HIV Prevention in friggin 2008

I belong to a listserv for HIV Prevention, which I worked in for a couple of decades. Here is my response to a recent article that was posted (and the article is posted below it). Gawd, I sound like a Libertarian.

From the article sent out in the Prevention newsgroup : [[The resources dedicated to HIV prevention and research among gay men, however, are not proportionate to their centrality in the epidemic. Prevention money is not following the epidemic.]]

Jerry (leader of the listserv and longtime HIV worker - Jill),

There’s no doubt in my mind that homophobia has played a big part in fueling the epidemic, especially early on, and still in rural areas where gay folks don’t get the societal support they need be accepted, to accept themselves and to live and love naturally. It’s hard to care about your own health and your future if you get the sense nobody else does. Those belonging to ethnic minority groups face added barriers to behavior change because of the many other challenges, stresses and stigmas they face.

But is that really what’s perpetuating the epidemic in a large part now? WHAT fucking “research” still needs to be done, for god’s sake?? Who has the responsibility to fund and carry out behavior change in the gay community - in cities like San Francisco and NYC - where homophobia plays a much smaller role but HIV continues to explode? The government? The CDC?
I worked in HIV prevention, control, research and epidemiology for 16 years. I was the only straight person on the Board of Directors of MPower. While doing the SHAS interviews for the Epidemiology dept., working in the STD clinic and research at the HIV clinic, I commonly heard intelligent, self-accepting gay men with HIV talk nonchalantly about having unprotected sex with anonymous
partners, while never discussing their or their partner’s HIV status. I would be called a homophobe for saying it, but I think there needs to be MORE stigma - not less - about this behavior; what I’d characterize as hateful activity between gay men.

Even Larry Kramer - HIV-infected early gay activist and founder of ACTUP (as you
well know) - was chastised and shunned for suggesting that the gay community needs to grow up, get responsible, learn to really love each other and their community and stop blaming the government or the straight community for a festering plight that continues to be inwardly fueled.

But Jerry, people are still playing games and ignoring the elephant in the room. There are still too many in HIV work who treat it like a cottage industry; more interested in getting more money for their programs, promotion in their careers, and personal power and attention and don’t really seem to care deeply or honestly about what is going on. Or even to see it. They are giving the same messages, teaching the same workshops, using the same lingo they did twenty years ago.

Certainly it was time for me to leave the field. I got frustrated, impatient, angry and burned out. Especially after I was called a homophobe, and told I was being “culturally insensitive” to say that reducing the number of anonymous sex partners (especially hunting for them on the internet) might be a strategy to use to prevent HIV infections. I was told that we should never utter the word “monogamy” as one possible option for those who will never accept condoms or give up anal sex. By a man who is married to his partner, himself.

Give me a fucking break! What kind of low expectations do we have for the gay community? How seriously do we take this still-deadly, horrific epidemic? Does anybody in the field even remember all the people we worked with and people we loved who died from AIDS? Do they witness and experience the horror and tragedy of young men seroconverting in this day and age? Or is it all just a game and a hobby; jockeying for power and more funds, schmoozing with colleagues, getting in front of the microphone and holding retreats?

When will we stop passing the buck? I think ACT UP needs to re-energize and target the anger where it belongs.
Where’s Our National Campaign Against Homophobia?
By Walt Senterfitt

The long-delayed release of the CDC’s new HIV incidence estimates for
the United States coincided with the opening of the International AIDS
Conference (IAC) in Mexico City. These two events had one striking
common theme: gay and bisexual men and other men who have sex with men
(MSM) are the core of the epidemic in the US and in many other parts of
the world and must be at the core of the response in order to end AIDS.

The majority of new HIV infections (more than 57%) are among gay,
bisexual and other MSM. [See below about terminology] Gay men are 10 to
30 times more likely to get HIV than are heterosexual men and the
population at large, in the US and worldwide.

