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Out Here: Gay and Lesbian Perspectives VI

Chapter 8

When HIV is Endemic amongst Gay Men

Michael Hurley

New and dramatic medical events like AIDS take decades or longer to run their historical course to prevention and cure.

– Cindy Patton1

While we might wish we could reach a point when no new infections occur among gay men in a single year, we know that once a disease becomes endemic to a population – as HIV has become endemic to American gay men – it requires radical interventions, such as vaccines or new technologies, to eliminate.

– Eric Rofes2

The biomedical and social relations between HIV and AIDS in Australia have been changing for the last 15 years. In this essay, I describe and analyse these changes and discuss some of their implications for HIV education and prevention amongst gay men.3

It took about four years for the distinction between HIV and AIDS to be firmly established after the initial reports of an outbreak of rare opportunistic infections and cancers amongst American gay men in 1981. In the year following, the same diseases were documented amongst injecting drug users and Haitians. The diseases resulted in rapid bodily deterioration and a rapidly increasing number of deaths. The cause of the diseases was at first unclear. Some scientists attributed them to ‘GRID’ – Gay Related Immune Deficiency. At this point, gay activists began to invent safe sex. They thought it likely that whatever was causing the diseases was sexually transmitted, and recommended the use of condoms. In 1983 Gay Men’s Health Crisis in New York City published Berkowitz and Callen’s How to Have Sex in an Epidemic. About a year later it was confirmed that the diseases were caused by the Human Immunodeficiency Virus (HIV). HIV attacked the immune system, and was spread through body fluids such as blood and semen, mostly through anal intercourse.4 The diseases associated with this viral infection became known collectively as Acquired Immune Deficiency Syndrome (AIDS). However, the scientific distinction between HIV infection and AIDS was blurred initially because, in terms of illness and the effects of epidemic, HIV and AIDS were synonymous. AIDS was largely untreatable – gay men, Haitians, intravenous drug users and soon people with haemophilia were dying at an alarming rate and though affected communities were responding to the epidemic in an extraordinary fashion, they were also reeling under its effects.5 Even so, over time, people with HIV and AIDS began to speak of living with the virus and its effects, rather than dying of AIDS. They resisted the notion that they were ‘victims’.

The distinction between HIV and AIDS is still frequently confused in Australia and other western countries. One of the reasons for this is that media coverage of local HIV epidemics has fallen substantially, and has been replaced by coverage of HIV/AIDS epidemics in countries where there are generally much higher levels of HIV prevalence, substantial continuing AIDS epidemics and limited rollout of successful antiviral treatments.6 In those countries HIV and AIDS are often still synonymous. A second reason is that much Australian population health based HIV research and associated prevention recommendations still proceed implicitly on the assumption that both HIV infection and an AIDS diagnosis are fatal. As a result, ‘prevention’ is officially configured through a no-risk lens (‘a condom every time’) that to a degree sidelines both the social contexts of sexual behaviour and desires for intimacy and pleasure, and those who practice risk reduction, especially sero-sorting. The theoretical efficacy of biomedical technologies, procedures and practices (for example, condom use under every circumstance, circumcision) is prioritised over consideration of the likely ongoing social effectiveness of prevention techniques and strategies.7

Historically, community-driven HIV education around safe sex was never only about condom use and behaviour change. It was a social apparatus organised around what would work.8 It included respect for the sexual and social practices of the affected populations: sex positivity,9 community mobilisation, the likelihood of particular kinds of behaviour change,10 harm reduction – needle and syringe programmes – and a concept of communal education that involved information provision, but was not reduced to it. This was highly effective amongst gay men. We now know that HIV infection rates fell dramatically in Australia after 1986. It is very likely that the changes which produced the lower infection rate can be attributed to a fear of death, reinforced by mass exposure to some of the bodily effects of AIDS. For many gay men now, neither of these is often the case, and has not been for some time.

