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Try out PMC Labs and tell us what you think. Learn More. The spread of HIV and other STDs among men who have sex with men MSM has been labeled a syndemic because in this population a of different and interrelated health problems have come together and interact with one another. The various elements of the syndemic have an additive effect, each one intensifying the others. These factors include the of infectious diseases endemic in this population, the high rate of substance abuse problems and psychological disorders, and the ificant percentage of MSM who have experienced childhood sexual abuse and other adverse events.

While MSM are disproportionately affected by HIV, syphilis, and other STDs, health activists from the gay community have systematically resisted the application of the full range of public health strategies traditionally used to prevent their spread. This paper deals with the history of the syndemic, the failure of various risk reduction strategies, and treatment as prevention.

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In the period October —May5 young men, all active homosexuals, were treated for biopsy-confirmed Pneumocystis carinii pneumonia at 3 different hospitals in Los Angeles, California. Two of the patients died. CDC This includes the transmission category MSM and use injection drugs. According to the CDC:.

CDC a. Infectious agents included Shigella sonnei, Shigella flexneri, Campylobacter spp.

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Infection with these parasites was a likely effect of anal intercourse, which was apt to put a man in contact with his partner's fecal matter, and was virtually a certainty through the then-popular practice of rimming, which medical journals politely called oral-anal intercourse. Shilts In addition, MSM were at risk for syphilis, gonorrhea, hepatitis A, B, and C, cytomegalovirus, Epstein-Barr virus, human papillomavirus, chancroid, lymphogranuloma venereum, granuloma inguinale, pubic lice, pinworms, scabies, and flea bites.

Many MSM had multiple recurrences of the same disease. The ritual of repeated infection and treatment had become part of the gay lifestyle Shilts Doctors were pessimistic:. Education of gay men to limit the nature and s of their sexual partners is unlikely to be productive on a large scale … traditional contact tracing is not productive in populations with large s of anonymous sexual contacts.

Handsfield Too much is being transmitted … We've got all these diseases going unchecked. There are so many opportunities for transmission that, if something new gets loose here, we're going to have hell to pay. Even as she spoke, the infectious agent Dr. Dritz feared was spreading through the gay community.

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Human immunodeficiency virus HIV is not easily transmitted. It requires percutaneous or mucosal contact with blood or other body fluids. HIV has a long latency period before the infected person's health deteriorates and during which he is capable of infecting others. Thus, the virus had spread throughout the gay community for several years before physicians realized they were dealing with a new disease.

They were shocked by the sheer of sexual partners reported, typically over Shilts The virus spread quickly. One year later, it was 58 percent Rompalo During the first decade of the epidemic, HIV infection was the equivalent of a death sentence.

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HIV infection usually doesn't kill outright, but destroys the immune system, making its victims prone to a range of other diseases. The first victims died of Pneumocystis pneumonia which under other conditions would have been treatable. The failure of their immune systems left victims vulnerable to a host of diseases, including toxoplasmosis a cat diseasecryptococcal meningitis, candidiasis, severe herpes, Cryptosporidium an animal parasiteencephalitis, and a fulminant form of Kaposi's sarcoma a skin cancer ly found mainly in older men of Mediterranean origin.

The disease at that time was labeled GRID gay related immune deficiency.

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Although the pathogen responsible had not been identified, experts were convinced that they were dealing with a disease caused by a virus and transmitted by semen and blood, and that the gay bathhouses were a likely venue for transmission, since many of the first victims could be linked to these establishments. When Dr. Dan Williams, a prominent gay NY physician, suggested that bathhouses catering to gay men be required to post s warning patrons about the danger of infection, the gay community reacted angrily, refusing to consider anything that would turn back the sexual liberation the bathhouses represented.

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Bythe pathogen that causes AIDS had been identified, the modes of transmission known, and a test developed to identify those infected. Instead, spokesmen for the gay community objected to any form of mandatory or routine testing. They insisted that all that was necessary was for everyone to use a condom every time. No one should be tested unless they wanted to be. All testing information should be absolutely confidential to avoid outing gay men. The names of the infected should not be reported.

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There should be no routine testing, no contact tracing, and no notification of possibly infected persons. No one had a moral responsibility to tell their sexual partners they were HIV positive.

