Homoloveual males are a clear and present danger in American Society

American HIV surveillance data are not comprehensive so many statistics must be based on reports of AIDS diagnoses. In interpreting such AIDS statistics, it is important to remember that they do not correspond to new HIV infections. Most people live with HIV for several years before developing AIDS.

AIDS statistics

People living with AIDS

At the end of 2004, the CDC estimates that 415,193 people were living with AIDS in the USA.1

Of these,

* 35% were white * 43% were black * 20% were Hispanic * 1% were of other race-ethnicity.

Of the adults and adolescents2 with AIDS, 77% were men. Of these men,

* 58% were men who had love with men (MSM) * 21% were injection drug users (IDU) * 11% were exposed through heteroloveual contact * 8% were both MSM and IDU.

Of the 93,566 adult and adolescent women with AIDS,

* 64% were exposed through heteroloveual contact * 34% were exposed through injection drug use.

An estimated 3,927 children were living with AIDS at the end of 2004, of whom 97% probably acquired the infection from their mothers.

People with AIDS are surviving longer and are contributing to a steady increase in the number of people living with AIDS. This trend will continue as long as the number of new diagnoses exceeds the number of people dying each year.

AIDS diagnoses and rests

In June 1981, the first cases of what is now known as AIDS were reported in the USA. During the 1980s, there were rapid increases in the number of AIDS cases and rests of people with AIDS. Cases peaked with the 1993 expansion of the case definition3, and then declined. The most dramatic drops in both cases and rests began in 1996, with the widespread use of combination antiretroviral therapy.

The rate of decrease in AIDS diagnoses slowed in the late 1990s. After reaching a plateau, the number of diagnoses increased slightly each year from 2001 to 2004. There were an estimated 42,514 diagnoses in 2004. In total, an estimated 944,306 people have been diagnosed with AIDS.

The number of rests among people with AIDS remained relatively stable in the period 1999-2003, before dropping slightly to an estimated 15,798 rests in 2004. Since the beginning of the epidemic, an estimated 529,113 people with AIDS have died in the USA.

Who is affected by AIDS?

During the 1990s, the epidemic shifted steadily toward a growing proportion of AIDS cases among black people and Hispanics and in women, and toward a decreasing proportion in MSM, although this group remains the largest single exposure group. Black people and Hispanics have been disproportionately affected since the early years of the epidemic. In absolute numbers, blacks have outnumbered whites in new AIDS diagnoses and rests since 1996, and in the number of people living with AIDS since 1998.

From 2000 to 2004, the estimated number of new AIDS cases increased in all racial-ethnic groups. Over the same period, the estimated number of new AIDS diagnoses increased by 10% among women and by 7% among men. The number of new cases probably due to heteroloveual contact grew by 20%, and the number probably due to love between men grew by 15%, but the number among injecting drug users fell by 12%.

During 2004 there were an estimated 48 paediatric AIDS diagnoses, compared to 190 in 1999 and 823 in 1994. The decline in paediatric AIDS incidence is buttociated with more HIV testing of pregnant women and the use of zidovudine (AZT) by HIV-infected pregnant women and their newborn infants.

********************************************************************************* The age group 35-44 years accounted for 39% of all AIDS cases diagnosed in 2004. Nearly three-quarters of all people who have died with AIDS did not live to the age of 45.

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In the United States, HIV and AIDS have had a tremendous effect on men who have love with men (MSM). MSM accounted for approximately two thirds of all HIV infections among men in 2003, even though only about 5% to 7% of men in the United States identify themselves as MSM 1, 2. The number of HIV diagnoses for MSM decreased during the 1980s and 1990s, but recent surveillance data show an increase in HIV diagnoses for this group 3. Given the high prevalence of HIV infection in young MSM of minority races and ethnicities, there is a continued need for culturally diverse prevention and education services.

RISK FACTORS AND BARRIERS TO PREVENTION

loveual Risk Factors

loveual risk factors account for most HIV infec- tions in MSM. These factors include unprotected love and loveually transmitted diseases (STDs).