The change in circumstances has produced considerable disquiet and a variety of responses in Australia and elsewhere. Much has stayed the same, especially sexual moralism. However, as Douglas Crimp put it in 2004,

[s]ometimes the déjà vu seems more like a nightmare from which we cannot awake… however there has been a drastic change, but it is a psychic change, a change in the way we think about AIDS, or rather a change that consists in our inability to continue thinking about AIDS.11

Crimp’s remark was made in the context of ongoing conservative hostility to funding safe sex education for gay men in the USA. In that context, it was perhaps difficult for Crimp to see the implications of a diminishing AIDS epidemic. Eric Rofes had a somewhat different take on the varieties of political moralism involved. Shortly before he died in 2006, Rofes wrote about how gay men in the USA were being demonised and pathologised by aspects of the ongoing response to increased HIV infection. He saw this as coming from Lesbian, Gay, Bisexual, Transgender (LGBT) organisations, and more liberal commentators, as well as from the political right. From his point of view they were denying the evidence of gay men’s commitment to safe sex, their resilience and creativity in the face of HIV, and the reality that HIV infection was endemic amongst gay men.12 This chapter is a reflection on some of the implications of Rofes’ argument in the Australian situation.

In what follows, I first discuss HIV and AIDS epidemics, and some of the differences between them. I then suggest some implications of these differences. I am aware that for many of us some of what I have to say touches on deeply painful matters. The years between 1983 and 1996 were those of increasing horror, and many of us were and are still deeply affected by what occurred. The number of deaths amongst men roseannuallyfrom 200 in 1988 to a peak of almost 700 in 1994 alone. The figures do not describe the individual pain and trauma, the multiple hospitalisations, the despair, the courage, the bedside care by volunteers, the funerals or the endurance required of those involved.I have not forgotten those who died, or those still living whose lives and health have been deeply affected by HIV and AIDS, or their partners, friends, families and sexual networks. I am also very aware that the situation is different in many other countries where AIDS is still rampant, treatment options are limited and discrimination is rife. The Australian context is a reminder that there are many HIV epidemics, not just one.

HIV and AIDS

The discussion here is framed by the following figure from the 2009 annual surveillance data reported by the National Centre in HIV Epidemiology and Clinical Research (NCHECR) at the University of New South Wales.

Diagnoses of HIV infection and AIDS in Australia 1981 to 2007
 

In this figure the lower line tracks the number of new AIDS diagnoses annually in Australia between 1981 and 2007. The upper line tracks new HIV diagnoses in the same period. AIDS diagnoses are not the same as HIV diagnoses. When AIDS occurs, it does so subsequent to an HIV infection. As the AIDS epidemic progressed, the period between an HIV infection and the onset of AIDS began to increase. Also, an HIV infection can occur well before it is diagnosed, and as a result the number of new HIV diagnoses in a given year is always larger than the number of new infections in any given year. This figure charts historical trends in new diagnoses of HIV and AIDS. It does not specifically chart newly acquired HIV infections according to the year in which the infection occurred, as distinct from when the diagnosis occurred.

The two lines in the figure meet coincidentally in 1994, and subsequently diverge. As it happens, 1994 was also the peak year for both the number of new AIDS diagnoses and of deaths from AIDS. Historically, over 90% of the people who made up the numbers represented by these two lines were gay men and included gay community connected Indigenous Australians and men from culturally and linguistically diverse backgrounds.13

While graphs such as this are important, to non-researchers they often seem dry and too detached from the stories embodied within them. That is their strength. They enable analysis. We use them to track epidemics. But the analysis requires that we know what occurred to the individuals, to the communities in which they lived and died, and what has changed. If we do not know these histories then we misinterpret what the data mean, especially if we assume they provide statistical norms against which we can assess what is occurring in the present.

After new treatments options became widely available from 1996 on, some of us spoke cautiously of improvised optimism, of a breathing space. There is a risk in hope. It can disappoint. In this case it paid off. In hindsight we now know how dramatically social relations and individual lives changed. Between 1994 and 2008 both AIDS diagnoses and AIDS deaths fell by about 90%. These were momentous, extraordinary changes. Further, since 2001, amongst people living with HIV, ‘estimated deaths from causes other than AIDS have exceeded AIDS deaths in Australia’.14

Even so, though the number of deaths annually is much lower, there are still people being diagnosed with AIDS. Many of the current AIDS diagnoses appear to occur as a result of late HIV diagnosis, are often from culturally and linguistically diverse populations and are usually somewhat less likely to be amongst gay men. Lower numbers do not mean these diagnoses do not matter. They matter to the individuals involved and their social networks – partners, friends, families. They also affect how medical and hospital care and other support resources are distributed and rearranged. People are still hospitalised and some do still die. While AIDS as an epidemic has largely faded, compared with the period between 1984 and 1994, we need to take into account what it means now to live with and manage an HIV infection, as we do for those with AIDS.

