Correction Appended: Aug. 20, 2008
These men never show up at gay bars, afraid to be found out. Many are married with children but still occasionally sleep with other men. They refuse to be labeled "gay" or "bisexual," insisting that their gay male partners may as well be women. With their layered identities and secretive, high-risk sexual practices, this group of "men who have sex with men" — an epidemiological term commonly used by HIV/AIDS workers — has become one of the toughest groups for health-care authorities around the world to target.
They make up a "hidden community," AIDS experts say, usually prevalent in cultures where the social stigma attached to homosexuality is severe. In some cultures, sex between men is prohibited outright; in the Islamic Republic of Mauritania in Africa, for example, gay sex is cause for execution, which drives many men underground and increases their likelihood of engaging in risky sex. Robert Gray, regional representative of Population Services International (PSI) Asia, an international NGO, predicts that this high-risk group will become a major driving force of the HIV/AIDS epidemic in Asia, Eastern Europe and other places over the next decade.
To stem the trend, activists on the front lines have been attempting to promote safe sex — even in countries where it is not allowed — rather than prevent sex altogether. In the African nation of Burundi, homosexuality is not recognized. "My government said gays and homosexuals don't exist — they are only found in Europe or America," says Burundian Georges Kanuma, 36, an openly gay activist. Frustrated with the lack of health services for gay patients, who are routinely shunned by Burundian physicians, Kanuma founded a nonprofit AIDS organization, Association National de Soutien Aux Seropositif et Aux Malades du SIDA (ANSS), eight months ago. ANSS's first task has been to provide gel lubricants to gay men in Burundi, where in 2004, the government banned NGOs from sending the taboo lubricant there, leaving many men to use unsafe substitutes during sex — Vaseline, for instance, which weakens latex condoms, compromising protection against HIV transmission. Kanuma has arranged to receive shipments of lubricants from NGOs in France, with a monthly supply of 2,000 packets to hand out to about 40 men who have come forward, a small proportion of the roughly 250 gay men in the capital city of Bujumbura. (Kanuma says an attempt last March to take a census of gay men throughout the rest of the country got him arrested.) "I always get anonymous calls from men asking for lube," says Kanuma. "They tell me not to ask any questions and just put the lube inside a magazine and leave it in the cafés or streets."
Many men who don't consider themselves gay also, predictably, do not consider themselves to be participating in high-risk behavior. But even among openly gay men who know they are carriers of HIV, there is increasing carelessness. In a recent U.S. study, Dr. Kenneth Mayer, an infectious-diseases expert at the Miriam Hospital and professor of medicine at the Warren Alpert Medical School of Brown University, found that nearly half (45%) of the 201 HIV-positive men surveyed were high-risk transmitters: among them, the most likely to transmit HIV to partners were young men who drank heavily (more than five glasses of alcohol a day at least once in the past six months), were diagnosed with HIV within the past nine years and reported using methamphetamine. Three-quarters of the surveyed men were Caucasian, half had graduated from college, and only half had a detectable HIV viral load. "Many young and recently diagnosed HIV-positive men have 'therapeutic optimism' — thinking that with the availability of certain treatments in the past nine years or so, the disease is curable and they are not infectious," Mayer says, adding that the result of his study, which was funded by the National Institutes of Health, will guide a national draft manual for AIDS social workers, to help them identify high-risk behaviors in the community.
As a by-product of efforts like these, activists hope to lower infection rates not only of HIV but also of other sexually transmitted diseases, such as syphilis, which affects men who have sex with men in the U.S. at high rates, according to Chris Beyrer, who directs the AIDS research center at Johns Hopkins University. The problem exists elsewhere in the West: data presented by Dutch researchers this month at the International AIDS Conference in Mexico City suggest that hepatitis C and HIV co-infections have become increasingly common among the Netherlands' homosexual men. At one Amsterdam clinic, run by the Public Health Service (GGD) of Amsterdam, researchers found that 18% of its 157 HIV-positive male patients had also contracted hepatitis C. "Because the hepatitis C virus attacks the liver and HIV/AIDS patients receive highly toxic antiretroviral drugs that take a toll on the liver, it makes treatment much more complicated," says Anouk Urbanus, who researches infectious-disease clusters for GGD Amsterdam.
HIV/AIDS patients at the Amsterdam clinic must now undergo mandatory hepatitis C screening; meanwhile, other studies suggest prevention efforts can be implemented much earlier. According to separate research conducted at the same Dutch clinic, 10% of 306 gay patients reported experiencing loss of sensation when using condoms, then intentionally ditching protection during sex. "We're making a proposal to the government to prescribe men with Viagra in order to increase their chance of using condoms," says Udi Davidovich, a senior researcher at GGD Amsterdam.
Initiatives like these may not work in every country, but the Dutch findings sound a warning bell. According to statistics from the Centers for Disease Control and Prevention (CDC), men who have sex with men accounted for 53% of all new HIV infections in 2006. "These data confirmed that we need to intensify our programs for men who have sex with men, and we need to plan strategically on how to move forward," says Kevin Fenton, director of HIV and sexually transmitted disease prevention at the CDC. Programs to curb unsafe sex have to be more widely cast, Fenton says — for example, targeting the prevention message to patrons of gay bars isn't enough, since closeted men don't show up there. To reach the highest-risk groups, suggests Johns Hopkins' Beyrer, perhaps a more modern approach is needed, such as reaching out through the Internet, where so many sexual encounters begin.
The original version of this story misstated the total number of HIV-positive male patients at one Public Health Service of Amsterdam clinic. The correct number is 157, not 689. The article also misspelled the name of a senior researcher with the Public Health Service of Amsterdam. The correct spelling is Udi Davidovich.