Much of the rhetoric at this year's International AIDS Conference was about achieving an "AIDS-free generation." This new optimism reflects the tremendous progress that has been made in both the science of HIV and our ability to translate that science into meaningful prevention and treatment programs, but if the United States is going to be part of that AIDS-free generation, we are going to need to refocus our attention on the domestic epidemic among gay men.
Gay men in the U.S. represent the largest proportion of new HIV infections. Young men who have sex with men (MSM) are the only risk group for which HIV incidence appears to be increasing.
For gay men of color, the crisis is especially dire. Between 2006 and 2009, the CDC estimates that HIV incidence increased by 21 percent among young people (13 to 29 years old), driven by a 34-percent increase among young MSM, which in turn was driven almost exclusively by a 48-percent increase among young African-American MSM. In spite of similar risk behaviors, black gay men are at greater risk of infection than any other risk group, in part because of lower rates of HIV and STI diagnosis and treatment. The severe racial disparities that characterize the HIV epidemic in the U.S. are one of the most important equality issues for the LGBT community.
Yet these data run counter to the prevailing perception of the epidemic within the gay community -- that is, that things were bad in the 1980s and early 1990s, but once effective treatments came online in the mid 1990s, the crisis passed. How could this be?
First, it is clear that a younger generation of gay men have not been reached with the prevention message. The gay community has been appropriately praised for the tremendous reduction in risky behavior that occurred in the early years of the epidemic. The early mobilization of the LGBT community against HIV, a mobilization that occurred in a hostile political climate and initially with little government support, resulted in an 89-percent decline in the estimated HIV transmission rate.
Today we are in danger of seeing that progress reversed. One indicator of the problem is the estimate by the Centers for Disease Control and Prevention that some 20 percent of HIV-positive Americans are unaware of their infection, and nearly half of new HIV infections originate in individuals who are unaware that they have HIV.
Second, scientific advances in treating HIV have led the public at large and many in the gay community to consider HIV a treatable, "chronic" disease. And indeed it is -- if people are diagnosed early, and if they have access to quality and sustainable care.
But the data suggest otherwise: The CDC estimates that only 28 percent of those with HIV are actually successfully treated, meaning that their HIV is suppressed. This is an avoidable problem if more people know their status and we take advantage of the opportunities provided by the Affordable Care Act to expand access to health coverage for all Americans, including the estimated 24 percent of people with HIV who lack insurance. And while we offer the message of hope that an HIV diagnosis is not a death sentence, we must reinforce the primary prevention message: avoiding HIV infection in the first place.
Third, the LGBT community's attention to HIV has declined. By the late 1980s the "professionalization" of the HIV response resulted in waning interest by LGBT organizations in HIV advocacy and mobilization. HIV was left to the growing number of national and local AIDS organizations that took up the cause.
But in mainstreaming HIV as the larger public health challenge that it is, the gay-specific voice has diminished. That's been a missed opportunity to reinforce the self-caring approach that supported so much of the early HIV prevention efforts among gay men. That is not to say that the larger LGBT agenda is not relevant to the fight against HIV. Indeed, it is central: We have solid evidence that higher-risk behavior among gay men is strongly associated with feelings of stigmatization because of sexual orientation and the legacy of family and societal discrimination. So the fights against discrimination, bullying, and hate crimes and for same-sex marriage all validate LGBT people and their relationships and have the potential for bringing a "whole health" approach to HIV prevention among gay men. But these struggles need to be united, not fragmented. And HIV prevention must resume its appropriate place in the larger LGBT agenda.
So what is to be done? Our organizations recently released an issue brief, titled "Ending the HIV Epidemic Among Gay Men in the United States," that outlines a comprehensive agenda that includes taking full advantage of the Affordable Care Act to assure HIV testing, care, and treatment are readily available for all who need them. It also calls for reforms in the health system toward a "whole health" approach to meeting the needs of LGBT people -- from mental health and primary care to HIV prevention interventions for HIV-positive gay men. Among the goals are assuring access to early treatment to decrease a person's HIV viral load, which will improve their health outcomes and reduce the likelihood that HIV will be passed on to others. We also need to scale up HIV testing among gay men and remobilize the LGBT community so that we repeat the successes of the 1980s in changing the course of the epidemic.
This is not a small agenda, and it is one that will require a realigning of resources and priorities inside government and in the community. But the lives of another generation of gay men hang in the balance.
While the focus on gay men is but one element of a national response to HIV (as demonstrated in the comprehensive approach taken by the Obama administration's National HIV/AIDS Strategy), rising HIV incidence among gay men poses the greatest threat to achieving the national goal of creating an AIDS-free generation.