In 1981, severe illness in a group of young gay men caught the attention of federal public health officials who could not explain the cluster of rare, deadly cases of pneumonia. This ominous medical mystery is widely regarded as the start of the HIV/AIDS epidemic, which continues to rage on every inhabitable corner of earth.
Over the past 30 years, HIV/AIDS in the U.S. has spread to many other populations, particularly low-income women of color and injection drug users. While no longer a singularly "gay disease," gay, bisexual and transgender people remain severely impacted by HIV/AIDS in the U.S. For young gay, bi, and transgender youth of color, alarming rates of HIV rival those of some Sub-Saharan countries. What can we learn from the 30-year history of the HIV/AIDS epidemic in order to forge a better, future response?
These are just some of the questions the AIDS Foundation of Chicago (AFC) is posing this year as it reflects on lessons learned from the past 30 years of HIV/AIDS. Chief among these questions is why, 30 years into the crisis, are rates of HIV highest among young gay men, particularly men of color? According to federal officials, rates of HIV among gay men are 50 times higher than any other group and, while new cases have plateaued for other groups, among gay/bi men and transgender, they continue to climb.
To help inform AFC's 2012 strategic plan, I interviewed Dr. Ron Stall, Professor and Chair of the Department of Behavioral and Community Health Sciences in the Graduate School of Public Health at the University of Pittsburgh, a leading HIV prevention expert. He began researching AIDS-related topics in 1984 on the AIDS Behavioral Research Project, one of the first longitudinal studies of AIDS risk-taking behaviors in the world.
Since that time he has published more than 140 peer-reviewed scientific papers on many different aspects of the AIDS epidemic, including research on determinants of risk-taking behaviors and HIV transmission, co-occurring epidemics, life-course issues important to AIDS-related risk-taking, and a portfolio of research on global AIDS issues. He is currently co-director of a certificate program in LGBT Health and is collaborating on several National Institutes of Health research projects focused on gay men's health.
Ron and I recently had the opportunity to check in and talk about the needs of gay men and youth. Only by understanding and responding to the epidemic among gay youth and adults can efforts to end the epidemic in the U.S. have any chance of success.
JIM: Your work concentrates on co-occurring health concerns that conspire to fuel the HIV/AIDS epidemic. Can you briefly describe this concept of "syndemics" and explain why it is so important to consider in terms of gay men's health and efforts to meet their HIV prevention needs?
RON: The term "syndemics" describes interacting and intertwining epidemics, or synergistic epidemics. Syndemics are found in many different human populations, but are very commonly found in populations that are at high risk for HIV. Syndemics research studies why HIV is so closely intertwined with epidemics of substance abuse, depression, violence and other psychosocial health problems. More important, syndemics research also studies how we can interrupt syndemic production by starting a larger health movement that works to lower risk for HIV by addressing multiple psychosocial health problems in a community.
I'm part of a research group that has conducted a set of investigations into syndemic production among gay men, and we were able to show that epidemics of substance use, depression, childhood sexual abuse and violence victimization are intertwining and making each other worse and in the process raising risk for HIV transmission. Our study was the first to show that this phenomena exists among gay men, but this analysis has now been replicated in several different studies, including one among MSM in Thailand. One implication of our analysis is that there is a lot more to gay men's health than a simple focus on HIV and that addressing these multiple health risks may work to lower HIV risk among gay male communities.
There has been a lot of talk about bullying these days, thanks to the brilliant "It Gets Better" campaign. Do you see bullying as something that feeds into syndemic production? What kind of research do we have around bullying and health outcomes for gay men, or more broadly, for LGBT people?
RON: Once you buy the idea that syndemics exist among gay men, the next question would be why is that so? We think that a very important piece to this puzzle is that gay men not only suffer far greater rates of violence victimization as adolescents, but that nearly all young gay men watch schoolmates being publicly victimized for having the same sexual orientation that they do. This sets gay men up early on to have a sense of being different, of being less than, of not being deserving, of being alone -- in short, for internalized homophobia at a very early age. And these experiences predispose young gay men to be more depressed, to have greater substance abuse profiles at a very early age, to have higher rates of having sex under the influence of alcohol or drugs and to suffer greater rates of violence victimization, each of which raise HIV risk profiles among young MSM. Dr. Mark Friedman in our group published an analysis to show the associations between the experience of violence victimization and bullying during adolescence and poorer health profiles -- including HIV seropositivity -- among adult gay men. We are conducting additional analyses from a separate cohort study to measure how the experiences of violence victimization at a young age predict syndemic production among middle-aged gay men.
"It Gets Better" speaks to the transience of being harassed and bullied -- that we won't be in that situation all of our lives, so we basically just need to hang on. You just explained how bullying can have negative health outcomes for people, so while the bullying may end, the consequences can continue. But there is another side to this story -- yes, it gets better, but you also get stronger. And coming out the other side of bullying can make people stronger, and more able to address challenges in their lives. This speaks to strength and resilience, which I know you have been thinking about. Tell us what we know about resilience and strength in terms of gay men's health and HIV prevention.
RON: While it is true that there are important health disparities that cluster and make each other worse among gay men, once you start looking for resilience to fight health problems among gay men, you start seeing it everywhere. For example, gay men may use more drugs than straight men, but for all of that drug use, we don't have comparable increased rates of behaviors that look like addiction. This suggests that there is an important, but unstudied, self-regulation process at work that men use to monitor their drug use and avoid addiction. And when gay men do get addicted to dangerous drugs such as tobacco and stimulants, we have very high rates of being able to resolve these addictions on our own.
And, of course, there are many, many men who've enjoyed full sex lives for decades on end and have not become HIV seropositive, not to mention the large numbers of seropositive men who've led full, healthy and productive lives even while battling a serious viral infection. We also exhibit important strengths in the way that we've always managed to build families, communities and political movements in very unfriendly contexts. Once you start looking at the data this way, you could be excused for concluding that resilience and strength in the face of adversity may be the two most important characteristics that distinguish gay and heterosexual men.
Why do you think we have focused so singularly on weaknesses and deficits? Why haven't we flipped this script and focused efforts on building the resilience of gay men, particularly toward improve their health? Why haven't we taken the collective wisdom of men -- young and old -- who have successfully avoided HIV infection to inform better HIV prevention responses?
RON: I think that our focus on deficits among gay men has to do with the long term effects of the shock of the discovery of the AIDS epidemic among gay men. We had this terrible new epidemic that seemed to miss most other populations. The questions of why we were so vulnerable to AIDS, and the study of our unique risk factors for this disease naturally followed. And, to be fair, this research frame has resulted in some important insights around HIV prevention and care.
That said, over time, it has also become clear that there are lots of men -- indeed the majority of gay men -- who've exhibited significant resiliencies when it has come to dealing with the HIV epidemic. The time has come to understand more about these resiliencies so that we can learn how better to respond to the many health problems affecting our community. Put another way, if we are interested in finding effective ways to treat substance abuse among gay men, are we better off studying men who became addicted or men who became addicted and quit on their own? Or men who use and don't become addicted? Each group is important, but it may be that the men who resolved substance abuse on their own are the experts from whom we can learn the most valuable lessons.
What are you currently doing to change the deficit dynamic, what can we look forward to?
RON: I'm working with a group of very smart colleagues to propose a theory of resilience among gay men, and to propose a research agenda to study strengths among gay men. There is an old saying that the most practical thing that one can do is to come up with a good theory. The time for a good theory to explain resiliencies among gay men -- and make use of these strengths to promote health in our communities -- is long overdue.