A better title for this article would be "Denial is NOT a river in Egypt."
Many Gay Men in U.S. Unaware They Have H.I.V., Study Finds: The vast majority of young gay and bisexual men in the United States who were found to have the AIDS virus in a new study were unaware of their infection, according to findings reported as the 14th International AIDS Conference opened here today. The rates of unawareness among minority gay men ages 15 to 29 in the study were staggeringly high. Among those found to have H.I.V., the AIDS virus, 90 percent of blacks, 70 percent of Hispanics and 60 percent of whites said they did not know they were infected.
OK. The numbers are appalling, I will agree.
Nonetheless, the newsworthy part of this is ... what, exactly? Is there something in there besides the numbers themselves we really didn't know?
The abstract for the research itself underscores the maddeningly incomplete nature of this report. The one thing that does come through in the research that is ... delicately understated in the article is that the men tested in the study are absolute and utter idiots:
Of [young men who have sex with men (MSM)] with unrecognized HIV infection, 257 (59%) perceived themselves at low or very low risk for being infected (P1:66% vs. P2:54%; p=.01); and in the six months before their interview, 214 (49%) had 3 or more male sex partners (P1:48% vs. P2:49%; p=.74) and 224 (51%) had unprotected anal intercourse (UAI) (P1:54% vs. P2:49%; p=.28). Of those who had UAI, 107 (48%) did not use condoms because they perceived themselves or their partners to be HIV negative or at low risk for infection (P1:46% vs. P2:49%; p=.69).
OK, granted, again, the information is incomplete. Were these men idiots, naively trusting (well, obviously), or merely lied to by people they should not have trusted in the first place? There's no way to tell from the abstract, and there's no more information on the study available at the site. The problem, in fact, is that you really can't tell whether one of two things is going on: are the people simply in denial about their risk factors, and therefore refusing to be tested? This is the most likely scenario. However, it is also possible that a number of them had tests done, engaged in unsafe sex, and then seroconverted during the interim. After all, recommendations are only for testing once every six months, and that is a very new update from a recommendation for annual testing. (To be sure, this is unlikely to account for very many of them, but surely it accounts for at least a few of them. However, you can't tell from the way the research is reported in the abstract, and the abstract itself makes me suspect that they may not have asked that question. Again, it's hard to tell.)
It's also entirely unclear how much overlap there is in the different risk categories. For example, the numbers allow -- just -- that the people who had three or more sexual partners are not the same as the people who engaged in unprotected anal intercourse. This is extraordinarily unlikely, I would think, but without further detail, it is just barely possible.
The CDC researchers in fact have a singularly depressing body of work regarding ethnicity in the US and AIDS available at the AIDS 2002 conference site; to wit:
In the NY Times article linked above,
"It is alarming that in the third decade of the epidemic we don't know why so few black gay men know their status," said Phill Wilson, executive director of the African-American AIDS Policy and Training Institute in Los Angeles. Mr. Wilson said more research was needed to send "the best prevention messages to ensure that these men know their risk and understand how to prevent infection."
To be sure, the statement is at least somewhat disingenuous. African American men don't know their status because they don't get tested. That is blindingly obvious. The questions that should be asked are: (1) Why are they engaging in unsafe sex when they know better? (2) What are the circumstances in which they're contracting the virus? (3) How can we get them to change their behaviors? (Technically, there is a fourth question -- why don't they get tested? -- but the answer to that is also blindingly obvious. First, many don't think of themselves as gay -- see below -- so they don't think they need to be tested. After all, only gays and drug users and Africans and Haitians get AIDS, right? Second ... they don't want to know. If they don't know, then it isn't true, right? What you don't know can't perturb your mind.)
