A major public health issue in the U.S. and globally is the continuing prevalence of HIV and AIDS. Disease incidence is highest among men who have sexual relations with other men, referred to as MSM or gay and bisexual men, although they compose just 2% of the country’s total population (HIV, 2012). In 2010, 61% of all persons newly infected with HIV or roughly 28,200 cases and 51% of all persons diagnosed with AIDS were MSM (HIV, 2012). Further, the incidence of HIV among MSM has risen alarmingly by 22% between 2008 and 2010 with most cases involving young men between 13 and 24 years old (CDC fact sheet, 2012; HIV and young men, 2012). This issue is of personal interest to me at present because of its resurgence despite the availability of highly-active antiretroviral therapy (HAART) and the continuing challenge of infection prevention as well.
The role of health education in efforts to prevent HIV and AIDS cannot be ignored. This fact is emphasized by statistics showing that in 2008, 44% of those diagnosed with HIV had no clue that they had the disease and most of them were young and racial minority men (HIV, 2012). Further, individual behaviors and sociocultural factors that increase the risks for infection and impede prompt diagnosis and treatment are modifiable and this can be achieved through education. For this reason, it is important for future health educators to have in-depth knowledge about the problem so that they would be in the best position to develop, implement and evaluate health education services geared towards effective prevention.
The increasing incidence of HIV and AIDS among MSM and the difficulty of prevention are due to individual behaviors which include high-risk sexual practices, alcohol consumption and drug use. HIV is a blood-borne infection and the major route of transmission is sexual intercourse (HIV, 2012). Specifically among MSM, a review of 53 published studies on sexual risk behavior showed that 40% of the population studied practiced unprotected anal intercourse (UAI) and 13-51% of UAI happened with HIV-negative or unknown status partners (van Kesteren, Hospers & Kok, 2007). The review also showed that the practice of UAI is significantly more prevalent among HIV-positive men and increases in frequency over time (van Kesteren, Hospers & Kok, 2007).
Further, it has been hypothesized that among MSM, a major reason for the resurgence in HIV incidence is high-risk sexual behavior associated with HAART and a belief that antiretroviral therapy eliminates the risks of viral transmission (Hart et al., 2010). In line with this erroneous notion, HIV-positive MSM on HAART no longer see the need to monitor their sexual behavior and so engage in risky practices such as UAI. However, research revealed that the use of antiretroviral drugs does not completely eradicate the virus and though HIV has not been detected in some of the blood samples studied, it was present in varying amounts in 30% of the semen samples obtained (Politch et al., 2012). There are also drug-resistant strains of the virus which, when acquired, will render HAART ineffective.
Besides high-risk sexual behavior, the use of alcohol is also associated with higher risks of HIV infection as do multiple sexual partners and drug use (Baliunas et al., 2010; Mackesy-Amiti, Fendrich & Johnson, 2010). Alcohol and drugs are deemed to increase self confidence, facilitate sexual encounters and enhance sexual experience among MSM. At the same time, unsafe intravenous drug practices such as the shared use of needles also raises the chances of HIV infection and is a secondary route of transmission
Clearly, the widespread practice of UAI especially among HIV-positive men and having multiple sexual partners increase the risk for infection among those who are not yet infected. There is also a need to dispel the notion that HAART removes all likelihood of disease transmission and to highlight the fact that drug-resistant viral strains exist. As such, the promotion of safer sexual practices is imperative even among MSM who are undergoing antiretroviral drug therapy. Finally, the use of drugs and alcohol which are associated with a higher incidence of infection must also be addressed.
What are clearly not elucidated in studies are the factors which are behind the rise in incidence among young MSM in recent years. It is my opinion that awareness about HIV is low among teenage and young adult MSM on one hand and on the other, unsafe sexual practices must have become increasingly more common. The 13 to 24 age group where a rise in HIV incidence has been noted corresponds to middle school, high school and university which means that most of the MSM involved must be students. It is probable that awareness building efforts regarding HIV and AIDS have generally missed schools and universities. At the same time, the widespread use of the internet and social networking websites noted among young people for dating and relationships could have had an impact on HIV incidence. These sites, especially those catering to MSM, can strongly influence beliefs and practices related to sex through online advice or peer information which may not necessarily be accurate as to promote health or aid in the prevention of HIV infection.
