Are young gay men particularly affected by HIV and AIDS?
In the USA, the UK, 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 is much higher than other groups such as heterosexual people or children.
In the USA, it is estimated that nearly 255,000 men who have sex with men were living with HIV/AIDS in 2007, and nearly 5,400 had died. Around 48% of all people diagnosed with AIDS in America in 2007 were probably exposed to HIV through male-to-male sexual contact.1 In the UK, by the end of June 2009, around 45,947 diagnoses of HIV had been in men who had probably become infected through sex with another man. 53% of these men were aged below 35.2
There are also other parts of the world where men who have sex with men, many of whom do not identify themselves as gay, are affected by HIV. For example, the primary HIV transmission route in Latin America is sex between men. In Brazil, men who have sex with men accounted for 40% of all AIDS diagnoses among males between 2000 and 2005.3 In some cities in Colombia, estimates of HIV prevalence among men who have sex with men range from 10% to 25%.4
Despite the continuing impact of HIV & AIDS there are signs that awareness is waning among young people. For example, research with British teenagers has shown decreasing awareness of HIV & AIDS.5 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 diseases 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.6
In the UK the numbers of young people with chlamydia, gonorrhea and genital herpes has risen by more than 100% since the 1990s.7
What needs to be done to prevent more young gay men becoming infected with HIV?
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:
- Raising awareness about HIV & AIDS, challenging myths and assumptions and reducing stigma by providing people with accurate, up-to-date information and opportunities to clarify their attitudes and values;
- Providing opportunities for people to develop their personal and social skills in order to enable and empower them to make decisions and carry them through in terms of protecting and promoting their sexual health;
- Providing accessible and appropriate sexual health services and advice including access to condoms;
- Providing access to HIV treatment and care.
Examples of effective HIV prevention among young gay men
A 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 Empowerment project, which was implemented in California, USA. This project was based in a gay community and involved young gay men working in gay venues and 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.8 9
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.
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 organization 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 together to talk about their feelings and experiences. Safer sex materials and condoms are made available.10
An intervention in Dakar, Senegal specifically designed for men who have sex with men, and particularly effective at reaching younger men, has been found to have successfully increased HIV knowledge and use of testing services. The program used peer educators to disseminate information and condoms. It also targeted the media to address issues facing gay men, and engaged health providers to make STD services more accessible to men who have sex with men.11
The development of special health services which appeal to young gay men can be a very effective form of HIV prevention intervention. In the UK a particularly successful service offers young gay men advice on a range of issues like bullying and coming out. The center keeps in touch with young gay men through a newsletter and website12 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.
Anal sex, young gay men and HIV
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.
Not all gay men have anal sex. Some don't like it or want to do it and others only do it rarely, even if they are in a relationship. 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.13 However, for those who do have anal sex condoms are essential for HIV prevention. Unprotected anal sex carries a high risk 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?
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.14
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.
...there is also a rumor out there that it's an urban myth. That is cross infection doesn't really happen HIV positive man15
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. A UK study of HIV positive gay men found that only a minority were concerned about the possibility of becoming infected with a new strain of HIV, or 'super infection' despite the long term effects on treatment options.16
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. Drugs and alcohol in these settings can make men less likely to protect themselves17 . Some research with gay men visiting gay clubs and bars in London has shown that there are small number of gay men who socialize 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, 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.18 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.19
I guess I'm putting the blame on the drugs but it's true that if I was totally sober then I would probably have thought of using condoms Young gay man20
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.21 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 behavior.22
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 are 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 programs and activities for young gay men should take into account the particular risks that can be associated with unprotected anal sex. This means that programs need to include the following:
- Information about how HIV is transmitted and why unprotected anal sex is particularly risky;
- Information about where to get and how to use extra strong condoms and lubricants. Really effective programs will include making sure that both are available to young gay men through health and community-based sources;
- Reminders to young gay men that it is their choice whether they have anal sex or not and opportunities for them to develop and enhance their confidence and inter-personal skills through which they can exercise this choice - enabling them to negotiate confidently with sexual partners about having sex, talking about HIV and about using condoms.
- Information and access to HIV testing and counseling. This may involve promoting existing services which offer testing and developing new and specific services which are easily accessible and especially appropriate to the needs to young gay men;
- Realistic messages targeting settings and situations in which young gay men can find it more difficult to maintain safer sexual behavior. This can involve developing materials and information especially for distribution in clubs, bars and holiday venues and resorts.
What role can schools play in HIV prevention for young gay men?
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 person 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 additional risk of becoming infected with HIV. Other good reasons are:
- All young people have a right to accurate information about sex and sexuality
The primary purpose of sex education is to enable young people to have control over and get satisfaction from their sexual lives and relationships. In order to do this they need information which is relevant to them, regardless of their sexual orientation. If sex education does not include coverage of relationships and sexuality other than those between men and women it not only excludes young gay men, lesbians and bisexual people, but also does not prepare young people to live with, tolerate and understand people who are sexually different from themselves. It is practically impossible to discuss issues like gender, sexual identity, HIV and AIDS and sexual feelings and relationships properly without dealing with sexual differences and orientation.
- Young people are already talking about homosexuality
Even when formal teaching and learning in a school does not cover issues to do with knowledge, attitudes and beliefs about gay men, lesbians and bisexual people, this does not mean that young people do not talk about it. In fact, young people talk about sexual difference a lot, but are often not well informed. Bringing some discussion into the formal context of sex education and other relevant subjects like lessons on literature and history provides teachers with an opportunity to correct misinformation and explore the basis and effects of prejudice and discrimination
- Reducing sexual risks
Providing young gay men with information about safer sex which is relevant to them can help enable them to reduce the risks they might run of becoming infected with HIV. Young heterosexual people may also believe that HIV is something which only affects gay men and therefore be taking additional sexual risks. Providing accurate information about risky activities rather than groups which are at risk of HIV can help redress this.
- Reducing stigma and bullying
Young people can be very prejudiced about homosexuality and particularly towards gay men. It is very common for homophobic comments to play a part in bullying. Many young gay men have terrible experiences of school as a result. Schools need both to have policies about behavior which make it clear that this is unacceptable and to address the misconceptions on which prejudices are generally based through positive teaching.
See our gay at school page for more about young gay men's perspectives on sex education and the school environment.
How do stigma and discrimination contribute to young gay men being at risk of HIV?
Stigmatizationand discrimination against gay men is widespread. Many governments throughout the world continue to criminalize homosexuality; globally, there are 80 countries that uphold laws banning sex between men and seven in which it is punishable by death (Iran, Mauritania, Saudi Arabia, Sudan and Yemen, as well as parts of Nigeria and Somalia).23 Even in many countries where homosexuality is not illegal, gay men are subject to different rules and laws about sexual behavior to heterosexual people. It was only in 2001 that the age of consent in the UK for two men to have sex together was lowered to 16 years old – the same as for a man and woman.24
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 a positive impact on confidence about negotiating sexual relationships and practicing safer sex.25
Permissive laws which equalize the rights of gay men with others in the population can help normalize 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. 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.
Who else can help prevent young gay men becoming infected?
It is not just the responsibility of gay men themselves and organizations 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 say that education, particularly in schools, is wrong or doesn't make a difference. By contributing to a reduction in the stigmatization 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.
