Via New York Times
The AIDS epidemic in America is rapidly becoming concentrated among poor, young black and Hispanic men who have sex with men.
Despite years of progress in preventing and treating H.I.V. in the middle class, the number of new infections nationwide remains stubbornly stuck at 50,000 a year — more and more of them in these men, who make up less than 1 percent of the population.
Giselle, a homeless 23-year-old transgender woman with cafe-au-lait skin, could be called the new face of the epidemic.
“I tested positive about a year ago,” said Giselle, who was born male but now has a girlish hair spout, wears a T-shirt tight across a feminine chest and identifies herself as a woman. “I don’t know how, exactly. I was homeless. I was escorting. I’ve been raped.”
“Yes, I use condoms,” she added. “But I’m not going to lie. I slip sometimes. Trust me — everyone here who says, ‘I always use condoms’? They don’t always.”
Besides transgender people like Giselle, the affected group includes men who are openly gay, secretly gay or bisexual, and those who consider themselves heterosexual but have had sex with men, willingly or unwillingly, in shelters or prison or for money. (Most of those interviewed for this article spoke on the condition that only their first names be used.)
Nationally, 25 percent of new infections are in black and Hispanic men, and in New York City it is 45 percent, according to the Centers for Disease Control and Prevention and the city’s health department.
Nationally, when only men under 25 infected through gay sex are counted, 80 percent are black or Hispanic — even though they engage in less high-risk behavior than their white peers.
The prospects for change look grim. Critics say little is being done to save this group, and none of it with any great urgency.
“There wasn’t even an ad campaign aimed at young black men until last year — what’s that about?” said Krishna Stone, a spokeswoman for GMHC, which was founded in the 1980s as the Gay Men’s Health Crisis.
Phill Wilson, president of the Black AIDS Institute in Los Angeles, said there were “no models out there right now for reaching these men.”
Federal and state health officials agreed that it had taken years to shift prevention messages away from targets chosen 30 years ago: men who frequent gay bars, many of whom are white and middle-class, and heterosexual teenagers, who are at relatively low risk. Funding for health agencies has been flat, and there has been little political pressure to focus on young gay blacks and Hispanics.
Reaching those men “is the Holy Grail, and we’re working on it,” said Dr. Jonathan Mermin, director of H.I.V. prevention at the C.D.C. His agency created its Testing Makes Us Stronger campaign — the one Ms. Stone referred to — and has granted millions of dollars to local health departments and community groups to pay for testing.
But he could not name a city or state with proven success in lowering infection rates in young gay minority men.
“With more resources, we could make bigger strides,” he said.
Gay black youths are hard to reach, experts say. Few are out to their families. Many live in places where gays are stigmatized and cannot afford to move. Few attend schools with gay pride clubs or gay guidance counselors.
“When we talked about H.I.V. in sex ed, the class started freaking out,” said Alex, 20, who was born in St. Croix but raised in New York. “One guy said, ‘We ain’t no faggots; why do we have to learn this stuff?’ So the teacher stopped and moved on to another topic.”
When those who are poor and homeless go to traditional gay hangouts, they become prey.
Kwame, a 20-year-old from Philadelphia, said that on his first day wandering around New York last year, he was propositioned by an older homeless man and by an older transgender person. The homeless man later admitted that he was infected, and added: “If you sit here long enough, you’re going to get some propositions — and that’s where you’re going to sleep tonight. It happened to me, and it’s going to happen to you.”
Kwame said he had sex that night — with a man he met at a gay services center, where he had gone in search of emergency housing. “I wore a condom,” he said. “I did it sort of out of guilt, or pity. It’s how I was raised. I didn’t want him to think I thought less of him. Also, I needed someplace to stay.”
According to a major C.D.C.-led study, a male-male sex act for a young black American is eight times as likely to end in H.I.V. infection as it is for his white peers.
That is true even though, on average, black youths in the study took fewer risks than their white peers: they had fewer partners, engaged in fewer acts of sex while drunk or high, and used condoms more often.
They had other risk factors. Lacking health insurance, they were less likely to have seen doctors regularly and more likely to have syphilis, which creates a path for H.I.V.
But the crucial factor was that more of their partners were older black men, who are much more likely to have untreated H.I.V. than older white men.