The HIV Futures Study conducted by the Australian Research Centre in Sex, Health and Society at La Trobe University and other research continues to indicate that people with HIV are generally living much longer, healthier lives than they were before highly active retroviral therapy became available.15 The average age for new HIV infections is 38, and though people who contracted HIV more recently are unlikely to have an HIV-related illness until they have lived with the virus for much longer, nearly 30% of people with HIV in Australia are now aged over 50. This proportion will keep rising, consequently over time there will be more and more older people living with HIV. Living longer with HIV makes you prone to earlier onset of age related conditions.16 It also contributes to an increase in the prevalence of HIV in Australia.

Even given all that, however, Elizabeth Pisani was pretty well right when she said in the Guardian in 2009 that treatments have meant that AIDS as distinct from HIV infection is largely a thing of the past in most western countries.17 At a population level in Australia, it is possible to suggest that socially we no longer have an AIDS epidemic. I am coming at this from a somewhat different angle to that taken by Gary Dowsett and David McInnes when they conceptualised ‘post-AIDS’ in 1995–1996, but it sits well with their analysis and its subsequent elaboration in the work of people like Eric Rofes, and myself.18 The post-AIDS discussion concerned the constantly changing social contexts of prevention education, and the multiple ways gay men, irrespective of serostatus, were responding to HIV in their sexual practices.

The research evidence base says that most gay men still practice safe sex most of the time, and about half do so all of the time. Analysis of survey data and interviews from the recent Pleasure and Sexual Health (PASH) study in which I am involved indicates continuing support for safe sex, but again makes it clear that many gay men now use condoms under sufferance.19 They do not like them. They use them because they have to, but if HIV were not a factor they would not. This is the case irrespective of both HIV status and their preferences in relation to condom use and risk reduction. A considerable proportion of unprotected anal sex in casual contexts is occasional and not the result of an intention present before the event. What is also clear, however, is that many men also use strategies to avoid condoms where they can, whether by negotiating ‘safety’ within relationships, or by choosing casual sex partners whom they know or believe have the same HIV status as themselves (sero-sorting). The PASH study indicates that,

those men who consciously seek opportunities to forego condom use are almost entirely those men who are fairly unconcerned about HIV, or even those who are ‘over’ HIV and think that it is no longer sufficiently serious to warrant sacrifices of their sexual pleasure.20

Many of the men also appear to engage sometimes or more frequently in various forms of risk reduction while also seeking to maximise sexual pleasure and intimacy. That is, the unprotected anal sex in casual contexts is accompanied by sero-sorting, withdrawal and less often, strategic positioning (only ‘topping’ or ‘bottoming’). The men universally value not transmitting HIV or becoming infected. In that sense, a general ethical and attitudinal consensus around safe sex is accompanied by a circumstantial practical ethics. The difficulties here include that in many circumstances the men cannot or do not properly know the status of their partners, that risk reduction is precisely what it says – reduced risk not risk elimination – and they often do not adhere to their own risk reduction practices. These result in new infection.

Not surprisingly, if we return to the upper line in the figure, what we see in Australia is an epidemic of HIV. The National Center in HIV Epidemiology and Clinical Research reports that ‘[t]he annual number of diagnoses of newly acquired HIV infection increased from 171 in 1999 to 308 in 2006 and declined to 281 in 2008.’21 Eighty-two per cent of those new HIV infections occurred amongst gay men. What the upper line indicates is that HIV is endemic amongst gay men, and that it has been since 1984. No news there, you may think, and in one way that is true, but the situation has changed. Since 1995, the HIV epidemic has been decreasingly accompanied by deaths from AIDS. That is, HIV incidence has risen, while diagnoses of AIDS have fallen. For the past 10 years, it has been very difficult to get the implications of this onto the table for discussion, much less keep them there in full view. It simply was not politically possible during a period of sustained rises in new HIV infections.