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If you follow [the guidelines on the use of condoms], you don't need to worry about whether your partners know that you're positive. You've already protected them from infection and yourself from reinfection. Just use your judgment about whom to tell—there's still discrimination out there. Rotello In spite of the known failure rate of condoms even of the best of conditions Kelly and St.

Bayer Initially, some MSM changed their behavior.

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New infections declined. However, research into the behavior of MSM found that many were not following the code. A survey of gay men in San Francisco found that Research :.

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Siegel et al. A study found that 67 percent of MSM admitted engaging in anal intercourse without condoms during the year. Many of those who initially adopted safer sex practices failed to persist:. It appears, then that some of the factors associated with continued participation in high-risk sexual behavior are resistant to current educative intervention.

Educational campaigns, however well executed and well intentioned, have been insufficient to stem the spread of HIV infections. Jones et al. Most of the men in our sample were highly educated, mature adults. All were well informed about the transmissibility of AIDS through sexual activity and could describe the specific measures necessary to protect against infection.

Yet even under these relatively ideal conditions, the large majority of these informed men did not adopt and maintain behavior to the extent necessary to prevent HIV infection in themselves or others.

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The gay AIDS establishment defended the right of infected persons to remain ignorant of their condition and the right of infected persons to conceal their contagious condition from others, including sexual partners and healthcare personnel. They wanted gay bathhouses kept open, arguing that they could be places to impart prevention education, and distribute condoms Nieves Prevention efforts were focused on self-protection rather than the duty to protect others:.

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It was considered crucial to articulate an ideology of solidarity, one that rejected as divisive all efforts to distinguish the infected from the uninfected. Nieves AIDS educators were:. Suggestions that the infected might have a duty toward others were often greeted with scorn. For example:.

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To mark the occasion of the city's [N. It was assumed by those outside the gay community that fear of contracting an incurable, debilitating disease would motivate gay men to refrain from risky sexual activity, but the gay community reacted to the crisis by romanticizing HIV infection:. HIV-positive status was portrayed in some homosexual publications as more fun.

An editorial in Steama magazine aimed at gay men, quotes a man who has been positive since the early years of the epidemic:. I'm so sick and tired of these Negatives whining about how difficult it is to stay safe. Why don't they just get over it and get Positive.

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Rotello I'm delighted to be Positive … The Negative world is defined by fear, ours by pleasure. Those who died of AIDS were memorialized as martyrs. Walt Odets, a gay psychologist—writing when the AIDS diagnosis was still a death sentence—argued that if it was a choice between anal intercourse AI and other high risk practices and life, homosexual men should feel free to choose AI and take their chances. Odets felt that those who deed the condom code ignore the realities of gay life:.

The idea that gay men would readily adapt to condoms, ignore or fail to recognize their limitations, and, according to many educators, have fun with them is rooted in homophobia.

Part i—the epidemic

Also homophobic is the expectation that gay men ought to feel shame and guilt for not liking them and, often, not using them. Odets condemned the social marketing model embodied in the condom code, and did not believe that this approach had ever really been successful. In this Odets was correct, a careful study of the epidemic revealed that the dramatic drop in new infections in the late s was in large part due to epidemic saturation Rotello— Epidemic saturation occurs when a ificant portion of an at-risk population is infected, usually those most vulnerable—in this case promiscuous gay men with multiple concurrent partners.

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Since, as the of the infected increased, the of uninfected decreased and since those uninfected at that stage of the epidemic were less likely to be engaged in multiple high-risk acts, the epidemic has fewer and fewer potential victims. It was burning itself out. However, as soon as more young men entered the gay community, the rate of new infections began to rise and continues to rise Morris and Dean ; Hoover et al.

The process of epidemic saturation was recorded in blood samples taken from MSM from toas part of a longitudinal hepatitis B vaccine trial. Testing revealed that by The data suggests that lack of knowledge about HIV transmission is insufficient in explaining risk-taking.

Rather, rationalization processes may be a factor in the sexual risk-taking behaviors of young HIV—negative men, and moreover, deep intrapyschic processes often heightened by concurrent substance useand the desire to please sexual partners may drive the decision-making of these men.

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