An ad campaign by the Gay Men’s Health Crisis is intended to reach gay and bisexual men of color in their neighborhoods and daily lives. (Image courtesy GMHC)
Public health struggles to reach gay ‘hidden population’ Experts say CDC must look for gay men outside of bars, bathhouses
Syphilis Symptoms: Many people have no symptoms, but signs of syphilis include chancre sore(s), skin rash, lesions, sore throat, patchy hair loss, head and muscle aches. Transmission: Spread through direct contact with syphilis sore, either via genitals, rectum or mouth. Treatment/vaccine: Easily cured by penicillin.
Gonorrhea Symptoms: Many people have no symptoms, but signs of gonorrhea include a burning sensation during urination, colored urine, swollen testicles, vaginal bleeding between periods, sore throat, rectal itchiness and bleeding. Transmission: Spread through direct contact with an infected penis, vagina, mouth or anus. Treatment/vaccine: Can be treated with antibiotics, but drug-resistant strains are developing.
Hepatitis B Symptoms: Vomiting, fever, fatigue, abdominal pain, dark urine, clay-colored bowel movements, joint pain, loss of appetite. Transmission: Unprotected sex with an infected partner, contact with blood or open sores of an infected person, oral-anal contact. Treatment/vaccine: No treatment for acute infection, but chronic infection treated with antiviral drugs. A three-shot Hepatitis B vaccine is also available.
Chlamydia
Symptoms: Many people have no symptoms, but signs of chlamydia include cervical infection, abnormal vaginal discharge, burning sensation when urinating, abdominal pain, pain during intercourse, pain and itching around the opening of the penis. Transmission: Transimitted during unprotected anal, oral and vaginal sex. Treatment/vaccine: Easily cured with antibiotics.
Human Papillomavirus (HPV)
Symptoms: Many people have no symptoms, but signs of HPV include genital warts. HPV can also lead to cervical cancer in women and anal cancer. Transmission: Passed through genital contact during both vaginal and anal sex. Treatment/vaccine: No treatment for virus itself, but warts and cancer can be treated. There is also a relatively new HPV vaccine known as Gardasil.
After laying on its deathbed at the turn of the century, syphilis is once again a “significant burden” in the U.S., with gay and bisexual men making up the majority of domestic syphilis cases, according to the Centers for Disease Control & Prevention.
In 1999, the CDC announced that only 6,657 cases of syphilis were reported in the U.S. — the lowest rate ever. Also in 1999, the CDC unveiled its “National Plan to Eliminate Syphilis,” which mainly focused on curbing the disease among heterosexual females.
During the eight years of CDC’s syphilis elimination project, gay and bisexual men experienced a spike in syphilis rates, and “largely account” for the STD’s national resurgence during that time. At the 2008 National STD Prevention conference last week, CDC officials said the number of syphilis cases remain low — just over 11,000 — but have increased for the seventh consecutive year.
Primary and secondary cases of syphilis increased 16 percent from 2006 to 2007, with an estimated 60 percent of cases occurring among gay and bisexual men. Gay and bisexual men comprised only 5 percent of syphilis cases in 1999.
The CDC hopes to stimulate awareness of syphilis among gay and bisexual men and urges those men to get tested for STDs at least annually, but the agency has had limited success making sure its messages reach the population most at risk for STDs and HIV/AIDS. Last summer, the CDC announced that only 20 percent of all gay and bisexual men ever came in contact with a CDC-sponsored HIV prevention intervention.
“CDC is starting to believe that as we move forward with an integrated platform for prevention, that we need to really have a strengthening of our preventive services to interact with men at all points — where they live, work and play,” Kevin Fenton, director of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention, said last week.
“It means partnering more effectively with our community-based organizations to do some of this outreach work,” said Fenton,who is gay. “It means going into venues where we can actually find high populations of men who have sex with men, for example, circuit parties, bathhouses.”
The CDC’s funding structure is one of the reasons it struggles to disperse safer sex messages to broad segments of gay and bisexual men, said Bill Stackhouse, director of the Institute for Gay Men’s Health at the Gay Men’s Health Crisis in New York.
“The CDC and other government funding sources have established a protocol where they are primarily funding interventions that reach individuals and groups — they are not funding enough … large scale attempts to reach people at the community level,” Stackhouse said.
