Gay, bisexual, and other men who have sex with men (MSM) represent around 2% of the United States population, yet are the population most severely affected by HIV. Gay, bisexual, and other men who have sex with men are the population most affected by HIV in the United States. In 2018, adult and adolescent gay and bisexual men made up 69% of the 37,968 new HIV diagnoses in the United States (US) and dependent areas. Approximately 492,000 sexually active gay and bisexual men are at high risk for HIV

Being a group with such high percentages of people living with HIV, gay and bisexual men have an increased chance of exposure.

Gay and bisexual men account for around 63% of new HIV infections and around 55% of the number of people  diagnosed with AIDS in the United States.

Many HIV infections of gay and bisexual men are due to risky sexual behaviors.  Most gay and bisexual men acquire HIV through anal sex, which is the type of sex with the highest chance of transmitting HIV. They also tend to have more sexual partners than other men, making it more likely to acquire HIV.

Homophobia

What is Homophobia?

“Homophobia is a pervasive, irrational fear of homosexuality. Homophobia includes the fear heterosexuals have of any homosexual feelings within themselves, any overt mannerisms or actions that would suggest homosexuality, and the resulting desire to suppress or stamp out homosexuality; and includes the self-hatred and self-denial of homosexuals.”

Homophobia and HIV

Homophobia is a significant barrier to HIV diagnosis, treatment, and prevention, and is a critical public health issue.

 

Homophobia and heterosexism interfere with health care access and services for LGBT individuals, feed support for counterproductive abstinence-only-until-marriage programming, fuel antigay social policies and other violence, and otherwise marginalize queer people of all ages.

 

Studies consistently demonstrate that homophobia contributes to the spread of HIV and that internalized homophobia increases HIV risk.

Speak Out: Real Voices

From Greater than AIDS

How HIV Stigma Compounded the Trauma of a Violent Anti-Gay Attack

By Todd Heywood

After I was attacked in my apartment by two men who targeted me for being gay and HIV positive, my face was swollen like a chipmunk during an autumn nut collection frenzy, and I had bloody wounds on the side of my face. To this day, my thumbs retain areas of numbness from radial nerve damage caused by the handcuffs they used to restrain me. My laptops, digital cameras, cash, digital recorder, television, cellphone and medications, including my HIV meds, were gone.

Homophobia and HIV

  • A news report in the medical journal The Lancet features the available data about how stigma against homosexuality across the globe is interfering with struggles to slow down the spread of HIV. The article notes that “most global cases of HIV are not due to homosexual transmission,” but anti-gay laws, harassment, intimidation, silence, and invisibility.

 

  • Homophobia and HIV stigma often leads to a lack of participation by people of color in HIV prevention services, a reluctance to test for HIV or to use condoms, and difficulty talking about HIV and sex. Being able to address homophobia and HIV stigma is vital in decreasing the spread of HIV in people of color.

 

  • In Sri Lanka, HIV health care providers identify that one of the major barriers in preventing HIV/AIDs from spreading in the society is the homophobic attitude present among people.

 

  • Researchers from the journal AIDS from United States, Norway, Germany, and the United Kingdom first measured national homophobic impulses across Europe by examining countries’ laws and social attitudes reported in surveys.

HIV and Homophobia in European Countries

  • The 2010 European MSM Survey (EMIS) from 175,000 reportedly gay or bisexual men living in 38 of these countries. The survey examined HIV-related service use, need, and behaviors, which varied among men in more homophobic countries and less homophobic countries.

  • Researchers found these men tended to know less about HIV and how to prevent it, and were less likely to use condoms. As a result, these men were at higher risk of contracting HIV when they did choose to have sex, although it was not as frequently.

  • According to the doctor in charge of Russia’s Federal AIDs Center, Vadim Pokhrovsky, “Our region is the only part of the world where the number of new cases keeps increasing and the treatment does not reduce mortality.”

 

  • Information campaigns and training programs have stopped and the rate of infection increased last year by 10%. The number of Russians who died from AIDS in 2013 increased 15%.

 

  • The suppression of outreach and education means that Russians are no longer talking about HIV and AIDS. Most people at risk are not tested, are increasingly marginalized, and don't even know how HIV is spread.

HIV Stigma and Public Health Concerns:

  • Negative attitudes toward HIV and homosexuality in people of color can hinder HIV prevention and treatment efforts. The isolation that homophobia and HIV stigma causes results in the silence around HIV.

 

  • Public health efforts in communities of color would be better if homophobia and HIV stigma did not exist. If gay and/or HIV-positive men felt supported in their families, at work, at school, at church, and on the street, they would be more likely to care about their health and the health of others.

