Sexual behaviors in the gay 90s and beyond

By the late 1980s, the gay community's ability to institute widespread behavioral change was well documented (Stall et al., 1988), and rates of AIDS infection among homosexual men were slowly dropping (CDC, 1990). In the midst of this success, however, data were beginning to surface that suggested that some MSM were struggling to maintain safe-sex behavior, and some had never conformed to the new norms (Stall et al., 2000). Younger men and men who did not have a close friend or lover with AIDS were more likely to engage in sexual risk-taking behavior (Ekstrand and Coates, 1990), as were men of racial and ethnic minorities (Stall et al., 2000). Men who used drugs in conjunction with sexual activity were also more likely to engage in sexual risk behavior (Ostrow et al., 1990). Some studies also indicated that feeling a part of a gay community (Joseph et al., 1991) and community expectations (Kelly et al., 1992) were positively associated with risk-reduction behavior. Stop AIDS, the San Francisco advocacy group formed in 1985 to promote a community-wide commitment to safe-sex behavior, had shut down in 1987, confident that this commitment was well established (Andriote, 1999), but reopened their doors in 1990 amid concerns about rising levels of unprotected sex and new HIV infections (Andriote, 1999). Reports from other cities of increases in sexually transmitted diseases (Handsfield and Schwebke, 1990) and rates of HIV infection among homosexual men (Kingsley et al., 1991) generated renewed concern.

In the mid-1990s, the promise of highly active antiretroviral therapy (HAART) furthered worry that risk reduction might not remain a priority. Several studies did show an association between lessened concern about infection with HIV/ AIDS because of HAART, and sexual risk-taking (Stall et al., 2000, Ostrow et al., 2002). In young MSM, treatment optimism was higher among men who perceived themselves at greater risk of being HIV infected (Huebner et al., 2004), while young MSM who were less concerned with the seriousness of infection were more likely to have more partners and to be men of color (Koblin et al., 2003). Throughout the 1990s both young MSM (Katz et al., 1998; Seage et al., 1997) and ethnic- or racial-minority MSM (CDC, 2001a; Blair et al., 2002) consistently demonstrated relatively higher HIV infection rates.

In 1998 the CDC launched the multi-site Young Men's Study with the goal of quantifying and better understanding the dynamics of HIV infection among young MSM. Data from this study showed that young MSM had high rates of HIV infection (Valleroy et al., 2000), that young Black MSM had higher rates of HIV than young White MSM (Celentano et al., 2005), and that recreational drug use was associated with HIV infection in young MSM (Celentano et al., 2006a). These three findings highlight areas of concern in the HIV/AIDS epidemic among MSM today.

In summary, young MSM (CDC, 2001a, 2001b), Black MSM (Millett et al, 2006), and MSM who use drugs or alcohol at the time of sexual intercourse (Colfax and Guzman, 2006; Koblin et al., 2006; Mansergh et al., 2006a) are at disproportionate risk of becoming HIV-infected. In each of these instances, the interplay of individual, environment, and disease is apparent. Young MSM coming to grips with their sexual identity and unaware of both historical and potential costs of infection with HIV/AIDS can be less likely to adopt the older gay community's norm of safe sex. Black MSM experience disproportionately high rates of STI, which can facilitate the transmission of HIV/AIDS. At the same time, they are less likely to be aware of their HIV-positive status than other

MSM (Millet et al., 2006), which also impedes the reduction of disease. MSM who are participating in a social life that includes partying at clubs and circuit parties, and using drugs in conjunction with sexual behavior, are adhering to a completely different set of community norms. Within this community, "club" drugs are associated with social disinhibition and heightened sexual experiences (Romanelli et al., 2003). Targeting these populations of MSM who are at particular risk is essential to limiting the HIV/AIDS epidemic in the United States.

As the United States marks the twenty-fifth anniversary of the HIV/AIDS epidemic, half a million Americans are living with HIV/AIDS, and 60 percent of these are MSM (CDC, 2005c). Since the very earliest days of the epidemic in the United States, MSM have been most affected by the disease. The response of this population to this epidemic has helped to chart its course, its successes, and failures. As the still single largest transmission category, the steps this group takes to alter and adopt risk reduction behaviors will have a critical impact on the ultimate course of this epidemic.

The experiences of American MSM may also provide insight into the progression of the HIV/AIDS epidemic among MSM in other societies. In the US, reductions in HIV/AIDS and other STI among gay men have been associated with a visible and active gay community. In many societies sexual activity between men remains a taboo, and in approximately 70 countries is even illegal (Timberlake, 2006). In such environments, successful surveillance and prevention activities are not possible. In some societies, a reluctance to acknowledge gay lifestyles can affect even the most basic prevention messages. In Thailand, for example, where the prevalence of HIV among MSM nearly doubled between 2003 and 2005 (van Griensven et al., 2006), a third of participants in a recent surveillance study did not understand at a basic level how HIV is transmitted (Mansergh et al., 2006b). The only hope for prevention of HIV/AIDS among MSM in such countries is a societal shift in the acceptance of certain sexual behaviors and lifestyles.

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