By Ceci Connolly
Washington Post Staff Writer
Thursday, August 7, 2008
MEXICO CITY, Aug. 6 -- Twenty-five years after AIDS was branded the "gay plague," the virus is again exacting a disproportionate toll on men who have sex with men, not only in the United States but also in countries where the epidemic is just emerging.
Globally, men who engage in homosexual relations are 19 times as likely to contract HIV as the rest of the population, according to data released at the International AIDS Conference. Here in Mexico, men who have sex with men are 109 times as likely as others to develop HIV, while in the United States, 53 percent of new infections in 2006 were in gay and bisexual men.
Homophobia, biology and misplaced confidence that AIDS has become a treatable chronic illness are contributing to a disturbing flashback among scientists and activists, who say much of the world appears to have forgotten the early lessons of the AIDS epidemic.
"We have come full circle," Michel Sidibe, assistant secretary general of the United Nations, said in an interview. "In the beginning, gay men in places like San Francisco and New York proved we could do prevention. When we moved from that and started talking about the broad scope of the epidemic, suddenly men who have sex with men became marginalized."
When the mysterious AIDS virus first appeared in the 1980s, it was labeled a homosexual disease. Conservative religious activists suggested the deadly illness was punishment for sexual behavior, and President Reagan remained silent.
Gay leaders, stunned by the rapid deaths of so many friends, mobilized an enormous grass-roots movement that sparked government action and, more significantly, effective prevention campaigns within the community. HIV infections among gay and bisexual men fell dramatically for a decade.
But since the mid-1990s, infection rates in gay men have been rising, especially in minority communities where homosexuality often still carries a powerful stigma.
The reasons for the rise include "prevention fatigue," confidence in new antiretroviral drugs, the use of methamphetamines and the arrival of a generation of young men who did not experience the ravages of the 1980s, said Richard Wolitski, acting director of the division of HIV/AIDS prevention at the Centers for Disease Control and Prevention.
"They haven't lived through the earlier days of the epidemic," he said. To them, AIDS may appear to be a manageable illness.
Many gay men in the United States employ a prevention strategy known as "serosorting" in which they try to calculate risk based on their own and their partner's HIV status. The problem with that approach, Wolitski said, is that a large number of men do not know they are infected and unknowingly spread the disease.
Simple biology also contributes to the problem, Wolitski noted. "This is a virus that is transmitted more easily via anal sex than vaginal sex," he said.
What worries public health leaders is that many countries, particularly in the developing world, appear to be repeating the early patterns of the epidemic.
"The same kinds of stigma and discrimination and institutionalized homophobia that failed gay men in America is now failing men who have sex with men in the rest of the world," said Kevin Robert Frost, chief executive of Amfar, the Foundation for AIDS Research.
An Amfar survey of 128 countries found that men who engage in sex with other men are at greater risk of contracting HIV than others in the population. The term "men who have sex with men" emerged a decade ago to account for men who do not identify themselves as gay or bisexual but nevertheless have sex with other men.
In Asia, these men are 18 times as likely to contract HIV as the general population, while in Africa they are four times as likely to be infected, according to Amfar.
"We were surprised how extreme it was," said Chris Beyrer, an epidemiologist at Johns Hopkins University who helped prepare the report. "It is dramatically higher across all regions."
In many cases, AIDS rates among gay and bisexual men are "directly related to the institutionalization of homophobia," Frost said.
Eighty-five countries, including Jamaica, Belize, India and Egypt, have laws criminalizing sex between men. It is punishable by death in seven countries, including Nigeria and Saudi Arabia, and by imprisonment in 76, according to the International Lesbian and Gay Association.
"It's difficult to provide services to men who have sex with men in countries where they don't acknowledge they exist," said Craig McClure, executive director of the conference sponsor, the International AIDS Society. Even if they do not face criminal penalties, gay men can experience stigma and discrimination that lead to low self-esteem and risky behavior such as unprotected sex.
"We live in an environment where nobody likes us," said Shivananda Khan, an activist who works with gay rights groups throughout East Asia. "We are told every day that we are horrible. Very few people love us. How do we cope with the constant, daily stigma? We drown our sorrows."
One of the hardest-hit regions is Latin America, which for the first time this week is hosting the biennial AIDS conference. Men who have sex with men in the region are 33 times as likely as others to be infected with HIV, the highest ratio found in the Amfar study.
"It is mostly the issue of machismo and homophobia," said Jorge Saavedra, head of Mexico's AIDS office.
Saavedra has emerged as one of the stars of the Mexico City conference and is credited with helping spotlight the issue of HIV in gay men this week.
His speech to delegates Tuesday was the first time since 1993 that the topic of men who have sex with men was featured in a plenary session. Though he has not concealed his sexual orientation, Saavedra made a point of spotlighting it, announcing to the crowd that he is gay, married and HIV-positive.
"It is not wrong to be gay," he said. "What is wrong is the need to be hidden."