The resources dedicated to HIV prevention and research among gay men,
however, are not proportionate to their centrality in the epidemic.
Prevention money is not following the epidemic. Furthermore, the total
“pot” for HIV prevention is way too small, and shrinking. Thus, the CDC
reports that fewer than 8% of gay and bisexual men surveyed in 15
cities received group-level HIV prevention services and only 15%
received individual-level interventions, i.e. 85-92 % of all MSM at
risk for HIV are not receiving the currently most effective prevention

If the CDC study had reached all gay and bisexual men, including
those in small towns and rural areas as well as those who would be
afraid to participate in such a survey, the true number of gay men not
being reached with effective prevention would no doubt exceed 95%! This
critical failure affects MSM of all races and ethnicities, but is most
dire among Black, Latino, American Indian and Asian and Pacific
Islander gay men whose risk of acquiring HIV is several times higher
than the already sky-high risk for white gay men.

Estimated Number of New HIV Infections, by Transmission Category, 2006

Source:CDC HIV/AIDS Facts, August 2008 (

The Government’s Non-Response

Why is there such a gap between the epidemic and the government’s
response? For starters, there is a scarcity of accepted interventions
for gay men that, in turn, is caused by a historic underinvestment in
research on HIV prevention among MSM. Only four of the 30
“best-evidence” prevention interventions in the CDC’s current updated
“Compendium of Evidence-based Interventions” and only four of the 17
packaged “DEBIs” (shorthand for a CDC project called Diffusion of
Effective Behavioral Interventions) are directed at MSM. State and
local health department and community-based organization prevention
programs are strongly encouraged, if not outright required, to use
these interventions in their federally-funded programs.

A strong legacy of fear and resistance abounds in the federal
government and, therefore, in academic research to honest and open
discussion of sex and sexuality in federally funded research, messaging
and programming – and that is most especially true for homosexuality,
transgenderism and all other forms of “non-normative” or diverse
sexuality. While this taboo is broadly cultural, it owes its specific
foundation in HIV prevention to the “Helms Amendment” which forbids the
use of any federal prevention program and evaluation dollars for
anything that might be considered “promoting” sex or sexual behavior
outside of heterosexual sex within marriage. Though somewhat
ameliorated by legislative compromise and judicial decisions, this
provision – originally known as “no promo homo” – remains on the books
as Section 2500 of the federal Public Health Service Act (42 U.S.C.
Section 300ee(b), (c), and (d)) and is enforced by the Centers for
Disease Control and Prevention (CDC).

While there is not such a clear legal restriction on using federal
money for research into homosexual behavior and identity and prevention
interventions for MSM, there have been periodic Congressional efforts
to impose such limitations. As a result, National Institutes of Health
(NIH) program announcements and peer review panels have effectively
self-censored in such a way as to effectively hamper this critical

“De-gay-ifying” HIV/AIDS

There has also been a consistent tendency over at least the last 15
years within much of the AIDS community itself – and certainly by the
media and other institutions of civil society enlisted in the struggle
against HIV/AIDS – to “de-gay-ify” HIV/AIDS. For example, messages
stress that HIV is an “equal opportunity virus” and that anyone can be
at risk, emphasize children and women at risk, and stress that HIV/AIDS
is, in its majority, now an epidemic in communities of color (while
simultaneously neglecting to stress that those most disproportionately
impacted in communities of color are gay and bisexual men).

This direction in messaging was in part well intended, to combat
the widespread assumption that if you are not a white gay man, AIDS is
not your problem and you are not at risk. It was also meant to get
beyond the intensified stigmatization of gay men and focus on the
behaviors that put one at risk. This approach has been embraced by many
HIV positive and other gay men who fear the added stigmatization of
having “gay” remain widely associated with “HIV/AIDS” in public
consciousness. Even from the start though, this approach was a
capitulation to rather than a confrontation of societal stigma and
prejudice against gay people, against transgender people, against all
people who are sexually “non-normative.” And it didn’t work. Homophobia
still is rampant, dollars have gone elsewhere, and, alone among the
exposure categories, HIV infection rates among gay men are rising.

HIV transmission and the AIDS epidemic are not just about the behavior.
They are also about the social and structural context of the behavior,
about the vulnerability and resilience of communities and populations,
about individuals living in communities having the awareness, tools and
support to protect themselves and their partners. Homophobia is itself
a major risk factor, as well as part of the risk context or
vulnerability, for HIV transmission among MSM and, indirectly, for
sexual transmission from men to women.