Put bluntly, gay men are not now living on ground zero and have not been for the past 15 years. However, it took several years for some of the implications to become apparent. Mostly, because any deviation from safe sex was represented in various ways as ‘dancing with death’.22 That is not true, and it is a very unhelpful metaphor through which to understand effective HIV education. Once new treatments came into the picture the meaning of an HIV infection changed. (There is no longer an almost automatic progression to AIDS following an infection.) Not surprisingly, so did the social relations between gay men, condom use, anal sex and risk taking. The rate of new HIV infections rose. We cannot proceed any longer by assuming that a continuously falling rate of new HIV infection is either the norm or sustainable. As important as the achievements of the first 15 years of the epidemic were in the establishment of a safe sex culture, the 1984 to 1999 section of the upper line in the figure presented earlier now has limited relevance for HIV prevention – unless your primary purpose is to maintain fear of disease and AIDS.

If the purpose of HIV prevention is fear then it has already succeeded. Many gay men, especially those who are HIV negative, are still highly fearful of HIV, yet, as the PASH study reports,

the main feature that characterises the men who retain this deeply-felt fear of HIV is that they are often men who claim to have never engaged in sexual risk behaviour such as UAIC [unprotected anal sex in casual contexts]. For many who remain so deeply fearful of HIV, their fears are both abstracted from knowledge and veer toward phobia. They often have relatively limited gay friendship and sexual networks, and limited contact with HIV-positive gay men.23

For these men anal sex itself is often problematic, and condom use is accompanied by fear (reliability, fear of breakage). This undermines the confidence required for ongoing ease in condom use.

We have not been able to face the implications of an HIV epidemic largely separated from AIDS, and responses based in fear of HIV and AIDS with any ease in a decade of rising HIV infection. Between 2000 and 2006, rises in new HIV infection produced a public health panic that foreclosed much discussion of how to do risk reduction in prevention education, and was not helped by political conservatism, and increasing criminalisation of HIV. Yet Australia still has one of the lowest HIV prevalence levels in the world. I am not complacent about that, but we do need a sense of proportion about these matters, even as we pay attention to how risk reduction is being done.

We do and will remember what came before, but as I have suggested, if we do not take into account that in this country we are no longer in an AIDS epidemic, we remember badly. The conditions that produced a constant decrease in new infections no longer hold. I am glad those conditions characteristic of an AIDS epidemic (high rates of morbidity and mortality, community crisis) no longer apply, even though I recognise that this shift creates challenges for prevention education. It is a situation further complicated by health funding streams that often, but not always, require gay men be represented in terms of deficit.

Deficit accounts of gay men primarily speak of them, in Rofes’ terms, as variously ‘damaged and dangerous’. Their ‘sexual practices, patterns of socializing, and cultural norms’ are represented as ‘troubling’.24 This is not to deny there are sometimes uneven health outcomes for gay men or other sexual minorities. Rather it is a refusal to construct the cultures involved only in reference to health disparities and disease. As Pitts et al. showed in the national Private Lives study: ‘despite health inequalities, it is also clear that most gays, lesbians, bisexuals, transgender and intersex people live happy and fulfilled lives’.25

This sense of fulfillment clearly matters to the people involved. However we refer to it – as social resilience, resistance, creative problem solving, social agency, community, the development of personal repertoires – we are describing an active capacity to live meaningfully. One part of the explanation is to be found in social connection: ‘[t]he strength and stability of relationships and friendships within GLBTI communities and the value placed on these things indicates a real capacity in our participants to live optimistically and well’.26 Deficit accounts reproduce queers as socially and politically marginal and sick in ways that do not recognise political achievement, social capacity or the strengths of their sexual cultures.27 While there are aspects of those cultures that can be challenged, any challenges need to be based on social respect and consideration of what will enable sustained change. There are mental health issues for some gay men, but as Dowsett has recently argued, unprotected sex is not primarily about relapse or low self esteem.28 Not only is much unprotected sex safe – negotiated safety, successful sero-sorting amongst HIV negative men and between HIV positive men – much depends also on the contextual prevalence of HIV.

