Rethinking Gay Men's HIV Prevention

posted: 14/04/2009

Not exactly failing, but not up to the job, is gay men’s health promotion in 2009. A landmark speech by Ford Hickson to the recent CHAPS gay men’s sexual health conference in Brighton exposed the very unbalanced forces driving and holding back the HIV epidemic.
 

Ford, one of the country’s leading HIV experts, told us that sexual risk-taking has all the big guns going for it, and risk reduction has little firepower. We need to make a blunt assessment of what the situation is now, work out a better approach, and stop beating ourselves up because HIV prevention seems to be ‘failing’.

Ford Hickson reminded us of the strong forces pushing sexual risk-taking: 

• The power of sexual pleasure. "If you do not understand sexual risk," he commented, "it is probably because you don’t appreciate sexual desire."
• The rapid growth of the gay scene into "a large business sector supplying services for sexual contact, and places for sex".
• Widespread homophobic shaming and blaming in society, leading to emotional isolation and low mood for many gay men.
• Gay men’s heavy self-medication with alcohol and drugs, which we then use to excuse our risk-taking.
• The general notion that anal sex is the only ‘real’ sex.
• The way bare-backing is pushed and sold. "Gay sub-culture has long legitimised the eroticisation of the unacceptable," and bareback porn is just the latest example.
• Safer sex is everyone's responsibility and this means often no one takes the responsibility. Just as health agencies are failing to take care of gay men, gay men are failing to take care of each other. 
• Our bias is to hope for the best, and we use twisted thinking: we tell ourselves we will be OK and that the risks are smaller than they really are. So we give ourselves the green light to take the chance.

Harm reduction – what weapons work, apart from fear?
Ford dismissed the common view that gay men no longer see HIV as worth avoiding. Ford pointed out that uninfected men’s fear of HIV, and of men with HIV, is excessive.

But many of the ways the HIV sector tries to cut risks are seriously mistaken. He criticised attempts to identify and target ‘high-risk’ individuals – a Jim’ll Fix It approach to HIV prevention. This tries to identify and ‘correct’ men who have unsafe sex. Trying to change the behaviour of men taking the most risks just ignores the reality. HIV risk-taking is very widespread. Each year half of all gay men will fuck without a condom; 1 in 100 will be unlucky, this year; or next year, or one of the years after that. Most of the unlucky ones aren’t taking more risks; anyone taking risks can be unlucky sometimes.

Money for prevention tight

The funding for precaution has been cut, while the numbers of men at risk have ballooned. There isn’t enough money to pay for anything except quick-prevention fixes that ignore underlying causes.

Shutting the prevention stable door after the horse has bolted

We try to stamp out unsafe sex rather than prevent it. Instead of schools teaching gay youth how to avoid learning risky habits before starting their sexual life, we wait and then try to fix adult men’s ‘bad’ sexual habits afterwards.

Prevention aims to get the most out of the money, but ignores many people at the greatest risk, because their needs are more complex and expensive.

Combination of prevention needed
We need a ‘combination of prevention’ that uses every way of reducing risk. Claiming that HIV prevention is failing is just victim-blaming. UK HIV prevention is simply not up to the huge size of the job and the pressures on men to take sexual risks.

For most of us most of the time, taking precautions against HIV during sex is fairly easy. Stopping all men from taking all HIV risks is impossible. Anyone who claims they have the solution to the HIV epidemic is either a liar or a fool.

Improve lives

Ford suggested we should stop measuring success by the number of new infections. Instead success is simply whether the men we work for have a better life. We are not failing because we are can’t hold back the vast forces we face. We are failing only if we do not try.

Ford’s illustrated speech is here. It made a deep impression on the gay men at the conference.
 

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