Not only individual behaviors but also mainstream attitudes regarding people who have HIV or AIDS also impact prevention efforts. People who develop HIV or AIDS often experience rejection by and even violence from other people because of the latter’s fear of contracting the disease, their negative judgments based on morality principles, and the need to convey punishment because of what is deemed nonconformity with mainstream sexual behaviors (Earnshaw et al., 2012). Specifically, it is an expected outcome for MSM to develop HIV or AIDS because of their “deviant” sexual orientation and as such they are blamed for their disease. These attitudes are also noted among healthcare providers which lead to less than optimal care provided for HIV and AIDS sufferers (Rutledge et al., 2011). For fear of suffering discrimination, stigma and violence, MSM often delay or refuse to obtain medical services for diagnosis and treatment (Earnshaw et al., 2012). Fear also prevents them from openly seeking information about the disease and safer sexual practices.
Stigma and acts of discrimination against MSM who have HIV and AIDS are not justified especially in health and other human service professions. The code of ethics of health education professionals supports human rights which includes the right to gender. It also upholds equal treatment in the provision of health education services which must be geared towards optimizing health and reducing the risks to disease (Code of ethics, 2011). It further promotes autonomy, which in the case of MSM, includes the freedom to choose a partner and enact sexual practices so long as these do not negatively affect health and wellbeing. Negative mainstream attitudes towards MSM who have HIV and AIDS are based on unfounded fears and group differences based on an established societal norm which, through health education itself, can be addressed to reduce stigma and discrimination.
There are many similarities and some differences in the HIV/AIDS situation among MSM in the U.S. and the United Kingdom. Like the U.S., HIV and AIDS were disproportionately high among the MSM subpopulation and like the U.S. the incidence rates among MSM have increased with the rate in the U.K. reaching its highest in 2010 at 3,000 new cases (Health Protection Agency, 2011). Similar to the U.S., the incidence of HIV among younger men in recent years was observed with 31% of new infections occurring among males younger than 35 years old in the U.K (Health Protection Agency, 2011). Majority of the MSM diagnosed with HIV were also White males and a disparity in incidence and infection outcomes have been noted among Blacks in both countries. However, unlike in the U.S., the U.K. has a high concern for HIV infections acquired abroad.
Both countries have rates of HIV among MSM below 1% compared to the total population though the rate in the U.K. is lower than the U.S. at 0.005% and 0.009% respectively. In both countries, HIV transmission is mainly through sexual intercourse and one out of every four infected MSM in the U.K. does not know that he is infected similar to the situation noted in the U.S. (Health Protection Agency, 2011). There is also high-quality health care for HIV and AIDS with wide availability of HAART and various diagnostic techniques. Thus, quality of life despite infection is high in both the U.S. and U.K. with a longer lifespan for HIV and AIDS sufferers.
One organization exclusively working for HIV prevention among MSM in the U.K. since 1998 is the Community HIV and AIDS Prevention Strategy (CHAPS) Partnership. It is currently funded by the country’s Department of Health and is a public and private partnership of 14 organizations (Our programme of work, n.d.). The CHAPS Partnership provides research-based educational resources and services for the promotion of HIV prevention tailored for the MSM population. One goal is to promote safe sex through nonjudgmental interventions taking into consideration the particular needs and concerns of the sector as a whole as well as specific groups such as the HIV-positive, ethnic minorities, drug users, younger MSM and those with low levels of literacy (Our programme of work, n.d.). These interventions are meant to enhance the quality of life by decreasing the likelihood of disease and recognizing and respecting individual sexuality. The other goal is to correct wrong assumptions about HIV and MSM.
The CHAPS Partnership provides education through print and online media or via counseling, group talks and outreach programs in order to present choices and empower MSM to make the right decisions regarding their sexual practices (Our programme of work, n.d.). Print resources are in the form of magazines, booklets, leaflets, posters, briefing sheets or written information in websites. Group talks and outreach programs develop prevention skills, fulfill individual social needs and address interpersonal concerns between partners (Our programme of work, n.d.). To increase access to education resources and services, these are made available in MSM websites, places that MSM frequent, clinics catering to MSM and the community. Resources and services have undergone pretesting to ensure appropriateness and acceptability (Our programme of work, n.d.).