 

  • Internalized homophobia may impact MSM’s ability to make healthy choices. In addition, the stigma that surrounds the HIV epidemic may limit their willingness to access health and preventive care.

 

  • Criminalization and homophobia severely hinder the ability of many MSM to access HIV prevention information and treatment. Faced with legal or social sanctions, male-male relationships are either excluded or exclude themselves from sexual health and welfare agencies because they fear being identified as homosexuals. 

 

  • The marginalization of MSM relationships results in higher numbers of multiple sexual partnerships and lower self-esteem, again leading to risky behaviors.

Homophobia: Endless Challenges for HIV Prevention:

  • HIV stigma, homophobia, and negative stereotyping of LGBTQ relations are key major factors to be approached in HIV prevention efforts

 

  • The Center for Disease Control and Prevention (CDC) has stated that stigma and homophobia may have a profound impact on the lives of MSM, and could influence them to engage in HIV risky behaviors.

 

  • Homophobia affects HIV in direct ways by driving discussion about MSM and homosexuality underground, legitimizing fear and prejudice, and compromising AIDS service organizations so that they cannot work publicly with LGBT and MSM communities.

Further Information on Global Cases of AIDS’ Connection with Homophobia:

 

  • “Researchers from Oxford University, the Population Council of Ghana and the Kenya Medical Research Institute reviewed AIDS studies conducted over the past few years and concluded that male-male sex was a major blind spot in AIDS research and policy in Africa.”

 

  • “According to Jamaican attorney Maurice Tomlinson, by denying these people the opportunity to be themselves, particularly the gay men are driven to have sex with men to mask their sexuality or try to “cure” it while others are forced underground thereby, away from HIV prevention and treatment.”

 

  • For example, a study published in 2016 on men who have sex with men in China found that depression experienced by Chinese men who have sex with men due to community norms and feelings of self-stigma around homosexuality directly affected HIV testing uptake.

 

  • In 2014, MSMGF (the Global Forum on men who have sex with men and HIV) conducted its third biennial Global Men's Health and Rights Study of just under 5,000 men who have sex with men from countries across the world. The results, published in 2016, indicate significant gaps in HIV prevention and treatment for both HIV-negative and HIV-positive men who have sex with men. It found perceptions and experiences of sexual stigma and discrimination to be associated with lower access to HIV services and lower odds of viral suppression.

 

  • Similarly, a study of men who have sex with men in Tijuana, Mexico found that self-stigma, or what the study describes as ‘internalized homophobia’ caused by cultural norms of machismo and homophobia, was strongly associated with never having tested for HIV, while testing for HIV was associated with identifying as homosexual or gay and being more ‘out’ about having sex with men. 

Anti-Gay Bias

 

In various communities of color, such as Latinos and African-Americas, an antigay bias is rooted in these communities and is considered the “norm”. It is part of the family’s traditions, attitudes, and values.

 

In the Latino community, for example, homosexuality is equated to weakness and is perceived to run counter to notions of machismo (community norms on what it means to be a man). As such, homosexuality in the Latino community is thought to hurt or embarrass the family. 

 

The African-American community sees homosexuality as an embarrassment to the African-American race as a whole. More specifically, homosexuality in the African-American community is often perceived as conflicting with gender roles and community norms about sexuality, and even to being sinful and unnatural.

 

With these traditions, customs, and abrasive remarks shoved down the proverbial throat of a young member of the LGBTQ+ community, being proactive in going to the clinic to get educated and even treated about HIV/AIDs, or even STIs is against what is taught to a person of color whom is part of the LGBTQ+ community.

 

With the constant negative perceptions from communities of color, over 40% of homeless youth are LGBT and many turn to sex work. This not only puts them at a higher risk for HIV, but may also increase their feelings of helplessness and loss of community.

Prevention Challenges and the CDC

  • A much higher proportion of gay and bisexual men have HIV compared to any other group in the US. Therefore, gay and bisexual men have an increased chance of having an HIV-positive partner.
    Stigma, homophobia, and discrimination affect the health and well-being of gay and bisexual men and may prevent them from seeking and receiving high-quality health services, including HIV testing, treatment, and other prevention services. These issues place gay and bisexual men at higher risk for HIV.

