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The spread of HIV and other STDs among men who have sex with men MSM has been labeled a syndemic because in this population a number of different and interrelated health problems have come together and interact with one another. The various elements of the syndemic have an additive effect, each one intensifying the others. These factors include the number of infectious diseases endemic in this population, the high rate of substance abuse problems and psychological disorders, and the significant percentage of MSM who have experienced childhood sexual abuse and other adverse events.

While MSM are disproportionately affected by HIV, syphilis, and other STDs, health activists from the gay community have systematically resisted the application of the full range of public health strategies traditionally used to prevent their spread. This paper deals with the history of the syndemic, the failure of various risk reduction strategies, and treatment as prevention.

In the period October —May , 5 young men, all active homosexuals, were treated for biopsy-confirmed Pneumocystis carinii pneumonia at 3 different hospitals in Los Angeles, California. Two of the patients died. This includes the transmission category MSM and use injection drugs. According to the CDC:. Infectious agents included Shigella sonnei, Shigella flexneri, Campylobacter spp. Infection with these parasites was a likely effect of anal intercourse, which was apt to put a man in contact with his partner's fecal matter, and was virtually a certainty through the then-popular practice of rimming, which medical journals politely called oral-anal intercourse.

Shilts , In addition, MSM were at risk for syphilis, gonorrhea, hepatitis A, B, and C, cytomegalovirus, Epstein-Barr virus, human papillomavirus, chancroid, lymphogranuloma venereum, granuloma inguinale, pubic lice, pinworms, scabies, and flea bites. Many MSM had multiple recurrences of the same disease.

The ritual of repeated infection and treatment had become part of the gay lifestyle Shilts There are so many opportunities for transmission that, if something new gets loose here, we're going to have hell to pay. Even as she spoke, the infectious agent Dr. Dritz feared was spreading through the gay community. Human immunodeficiency virus HIV is not easily transmitted.

It requires percutaneous or mucosal contact with blood or other body fluids. HIV has a long latency period before the infected person's health deteriorates and during which he is capable of infecting others.

Thus, the virus had spread throughout the gay community for several years before physicians realized they were dealing with a new disease. They were shocked by the sheer number of sexual partners reported, typically over Shilts , The virus spread quickly. One year later, it was 58 percent Rompalo During the first decade of the epidemic, HIV infection was the equivalent of a death sentence.

HIV infection usually doesn't kill outright, but destroys the immune system, making its victims prone to a range of other diseases. The first victims died of Pneumocystis pneumonia which under other conditions would have been treatable. The failure of their immune systems left victims vulnerable to a host of diseases, including toxoplasmosis a cat disease , cryptococcal meningitis, candidiasis, severe herpes, Cryptosporidium an animal parasite , encephalitis, and a fulminant form of Kaposi's sarcoma a skin cancer previously found mainly in older men of Mediterranean origin.

The disease at that time was labeled GRID gay related immune deficiency. Although the pathogen responsible had not been identified, experts were convinced that they were dealing with a disease caused by a virus and transmitted by semen and blood, and that the gay bathhouses were a likely venue for transmission, since many of the first victims could be linked to these establishments. Dan Williams, a prominent gay NY physician, suggested that bathhouses catering to gay men be required to post signs warning patrons about the danger of infection, the gay community reacted angrily, refusing to consider anything that would turn back the sexual liberation the bathhouses represented.

By , the pathogen that causes AIDS had been identified, the modes of transmission known, and a test developed to identify those infected. Instead, spokesmen for the gay community objected to any form of mandatory or routine testing. They insisted that all that was necessary was for everyone to use a condom every time. No one should be tested unless they wanted to be. All testing information should be absolutely confidential to avoid outing gay men. The names of the infected should not be reported.

There should be no routine testing, no contact tracing, and no notification of possibly infected persons. No one had a moral responsibility to tell their sexual partners they were HIV positive.

If you follow [the guidelines on the use of condoms], you don't need to worry about whether your partners know that you're positive. You've already protected them from infection and yourself from reinfection. Just use your judgment about whom to tell—there's still discrimination out there. Rotello , In spite of the known failure rate of condoms even of the best of conditions Kelly and St.

Initially, some MSM changed their behavior. However, research into the behavior of MSM found that many were not following the code.

A survey of gay men in San Francisco found that Research A study found that 67 percent of MSM admitted engaging in anal intercourse without condoms during the previous year. Many of those who initially adopted safer sex practices failed to persist:. It appears, then that some of the factors associated with continued participation in high-risk sexual behavior are resistant to current educative intervention.

Educational campaigns, however well executed and well intentioned, have been insufficient to stem the spread of HIV infections. Most of the men in our sample were highly educated, mature adults. All were well informed about the transmissibility of AIDS through sexual activity and could describe the specific measures necessary to protect against infection.