In the U.S., the Institute for Gay Men’s Health (IGMH) is one organization working to promote HIV prevention among gay men in New York. Its aim is to deal with the reasons behind the HIV/AIDS epidemic, modify negative beliefs about the issue and foster behavioral change among MSM and the public (We are GMHC, 2013). Education is seen as a way of empowering MSM so that they can lead healthier lives.
HIV prevention is achieved through three different campaigns. The testing campaign seeks to increase HIV testing services utilization among gay men through the David Geffen Center for HIV Testing and Health Education (Testing campaigns, 2013). The campaign on health awareness involves telephone counseling and HIV prevention education through its helpline and email (Substance use campaigns, 2013). The campaign on substance use involves the dissemination of real life stories of MSM who have used drugs to increase awareness about the negative effects of drug utilization. Links to resources which can assist MSM in stopping drug use are made available.
Based on the information available on their respective websites, CHAPS has a wider reach in terms of prevention education because of the variety of media it uses and its being active in seeking out MSM whereas the IGMH provides testing and help line services only for those who seek them. The CHAPS Partnership also utilizes research evidence gained from MSM participants in the development of its interventions catering to MSM in general and also special subpopulations thereby ensuring that these are needed, will work and are meaningful to MSM. On the other hand, the IGHM uses research primarily to evaluate and improve its existing services which target MSM in general. The focus of CHAPS is on quality of life with emphasis on empowerment or being able to make choices in the areas of health and sexuality while the IGHM mainly provides a fixed range of services offered to MSM. Overall, the CHAPS Partnership is more transparent in how it operates because the rationale behind their interventions, the expected outcomes and data monitoring are made available in their website.
At the country level, there are strategies being used for HIV/AIDS prevention among MSM. In the U.S., the CDC has launched the Let’s Stop AIDS Together, a five-year campaign involving public health education, HIV testing and encouraging advocacy at the community level (Act against Aids, 2012). The campaign is based on the principle that HIV and AIDS should be regarded as a public concern and not an issue limited to gay and bisexual men. Health education aims to build awareness about HIV and AIDS, its transmission and prevention measures using online and print media. Specifically for MSM, the Testing Makes Us Stronger campaign makes testing accessible to them leading to prompt diagnosis and treatment (Act against Aids, 2012).
Advocacy aims to create support for MSM and HIV-positive individuals by encouraging them to share their personal experiences in story-telling sessions which convey the main message that HIV-positive individuals are people just like everybody else (Act Against Aids, 2012). These also clarify misconceptions about the disease and MSM. State and local health agencies and health care professionals are also mobilized to provide education, behavior modification and medical interventions such as testing, condom use and microbicides use to promote safe sex. In summary, HIV prevention in the U.S. is achieved using a multistrategy of mass media education campaigns, cognitive-behavioral interventions, biomedical approaches and community-based efforts (Sullivan et al., 2012).
In the U.K., multisectoral coalitions are the main machinery for campaigns and intervention services delivery as exemplified by the CHAPS Partnership and also the Halve It initiative by the National Aids Trust, the latter aiming to reduce by half the number of undiagnosed HIV cases through the promotion of early HIV testing (Halve It campaign, 2013). Prevention messages in mass media campaigns is meant not to sound like instructing MSM what they should do but to provide choices and influence MSM to get tested, use condoms, use lubricants, reduce the number of partners or seek treatment as treatment itself is regarded as a prevention method. Help-line educational resources and messages have also been updated in line with this prevention approach. The emphasis is on respecting the rights of MSM to choose their sexual partners, practice sex and express their sexuality while also promoting their rights to health (National Aids Trust, 2010).
Primary care is also being tapped to provide health education and other preventive interventions as it was observed that HIV prevention has not been prioritized in recent years even with increases in HIV incidence. Further, institutions such as the National Aids Trust are looking into formal collaboration with establishments catering to MSM to see how health promotion and prevention messages and resources can be advanced in these venues (National Aids Trust, 2010). Policy changes are also being advocated which include the allocation of greater funding for prevention programs and prioritization of HIV prevention at the national level. Support is also being given to continuing research on what prevention strategies work best including new techniques such as pre-exposure prophylaxis (PrEP).