  • 1 in 6 gay and bisexual men with HIV are unaware they have it. People who don’t know they have HIV cannot get the medicine they need to stay healthy and prevent transmitting HIV to their partners. Therefore, they may transmit the infection to others without knowing it.
    Most gay and bisexual men get HIV from having anal sex without protection (like using a condom or taking medicine to prevent or treat HIV). Anal sex is the riskiest type of sex for getting or transmitting HIV. Receptive anal sex is 13 times as risky for getting HIV as insertive anal sex.
    Gay and bisexual men are also at increased risk for other sexually transmitted diseases (STDs), like syphilis, gonorrhea, and chlamydia. Having another STD can greatly increase the chance of getting or transmitting HIV. Condoms can protect from some STDs, including HIV.
    Socioeconomic factors such as limited access to quality health care, lower income and educational levels, and higher rates of unemployment and incarceration may place some gay and bisexual men at higher risk for HIV.

CDC and its partners are pursuing a high-impact prevention approach to maximize the effectiveness of current HIV prevention interventions and strategies among gay and bisexual men. Funding state, territorial, and local health departments is CDC’s largest investment in HIV prevention.
Under the strategic partnerships and planning cooperative agreement, CDC will fund a national organization to support integrated HIV programs through the development of strategic national partnerships and enhanced communication efforts. This funding opportunity will also provide funding to health departments to engage community partners in a planning process to help develop jurisdictional Ending the HIV Epidemic plans.


Under the integrated HIV surveillance and prevention cooperative agreement, CDC awarded around $400 million per year to health departments for HIV data collection and prevention efforts. This award directs resources to the populations and geographic areas of greatest need, while supporting core HIV surveillance and prevention efforts across the US.


In 2019, CDC awarded a cooperative agreement to strengthen the capacity and improve the performance of the nation’s HIV prevention workforce. New elements include dedicated providers for web-based and classroom-based national training, and technical assistance tailored within four geographic regions.


CDC is funding a demonstration project in 4 jurisdictions to identify active HIV transmission networks and implement HIV interventions for Hispanic/Latino gay and bisexual men. Activities include assessing transmission and risk networks, HIV testing, and linking people with HIV to care and treatment.


In 2017, CDC awarded nearly $11 million per year for 5 years to 30 CBOs to provide HIV testing to young gay and bisexual men of color and transgender youth of color, with the goals of identifying undiagnosed HIV infections and linking those who have HIV to care and prevention services.
Under the flagship community-based organization cooperative agreement, CDC awarded about $42 million per year to community organizations. This award directs resources to support the delivery of effective HIV prevention strategies to people at greatest risk.


Through its Let’s Stop HIV Together campaign, CDC provides gay and bisexual men with effective and culturally appropriate messages about HIV testing, prevention, and treatment​

More HIV Connections with Homosexuality

 

  • The first cases of AIDS were identified in gay men in the USA, and the disease was originally termed gay-related immune deficiency (GRID). Mobilization of attention and resources was slow, partly because of the association between AIDS and male homosexuality and corresponding reluctance on the part of government officials to acknowledge the importance of the epidemic. 25 years later, the same reluctance is evident in many parts of the world, and again, scarcity in attention and resources is affecting responses to HIV transmission in homosexual men.

  • The complex relation between homosexuality and HIV continues to mark the epidemic, even in countries where most infections are unrelated to homosexual contact.

  • That most societies regard homosexuality with a mixture of disdain and disgust has therefore been, and remains, a major factor in the development of the epidemic.

  • Despite major changes over the past two decades, sex between men remains misunderstood, feared, and discriminated against in most parts of the world. In January, 2011, a prominent Ugandan gay activist, David Kato, was murdered shortly after winning a lawsuit against a local magazine, which had published his name and photograph identifying him as gay and called for his execution.

  • At his funeral, the Christian preacher preached against gays and lesbians, before activists ran to the pulpit and grabbed the microphone from him, forcing him to retreat to Kato's father's house.

  • A few months earlier, in the USA, a series of suicides of adolescent boys occurred after constant taunts and bullying because of their sexuality.

  • Few societies are without equivalent stories of persecution and bullying on the basis of sexual orientation or perceived deviance from accepted gender norms. An important difference exists within state sanctioned discrimination: many countries retain criminal sanctions against all forms of male (and sometimes female) same-sex behavior, whereas other jurisdictions have legislated antidiscrimination protection on the grounds of sexuality and gender. But legal protections do not by themselves change dominant attitudes unless effective means are available to support people who experience discrimination and persecution.

Stigma

 

Even though most global cases of HIV are not due to homosexual transmission, the connection between homosexual vulnerability to HIV and stigma has been a continuous issue in responses to the epidemic. Indeed, much of the stigma of AIDS is due to its association with marginalized groups and behaviors (homosexuality, sex work, injecting drug use). This association makes the development of effective programs to reach those most affected more difficult.