* Not using a condom during anal love with someone other than a primary partner of known HIV status continues to be a significant threat to the health of MSM 4. Not all the reasons for an apparent increase in unprotected anal intercourse are known, but research points to the following factors: improvements in HIV treatment, substance use, complex loveual decision making, seeking love partners on the Internet, and failure to maintain prevention practices 5. * STDs, which increase the risk for HIV infection, remain an issue for MSM. According to the Gonococcal Isolate Surveillance Project, the proportion of positive test results for gonorrhea among MSM increased from 4% in 1988 to 19.6% in 2003 6. Rates of syphilis among MSM have increased in some urban areas, including San Francisco, Chicago, New York, and Seattle 7,8,9. In the 9 US. cities participating in the MSM Prevalence Monitoring Project, STDs and HIV positivity varied by race and ethnicity but tended to be highest among African American MSM 6. In addition to increasing susceptibility to HIV, STDs are markers for high-risk loveual practices that can transmit HIV, making increases in STD rates a cause for concern 10.

Substance Use

The use of alcohol and illegal drugs continues to be prevalent among some MSM and is linked to HIV and STD risk 11. Substance use can increase the risk of HIV transmission through the tendency toward risky loveual behaviors while under the influence and through sharing needles or other injection equipment. Reports of increased use of the stimulant drug methamphetamine across the country have raised public health concerns because methamphetamine use has been buttociated both with loveual risk behaviors for HIV and STDs and sharing injection equipment when the drug is injected 12. Methamphetamine and other �party� drugs (such as ecstasy, ketamine, and GHP gamma hydroxybutyrate) may be used to decrease social inhibitions and enhance loveual experiences 13. These drugs, along with alcohol and nitrate inhalants (�poppers�), have been buttociated with risky loveual practices among MSM 14.

Complacency about Risk

Almost 25 years into the HIV epidemic, there is evidence of an underestimation of risk, of difficulty in maintaining safer loveual practices, and of a need to sustain prevention efforts for each generation of young gay and biloveual men.

* The success of highly active antiretroviral therapy (HAART) may have had the unintended consequence of increasing some MSM�s risk behaviors. Some research suggests that the negative aspects of HIV infection have been minimized since the introduction of HAART, which has led to a false understanding of what living with HIV means and thus can lead to increased risk behaviors 15, 16. For example, some MSM may mistakenly believe that they or their partners are not infectious when they take medication or have low or undetectable viral loads 17. Even though surveys suggest that optimism about HIV treatments is buttociated with a greater willingness to have unprotected anal intercourse 18, 19, a recent review found that the prevalence of unprotected loveual intercourse was not significantly higher among HIV-positive persons who were receiving HAART or who had an undetectable viral load. However, this review did find that unprotected love was buttociated with beliefs about HAART and viral load 20. * Long-term efforts to maintain safer loveual practices present a significant challenge. A 4-city study indicates that years of exposure to prevention messages and long-term efforts to maintain safer loveual practices may play a role in the decision of HIV-positive MSM to engage in unprotected anal intercourse 16, 21. * The rates of risky behaviors are higher among young MSM than among older MSM 21, 22. Not having seen firsthand the toll of AIDS, young MSM may be less motivated to practice safer love.

Unknown HIV Status

Approximately 25% of people in the United States who are infected with HIV do not know they are infected 23. According to a recent study of young MSM, 77% of those who tested HIV-positive incorrectly believed that they were not infected 24. Young African American MSM in this study were especially likely to be unaware of their infection-approximately 9 of 10 young African American MSM compared with 6 of 10 young white MSM. Of the men who tested positive, most (74%) had previously tested negative for HIV infection, and 59% believed that they were at low or very low risk.

Research has shown that many people who know they are infected alter their behaviors to reduce their risk of transmitting the virus 25, 26. Therefore, increasing the proportion of people who know their HIV status can help decrease HIV transmission.