If I were asked to recommend resources about HIV/AIDS among MSM, I will suggest David France’s documentary How to Survive a Plague. The film chronicles the efforts of the AIDS Coalition to Unleash Power (ACT UP), an MSM activist organization, in pressure politics targeting policymakers and pharmaceutical companies in order to hasten the development of drug treatments for AIDS and to make these drugs accessible. They succeeded. What is interesting in this movie is its emphasis on the need for collective action to achieve change in the face of political and social discrimination. A major lesson is that gay and bisexual men should not passively hide or stand aside and watch their advocates work on their behalf. Instead, they should be at the frontlines themselves actively working with others for the in order for to improve their sector’s health and wellbeing.
A good website is http://napwa.org.au by the National Association of People with HIV Australia (NAPWA), a grassroots advocacy group consisting of community-based organizations of HIV-positive people. The website is created by and for HIV-diagnosed individuals and their families and advocates and is what makes it interesting. It provides professionally-reviewed and current information on living with, treating and defeating HIV on the website and its online magazine Positive Living (About this site, n.d.). Although NAPWA does not exclusively cater to MSM, the educational resources available for MSM in the website are helpful. Collectively called Real Time, the workbook materials encourage reflection among MSM regarding gay sex and assist them in risk-reduction. Positive Living articles for MSM focus on HIV research, depression, sexual dysfunction, unprotected sex, real life stories, legal battles, and campaigns in the MSM sector.
Lastly, a good book on the topic of HIV/AIDS among MSM is Aging with HIV: A Gay Man’s Guide by James Masten and published in 2011. With a longer lifespan afforded by HAART, more and more HIV-positive men find their way into older adulthood. This stage of life poses physical and psychological challenges as body functions begin to deteriorate, job roles are relinquished during retirement and long-term partners are nonexistent. HIV-positive gay men face the additional challenge of living with a chronic disease. The book assists older adult gay men navigate this life stage by discussing common changes, the challenges they might encounter, and strategies they can use to cope so that they can have the best possible aging experience despite infection with HIV (Masten, 2011).
A specific educational approach developed to address this issue is the internet-based counseling called the Prevention Organization with Empowerment Resources on the Net which provides services to MSM in Kansas City (PowerON) (Moskowitz, Melton & Owczarzak, 2009). The counselors created their own profiles in Gay.com, a social networking site for MSM, and thus were able to chat with MSM users about various topics about testing, high-risk sexual behaviors, HIV and STD, coping with infection and sexuality (Moskowitz, Melton & Owczarzak, 2009). Whenever the opportunity arose, the counselors provided information about HIV prevention consistent with the public health information being disseminated by the city.
Based on need, the counselors referred the MSM clients to testing and medical consultation services. They also posted messages which let users know they can ask for HIV/STD-related information by sending instant messages. Transcripts of 245 chat sessions or 90% of those included in the study showed that health education and counseling were provided to clients (Moskowitz, Melton & Owczarzak, 2009). The benefit of this approach is that MSM can have immediate answers to their most pressing concerns from a member of their own community, albeit online, through a medium that is acceptable, convenient and upholds their privacy. This approach can be adapted to other social networking sites for MSM which have a chat feature.
As a health educator in the future, I can contribute to HIV and AIDS prevention by advocating MSM’s right to health information regarding HIV and AIDS. Seeing the rise in HIV cases among adolescent and young adult MSMs, I will seek out and work with advocate groups to promote HIV prevention education in this subpopulation. In order for me to work effectively as an advocate for young MSMs, I would need to have in-depth information about them including trends in infection rates, sexual risk behaviors, factors influencing these behaviors, sources of sexual health information, common concerns and education needs. At the national level, I can help in the drafting and pilot testing of educational materials in print or video form or as resources for online information dissemination and counseling. I can also volunteer as an online or offline counselor. At the international level, I can assist in the conduct of research about the HIV and AIDS situation of less developed countries where infection rates are highest and communicate findings to governments so that they can formulate appropriate public health responses. I can also aid in raising funds to help organizations in those countries sustain their HIV prevention efforts.
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