Among the poor, untreated or inadequately treated H.I.V. is the norm, not the exception, said Perry N. Halkitis, a professor of psychology and public health at New York University. According to the C.D.C., 79 percent of H.I.V.-infected black men who have sex with men and 74 percent of Hispanics are not “virally suppressed,” meaning they can transmit the infection, either because they are not yet on antiretroviral drugs or are not taking them daily.
Giselle admitted to sometimes skipping days. “The medicine gets you sick,” she said. “It messes up your mental state. Or it can be freezing and I’m sweating.”
Missed doses let the virus rebound, sometimes in drug-resistant strains, experts said.
Other risk factors include depression and fatalism. In a2012 project by the National Youth Pride Services, an advocacy organization for gay black youths, more than half of the young gay black people questioned said they feared their friends or families would disown them if they came out as gay, and about 4 in 10 said they had contemplated suicide over being gay.
“The image of a black gay man almost doesn’t exist,” said Shariff Gibbons, 25, who works with other young men at GMHC. “In the black community, the image that ‘gay men are sissies’ is amped up a billion times. And we all have an aunt who goes to church and says, ‘Being gay is wrong.’ That makes young men hide.”
Roderick, 22, said his aunt, who took him in after his parents were arrested on drug charges, became furious after he told her at age 15 that he was gay. Later he attended a small New Jersey university and studied to be a veterinarian. But when his aunt learned that he was dating a white man, she demanded that he return home and go to a local community college.
She and his cousins called him an “Oreo” and even viler names, he said. “It got to where I felt I was going to snap, and kill myself or kill them. I didn’t want to do either, so one night I took my cousin’s bike and I left, and took a train to New York. I’m just basically dead to my family now.”
In New York, he found housing through the Ali Forney Center, which is named after a young gay rights advocate murdered in 1997 and which shelters gay minority youths, who are often abused in regular shelters. Roderick briefly supported himself by having sex for money at parties organized through Craigslist. But he gave that up, he said, has one partner and is applying for veterinary scholarships.
Several young men described having felt isolated and scared as teenagers, and so depressed that they hardly cared if they lived or died, which left them indifferent about using condoms, especially when they were offered money not to. And many turned to empathetic older men who had gone through the same crises in their youth. Alex said his mother threatened to throw him out when she caught him with another boy when he was a teenager — but she needed the disability checks he receives because of nerve damage done at birth.
“I have three strikes against me: I’m black, I’m gay, and I’m in a wheelchair,” he said. “All I wanted was love and comfort and being with someone in the world.”
Sex with strangers was as close as he could get. His first time was in a stairwell of his housing project with a man he met on a black gay chat site.
“It was a hit and a bounce and leave,” he said. “Unprotected oral and anal.” When he was older, he sold himself on the Chelsea Piers.
Two scary events — getting syphilis and being raped by an older man he thought loved him — brought him to GMHC, which offers separate support groups for black and Hispanic men, teenagers and transsexuals. They offer advice, H.I.V. tests and help on being openly gay.
For example, several men said they joined after being handed GMHC “I Love My Boo”fliers, which show young black male lovers holding hands and kissing in Central Park.
An Inadequate Response
But scattered local programs like these, and those offering housing, legal and medical help and other services, are not turning the tide of infections because the national response is fragmented and hesitant.
Few black political or religious leaders talk regularly about the problem — though there are exceptions, including Representative Barbara Lee, a Democrat from Oakland, Calif., and the Rev. Dr. Calvin O. Butts III of the Abyssinian Baptist Church in Harlem. Ms. Lee and several other congresswomen publicly take annual H.I.V. tests. Few men in the Congressional Black Caucus agree to join them, one of her aides said.
Dr. Butts has endorsed home H.I.V. tests from the pulpit and exhorted his congregants to accept gay relatives, but many black clergy members are far less accepting; some have fought same-sex marriage ballot measures.
Many programs have been proposed and tested, including financial incentives: paying parents who accept their gay sons to meet with parents who reject theirs; paying men who bring in friends for H.I.V. tests; and paying older black men to give cooking lessons and safe-sex advice to younger ones. But none have been widely adopted.
At a recent GMHC forum on why its programs for young black men were being cut, Janet Weinberg, the agency’s acting chief executive, said the epidemic was in some ways still where it was 30 years ago.
“We have the tools to end it,” she said, “except for the government’s indifference.”