Care and support for people living with HIV/AIDS

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Prevention: daunting challenges aheadMen who have sex with menIn many countries around the world, openly “gay” communities are rare or non-existent.Male homosexual behaviour, on the other hand, exists in every country. It ofteninvolves penetrative anal sex between men, an act that carries a high risk of HIVinfection.Sex between men is one of the major forces behind the HIV epidemic in many highincomecountries and in some parts of Latin America. In Asia, the contribution of sexbetween men to the HIV epidemic has been recorded regularly but has rarely beenquantified. Most of the countries with openly gay communities are in the industrializedworld, which are also the countries with the best access to prevention informationand to therapy and other care. In developing countries, men who have sex withmen are far more likely to do so in hidden ways (see below), and they are less likelyto have access to prevention information and services and care.Prevention is faltering in high-income countriesAIDS was first identified among gay men in the USA. By the time the virus thatcauses the syndrome was isolated, around 1983-1984, HIV had already spreadwidely throughout the gay community, and was beginning to be found in othergroups, too. The reaction of the gay community in the United States and elsewherewas rapid and forceful. Prevention campaigns were organized on a huge scale, andthey were largely effective. In particular, consistent condom use during anal sex rosefrom virtually nothing before the advent of AIDS to around 70% by 1995.Studies among gay men in a few cities where antiretroviral therapy for individualswith HIV is widely available have shown that men may be growing complacent aboutthe risk of AIDS. A study in the Australian cities of Sydney and Melbourne in 1998found that a third of gay men were less worried about HIV infection than they werebefore antiretroviral drugs became available. And they appeared to act on this newsense of security: these men were 40% more likely to have had recent unprotectedanal sex than men whose fear of infection was not changed by the advent of therapy.Remarkably similar results were found among gay men in New York, SanFrancisco and London.Risk behaviour is undeniably on the rise in some communities. Regular surveys ofseveral thousand gay men in San Francisco have found an increase in the proportionreporting that they had unprotected anal sex and multiple partners in the pastsix months. As Figure 25 shows, these increases in risk behaviour are paralleled byrising rates of rectal gonorrhoea – a reversal of the falling trend seen up to 1993.More worrying still, surveillance systems using sophisticated testing methods showthat in San Francisco the rate of new HIV infections in men with rectal gonorrhoeanearly doubled between 1996 and 1998. The rate of HIV incidence also rose among65
Report on the global HIV/AIDS epidemic – June 2000men presenting for voluntary counselling and testing, nearly tripling from 1.3% in1997 to 3.7% in 1999.Figure 25. Rectal gonorrhoea and sexual risk behaviour among men whohave sex with men, San Francisco, USA, 1994-1998100cases of rectal gonorrhoeaper 100 000 populationproportion reporting risk behaviour (%)8060404233232021273838442001990 1991 1992 1993 1994 1995 1996 1997 1998multiple partners in the past six months unprotected anal sex in the past six months rectal gonorrhoea rateSource: San Francisco Department of Public Health (California), USA, 1999The San Francisco surveys show that risk behaviour is increasing most rapidlyamong men under 25. In this age group, the percentage who had had unprotectedanal sex and multiple partners in the past six months rose from 22% in 1994 to 32%in 1997. In 1997, 68% of the young men reporting unprotected anal sex with morethan one partner in the previous six months did not know the HIV status of at leastone of their partners. Alarming rates of continuing HIV infection have been detectedelsewhere in the country too, with the help of methods that allow public health officialsto calculate what proportion of HIV tests are recent infections. Among nearly3500 young gay men aged 15–22 in seven US cities, nearly 3% became newlyinfected with HIV each year between 1994 and 1998, with the highest rate of newinfections seen in African-American men.Complacency may not be the only factor involved in these worrying trends amongmen under 25. It is possible that some young men are not using condoms becausethey do not identify with the group of HIV-positive gay men, or because informationprogrammes have failed to reach or convince them. The time may have come for66
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UNAIDS/00.13E (English original, Ju
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Report on the global HIV/AIDS epide
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AIDS in a new millennium: a grim pi
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National responses to the epidemic:
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Annex 1.How reliable are estimates
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Annex 2. HIV/AIDS estimates and dat
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Table of country-specific HIV/AIDS
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