Yet even under these relatively ideal conditions, the large majority of these informed men did not adopt and maintain behavior to the extent necessary to prevent HIV infection in themselves or others. The gay AIDS establishment defended the right of infected persons to remain ignorant of their condition and the right of infected persons to conceal their contagious condition from others, including sexual partners and healthcare personnel.

They wanted gay bathhouses kept open, arguing that they could be places to impart prevention education, and distribute condoms Nieves Prevention efforts were focused on self-protection rather than the duty to protect others:. It was considered crucial to articulate an ideology of solidarity, one that rejected as divisive all efforts to distinguish the infected from the uninfected.

Suggestions that the infected might have a duty toward others were often greeted with scorn. To mark the occasion of the city's [N. It was assumed by those outside the gay community that fear of contracting an incurable, debilitating disease would motivate gay men to refrain from risky sexual activity, but the gay community reacted to the crisis by romanticizing HIV infection:. HIV-positive status was portrayed in some homosexual publications as more fun. An editorial in Steam , a magazine aimed at gay men, quotes a man who has been positive since the early years of the epidemic:.

I'm so sick and tired of these Negatives whining about how difficult it is to stay safe. Why don't they just get over it and get Positive. Those who died of AIDS were memorialized as martyrs. Walt Odets, a gay psychologist—writing when the AIDS diagnosis was still a death sentence—argued that if it was a choice between anal intercourse AI and other high risk practices and life, homosexual men should feel free to choose AI and take their chances.

Odets felt that those who designed the condom code ignore the realities of gay life:. The idea that gay men would readily adapt to condoms, ignore or fail to recognize their limitations, and, according to many educators, have fun with them is rooted in homophobia. Also homophobic is the expectation that gay men ought to feel shame and guilt for not liking them and, often, not using them. Odets condemned the social marketing model embodied in the condom code, and did not believe that this approach had ever really been successful.

In this Odets was correct, a careful study of the epidemic revealed that the dramatic drop in new infections in the late s was in large part due to epidemic saturation Rotello , — Epidemic saturation occurs when a significant portion of an at-risk population is infected, usually those most vulnerable—in this case promiscuous gay men with multiple concurrent partners.

Since, as the number of the infected increased, the number of uninfected decreased and since those uninfected at that stage of the epidemic were less likely to be engaged in multiple high-risk acts, the epidemic has fewer and fewer potential victims.

It was burning itself out. However, as soon as more young men entered the gay community, the rate of new infections began to rise and continues to rise Morris and Dean ; Hoover et al.

The process of epidemic saturation was recorded in blood samples taken from MSM from to , as part of a longitudinal hepatitis B vaccine trial. Testing revealed that by , The data suggests that lack of knowledge about HIV transmission is insufficient in explaining risk-taking.

Rather, rationalization processes may be a factor in the sexual risk-taking behaviors of young HIV—negative men, and moreover, deep intrapyschic processes often heightened by concurrent substance use , and the desire to please sexual partners may drive the decision-making of these men. I think that it's very dangerous for AIDS organizations or public health in general to tread that far into moralizing and prescribing particular sets of morals upon any give population, because you're going to have that segment of that population who feels differently, and who holds different shared values, who will organize in resistance and in rebellion and in retaliation to that, and I do see barebacking, in some small ways, as a manifestation of that.

If barebacking takes place between two men who are both positive, there is still the risk of contracting another STD or a different strain of HIV. Men who have tested HIV negative and are in a relationship, could engage in the behavior without risk, assuming that both are faithful.

Unfortunately, monogamy among gay men is rare. A study done in the Netherlands concluded that gay men in relationships were actually at higher risk of infection Xirdou et al. The development of highly active anti-retroviral therapy ART transformed HIV infection from a death sentence to a chronic disease. However, optimism about treatment caused many MSM to become even more careless about prevention.

Estimated HIV prevalence increased from Unprotected anal intercourse with a partner of different or unknown HIV serostatus increased from 9. Mean number of male partners increased from A study published in found that 42 percent of HIV-positive MSM reported sex without disclosing their infection, predominantly in nonexclusive relationships Ciccarone et al. Gay AIDS activists refuse to admit their strategy has failed and continue to push for more money for education, particularly in schools.

There is, however, no evidence that the thousands of MSM, who become HIV positive each year, have not heard of AIDS, do not know how it is spread, and do not know how to prevent infection. Of these 3, This is reason for concern since infection with another STD is a sign that these HIV-positive men or their partners were having sex with other partners.

Of the 11, who refused testing, the anonymous testing revealed that were HIV positive. These HIV-positive men went back into the community, untreated, and purposefully ignorant of the threat they posed to others. This includes the 4 percent of MSM who are also intravenous drug users.

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