The International AIDS Conference stressed repeatedly the need to move
the social and structural context, environment and interventions front
and center. The CDC and the NIH have long given lip service to this
dimension, but have devoted neither the money and other resources nor
confronted the barriers to do so. There are no structural and social
interventions whatsoever in the CDC’s Compendium of Effective
Interventions or DEBIs. There is nothing in the public portfolios of
the CDC, NIH, SAMHSA (Substance Abuse & Mental Health Services
Administration) or HRSA (Health Resources and Services Administration)
that confront and target homophobia as a key barrier to ending the US
HIV epidemic.

Mexico’s Example

The IAC also highlighted the experience of the Mexican national health
ministry and national AIDS program in targeting homophobia as a central
priority in its HIV prevention response. The national AIDS program,
CENSIDA, led by an openly gay and HIV positive physician, Jorge
Saavedra, has for the last several years engaged in social marketing
and community mobilizations against homophobia and has funded local

The IAC was preceded by the First International March Against
Stigma, Discrimination and Homophobia to the central national square in
Mexico City. The march included tens of thousands of Mexicans from all
sectors of civil society with Dr. Saavedra and the Mexican Minister of
Health in the front rank. In his welcome to the opening ceremony of the
Conference, the conservative Catholic President of the Mexican
Republic, Felipe Calderon, called for a continuing national campaign to
end homophobia. While Mexican activists in the trenches may be rightly
skeptical of the hypocritical gap between rhetoric and reality, can you
imagine George Bush saying this or HHS Secretary Leavitt in such a

Mexico is heavily Roman Catholic, socially conservative, and ruled
by its most conservative national political party. If it can
nevertheless recognize the fight against homophobia as central – and
say so – why can’t the United States?

Therefore, We Demand:

  • That the agencies responsible for leading the federal government’s
    response to the AIDS crisis take the lead in announcing and
    orchestrating as a public health priority an explicit, multi-faceted,
    multi-year campaign against homophobia, stigma and discrimination
    against sexual diversity.
  • That this campaign be embraced and supported by state and local
    governments as well, and by media, non-governmental and private sector
    organizations with any relation to the fight against AIDS.
  • That the campaign include social marketing and other appropriately
    targeted messaging as well as funding for innovative local and national
    community mobilizations, individual and group level interventions.
  • That the lead agencies and community partners assess all current
    laws, policies and programs that explicitly or implicitly reinforce
    homophobia and stigma and/or act as barriers to effective
    anti-homophobia messaging and interventions, and change or propose
    changes to such laws and policies as soon as possible. This includes a
    careful review and, where necessary, revision of all current and future
    guidelines relating to HIV/STD/drug abuse prevention programs and a
    specific effort to repeal all vestiges in law of the original “Helms
  • That, affirmatively, promoting healthy expressions of diverse
    sexuality be recognized as a key requirement of advancing public health
    and should therefore be reflected as appropriate in all health-related
    publications and guidelines. This specifically includes guidelines,
    funding and curricula for adolescent and school health programs related
    to sex, sexual behavior and sexual identity.
  • That the NIH, through the Office of AIDS Research and other
    mechanisms, and in coordination with the CDC, prioritize the
    development of social and structural interventions and strategies that
    will most effectively undermine public and private homophobia, stigma
    and discrimination. These must include the development of better
    measurement and evaluation tools for assessing progress against
    homophobia and stigma, for social and structural interventions in
    general, and for combination prevention packages or strategies.
  • That this campaign against homophobia and for healthy sexual
    diversity must primarily be funded through new funding as part of a
    renewed and expanded national commitment to end AIDS, rather than by
    reducing funding of other effective programs and research.
  • That this campaign recognize and reflect the multiple, interlocking
    social and structural strategies needed to combat the other root causes
    of the continued HIV epidemic, including, in particular, racism and
    xenophobia, women’s oppression, transphobia, mass imprisonment, the
    “war on drugs,” disempowerment of youth, and homelessness and other
    manifestations of poverty. Homophobia manifests quite differently in
    different communities and in combination with other forms of social
    oppression. Our response must be commensurately sophisticated and well
    We ask for input, collaboration and support in this effort from our
    partners and allies throughout the AIDS movement and communities as
    well as other fighters for social justice. Recognizing the centrality
    of gay, bisexual and other men who have sex with men in the response to
    this epidemic, and demanding an appropriate national response, in no
    way should distract us from other critical campaigns and emphases in
    the fight to end AIDS. Rather, a grounding in all the truths that
    ending AIDS is a fight for social justice and that “an injury to one is
    an injury to all” will make us stronger, each and all.

