BY PERRY N. HALKITIS, PhD | I have chosen to frame this discussion in terms of young gay men. They are the ones being most impacted by the HIV epidemic, yet still have the opportunity to work to make behavioral changes. The resulting ideas are driven by a decade’s worth of behavioral research and the voices of hundreds of young gay men with whom we have had the opportunity to work and study (at the Center for Health, Identity, Behavior, and Prevention Studies at New York University).
Focus on Total Health
An HIV prevention program for gay men must be part of a holistic gay men’s health program. It is no longer sufficient — and in fact unconscionable — to provide HIV prevention services in the absence of drug and mental health counseling. Sexual health programs must address the realities of all sexually transmitted infections (STIs) to which gay men are susceptible. Too often, we forget that syphilis, gonorrhea, Hepatitis B and C are very much in our midst and — when left untreated — can exacerbate the spread of HIV.
Community-based HIV programs must be designed to address all the physical and mental health conditions gay men face. I never want to see another “How to Use a Condom” seminar. Support groups, one-on-one counseling and education programs should, of course, teach safer sex techniques (since many young gay men do not know how to use a condom correctly and how choose the appropriate lubricant). But this education must exist within a larger context — one that fully addresses the synergies of health risks.
A proactive HIV prevention program must also help young gay men confront the pain associated with years of victimization — empowering them to make healthier choices and not to disguise these negative feelings with endless bouts of sex and drugs.
One would think that medical practitioners would readily enact such an approach for assuring the health of gay men. But these individuals often lack the skill or time to effectively address matters of total health with their patients. How often has your medical practitioner asked whether you were having safe sex, while shaking his head in the affirmative? How much time has your medical provider spent discussing your drinking during a routine health checkup or an HIV test? Health care providers focus on pathogens and their treatment and are limited in what they can offer by our defunct health care system.
Thus, this holistic approach to gay men’s health — where health is viewed as an interplay of the biological, psychological, and social domains — must be directed and driven by our leading AIDS service organizations. They are best suited to address these health conditions in a manner that is personally meaningful for gay men. But with this responsibility there is also a need for AIDS Service Organizations (ASOs) to engage and employ skilled staff who have the education and training to deliver these types of services — or to professionally develop their current staff to reach these higher skill levels. Caring about HIV is a good thing, but it cannot be the sole prerequisite needed to deliver HIV prevention services at ASOs.
Focus on Resiliency
How resiliency informs HIV prevention is understood in three ways.
First, most HIV prevention programs are based on deficit models — in other words, we focus on behaviors of risky gay men and build programs around reducing their risk. But for every two young gay men who engage in unsafe sex and use drugs there are likely eight who do not. We have as much (if not more) to learn from these young gay men who demonstrate healthy behaviors as we do by designing programs around risky men. For years, psychologists have understood that you study your success stories and try to emulate what is being “done right.” Those providing HIV prevention services have not fully understood the benefit of such an approach.
Second, HIV prevention programs that seek to understand the complexities of health issues for gay men must also celebrate the resilience of the gay community and our successes. As a population, we have been burdened and devastated by HIV — but we also have survived, and we continue to make viable and significant contributions to our society. We have supported each other throughout the first 15 years of the epidemic when death surrounded us, and somehow we have managed to maintain our place in the world. Thus, HIV prevention programs must acknowledge and celebrate this resilience.
Finally, HIV prevention programs must recognize our success in other parts of our lives. We are highly educated. We often have successful careers as well as meaningful friendships, partnerships and marriages. These elements must be brought into discussions of HIV prevention.
Focus on Political Activism
I strongly believe that the reversal of “Don’t Ask Don’t Tell,” overturning of the Defense of Marriage Act, and the legalization of gay marriage in all 50 states will have a direct and beneficial effect on the HIV epidemic in gay men. The denial of our civil rights places us at risk.
Telling a young gay man he doesn’t deserve the right to marry the one he loves indicates to him he is less worthy than others — thus increasing his psychological burden and potentially fueling his drinking, drugging, and sexing.
HIV prevention programs must thus also educate a new generation of young gay men to demand their rights, and to empower them with the political activism and lobbying skills so that their voices are heard. This will lead to the social healing of these young gay men, will serve as a call to action, and will create a sense of control of the future and of their destiny, which I propose will translate to control of their own health destiny also. Continuing to deliver HIV in a vacuum separate from these political realities not only demonstrates a complete disregard for the multitude of issues with which gay men are struggling, but also will serve to continue to alienate a generation of young gay men for whom HIV is not their primary presenting concern.
There are numerous other factors to consider — including, but not limited to, more sophisticated use of e-technologies to involve young gay men in a total health program. Unfortunately, most ASOs are stuck in the ways used with my generation, which came of age in the mid-1980s.
To be relevant to a new generation of gay men, HIV prevention programs must expand to encompass all aspects of health and celebrate the successes of gay men. At the same time, we must recognize that as the HIV epidemic continues to exist, new generations of young gay men will be coming into their own during different social, political, and historical periods, each with its own particular needs and expectations.
In the end, this major reframing of HIV prevention will take time to evolve. But we must act now. Fortunately, my interactions with my colleague Sean Cahill at Gay Men’s Health Crisis — indicating the agency’s recent lobbying efforts to DHHS and CDC — suggests to me that at least one ASO is on the right path.
Perry N. Halkitis, PhD is Professor of Applied Psychology and Public Health at the Steinhardt School of Culture, Education, and Human Development, New York University.
Editor’s Note: Chelsea Now’s “In Their Own Words” column devotes space to a youth, a senior, a community activist or a community organization.
In our Aug. 11 edition, Perry N. Halkitis wrote about redirecting HIV prevention for gay men. Halkitis suggested that efforts have fallen short due to the fact that programs enacted on the community level do not sufficiently acknowledge how HIV is driven by the intolerance and stigma that gay men face. In this companion piece, he provides suggestions for how those enacting HIV prevention programs can expand the scope of their work to more effectively address the realities of gay men’s lives.
