Prevention for Positives: The New CDC Initiative

As a clinical psychologist, I have long been involved in both critiquing and developing HIV prevention by and for gay men – and I have seen both the realized utility and the unrealized potential of such prevention.  Last year the Centers for Disease Control and Prevention (CDC) announced an initiative that would essentially eliminate the culturally and psychologically sensitive HIV prevention gay men have achieved over these past two decades.  Little in the CDC’s “Advancing HIV Prevention: New Strategies for a Changing Epidemic – United States, 2003” is actually new.  Rather, it invokes the “enforcement” model that spawned the discipline of public health in the TB epidemic of early twentieth-century America.  The CDC’s retreat to “proven public health approaches” represents a “normalization” of handling of the AIDS epidemic that some policy makers (few of them gay) have argued for almost since the discovery of HIV.  Perhaps most disturbingly, the initiative imposes, in the guise of “prevention,” the humanly repressive values of the political right that now controls CDC funding.

With the initiative, the CDC mandates HIV testing as a “part of routine medical care.”  Many “ordinary” medical settings – a physician’s office or a clinic – cannot provide counseling for those contemplating the often difficult issues of HIV testing.  Contending that such requirements “should not be a barrier to testing,” the CDC proposes “simplified . . . procedures,” that handily dispense with counseling.  For those who test positive,  the CDC prescribes sexual-partner notification and “prevention and care services” for the newly diagnosed.  This plan raises potentially disturbing human issues, doubts about prevention efficacy, and doubt even about exactly what is meant by the term “prevention.”  HIV-negative gay men are no where mentioned in the plan, a plan purportedly about keeping HIV-negative men negative.  The single element of the proposal that is actually new is the apparently central role for HIV positive men in preventing new infections.  The enforcement model has long posited the idea that identification and behavioral control of the “disease carrier” is the key to protecting the “public at large.”

The promotion of large-scale HIV testing as prevention – meaning the primary prevention of new infections – is simplistic and disturbing.  Testing, per se, is not prevention, just as the collection of automobile accident data is not driver education.  We do not prevent new infections by simply finding out who is already infected.  The CDC would have us believe that only those who know they are positive can decide not to transmit HIV.  By its own statement, three-quarters of HIV positive people in the US do know they have HIV, yet there is no evidence that HIV is disproportionately transmitted by those who don’t know.  The CDC asserts that those who are newly diagnosed reduce behaviors that expose others.  However, both the data and my observations as a psychotherapist suggest that knowing one’s status changes behavior with lovers much more than with “anonymous” partners.  While the CDC cites the efficacy of “proven public health approaches” in managing other STDs, the incentives to test and notify partners are very different with HIV than with more easily treated and more benign STDs like gonorrhea or syphilis.  Finally, in support of it’s plan the CDC notes that during 2000, fully 31% of those who tested positive for HIV did not return to learn their test results.  People are, for many important reasons, ambivalent about testing and knowing their result.  It is certain that the prospect of partner notification will enhance neither the incentives to test nor the desire to return for results.

The implausibilities of the CDC proposal would seem at least partially clarified were it based on a requirement for in voluntary – mandatory – testing.  Perhaps the CDC is counting on only a small minority questioning the components of routine medical care, resulting in the “semi-voluntary” testing of many who would otherwise not willingly be tested.  This idea is all the more troubling because the CDC is dispensing with pretest counseling and no where in the proposal requiring that the patient give explicit consent for the test or be informed of the consequences of a positive test. While most would agree that positive men ought to have a role in preventing new infections, they surely cannot be assigned the entire task.  The scapegoating of positive men within gay communities or their criminalization by the larger society would accomplish nothing for prevention and do irreparable harm.  Positive men must not become the object of our frustrations and pain with the epidemic.

While the CDC now seeks to normalize handling of the epidemic, there have always been, and still are, many good reasons for innovative, “special” approaches to HIV prevention for gay men.  Among these are the unusual medical course of HIV infection; the concentration of infection in communities defined by sexual orientation; the very high levels of infection in those communities; the special political, social, and psychological issues of those communities; and the well-founded fear of social and economic discrimination.  These issues have not changed.  What has changed, in addition to the American political climate, is that gay men are increasingly acknowledging that we do, indeed, continue to infect each other.  While that acknowledgment is crucial to improving our prevention, it has also made us vulnerable to society’s impatience and imposed, simplistic solutions like those from the CDC.

That gay men continue to become infected – that our innovative approaches have not provided perfect, or even excellent, results – is actually no surprise to those who struggle professionally with public health issues.  Human emotional life is a complex matter.  Our results, however, can be improved upon by understanding ways that our prevention has fallen short.  The numbers of infected men, and the ease with which our feelings about HIV became entangled in our feelings about being gay, generated a central paradox for prevention efforts that, to this day, we have not been able to confront or resolve:  How do we authentically support the lives of infected men while telling uninfected men that it is important to remain uninfected?   In the face of that paradox, much of our prevention work retreated into a peculiar, confusing equivocation that focused on behaviors but left unmentioned our purpose.  We have spoken about using condoms or having  “safe sex.”  But since the debut of the HIV test in 1986 – and the discovery that fully half of us were infected – we have rarely dared speak explicitly about the sole purpose of primary prevention, which is keeping HIV-negative men negative.

Over the last 20 years, the innovative prevention work by and for gay men has accomplished something new and important in the world of public health: an insightful, authentic look at human feelings and sexuality.  It is this, above all else, that the repressive political forces now speaking through the CDC would crush.  In place of insight, these forces would have us retreat into shame about being gay, about having HIV and about imperfect results from an effort that has been fundamentally decent, sound and right.  If not merely good-looking statistics, but the real quality of human life is our concern, simplistic approaches to prevention in sexual matters – those of the CDC or those of our own sometimes confused community efforts – will accomplish little.  The current unhappy condition of American consciousness must not bully us into confusion, shame or apology.  We must insist on a renewed effort to address the important issues for gay lives in the epidemic: how to live as honestly, as self-acceptingly and as happily as possible.  All else being equal, that pursuit must include the minimization of new HIV infections by means respectful to all gay men.  We can do this and we should.