The most recent seroconversion study indicates that while the men in that study are those who took risks and did seroconvert and have taken responsibility for that, they are also in many ways similar to the men who have not seroconverted, but have also occasionally or more frequently practiced unprotected anal sex in casual contexts. They have similar educational backgrounds, are knowledgeable about safe sex, are older, are strongly community connected, are sexually adventurous and play in similar contexts.29 Social research tells us that seroconversion is circumstantial and contextual. It is not caused by moral failure or complacency. This is not a discussion about good and bad gay men. It is about what it means to be sexually active in a situation of endemic HIV.

Implications for HIV Education and Prevention

Short of a vaccine or a cure, it appears we are highly unlikely to see a sustained fall in the number of new HIV infections. HIV is endemic because there are no preventative vaccines and it is quite possible there will not be for a long time, if ever. I first heard an imminent vaccine trumpeted in 1987. We now know that it is very hard scientifically to create a vaccine.30 In terms of both managing living with HIV and doing HIV prevention, the closest thing to a cure appears to be undetectable viral load amongst people living with HIV.

I anticipate that what we will see over time is a series of rises, hopefully small, and falls in the annual number of new infections. New HIV infections have remained stable in New South Wales and Victoria for the past two years. The plateau, however, is at a higher level than it was in 1999. For many this is a politically unpalatable scenario. For other people it is shocking. From my perspective as a researcher, it is to be expected, irrespective of what I might feel about it personally.

Like it or not, what we see on the upper line in the figure post-1999 is a much more realistic representation of what is statistically normal now than what occurred before. If condom use between 1984 and 1996 marked a community-based response fed by the fear of an almost untreatable virus, constantly rising AIDS deaths and considerable social hostility, it now only partly does so. While the general commitment to infection prevention remains, the context has changed. Even in the earlier context, however, the Sustaining Safe Sex survey in the early 1990s indicated that men were practicing negotiated safety well before it was named or officially promoted in the mid-1990s.31 We see a similar time lag between 1996 and 1999. Organisations responded somewhat cautiously to the relatively rapid changes in gay men’s sexual behaviour and sexual cultures. When rates of sexually transmitted infections rose and then new HIV infections increased in the 2000s, behaviour changed again. That appears to be what happens, at least in the medium term, when you no longer have an AIDS epidemic. Education and information provision still work, and in the case of Sexually Transmitted Infections (STIs) the curative effects of treatments are well known amongst the more experienced.

Endemic HIV epidemics in the absence of AIDS appear to be characterised by increasing HIV prevalence, marked variations in HIV incidence, increasing sexual adventurousness and risk taking including unprotected anal intercourse in casual sex contexts and substantially diluted knowledge amongst non-HIV positive gay men of what it is like now to live with and manage an HIV infection. While the majority of men in PASH agreed that HIV is no longer a death sentence and nearly a third believed it is a less serious threat than it was in the past, only about half believed that rates of HIV infection were increasing in the area where they lived.

Safe sex was invented by gay men under extraordinary circumstances. In the space of about 12 years somewhere between a third to a half of my generation of gay identifying men and a smaller number of lesbians died. I am still enormously relieved that subsequent generations of gay men, and many gay men in general, now know less and less of what it means to live in an AIDS epidemic, even though this makes HIV prevention more difficult. I wish more knew the history, but I am glad they did not experience it. There is more to life than fear of disease and death. In the PASH study, ‘over half knew no one who had died of AIDS, almost a half spent no time with PLHIV [People Living with HIV] and only a small minority knew anyone diagnosed with HIV in the previous year’.32 I also wish, however, they knew more about what is involved now in managing HIV infection over a lifetime, and how best to respond to a friend disclosing their HIV positive status. Those involved in the response to an endemic HIV epidemic will live with the associated frustrations and sorrows until the HIV epidemic is also over, but the operative word here is live.

Our task is to contain new infection as best we can, until something happens to radically affect the picture. There are three things we can do in relation to keeping HIV contained. The first is to sustain current HIV and STI testing rates amongst gay men, in particular by advocating for the introduction of easily accessible rapid HIV testing. There was substantial support for this amongst the men in the PASH study. Second, not all gay men relate to sexual risk taking in the same way. We can support those gay men who use risk reduction to sustain those risk reduction practices, rather than simply position them as problematic. Those doing risk reduction, whether episodically or frequently, need to be included in a long term conversation, spoken with, not just spoken to, or spoken about.33 That is beginning to happen, but the process is slow.

