Barebacking and AIDS 2009

What's in a word??

Can a little loaded term like "barebacking"-used as a thinly veiled, homophobic demonization of unsafe sex practices-so effect an at-risk population that the resulting stigma becomes a significant contributing factor to an increase in HIV infection within that population? And if so, what's to be done??

But before we explore the potent ways in which (to partially quote William S. Burroughs) "language is a virus," who exactly is at risk??

Rise in transmissions

Francisco Roque, Associate Director of the Institute for Gay Men's Health at GMHC (Gay Men's Health Crisis; www.gmhc.org), observes "We are seeing a rise overall in transmission rates, particularly as it relates to young people and gay men in general." There's been a steady increase, says Roque, among young black and Latino men who have sex with men; "and that's important to note."?

Just as alarming as the steady increase is the recently revealed fact that "The HIV epidemic in the United States is-and has been-worse than previously estimated." That's the conclusion reached from a CDC (Center for Disease Control and Prevention; (www.cdc.gov) report. In September, 2008, the CDC released the first statistics from their new HIV incidence surveillance system. That report estimated "that 56,300 new HIV infections occurred in the United States in 2006." What's alarming about that number is that it doesn't "represent an actual increase in the annual number of new infections, but rather, a better way of estimating."?

A separate CDC historical trend analysis "suggests that the number of new HIV infections was never as low as the previous estimate of 40,000 new infections annually and has been roughly stable since the early 2000s."

In terms of identifying the most at-risk groups, "The new estimates provide a profile of HIV/AIDS in the United States that is primarily young, male, and African American. The epidemic also disproportionately affects Hispanics and Latinos; particularly Hispanic and Latino men who have sex with men (MSM). Indeed, gay and bisexual men of all races and ethnicities are the most affected of any group of Americans."

But why is that? These populations have been exposed to the same messages about safe sex-so what accounts for the behavior which has resulted in disproportionate infection rates?

The barebacking stigma

Carrie Davis, director of adult services at NYC's Lesbian, Gay, Bisexual & Transgender Community Center (www.gaycenter.org), notes that "Young people in general aren't using safer sex, whether they're straight, queer, high risk, low risk."

Yet when "We take a term like barebacking, which has become highly stigmatized, and apply it to a specific group of people"-even though "large numbers of straights engage in the same behavior. If a straight boy and a straight girl get together and have sex without a condom, we call it unprotected sex; but when two young gay men get together and have sex without a condom, we call it barebacking."

Roque says that when we characterize unprotected sex as barebacking, "There are connotations that go along with that. We're painting a picture of gay men which says they are reckless and irresponsible."

But can we really link the resulting stigma of those labeled as "barebackers" to their decision to have unprotected sex? Roque: "There are lots of reasons these groups (young black and Latinos) have unprotected sex; isolation, reactions to oppression, homophobia. It's also important to explain it's not necessarily that these groups are having higher rate of unprotected sex than other groups; it's that there's more infection in the pool in which they're having sex. If black gay men are having sex with black gay men, there's a higher chance for HIV transmission to occur.

That applies to gay men in general." Statistically speaking, Roque notes there are more heterosexual folks having unprotected sex than there are gay men having sex. "But because there's a higher concentration of HIV inside gay communities, the rates of transmission are significantly higher. That becomes important because things like this begin to stigmatize a population."

The September, 2008 CDC report backs up Roque's assertion, noting "It is not acceptable for any young American to grow up without the knowledge, skills, confidence and motivation necessary to protect themselves against HIV for their entire lifetimes." For Davis, that confidence and motivation is directly impacted by the words we choose: "Language can be a very important tool, but it can also be a weapon. When I work w the LGBT population, I want to be very careful that I am using language that helps normalize their experience and their identities."?

New ways to reach out and touch

It used to be that when a problem arose within the gay community; coping strategies were to be found on posters plastered throughout the "gayborhood" as well as roving researchers and outreach workers who met their target audience on their own turf. But these days, notes Roque, "We can no longer go to bathhouses and find gay men. Everyone is online, so it's important for us to have an online presence." GMHC has worked hard to establish that electronic presence, and make sure they have a variety of programs and strategies "that target young people"-such as "My Ballrooom Life" (www.myballroomlife.com), a microsite designed to bring the safer sex message to young lesbian, gay, bisexual and transgender youth (primarily black and Latino) in the house and ball scene.

Outreach and prevention work on Face book and MySpace has also proved effective. Roque: "We work with folks within the community to develop blogs, messaging and online chats." By "infiltrating social networks and disseminating information," and "folks are more likely to pass along information via the Internet than they are in person."

That method is quickly eclipsing (although not entirely replacing) previous social marketing efforts which relied on calling one's attention to a poster on a bus shelter or handing out cards and pamphlets in the bars. The Internet's anonymity, says Roque, creates a sense of security in which people are ultimately more likely to contemplate a difficult message: "The data folks report that if you give somebody a palm card with information about HIV testing, they're not as likely to give it to somebody who needs, it; but they're more likely to forward a link to someone online. It's less in your face; there's a certain comfort that may seem small, but it's really significant."

But is the dissemination of information online really effective, any more or less so than what a potent message on a poster can accomplish? Roque admits "That's very hard to measure. It's difficult to say people are having less unprotected sex because of our work on the Internet. But dialogue is occurring in ways that it didn't before. We're reaching folks that might not be at the gay bar, might not come into our building; so we're having new dialogue with new people that we would otherwise not reach."

The real goal in such outreach work, says Roque, is not to focus on increasing condom use-it's to shift the social norms.

Davis also agrees that the Internet is the present, and future, space in which micro targeted audiences will be found, and will be most receptive to information and coping strategies. But that alone, she says, is not enough-and does not speak to the root cause of one's decision to have unprotected sex. Davis: "We know that safer sex is not a compelling message. It's a medical model to looking at HIV, when we really need to be thinking of it as a public health concern."

That medical model, she says, has already been received and absorbed. "Queer young people know the drill. They could teach a class on" condom use and safer sex practices. What Davis is more concerned about is "looking at the entire lives of young people; what stigma do they face, what's their home and school environment like; what messages are they receiving from our culture that make them feel worthwhile?"

In the broadest sense, she says, altering the cultural message to one of affirmation instead of accusation is the answer; a significant shift in prevention strategy that has everything to do with creating a sense of self-worth which ultimately convinces a young person that their health is worth protecting. When Davis does an assessment with someone, she's not launching into a lecture about the evils of barebacking; instead, she's "listening to the areas in their lives where they are struggling disconnecting and isolating. At the same time, I am trying to assess what gives them a sense of worth and value. At the same time, we want to look at risk factors and reduce them. It's a simple matrix, but it doesn't focus on condom use at its center. It's about individuals and the complexity of their lives."

Ultimately, asserts Davis, the problem is not going to be solved by "making people feel bad because they don't use a condom. Very few people will change their behavior just because they've been made to feel bad about something. That's a very short path to failure." ?????