems can arise here if either of them does have sex with someone else. Then they have to deal with potential difficulties of telling their partner about it because they will have to use condoms until they can be sure they haven't contracted any infections including HIV. Using condoms with every partner means this situation doesn't have to arise. Some gay men may choose to have unprotected anal sex because they are both infected with HIV. In fact, this is still risky because they might pass on other diseases which can make them particularly ill because their body's immune system is already weakened by HIV. They can also be repeatedly re-infected with HIV which can counteract the benefits of any treatment. Men can find themselves in circumstances where they feel less cautious about protecting themselves and their partners than they usually do. This can be in social situations like in clubs and bars or when they are on holiday. Some research with gay men visiting gay clubs and bars in London has shown that there are small number of gay men who socialise at these venues who have had significantly more sexual partners than most other gay men or heterosexual men and women. The research in London had some parallels with that in North America (CDC, 1999) showing that about a third of men have had unprotected anal sex in the year before being questioned. These men tended to be under 25 or over 40 years old (Dodds et al. 2000). Research with gay men on their sexual experiences on holiday showed a similar trend with a small number taking risks they wouldn't usually take at home because they thought there was less risk of meeting someone with HIV, there were more opportunities to have sex with new partners and because they felt under less pressure to have safe sex (Clift and Forrest, 1999). Research has shown that some young people, including young gay men, can see taking risks as valuable. For some it feels like an important part of learning to make decisions for themselves (Wight et al. 1998). It is also the case that being too worried about risks associated with sex can also make them feel fatalistic about the outcomes of their behaviour (van der Velde and van der Pilgt, 1991). Some young gay men may find it difficult and embarrassing to raise the issue of using condoms in some circumstances and to negotiate using them. For some men asking a partner to wear a condom can feel like they suggesting that they might have HIV or another sexually transmitted disease. The best strategy is probably for a man to point out to a sexual partner that they want to use a condom because it protects them both. Talking about using condoms can be very difficult nonetheless. In some situations men may not have access to condoms - either because they aren't carrying any with them or can't find anywhere to obtain them. It is recommended that special stronger condoms are used for anal sex and for some young men asking for these may be difficult because it means they have to effectively disclose their sexuality when they might not want anyone to know or feel confident about their sexual identity. What should be done about this?HIV prevention programmes and activities for young gay men should take into account the particular risks which can be associated with unprotected anal sex. This means that programmes need to include the following:
What role can schools play in prevention?Schools have a very important part to play in supporting HIV prevention for young gay men. This does not mean that schools are a good place to do prevention work which is just aimed at young gay men because they are not generally places where they feel safe and secure about being identified. But in whatever HIV prevention schools do through their health education provision there should be acknowledgement that in almost every group of young people there will be at least one young gay men and therefore the HIV prevention should acknowledge their needs and experiences. Moreover, all young people, whether they are gay or heterosexual, need to know about and to understand the experiences and particular risks that young gay men may be at. This can help reduce stigma and prejudices which still exist about gay men and HIV and means that heterosexual young people do not grow up thinking that the disease only affects them. Raising the issue of homosexuality can be difficult because it is politically sensitive. One good reason to make sure homosexuality is covered is because in every school there will be young men who either know that they are gay or might have a sexual relationship with another man at some point in their lives. If they do not receive information about condom use, sources of advice and support and so on, which is relevant to them it can place them at addition HIV risk. Other good reasons are:
More generally, how do stigma and discrimination contribute to young gay men being at risk of HIV?Stigmatisation and discrimination against gay men is widespread. In many countries gay men may have to abide by different rules and laws about sexual behaviour to heterosexual people. It is only in recent years in the UK, for example, that the age of consent for two men to have sex together has been lowered to 16 years old - the same as for a man and woman. In the USA there are different rules and laws about sex between young men in different states and in some other countries it is completely illegal. Permissive laws which equalise the rights of gay men with others in the population can help normalise sexual differences and restrictive laws can be widened to make sure that discrimination on the basis of sexual orientation is treated as are other forms of discrimination. The social stigma about being gay can make it difficult and even dangerous for young men to disclose their sexuality and 'come out'. Many young gay men worry that their family and friends will react negatively if they find out that they are gay. The development of support networks for families plays an important role in increasing acceptance. Feeling accepted and supported as a young gay man is very important in terms of self-acceptance and self-esteem. Having high self-esteem among young gay men has been shown to have positive impact on confidence about negotiating sexual relationships and practising safe sex (Weikert, 2001) Gay men suffered particular stigmatisation when they were widely perceived to be responsible for the epidemic rather than affected by it. Raising public awareness and understanding has an important play in challenging misconceptions like this. In the UK the Terrence Higgins Trust has mounted a mass media campaign aiming to challenge stigma. Who else can help prevent young gay men becoming infected?It is not just the responsibility of gay men themselves and organisations like schools and health services to prevent young gay men from becoming infected with HIV. Many other people have a part to play too. For example, the families and friends of young gay men can provide especially valuable emotional support. Where families and friends acknowledge and accept the sexuality of young gay men it can make it easier for them to feel confident about being themselves, talking about their concerns and taking care of themselves. Everybody can share in the responsibility of challenging prejudice and discrimination against young gay men whenever they see or hear it as leaving it unchallenged only contributes to young gay men's invisibility and vulnerability. Everybody can also join in challenging those people who say that prevention isn't necessary and who that education, particularly in schools, in wrong or doesn't make a difference. By contributing to a reduction in the stigmatisation of young gay men everybody helps to make the way clearer for targeted prevention work and for young gay men to come forward and get the help and support that they need. Authors : Simon Forrest and Annabel Kanabus. Minor amendments made by Rob Noble, October 2004. References
Last updated December 21, 2004 |