Third, we need to rethink what we are doing when we speak about risk, accept that we are working in a new situation and advocate around this with policy makers and politicians. This is a moment to be brave. State and federal elections will affect what community organisations and health departments can do. Yes the politics are difficult, but if community leaderships are driven only by caution in their relations with funders, and their reputations, the more benign, sanitised and ultimately irrelevant the health promotion resources produced will be. Official responses driven only by caution may well involve the men most able to have an effect on new HIV and STI infections increasingly detaching from what the organisations are saying. They need to be supported with practical, relevant information on how to stick with risk reduction, particularly at those moments when pleasure undercuts care of the self. HIV policy infrastructures have a major role here in brokering this at state and Commonwealth levels. The zero tolerance approach to sexual risk taking that characterises some STI and HIV research and much of the prevention in Australia has the potential to increase resistance to testing. Goodwill and professionalism require that testing occur without sexual moralism.

Endemic HIV in these circumstances involves, to use that quaint 1990s term, a paradigm shift. We still need medium to long term thinking separate from National AIDS Strategies, changes of government, funding arrangements and moral panics. Think tank style activities can play a major role here.

I recall the economist Ernest Mandel counselling a young revolutionary in the 1970s to remember that it took 600 years to overthrow feudalism. As you see, I also tend to the longer view. What is remarkable, from my point of view, is the creativity involved in how gay men respond to reducing the risk of infections, after 25 years, and the relative smallness of the numbers involved in the increases in new infections. Most gay men are not living with an HIV infection. Nor will they.

Endnotes - Chapter 8

1 Cindy Patton, Sex and Germs: The Politics of AIDS, Boston: South End Press, 1985.

2 Eric Rofes, ‘Gay Bodies, Gay Selves: Understanding the Gay Men’s Health Movement’, White Crane, 2005, available at, http://www.ericrofes.com/books/gay_bodies_gay_selves.pdf, date accessed 26 April 2010. Over time, Rofes had strongly advocated for an ‘assets-based’ approach to gay men’s health, taking a lead role in the formation of a multi-issue, multicultural gay men’s health movement that included HIV and AIDS, but was not defined by them. He came to this position after a long history of early gay activism, substantial involvement in HIV and AIDS organisations, and careful consideration of both the effects of HIV on gay communities and the benefits of the treatments that emerged in 1996 and later. In two of his books, Reviving the Tribe (1996) and Dry Bones Breathe (1998) he argued fiercely for recognition of wider perspectives on the communal, life-affirming nature of gay communities and sexual subcultures.

3 I thank Ross Duffin, Bill O’Loughlin and Graham Willett for comments on various drafts of this chapter. They bear no responsibility for the argument within it.

4 Because this article is primarily about gay men, I have not referred here to mother-to-child transmission through breast milk or in vitro infection or vaginal intercourse, each of which has its own discovery histories.

5 See, Dennis Altman, AIDS and the New Puritanism, London; Sydney: Pluto Press, 1986; Douglas Crimp, ‘Mourning and Militancy’, October, vol. 51 (1989), pp. 3–18.

6 See, Nilanjana Bardhan, ‘Transnational AIDS-HIV News Narratives: A Critical Exploration of Overarching Frames’, Mass Communication and Society, vol. 4, no. 3 (2001), pp. 283–309; Michael Hurley et al., ‘Mainstream Print Media Reporting of HIV Increases 2000–2003’, HIV Australia, December 2003 – February 2004.

7 ‘The concept of “risk” itself poses a challenge. In public health, we typically look at issues such as HIV and other STIs as posing a “risk”, with the presumption that our task is to eliminate or minimise that risk. This is the position of rational actors, who make decisions based on a “risk-calculation” to minimise potential harms (firstly to themselves and secondarily to others) while maximising potential rewards. However, this perspective is usually founded on the premise that individuals will primarily be concerned with the first half of this calculation (to minimise harms), and the maximising of rewards is only secondary, if it is given any real consideration at all. This may not necessarily be the way everyone approaches such calculations’, Garret Prestage et al., Pleasure and Sexual Health: The PASH Study, 2009 Sydney: National Centre in HIV Epidemiology and Clinical Research, 2010, p. 16.

