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How we have failed gay men (November 2002)

The 2001 Gay Men's Sex Survey, Know the Score, has been published. "No evidence of an increase in 'HIV complacency' among gay men," says an accompanying press release from the Terrence Higgins Trust. This is because 97 per cent of gay men, when asked, agreed that "HIV is still a serious condition".
We think the press release is a tad complacent. Gay men may think HIV is serious, but that hasn't much impact on what some do.
Last year, twice as many gay men caught gonorrhoea than in 1998; three times as many, chlamydia; fifteen times as many, syphilis. As for HIV, 1,400 UK gay men, give or take a hundred either way, have become HIV positive every single year since 1988.
That's nearly 20,000 too many. A 'successful' HIV prevention campaign would at least bring the HIV rate down; at best, to zero. Why, despite squillions spent on safer-sex campaigns, are they not working better? We think gay men's HIV prevention has made three mistakes.
One: it's tried to reduce HIV transmission by changing gay men's behaviour rather than directly cutting infection risk. Imagination and dosh have gone to waste on persuading gay men to 'love and respect' each other, to quote GMFA's campaign. A worthy aim. But behaviour change is too slow.
Such campaigns might eventually produce some very loving, sorted...HIV positive gay men. In the same way, if you tried to cut HIV by weaning heroin users off needles, instead of providing clean ones, you'd end up with some sober, strong...HIV positive ex-junkies.
Two: it's targeted wastefully. The journal Nature recently said that there's no such thing as a 'medium' number of sex partners, even among gay men. Most have a few; a few have a lot. Target the few with intensive medical interventions specifically. Know the Score reveals that just one-eighth of HIV negative gay men are the 'busy boys' who have sex with more than 30 partners a year. They're also more likely to have unprotected sex. This makes them 20-50 times more vulnerable to HIV.

These guys are identifiable - they show up at GUM clinics. You don't lecture them. You don't send them to counselling, or not anyway with the sole aim of making them use condoms. What you do is try to make it medically impossible for them to catch HIV.
You give them one HIV pill a day - tenofovir is the best choice. It acts as a 'chemical vaccine'. Trials are starting soon. You also automatically include an HIV test among those done at GUM checkups (with an opt-out clause). You campaign for the urgent development of microbicides and their incorporation into every sexual lube. And, yes, free condoms everywhere.
Three: prevention campaigns have concentrated on the gay men who don't have HIV. HIV positive men are 'bolted on' to mainstream gay men's campaigns, and addressed in the same language. But HIV positive men have different needs and priorities, have more unsafe sex, and can't be scared by HIV. And attempts to guilt-trip them, as did the US 'HIV Stops with Me' campaign, will only make them more guilty, less likely disclose their status.
As a matter of urgency, we need a sexual health campaign designed specifically for positive gay men. It must talk about every other damn thing than transmitting HIV. It must inform them, bluntly, that barebacking is bad for you; that syphilis accelerates dementia (did you know that?); that hepatitis C will really mess up your treatment chances; that you can still catch resistant HIV.
These measures have been criticised as 'mechanical'. We think 'mechanical' options are the only compassionate and humane ones for the angry, the depressed, the drunk, the drugged, the dumped, the self-hating, the young and na´ve, the old and lonely. The minority of gay men, in other words - and some of us are or have been those men - who are out of control with their sexuality.

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