What’s Really Driving the HIV Epidemic Among Gay/Bi Men?

It's time to think about new or untreated HIV as a symptom of trauma.

Posted Sep 27, 2017

John-Manuel Andriote/photo
Source: John-Manuel Andriote/photo

The federal Centers for Disease Control and Prevention (CDC) says that if current rates of new HIV infections continue, one in six gay/bi men will be diagnosed with HIV in their lifetime. Even more startling, one-half of black/African-American gay/bi men and one in four Latino gay/bi men will become infected.

Alarming as these numbers are, they will continue to climb until we change the way we think about HIV.

New research makes it clear the best way to think of a new HIV infection, or a resurgent infection in someone living with HIV who isn’t properly taking his medication is that it is really a symptom of something else: trauma.

Consider this: A large study of gay and bisexual men found that nearly half (46 percent) of gay men who report condomless anal sex, higher rates of alcohol or other substance use, more sexual partners, and more sexually transmitted infections, also report being sexually abused as boys. The numbers are even higher among African-American men.

“Having that history is repeatedly associated in every sample of gay men with an increased likelihood of being HIV-positive,” said one of the researchers, Conall O’Cleirigh, Ph.D., in an interview for my new book Stonewall Strong: Gay Men’s Heroic Fight for Resilience, Good Health, and a Strong Community. O’Cleirigh is a gay man, staff clinical psychologist in the psychiatry department at Massachusetts General Hospital, and an assistant professor of psychiatry at Harvard. He specializes in the use of cognitive behavioral therapy to treat depression and other mood disorders, post-traumatic stress disorder (PTSD), and anxiety disorders, particularly among sexual minorities.

At the University of California San Francisco, Edward Machtinger, M.D., a gay man, professor of medicine, and director of UCSF’s Women’s HIV Program, told me in an interview for Stonewall Strong that addressing trauma—including childhood sexual abuse—literally has the potential to transform primary medical care. Instead of treating symptoms with medications, this new paradigm of “trauma-informed care” aims to address medical and mental health problems by getting to the root causes of so many of those problems—and thereby promote genuine healing.

Machtinger described a study at another UCSF clinic, looking at older gay men. It found a rate of current PTSD of 12 percent, a rate dramatically higher than general rates of PTSD among men. “To me,” he said, “HIV is a symptom, especially in new cases of HIV, of a far bigger problem: unaddressed trauma.”

For younger gay men, Machtinger said, “Their HIV seems to be a symptom or consequence of an underlying history of trauma or discrimination, toxic stress, or whatever else is going on in their lives that puts them at risk for HIV.” He pointed out that many older gay men in San Francisco who have lived with HIV for years—like the men featured in the San Francisco Chronicle’s March 2016 story “Last Man Standing”—struggle against depression, isolation, and thoughts of suicide. “These aren’t consequences of their HIV medication or the HIV virus,” he said, “they are related to underlying histories of trauma that are largely going unaddressed by simply treating their HIV with medication.”

Describing an analysis of the causes of death in people with HIV in San Francisco that he was doing with the city’s health department, Machtinger said it was clear “how inadequate our death statistics are.” Referring to how the deaths are categorized when someone with HIV dies, he said it’s irresponsible to report that approximately 40 percent of people living with HIV are dying of AIDS. In fact, said Machtinger, “They are really dying from substance abuse, depression, PTSD, and other consequences of trauma that lead people to stop taking their medications. It’s like dying from a completely preventable condition.”

As for solutions, Machtinger said, “Reducing isolation is by far the most effective way I have found to help people develop coping mechanisms that are more healthy, that allow them to leave abusive partners, to forgive themselves, and ultimately to become leaders in their communities.” He added, “The single most effective intervention that we have, and that I have witnessed to help people heal from the impact of trauma, has been disclosure and community-building. Period.”

In 1998, only two years after combinations of medication made it possible to live with HIV rather than develop AIDS and die, the late and noted gay and AIDS activist Eric Rofes seemed to foresee what medical scientists, such as Conall O’Cleirigh and Eddy Machtinger, have demonstrated in their research. In his book Reviving the Tribe: Regenerating Gay Men’s Sexuality and Culture in the Ongoing Epidemic, Rofes wrote, “AIDS prevention efforts targeting gay men should be reconceptualized as multi-issue gay men’s health programs that include strong components concerned with substance use, basic needs (food, housing, and clothing), and sexual health (broadly defined). They would no longer take as their central mission limiting the spread of HIV, but instead aim to improve the health and lives of gay men.”

Lifetimes of trauma—including childhood sexual abuse, bullying, rejection, religious condemnation, and legally sanctioned discrimination—do not set gay men up for healthy adulthoods.

But if we—and the CDC, whose job is to protect the public’s health by properly spending our tax dollars on effective interventions—focus first and foremost on healing our traumas, we will finally see real change in the numbers and the beginning of the end of HIV and AIDS among American gay men.