There is no reasonable complete answer to the first question. Part of the issue is that since homosexual conduct is held in such contempt among black communities -- many of whom persist in thinking of homosexuality itself as a "white man's disease" -- that people conduct their relations in desperate secrecy, a secrecy that does not lend itself to open discussions of having safer sex. Part of the issue is that so many of those who engage in sexual conduct with men are also involved with women; the whole "down low" thing. (About which I have commented one time or maybe twice before.) You would think that would make them more likely to engage in safer sex -- you don't have to explain to your woman why she caught some STD when she's only been sleeping with you if you don't bring one home, after all -- but against all sanity, it hasn't. I suppose it detracts from the excitement of the moment, the illicit thrill, if you actually plan. Moreover, it would require you to actually plan, and that would require them to confront what they're doing, which they're not ready to do.
The circumstances in which they are contracting the disease ... Now that is the sort of thing that leads to black, black laughter, of the kind that makes people wonder if you have quite lost your mind. A great many of these African American men are contracting the disease from each other through the previously mentioned illicit and unsafe sex. However, those men have to pull it in from somewhere, don't they? Wherever could it be coming from? Those CDC researchers have a charming little theory, which they are not quite stating directly:
[African American men who have sex with men (AAMSM)] were no more likely to report ever being forced to have sex (p>.05), but more likely to report bisexuality (p<.0001), or ever having STDs (p<.001) or being in jail (p<.0001). [...] AAMSM also report lower prevalence of factors associated with HIV risk (drug use and forced sex) other than STD or jail.
So.
In our wisdom, we propounded as a society a "get tough on crime" policy that resulted in unprecedented numbers of African American men (as well as Hispanic men) being sent to jail.
Where they had unprotected sex with each other -- the prison systems in their wisdom (with one or two notable exceptions) deciding that giving prisoners condoms was encouraging illicit sex, which the prisoners would have anyway. (Please note: the bit about "forced sex" can be utterly disregarded. Research indicates that men do NOT report being raped, even anonymously, unless the physical damage is so severe that they need medical help. It is entirely likely that many of those who had sex in prison were forced, either by rape or by being given a "submit to me or take on the whole gang" choice. Really, these researchers are themselves so naive sometimes you just want to shake them.)
Having had sex with infected men in prison -- and prisons typically only test for HIV on intake or when someone starts showing symptoms of AIDS; short sentence prisoners who have sex with infected men in prison may never show symptoms while they're there -- these men then come out and bring the disease back with them into the community.
Isn't that just ever so special?
It's not as if this type of consequence wasn't foreseen. It's not as if we didn't know. Society just didn't care.
So let us not express such surprise that African American men are infected at such an appallingly higher rate.
What can be done about it? ... Honestly, I'm not sure. To be frank, it requires behavioral change and community change and perhaps societal change at large. I suspect the community and behavioral change will come about only when the death rates due to AIDS start approaching sub-Saharan Africa rates. And make no mistake; without immediate behavioral and community attitude changes, we will die at those rates. Many of the things that produce that sort of death rate in Africa -- poverty, lack of education, lack of medical support infrastructure, etc -- also apply to black communities in this country, if not to those horribly grinding extremes. What is likely to happen once death and infection rates start wheeling that desperately out of control are two things: (1) black communities will decide that the government has no intention of helping and that they have to make changes themselves. Unfortunately, some of the changes are likely to be rather grim, involving ostracism and a little bit of murder here and there before things get under control. (2) The government -- no no, not THIS government, for heaven's sake, a later one with, like, brains and heart and compassion, the sort of things that this administration has no use for -- the government will somehow be forced to take a hard look at the statistics, and will find itself deeply and powerfully embarrassed, and decide that perhaps it should do something.
An unusually cynical viewpoint? ... perhaps. But it's not as if all of this hasn't been known for a little while now. Granted, in the past year, we've all been a bit distracted. Still ... does anyone out there really think that THIS administration has plans to do something about the problem?
Posted by iain at July 09, 2002 12:05 AMComments
This is the most depressing analysis I've read in a long while. I wish I could do something more than sigh, but my votes are already going to the few people who care.
Posted by lurksalot at July 9, 2002 02:02 PM