By the late 1980s, the term MSM started being used to describe the reality that many men have sex with each other without any sense of homosexual identity, and this term is now widely used in discussions of HIV and AIDS.

In 2011, the UN General Assembly High Level Meeting on AIDS spent much energy in debating whether to specifically mention MSM (along with sex workers and injecting drug users) in their declarations on HIV and AIDS. Opponents, led by Arab and African states and the Vatican, claimed that to name a group was to legitimize it.

Almost everywhere, rates of HIV infection are higher in men who have sex with men than in the rest of the population. This is partly because of inadequate information, denial of resources for prevention services of all sorts, and because heterosexism and homophobia marginalize people and make them less able to adopt preventive techniques, even if they are available. Although difficult to prove conclusively, good evidence shows that greater stigma and criminalization helps increase vulnerability to infection. The best evidence comes from a comparative study in the Caribbean regions, in which infection rates in homosexual men were significantly higher in countries that criminalized same-sex behavior (eg, Jamaica and Guyana) than in those that did not (eg, Dominican Republic and Surinam).

However, the lowest rate of infection in this study was in Cuba, which until recently, has been deeply hostile to homosexuality. This finding reminds us that many variables can affect vulnerability to HIV, and even where strong correlations exist these might not be causal.

Homophobia both increases vulnerability and reduces access to services. Prevention programs directed towards homosexual men are often harassed by police, and official silence means that some men mistakenly believe that homosexual intercourse is safe. In much of the former Union of Soviet Socialist Republics, Africa, and the Middle East, where any recognition of rights or citizenship is denied to homosexuals, programming of services to include MSM is difficult to achieve.

Homophobia affects HIV in direct ways by driving discussion about MSM and homosexuality underground, legitimizing fear and prejudice, and compromising AIDS service organizations so that they cannot work publicly with LGBT and MSM communities. Ironically, a few African countries (despite legal proscriptions against same-sex conduct), have included MSM as a vulnerable population in their National Strategic Plans (eg, Kenya, Zimbabwe, Angola, and Senegal).

The AIDS epidemic has opened up space for research, discussion, and action around sexuality, which in some countries has brought about remarkable shifts in government policies. Various developed countries have implemented school programs aimed at decreasing homophobia and winning greater acceptance for sexual and gender diversity. These programs have been aided in recent years by a substantial emphasis on tackling homophobic prejudice made by some popular television programs (eg, Glee or Modern Family). Homosexual characters are beginning to emerge in cinema elsewhere, such as in India with the film Dostana. Changes in attitudes within most western countries have been striking, with some observers claiming an important decrease in homophobic attitudes, despite evidence of continuing bullying and marginalization.

Discrimination

  • HIV disproportionately impacts segments of the LGBTQ community.

  • According to the U.S. Centers for Disease Control and Prevention (CDC), there are 1.2 million people living with HIV (PLWH) in the United States, and approximately 40,000 people were diagnosed with HIV in 2015 alone. While the annual number of new diagnoses fell by 19% between 2005 and 2014, progress has been uneven. For example, gay and bisexual men made up an estimated 2% of the U.S. population in 2013 but 55% of all PLWH in the United States. If current diagnosis rates continue, 1 in 6 gay and bisexual men will be diagnosed with HIV in their lifetime. For Latino and Black men who have sex with men, the rates are in 1 in 4 and 1 in 2, respectively.

  • Transgender people have also been hit especially hard by the epidemic despite comprising a similarly small percentage of the U.S. population. While better data is needed to understand the full impact of HIV on the transgender community, one international analysis found that transgender women in certain communities have 49 times the odds of living with HIV than the general population. Although HIV prevalence among transgender men is relatively low (0-3%) according to the CDC, some data suggest transgender men may still yet be at elevated risk for HIV acquisition.

  • Discrimination against LGBTQ people makes us particularly vulnerable to HIV.

  • In most states, it is perfectly legal to discriminate against someone on the basis of their sexual orientation or their gender identity in one or more aspects of their life, including employment, housing, and public accommodations. Explicit non-discrimination protections based on sexual orientation or gender identity do not exist at the federal level either.

  • Dealing with the potential consequences of bias and discrimination – job loss, homelessness, lack of healthcare insurance – often results in LGBTQ people engaging in behaviors that facilitate the spread of HIV. For example, in the face of persistent employment discrimination, many transgender women are left with few other options but to engage in survival sex work in order to meet their most basic needs. According to a 2015 survey of more than 27,000 transgender people, “The rate of HIV [diagnosis] was...five times higher among those who have participated in sex work at any point in their lifetime” than among those who have not.

