What are the HIV Prevention Needs of Young Men Who Have Sex with Men?
Are young MSM at risk for HIV?
Yes. Over half of all the reported HIV and AIDS cases among males aged 13-24 in the US were due to male-male sexual contact. Various studies found that 26% to 50% of young men who have sex with men (MSM) report recent unprotected anal intercourse, and much of this unprotected sex occurred with a partner of unknown or different HIV status. Rates of sexual risk-taking among young MSM are also increasing. The term young MSM includes men who self-identify as gay or bisexual, as well as non-gay/bi-identified MSM under 30 years old.
A large number of urban young MSM are already infected with HIV. A study of 15- to 22-year-old young MSM in seven cities (Baltimore, MD; Dallas, TX; Los Angeles, CA; Miami, FL; New York, NY; San Francisco Bay Area, CA and Seattle, WA) showed a high overall HIV prevalance: 7%, ranging from 2% -12%. Moreover, 82% of the HIV+ men had no idea they were HIV+ before this testing.
Young MSM of color, especially African American men, are disproportionately impacted. In the multi-city study, 14% of the African Americans tested HIV+, compared to 13% among mixed race men, 7% among Hispanics, 3% among Asians and 3% among whites.
Why do young MSM take risks?
Unfortunately, there are no simple answers to this question. The explanations for unsafe sex are complex and multi-faceted. Adolescence and young adulthood are often characterized by experimentation and exploration of sexuality and drug using. While most young MSM will engage in some HIV risk behaviors at some point in their lives, only a small percentage are consistent risk takers. Many young MSM struggle with individual, interpersonal and societal stressors that may interfere with their ability to protect themselves.
For some young MSM, individual factors can lead to unsafe sex, such as: feeling invulnerable to HIV; having high levels of optimism about HIV antiviral medications; perceiving that unsafe sex is more pleasurable than safer sex; being depressed or sad; having conflicting allegiance with either their racial or sexual identity; and using alcohol or other drugs (e.g. speed/crystal, poppers).
Protecting one’s health is not necessarily a young MSM’s top concern. Interpersonal motivations may be more pressing—wanting to fit in, to find companionship and intimacy. However, interpersonal issues can also contribute to unsafe sex, such as finding it difficult to communicate or negotiate safer sex with a sexual partner. Young MSM who are in a relationship are more likely to have unsafe sex than single young MSM.
Societal factors may also influence the risk-taking of young MSM. Many young MSM find themselves isolated or rejected by traditional sources of support like family, school, or religious community.9 Homophobia, racism and poverty also place young MSM at risk. Some young MSM, especially those living on the street, are struggling with daily needs like avoiding violence, finding a place to live, or obtaining food. These pressing needs may overshadow the concern for safer sex and injection practices.
Young MSM have few public places to meet each other. Gay bars and public cruising areas are some of the more visible and accessible places, offering anonymity for young men exploring their sexual identity. These venues are also associated with high levels of risk-taking. They are highly sex-charged and the bar scene’s emphasis on alcohol sets the stage for engaging in sex while intoxicated. This is consistently found to contribute to unsafe sex.
Little is known about the Internet’s role in the lives of young MSM, including how young MSM use the Internet to obtain social support, make new friends, find romantic partners, and/or cruise for sex.
What’s being done?
The Mpowerment Project is a multilevel, sex- and gay-positive, peer-based intervention in which young men take charge. Because HIV may not be particularly compelling for many young MSM, the project focuses on young MSM’s social concerns. The young men plan and coordinate activities to create a stronger and healthier community for themselves in which safer sex becomes the mutually accepted norm. Participants in the Project have reduced rates of unprotected anal intercourse with casual partners and boyfriends. Mpowerment, proven effective as an HIV prevention intervention, provides CBOs with training and a manual for replication.
The COLOURS Organization in Philadelphia, PA targets young MSM of color with support groups, peer educator training and individual case management. They do street outreach at sex clubs and bars frequented by MSM of color, providing condoms and counseling to young MSM who partner with older men. They also promote gay-friendly drug and alcohol treatment services for young MSM.12
The American Psychological Association has implemented the Healthy Schools Project for Lesbian and Gay Students. The Project trains school psychologists, counselors, nurses and social workers to work effectively with gay, lesbian and bisexual students. The goal is to make schools a friendlier environment for these students and make HIV prevention education more relevant to them.13
“Chico Chats,” a program of the STOP AIDS Project in San Francisco, CA, consists of a one-month intensive series of workshops. Participants get to know each other while engaging in facilitated conversations about body image, relationships and identity and how these issues relate to HIV. Learning community organizing and mobilization techniques is a key component of these workshops as well. Participants formed an activist group called ¡Ya Basta! (Enough Already) and designed a video and workshop examining the issues of sexual silence and coming out in Latino families. The video is being shown throughout Latino communities in San Francisco.14
Effective programs for young MSM must address the context of their lives and the individual, interpersonal and societal factors that put them at risk. Comprehensive health and sexuality education must target both those who identify as gay or bisexual and those who do not. Unfortunately, many school-based programs focus on reproduction or abstinence until marriage, further marginalizing young MSM.