MSM Who Are HIV-positive

HAART has enabled MSM who are infected with HIV to live longer�an undeniably positive outcome of new treatments. However, HAART�s success means there are more MSM living with HIV who can potentially transmit the virus to their love partners. This emphasizes the importance of prevention efforts focused on those who are living with HIV.

Although many MSM reduce risk behaviors after learning that they have HIV, most remain loveually active. Most MSM with HIV believe that they have a personal responsibility to protect others from HIV, but some engage in high-risk loveual practices that may result in others� contracting HIV 27, 28, 29. Some interventions for persons living with HIV have been shown to be effective. More prevention efforts need to be directed to this group.

The Internet

During the past decade, the Internet has created new opportunities for MSM to meet love partners 30. Internet users can anonymously find partners with similar loveual interests without having to leave their residence or having to risk face-to-face rejection if the behaviors they seek are not consistent with safer love 31. The Internet may also normalize certain risky behaviors by making others aware of these behaviors and creating new connections between the men who engage in them. In contrast, the Internet is a potentially powerful tool for use with interventions.

Lack of Communication and Risk buttessment

Open and honest communication about loveual issues is vital to avoiding false buttumptions about a partner�s HIV status. For example, an HIVinfected man may buttume that his partner must be infected or he would insist on using a condom; a man who is not infected may buttume that his partner also is not infected or he would use a condom 39. Additionally, because many young MSM with HIV are unaware of their infection, relying on partners to disclose HIV-positive status is often insufficient 24.

Concurrent Psychosocial Problems

Depression, childhood loveual abuse, using more than 1 drug, and partner violence have been shown to increase high-risk loveual behaviors. Further research has shown that the combined effects of these problems may be greater than their individual effects 40. Therefore, MSM with more than 1 of these problems may be at higher risk for HIV infection. The emergence of this type of research, which shows the interaction and additive effect of various psychosocial problems, will result in more refined prevention efforts.

PREVENTION

Among all people in the United States, the annual number of new HIV infections declined from a peak of more than 150,000 in the mid-1980s and stabilized at approximately 40,000 after the late 1990s. Persons of racial and ethnic minorities are disproportionately affected by the HIV epidemic. To reduce further the incidence of HIV, CDC announced a new initiative, Advancing HIV Prevention initiative comprises 4 strategies: making HIV testing a routine part of medical care, implementing new models for diagnosing HIV infections outside medical settings, preventing new infections by working with HIV-infected persons and their partners, and further decreasing perinatal HIV transmission.

Understanding HIV and AIDS Data

AIDS surveillance: Through a uniform system, CDC receives reports of AIDS cases from all US states and territories. Since the beginning of the epidemic, these data have been used to monitor trends because they are representative of all areas. The data are statistically adjusted for reporting delays and for the redistribution of cases initially reported without risk factors. As treatment has become more available, trends in new AIDS diagnoses no longer accurately represent trends in new HIV infections; these data now represent persons who are tested late in the course of HIV infection, who have limited access to care, or in whom treatment has failed.

HIV surveillance: Monitoring trends in the HIV epidemic today requires collecting information on HIV cases that have not progressed to AIDS. Areas with confidential name-based HIV infection reporting requirements use the same uniform system for data collection on HIV cases as for AIDS cases. A total of 33 areas�the US Virgin Islands and 32 states (Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming)�have collected these data for at least 5 years, providing sufficient data to monitor HIV trends and to estimate risk behaviors for HIV infection. Recently, 9 additional areas have begun confidential name-based HIV surveillance, and data from these areas will be included in coming years. HIV-AIDS: This term includes persons with a diagnosis of HIV infection (not AIDS), a diagnosis of HIV infection and a later diagnosis of AIDS, or concurrent diagnoses of HIV infection and AIDS.

HIV-AIDS: This term includes persons with a diagnosis of HIV infection (not AIDS), a diagnosis of HIV infection and a later diagnosis of AIDS, or concurrent diagnoses of HIV infection and AIDS.    