  • Anti-LGBTQ bias further enables the spread of HIV by discouraging many in our community from getting tested or treated for HIV for fear of harassment. A 2014 Kaiser Family Foundation survey of gay and bisexual men in the U.S. found that 15% of them had received poor treatment from a medical professional as a result of their sexual orientation, and least 30% did not feel comfortable discussing their sexual behaviors with a healthcare provider. For gay and bisexual youth who are just beginning to explore their sexuality, homophobia and other forms of anti-LGBTQ bias help explain why so many young people in our community are unaware of their HIV status.

  • Such rampant levels of anti-LGBTQ bias is particularly worrisome when so few PLWH in the U.S. seem to have the virus under control. Of the 1.2 million people living with HIV in the U.S. in 2011, only 30% of them had consistently taken their medication and were able to lower the amount of HIV in their bodies to undetectable levels. While undetectable, a person living with HIV remains in good health, and it is virtually impossible to transmit the virus to a partner. Prevention options (e.g., condoms, Pre-Exposure Prophylaxis) exist for those in relationships where one partner is not yet undetectable.

LGBT.jpg
LGBT 2.png

Healthcare

  • Gains in coverage under ACA for LGBTQIA+ individuals

  • A separate 2013 survey found that among LGBT individuals estimated to have incomes under 400% of the federal poverty level (FPL), almost 4 in 10 had medical debt and more than 4 in 10 reported postponing medical care due to costs.

  • HIV data relating to LGBT people is also grossly under-reported, inconclusive or not reported at all. For example, while Ukraine's National Target Program calls for tolerance and less discrimination towards people living with HIV, it does not specifically mention stigma against men who have sex with men or transgender people. As a result, these groups have very limited access to specialised programmes, even in comparison with other key populations such as people who inject drugs and sex workers. In addition, many programmes are typically focused on medical interventions and do not take into account human rights issues.

lgbtq 2.jpeg
lgbtq 1.jpg
  • The Affordable Care Act (ACA) helped address this issue by prohibiting health care providers and insurance companies from engaging in discrimination. As a result of several court rulings and an Obama administration rule, LGBTQ people are explicitly protected against discrimination in health care on the basis of gender identity and sex stereotypes. 

  • Despite existing protections, LGBTQ people face disturbing rates of health care discrimination—from harassment and humiliation by providers to being turned away by hospitals, pharmacists, and doctors.

  • 8% said that a doctor or other health care provider refused to see them because of their actual or perceived sexual orientation.

  • 6% said that a doctor or other health care provider refused to give them health care related to their actual or perceived sexual orientation.

  • 7% said that a doctor or other health care provider refused to recognize their family, including a child or a same-sex spouse or partner.

  • 9% said that a doctor or other health care provider used harsh or abusive language when treating them.

  • 7% said that they experienced unwanted physical contact from a doctor or other health care provider (such as fondling, sexual assault, or rape)

MORE RESOURCES

Sources

http://www.cdc.gov/hiv/group/msm/

https://www.facebook.com/EqualityFed

https://www.youtube.com/watch?v=r6D3hkh6qJI

http://www.thebody.com/content/77843/hiv-stigma-in-the-aftermath-of-a-brutal-attack.html

http://www.thebody.com/content/art54913.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4323089/

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2960920-9/fulltext

http://content.time.com/time/world/article/0,8599,1911757,00.html

http://www.nationnews.com/nationnews/news/67210/homophobia-leading-hiv

https://www.avert.org/professionals/hiv-social-issues/homophobia

https://www.avert.org/global-hiv-and-aids-statistics

https://www.hivlawandpolicy.org/issues/homophobia

https://www.hivlawandpolicy.org/issues/homophobia

https://www.cdc.gov/hiv/library/infographics/index.html

https://www.unaids.org/en/resources/presscentre/featurestories/2012/august/20120828punitivelaws

https://www.hrc.org/resources/hrc-issue-brief-hiv-aids-and-the-lgbt-community

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2960920-9/fulltext#secd25581298e807

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2960920-9/fulltext

https://www.cdc.gov/stophivtogether/index.html

https://www.cdc.gov/hiv/group/msm/

https://www.avert.org/professionals/hiv-social-issues/homophobia 


https://www.americanprogress.org/issues/lgbtq-rights/news/2018/01/18/445130/discrimination-prevents-lgbtq-people-accessing-health-care/ 


https://www.kff.org/report-section/health-and-access-to-care-and-coverage-lgbt-individuals-in-the-us-health-challenges/ 


https://www.lgbtmap.org/HIV-AIDS 

All graphics by Jaclyn Saik