On Wednesday, GMHC launched a new social marketing campaign called “I Love My Boo” that features the tagline “Safer sex is one way we show our love.” The images target young black and Latino gay and bisexual men, but are on display on telephone kiosks in diverse neighborhoods throughout New York City.
“It’s a public setting, and the message is not only to the young men themselves, but it also is aimed at the wider community,” said Stackhouse, who noted that the month-long campaign is funded by the state health department.
The only HIV/AIDS prevention messages approved by CDC are known as DEBIs, or the Diffusion of Effective Behavioral Interventions. Many of the DEBIs are structured in a way that delivers the prevention message only to people participating in a small group, usually facilitated by a community- based AIDS organization.
The CDC must move beyond targeting gay men at community organizations, bars, and sex venues, and begin investing in campaigns that have the potential to reach gay people wherever they are, Stackhouse said. “Until we do that, we’re never going to reach [substantial numbers of gay and bisexual men],” Stackhouse said.
So few gay and bisexual men coming in contact with CDC messages is evidence that the agency “probably is not targeting, not funding, and not partnering in the appropriate ways,” said Jason Riggs, deputy director of the Stop AIDS project in San Francisco.
Much of the CDC’s interaction with and understanding of gay men comes from a handful of venues often used to collect data. “The largest source of CDC data on [gay and bisexual men], the National HIV Behavioral Surveillance System, recruits participants from bars, street locations, dance clubs, cafes/retail stores, Gay Pride events, social organizations, gyms, sex establishments and parks,” said Richard Woliski, deputy director for behavioral social sciences at the CDC.
In addition to collecting data, these venues are also often used to deliver safer sex message to gay and bisexual men.
“Most of these efforts are focused on trying to reach men at the greatest risk, such as those who are not in a monogamous relationship with a partner whose HIV status is the same as their own,” Woliski said.
“Some of these programs are focused on bars, sex clubs, the Internet, and other settings where men may meet sex partners,” he said. “Other activities are focused on more general settings where men may meet primarily for social or other purposes, or use the social networks of [gay and bisexual men] to reach other men who may not be actively involved in the gay community.”
In a time of scarce resources, it’s important the CDC and its partners go where they know gay and bisexual men are, said Rudy Carn, executive director of the National AIDS Education & Services for Minorities in Atlanta.
“[Club promoters] come in contact with about 80 percent of the black gay population at one point,” said Carn, who added that bathhouses and sex parties are also appropriate priorities. “I know it’s something people may not condone, but sex parties do exist and that’s a venue that needs to be addressed.”
But the CDC will continue missing many gay and bisexual men with its prevention messages if it relies exclusively on institutional venues, Carn said. “The majority of people at risk for HIV and STDs are not going to go to a health clinic,” Carn said.
The CDC also realizes the limitations of relying heavily on bars and bathhouses for data on gay men, Woliski said.
“Obviously, where someone is recruited can make a big difference,” he said. “If only high-risk venues are used for recruitment, the results would not be representative of all [gay and bisexual men].”
There are no gay bars, bathhouses or community centers in Auburn, Ala., at which Malcolm Webster can recruit gay men for safer sex interventions. Working as an AIDS outreach worker at the East Alabama Medical Center, Webster often locates “gatekeepers” in the community who can be trained to deliver prevention messages to their friends — a method used in one of the CDC’s DEBIs.
“Here, it’s either you know somebody who knows somebody, or you’re online,” Webster said, noting the internet’s potential to tap into “a very hidden population.”
The CDC has increasingly been turning to the Internet as a way to reach as many gay people as possible, especially those who may not frequent gay organizations and clubs.
“If the internet is where people are, then that’s where public health has to be,” said Mary McFarlane, an internet specialist in the CDC’s division of STD Prevention.
As difficult as it is to engage gay men and collect data about their sexual health, hardly anyone is paying attention to STDs among lesbians, said Linda Ellis, executive director of the Atlanta Lesbian Health Initiative.
“I think there hasn’t been a health crisis that has put lesbian health or lesbians’ experience with sexually transmitted diseases on anyone’s front burner,” said Ellis, who added the apathy is “exacerbated by the fact that lesbians appear to be kind of the ‘safest’ population related to HIV.”
Lesbians are at risk for STDs that are transmitted skin-to-skin such as herpes, and HPV, which causes cervical cancer.
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