8 ‘Anal intercourse is one of the central practices in the gay/bisexual repertoire… for considerable numbers of men it has been experienced as a central part of being gay… It is hardly surprising that statements of the personal importance of anal sex are consistently and strongly associated with frequency of practice. From this point of view, insisting on a total safe sex regime may be counter-productive. Over-rigid rules are impractical and invite blowouts: the net effect may be greater risk than a more moderate regime from the start’, Susan Kippax et al., Sustaining Safe Sex: Gay Communities Respond to AIDS, London: Falmer, 1993, p. 77. See also the reflections on the first 10 years of safe sex in, E. King, Safety in Numbers: Safer Sex and Gay Men, London; New York: Cassell 1993; and, Bruce Parnell, ‘Changing Behaviour’, in Eric Timewell et al., eds, AIDS in Australia, Sydney: Prentice Hall, 1993, pp. 185–205.

9 ‘[T]he key to this approach is modifying what you do – not how often you do it nor with how many partners’, Berkowitz and Callen, How to Have Sex in an Epidemic, One Approach, News from The Front Publications, 1983, p. 3. See also, Douglas Crimp, How to Have Promiscuity in an Epidemic, Cambridge, MA: The MIT Press, 1987; and, Simon Watney, Policing Desire: Pornography, AIDS and the Media, London: Comedia, 1987.

10 See, Parnell, ‘Changing Behaviour’; Kippax et al., Sustaining Safe Sex; and, Gary Dowsett, Practicing Desire: Homosexual Sex in the Age of AIDS, Stanford: Stanford University Press, 1996.

11 Douglas Crimp, Melancholia and Moralism: Essays on AIDS and Queer Politics, Cambridge, MA: The MIT Press, 2004, p. 17.

12 Rofes was an invited keynote speaker at the first Australian national lesbian, gay, transgender and bisexual health conference, Health in Difference, organised by the Australian Federation of AIDS Organisations in 1996. There have always been substantial differences in the Australian and US responses to AIDS and HIV, much of it due to America’s lack of a public health system, more limited government support for a community-based response, and a more puritan sex culture. Even so, there have also been important crossovers at the level of how gay men, lesbians, their allies and friends have built strong cultures in the face of social hostility and disease, and have celebrated communal life and sexual pleasure. See, Juliet Richters et al., Health in Difference: Proceedings of the First National Lesbian, Gay, Transgender and Bisexual Health Conference, Sydney, 3–5 October 1996, Sydney: Australian Centre for Lesbian and Gay Research, 1997.

13 In 2009, new HIV infections amongst Indigenous Australians occurred at the same per capita rate as in non-Indigenous populations; however, rates of other sexually transmitted infections were considerably higher. Amongst CALD populations, ‘the per capita rate of HIV diagnosis in Australia in 2006–2008 was at more than eight times higher among people born in countries in sub-Saharan Africa than among Australian born people’. See, National Centre in HIV Epidemiology and Clinical Research 2009, pp. 7–8.

14 J. Murray et al., ‘Rapidly Aging HIV Epidemic Among Men Who Have Sex With Men in Australia’, Sexual Health, vol. 6, no. 1 (2009), pp. 83–86.

15 Jeffrey Grierson et al., HIV Futures 6: Making Positive Lives Count, monograph series no. 74, Melbourne: Australian Research Centre in Sex, Health and Society, Latrobe University, 2009; The Antiretroviral Therapy Cohort Collaboration, ‘Life Expectancy of Individuals on Combination Antiretroviral Therapy in High-Income Countries: A Collaborative Analysis of 14 Cohort Studies’, The Lancet, vol. 372, no. 9635 (26 July 2008), pp. 293–299.

16 See, Ross Duffin, ‘Ageing with HIV’, Talkabout, November 2009, available at, http://positivelife.org.au/talkabout/2009/oct-nov/ageing-hiv, date accessed April 2010.

17 Elizabeth Pisani, ‘HIV Doesn’t Always Kill’, Guardian, 9 September 2009, p. 34. See also her ‘One HIV Test, But Two Results’, Guardian, 23 February 2010, p. 30.

