Report on the Global HIV/AIDS epidemic

Prevention: daunting challenges ahead

Men who have sex with men
In many countries around the world, openly "gay" communities are rare or non-existent. Male homosexual behaviour, on the other hand, exists in every country. It often
involves penetrative anal sex between men, an act that carries a high risk of HIV
infection.
Sex between men is one of the major forces behind the HIV epidemic in many highincome countries and in some parts of Latin America. In Asia, the contribution of sex
between men to the HIV epidemic has been recorded regularly but has rarely been
quantified. Most of the countries with openly gay communities are in the industrialized world, which are also the countries with the best access to prevention information and to therapy and other care. In developing countries, men who have sex with
men are far more likely to do so in hidden ways (see below), and they are less likely
to have access to prevention information and services and care.
Prevention is faltering in high-income countries
AIDS was first identified among gay men in the USA. By the time the virus that
causes the syndrome was isolated, around 1983-1984, HIV had already spread
widely throughout the gay community, and was beginning to be found in other
groups, too. The reaction of the gay community in the United States and elsewhere
was rapid and forceful. Prevention campaigns were organized on a huge scale, and
they were largely effective. In particular, consistent condom use during anal sex rose
from virtually nothing before the advent of AIDS to around 70% by 1995.
Studies among gay men in a few cities where antiretroviral therapy for individuals
with HIV is widely available have shown that men may be growing complacent about
the risk of AIDS. A study in the Australian cities of Sydney and Melbourne in 1998
found that a third of gay men were less worried about HIV infection than they were
before antiretroviral drugs became available. And they appeared to act on this new
sense of security: these men were 40% more likely to have had recent unprotected
anal sex than men whose fear of infection was not changed by the advent of therapy. Remarkably similar results were found among gay men in New York, San
Francisco and London.
Risk behaviour is undeniably on the rise in some communities. Regular surveys of
several thousand gay men in San Francisco have found an increase in the proportion reporting that they had unprotected anal sex and multiple partners in the past
six months. As Figure 25 shows, these increases in risk behaviour are paralleled by
rising rates of rectal gonorrhoea - a reversal of the falling trend seen up to 1993.
More worrying still, surveillance systems using sophisticated testing methods show
that in San Francisco the rate of new HIV infections in men with rectal gonorrhoea
nearly doubled between 1996 and 1998. The rate of HIV incidence also rose among

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