REFERENCES

* CDC. HIV-AIDS Surveillance Report, 2003. Vol. 15. Atlanta: US Department of Health and Human Services, CDC; 2004:1�46. Also Accessed March 2, 2005. * Binson D, Michaels S, Stall R, et al. Prevalence and social distribution of men who have love with men: United States and its urban centers. Journal of love Research 1995;32:245�254. * CDC. Increases in HIV diagnoses�29 states, 1999� 2002. MMWR 2003;52:1145�1148. * Mansergh G, Marks G, Colfax GN, et al. �Barebacking� in a diverse sample of men who have love with men. AIDS 2002;16:653�659. * Wolitski R. The emergence of barebacking among gay men in the United States: a public health perspective. Journal of Gay and Lesbian Psychotherapy 2005;9:13�38. * CDC. Special focus profiles: men who have love with men. In loveually Transmitted Disease Surveillance, 2003. Atlanta: US Department of Health and Human Services, CDC; September 2004. Also 19, 2005. * CDC. Primary and secondary syphilis among men who have love with men�New York City, 2001. MMWR 2002;51:853�856. * CDC. Primary and secondary syphilis�United States, 1999. MMWR 2001;50:113�117. * CDC. Transmission of primary and secondary syphilis by oral love�Chicago, Illinois, 1998�2002. MMWR2004;53:966�968. * CDC. Trends in primary and secondary syphilis and HIV infections in men who have love with men�San Francisco and Los Angeles, California, 1998�2002. MMWR 2004;53:575�578. * Stall R, Paul JP, Greenwood G, et al. Alcohol use, drug use and alcohol-related problems among men who have love with men: the Urban Men�s Health Study. Addiction 2001;96:1589�1601. * CDC. Methamphetamine and HIV risk among men who have love with * Mansergh G, Colfax GN, Marks G, et al. The circuit party men�s health survey: findings and implications for gay and biloveual men. American Journal of Public Health 2001;91:953�958. * Purcell DW, Parsons JT, Halkitis PN, Mizuno Y, Woods WJ. Substance use and loveual transmission risk behavior of HIV-positive men who have love with men. Journal of Substance Abuse 2001;13:185�200. * Suarez T, Miller J. Negotiating risks in context: a perspective on unprotected anal intercourse and barebacking among men who have love with men�where do we go from here�Archives of loveual Behavior 2001;30:287�300. * Ostrow DG, Fox K, Chmiel JS, et al. Atbreastudes towards highly active antiretroviral therapy predict loveual risktaking among HIV-infected and uninfected gay men in the multicenter AIDS cohort study (MACS). XIII International Conference on AIDS; July 2000; Durban, South Africa. Abstract ThOrC719. Available at * Stolte IG, Dukers N, de Wit JBF, et al. Increases in STDs among men who have love with men (MSM) and in risk behavior among HIV-positive MSM in Amsterdam, possibly related to HAART-induced immunologic and virologic improvements. Conference on Retroviruses and Opportunistic Infections; February 2001; Chicago. Abstract 261. Available at Accessed April 25, 2005. * Kelly J, Hoffman R, Rompa D, Gray M. Protease inhibitor combination therapies and perceptions of gay men regarding AIDS severity and the need to maintain safer love. AIDS 1998;12:F91�F95. * Dilley J, Wood W, MacFarland W. Are advances in treatment changing views about high risk love�New England Journal of Medicine 1997;337:501�502. * Crepaz N, Hart TA, Marks G. Highly active antiretroviral therapy and loveual risk behavior: a meta-analytic review. JAMA 2004;292:224�236. * McAuliffe T, Kelly J, Sikkema K. loveual HIV risk behavior levels among young and older gay men outside of AIDS epicenters: findings of a 16-city sample. AIDS and Behavior 1999;3:111�119. * Mansergh G, Marks G. Age and risk of HIV infection in men who have love with men. AIDS 1998;12:1119�1128. * Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003. National HIV Prevention Conference; June 