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Addressing the Gaping Hole in HIV Prevention: A Plea for Public Health Action

By Lisa Fitzpatrick, M.D., M.P.H.

September 6, 2011

The CDC has yet again released a report highlighting the growing HIV disparity in young, black men who have sex with men (MSM). Over a decade ago, similar attention was called to what then appeared to be a public health blemish in this population. Because our prevention efforts have been largely cosmetic and woefully inadequate, the 7% increase in the infection rate among black MSM suggests this blemish is now a gushing and gaping wound requiring urgent public health action.

Why have we made so little progress in addressing what was long ago forecast as a potential public health crisis? My recent evaluation of a newly diagnosed, HIV-positive patient highlights why our cosmetic response to HIV has largely ignored root causes of HIV transmission in young, black MSM.

The 26-year-old, black, gay man walked into my office a few days after learning he was HIV positive. He was cheerful, spoke calmly and shared that his diagnosis was not unexpected, since his sexual network inconsistently used condoms. He nonchalantly admitted HIV infection is often seen as inevitable among young, gay men. He also described denial among HIV-positive young men who ignore their disease and engage in unprotected sex. When I asked if he had disclosed his HIV status to anyone, he quickly looked away and related concerns about social isolation and rejection. He left my office a bit more somber than he had been when he arrived. The following visit, I diagnosed him with syphilis.

This encounter and many others like it highlight well-known and exhaustively researched social challenges that blatantly contribute to the perpetuation of HIV infection in black MSM. The HIV prevention status quo is unacceptable, because we have too much information to continue ignoring a few salient issues that have yet to be adequately confronted.

First, young MSM have developed a fatalistic view of HIV. The rising rates of HIV are largely among a generation of young MSM with no historical memory, fears, experience or outrage with respect to HIV. Education by respected messengers about the realities of HIV, including lifelong dependency on medications, is needed to agitate and pierce the psyches of young MSM. We will never control the epidemic if young MSM continue to accept HIV as fate. Therefore, HIV-positive persons who are willing to speak openly about their sexuality and HIV status should be identified and supported to conduct intensive outreach in the social and sexual networks of young MSM.

Second, we have no concrete action plan to reduce stigma and homophobia. Born from xenophobia, these must be counteracted by exposure to people with HIV, education and discussion. Stigma is widely accepted to be a contributor to the increasing rates of HIV among black MSM. In fact, in response to the recent public health report, Jonathan Mermin, M.D., director of the CDC's Division of HIV/AIDS Prevention, stated, "It's time to renew the focus on HIV among gay men and confront the homophobia and stigma that all too often accompany this disease." This is true, but we have no concerted efforts to broadly engage in sustained conversations about either problem. Our discussions about stigma and homophobia amount to water cooler conversations among the converted.

There are many voices warranted in this discussion. Why haven't we linked our loyalty and support for societal opinion leaders (such as the clergy, athletes and artists) to their willingness to help elevate these conversations? We can increase tolerance and understanding among the general public if we commit as much time and resources to HIV education in schools, churches and community centers as we do to convening meetings, preaching to the converted and writing HIV reports that the community will never read.

Finally, we are afraid to initiate and follow through on discussions about personal responsibility among HIV-positive persons. HIV prevention among positives should become a cornerstone of our response. We must find a balanced approach that allows for discussion about accountability among HIV-positive persons who continue to engage in high-risk behavior while remaining responsive to social challenges that hinder disclosure of HIV status.

Such a combination of accountability and protection may appear mutually exclusive, but this does not absolve us of the need to openly acknowledge the stalemate and begin this discussion. One of the goals of the White House's National HIV/AIDS Strategy is to "reduce new HIV infections," but we will never achieve it if our approach continues to be devoid of this conversation and discussion of potential solutions.

In August, the CDC convened its annual prevention conference. Community advocates were present, and impassioned provocations demanded more government intervention, recycled research and increased funding for MSM-related prevention. But none of these approaches is the solution. In addition, a wealth of discussion took place about recent medical triumphs in HIV prevention, such as "treatment as prevention" and other new "tools" to end the epidemic. These medical interventions are incredible advances in our prevention capacity, but they do not obviate the need for us to renew our focus on basic HIV prevention.

The HIV epidemic among MSM is rooted in community-based challenges that demand a simple, inexpensive, grassroots response; a response that fosters dialogue, tolerance and acceptance. Unless we are content to continue applying cosmetics to conceal this gaping public health wound, we must confront the issues that have long been ignored and stop the bleeding. Anything less portends a public health disaster for young, black MSM -- and for all of us.


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