18 See, Gary Dowsett and David McInnes, ‘Gay Community, AIDS Agencies and the HIV Epidemic in Adelaide: Theorising “post-AIDS”’, Social Alternatives, vol. 15, no. 4 (1996), pp. 29–32; Eric Rofes, Dry Bones Breathe: Gay Men Creating Post-AIDS Identities and Cultures, Binghamton, NY: Haworth Press, 1998; and, Michael Hurley, Then and Now: Gay Men and HIV, monograph series no. 46, Melbourne: Australian Research Centre in Sex, Health and Society, La Trobe University, 2003.

19 Part of this can be explained by the tension inherent in the differing economies of desire involved in anal sex for gay men: ‘There are two different but related domains of desire at work here. The first involves wanting to avoid infection, and what makes that possible. It is constituted around disease, condom use and risk, and a desire for no disease, no risk and no need for condoms. The second involves what counts as sexually desirable, and how that desire may be satisfied. It is constituted around pleasure. These two domains are potentially present when sex is negotiated circumstantially. Both are involved in care of the self and others. The practical challenges in negotiating the tensions between the desire to stay HIV-negative or to not transmit HIV, condom use and sexual desire and pleasure are ongoing’, Prestage et al., Pleasure and Sexual Health, p. 5.

20 ibid., p. 157.

21 National Centre in HIV Epidemiology and Clinical Research, 2009 Annual Surveillance Report. HIV/AIDS, Viral Hepatitis and Sexually Transmissible Infections in Australia, Sydney, p. 7.

22 See, Michael Hurley and S. Croy, HIV Infection, Gay Men, the Media, and the Law, forthcoming; and, Hurley, Then and Now. For a different view, see, Steve Dow, Gay, Altona, Vic.: Common Ground, 2001.

23 Prestage et al., Pleasure and Sexual Health, p. 155.

24 Rofes, ‘Gay Bodies, Gay Selves’.

25 Marian Pitts et al., Private Lives: A Report on the Health and Wellbeing of GLBTI Australians, monograph series no. 57, Melbourne: Australian Research Centre in Sex, Health and Society, La Trobe University, 2006.

26 ibid., p. 62.

27 These issues have been taken up in recent social health research. See, Lynne Hillier et al., ‘Guest Editorial: Mental Health and LGBT Communities’, Gay and Lesbian Issues and Psychology Review, vol. 4, no. 2 (2009), p. 65. See also, Michael Hurley, ‘Who’s on Whose Margins’, in Marian Pitts and Anthony Smith, eds, Researching the Margins, London: Palgrave Macmillan, 2007, pp. 160–189; and, Graham Willett, Living Out Loud: A History of Gay and Lesbian Activism in Australia, Sydney: Allen and Unwin, 2000.

28 Gary Dowsett, ‘Dangerous Desires and Post-Queer HIV Prevention: Rethinking Community, Incitement and Intervention’, Social Theory and Health, vol. 7 (2009), pp. 218–240.

29 Garrett Prestage et al., HIV Seroconversion Study: Newly Diagnosed Men in Australia 2007–2009, Sydney: National Center in Clinical Research and HIV Epidemiology, University of New South Wales, 2009.

30 For some of the science involved, see, Kendall Smith, ‘The HIV Vaccine Saga’, Medical Immunology, vol. 2, no. 1 (2003), available at, www.medimmunol.com/content/2/1/1, date accessed April 2010.

31 See, Kippax et al., Sustaining Safe Sex; and, Dowsett, Practicing Desire, 1996.

32 Prestage et al., Pleasure and Sexual Health, p. 6.

33 See, Tony Valenzuela, ‘Men Who Bareback Should Be Made Partners in Health Promotion, Not Banished’, 10 August 2009, available at, www.trevorhoppe.com/blog/archives/2009/08/men_who_bareback.html, date accessed April 2010.

Cite this chapter as: Hurley, Michael. 2011. ‘When HIV is Endemic amongst Gay Men’, in Out Here: Gay and Lesbian Perspectives VI, edited by Smaal, Yorick; Willett, Graham. Melbourne: Monash University Publishing. pp. 120–134.

Out Here: Gay and Lesbian Perspectives VI

   by Yorick Smaal, Graham Willett