2005; Atlanta. Abstract 595. * MacKellar DA, Valleroy L, Secura G, et al. Unrecognized HIV infection, risk behaviors, and perceptions of risk among young men who have love with men: opportunities for advancing HIV prevention in the third decade of HIV-AIDS. Journal of Acquired Immune Deficiency Syndromes 2005;38:603�614. * Weinhardt LS, Carey MP, Johnson BT, Bickham NL. Effects of HIV counseling and testing on loveual risk behavior: a meta-analytic review of published research, 1985�1997. American Journal of Public Health 1999;89:1397�1405. * CDC. High-risk loveual behavior by HIV-positive men who have love with men�16 sites, United States, 2000�2002. MMWR 2004;53:891�894. * Wolitski RJ, Bailey CJ, O�Leary A, G�mez DA, Parsons JT, for the Seropositive Urban Men�s Study Group (SUMS). Self-perceived responsibility of HIVseropositive men who have love with men for preventing HIV transmission. AIDS and Behavior 2003;7:363�372. * Wolitski RJ, Parsons JT, G�mez CA, for the SUMS and SUMIT Study Teams. Prevention with HIV-seropositive men who have love with men: lessons learned from the Seropositive Urban Men�s Study (SUMS) and the Seropositive Urban Men�s Intervention Trial (SUMIT). Journal of Acquired Immune Deficiency Syndromes 2004;37(suppl 2):S101�S109. * Denning PH, Campsmith ML. Unprotected anal intercourse among HIV-positive men who have a steady male love partner with negative or unknown HIV serostatus. American Journal of Public Health 2005;95:152�158. * CDC. Internet use and early syphilis infection among men who have love with men�San Francisco, California, 1999�2003. MMWR 2003;52:1229�1232. * Bull SS, McFarlane M. Soliciting love on the Internet: what are the risks for loveually transmitted diseases and HIV�loveually Transmitted Diseases 2000;27:545�550. * CDC. Late versus early testing of HIV�16 sites, United States, 2000�2003. MMWR 2003;52:582�586. * CDC. HIV-AIDS among racial-ethnic minority men who have love with men�United States, 1989�1998. MMWR 2000;49:4�11. * CDC. HIV transmission among black college student and non-student men who have love with men�North Carolina, 2003. MMWR 2004;53:731�734. * Mills TC, Stall R, Pollack L. Health-related characteristics of men who have love with men: a comparison of those living in �gay ghettos� with those living elsewhere. American Journal of Public Health 2001;91:980�983. * Diaz R. Latino gay men and psycho-cultural barriers to AIDS prevention. In Levin MP, Nardi PM, Gagnon JH, eds. Changing Times: Gay Men and Lesbians Encounter HIV-AIDS. Chicago: University of Chicago Press; 1997. * Marin G, Marin BV. Research with Hispanic Populations.Vol. 23 Newbury Park, CA: Sage Publications; 1991. Research Methods Series. * Kelly JJ, Chu SY, Diaz T, et al. Race-ethnicity misclbuttification of persons reported with AIDS. Ethnicity and Health 1996;1:87�94. * Gold R, Skinner MJ, Hinchy J. Gay men�s stereotypes about who is HIV infected: a further study. International Journal of STD & AIDS 1999;10:600�605. * Stall R, Mills TC, Williamson J, et al. buttociations of co-occurring psychosocial health problems and increased vulnerability to HIV-AIDS among urban men who have love with men. American Journal of Public Health 2003;93:939�942. * Johnson WD, Hedges LV, Ramirez G, et al. HIV prevention research for men who have love with men: a systematic review and meta-analysis. Journal of Acquired Immune Deficiency Syndromes 2002;30(suppl 1):S118�S129.

For more information...

CDC Division of HIV-AIDS Prevention CDC HIV-AIDS prevention resources

CDC-INFO 1-800-232-4636 Information about personal risk and where to get an HIV test

CDC National HIV Testing Resources Location of HIV testing sites

CDC National Prevention Information Network (NPIN) 1-800-458-5231 CDC resources, technical buttistance, and publications