There is an urgent need to create prevention and wellness programs specifically for young MSM of color. Existing programs for older MSM of color should also be accessible to young MSM. These programs should address issues of sexuality, gay identity, culture, race/ethnicity, racism, homophobia, poverty and violence. Programs must also consider the HIV prevention needs of both HIV positive and HIV negative young MSM. Special attention is necessary to reach marginalized young MSM, such as those who are homeless, engaged in commercial sex work or involved with the criminal justice system. These young men may not identify as gay or bisexual, and may have immediate needs for food and shelter to address.
Programs are needed that foster support for young MSM and involve them directly in planning and implementation. Support might encompass creating safe places for young MSM to socialize and access services, developing school-based sexuality and gay-awareness programs and helping young MSM advocate for greater acceptance by schools, families, religious communities, the gay community at large and communities of color.15
Societal homophobia may impede implemention of prevention programs for young MSM and may discourage young MSM from accessing prevention services.16 Political concerns must not be allowed to interfere with HIV prevention services for young MSM. Targeting young MSM with HIV prevention messages and services is an appropriate response to a grave public health threat. Unless action is taken quickly, we will lose many young men to HIV.
- Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report . 2000;12.
- Molitor F, Facer M, Ruiz JD. Safer sex communication and unsafe sexual behavior among young men who have sex with men in California. Archives of Sexual Behavior. 1999;28:335-343.
- Kegeles SM, Hays RB, Pollack LM, et al. Mobilizing young gay and bisexual men for HIV prevention: a two-community study . AIDS. 1999;12:1753-1762.
- Hays RB, Kegeles SM, Coates TJ. Unprotected sex and HIV risk-taking among young gay men within boyfriend relationships . AIDS Education and Prevention. 1997;9:314-329.
- Ekstrand ML, Stall RD, Paul JP et al. Gay men report high rates of unprotected anal sex with partners of unknown or discordant HIV status . AIDS. 1999;13:1525-1533.
- Valleroy LA, MacKellar DA, Karon JM et al. HIV prevalence and associated risks in young men who have sex with men . Young Men’s Survey Study Group. Journal of the American Medical Association. 2000;284:198-204.
- Strathdee SA, Hogg RS, Martindale SL et al. Determinants of sexual risk-taking among young HIV-negative gay and bisexual men . Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1998;19:61-66.
- Choi KH, Kumekawa E, Dang Q et al. Risk and protective factors affecting sexual behavior among young Asian and Pacific Islander men who have sex with men: Implications for HIV prevention . Journal of Sex Education & Therapy. 1999;24:47-55.
- Beeker C, Kraft JM, Peterson JL, et al. Influences on sexual risk behavior in young African-American men who have sex with men. Journal of the Gay and Lesbian Medical Association. 1998;2:59-67.
- Greenwood GL, White EW, Page-Shafer K, et al . Correlates of heavy substance use among young gay and bisexual men: The San Francisco Young Men’s Health Study . Drug and Alcohol Dependence. 2001:61:105-112.
- CDC. Compendium of HIV prevention interventions with evidence of effectiveness . 1999.
- The COLOURS Organization, Inc . Philadelphia, PA. 215/496-0330.
- Clay RA. Healthy Schools project hoped to ease discrimination . APA Monitor. 1999;30.
- The STOP AIDS Project . Q Action, ¡Ya Basta! San Francisco, CA. 415/865-0790×303.
- Seal DW, Kelly JA, Bloom FR, et al. HIV prevention with young men who have sex with men: what young men themselves say is needed . AIDS Care. 200;12:5-26.
- Stokes JP, Peterson JL. Homophobia, self-esteem, and risk for HIV among African American men who have sex with men . AIDS Education and Prevention. 1998;10:278-292.
Prepared by Pilgrim Spikes MPH Phd, Bob Hays PhD, Greg Rebchook PhD, Susan Kegeles PhD, CAPS
Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to CAPS.firstname.lastname@example.org. © April 2001, University of California