Terminology – Culture, Identity and Behavior
How to refer to men who have sex with other men, exclusively or
some of the time is a challenge for which there is no easy solution.
“Gay” came to be used most commonly, but only within the last few
decades and many men, even many who readily identify as exclusively
homosexual, have never or no longer embrace the term. For some it is
too heavily associated with white men to be acceptable; yet other
proposed terms such as “same gender loving” have not achieved
widespread consensus either.

For others, “gay” is too limiting or old-fashioned, when sexuality
is much more diverse and fluid. For some, it implies a connection to a
particular community or subculture they do not wish to embrace, or
refers too much to an identity rather than a behavior. “Bisexual” is
also problematic for many, even those who acknowledge having sex with
both men and women. Many men who have sex with other men identify
themselves as heterosexual, straight or other terms for culturally
normative sexual behavior and identity.

Because of this complexity and lack of consensus, and the desire to
be behaviorally descriptive in discussing HIV risk and in targeting HIV
prevention efforts, the CDC and community allies came up with the term
“men who have sex with men” or MSM. This works for some purposes, but
how many individuals identify themselves as an MSM? This term, while
epidemiologically accurate and inclusive, is often criticized for
leaving out the critical aspects of identity, culture and community in
understanding sexuality and diverse sexual expression. Yet to simply
say “gay” or “gay and bisexual” may mistakenly imply that the speaker
assumes that all men who have sex with other men are essentially the
same, and understand their sexuality the same way.

For want of a better solution, we have used “gay,” “gay and bisexual,”
“MSM” or “gay, bisexual and other MSM” more or less interchangeably in
this article. We are quite aware, though, of the very important
cultural and individual differences and contradictions in any such
shorthand references and, more importantly, in figuring out how to
reach and support everyone to whom this rubric applies.

No offense, but what’s the debate?


I dunno.

It’s on page 16

The OP makes many good points.

I’m gay, over 50 years old, and I’ve been out for over 30 years. I’ve lived in Oakland or San Francisco since 1975. I’ve personally known more than 100 men who have died of AIDS.

I say this just to give some perspective; as you did. A heterosexual person working in HIV prevention for 16 years. And I feel your frustration.

Yes, I agree, gay men need to be more careful, responsible, or any other word you want to use to prevent the spread of HIV. And as a gay man in and around San Francisco before there was such a thing as AIDS, I know (imho) that most gay men did change their ways and practice safe sex.

But not to make excuses for the gay men, or hijack, but you could have wrote the same post about many things people (still) do that they know is dangerous or deadly.

Why do people still smoke? What about teen pregnancies, riding a motorcycle without a helmet, not using seat belts, drinking to excess, eating a high fat diet. The list could go on.

I don’t know the answers. That’s why there is and should be research about all types of dangerous activities people do, and why they do it.

Looks like witnessing

You’re certainly correct, a similar thread could be written about any of those subjects. The OP, however, has experience dealing with this issue, not those other ones. Basically, every topic in this forum could be waved away using the line of thinking you’re describing.

People have made threads on all of those other dangerous activities at one time or another, and undoubtedly they will again. I don’t see why this topic should be off limit.

I didn’t read it as a suggestion that it be off limits, but rather as a suggestion that it is an example of a larger problem.

ETA: Guess I should say that I’m an HIV educator.

I saw some good points in there, but then it started looking like you cut and pasted some kind of report on the end of what you were writing. Maybe you can summarize in one paragraph what you wish to debate?

Jill, not to be a junior mod, but mightn’t this thread be better suited to the Pit?