Most Humans With HIV Are Straight
Why are the US and Europe different? Can we end HIV?
Did I surprise you with my headline?
Most well informed, open-minded people understand that HIV and AIDS don’t exclusively impact gay male communities, but they know that gay men and transgender women are especially at risk for sexual transmission of the virus.
Right? Well, yes, but that’s not the whole story. What if I told you that almost everyone in the world with HIV contracted the virus through plain vanilla, penis/vagina sex?
That’s true, and I’ll show you data in a minute, but let me back up first.
In the United States and Europe, HIV decimated gay male communities in the 1980s and 90s. I’ve written a lot about what I call the Plague Years, when the Sword of Damocles dangled over gay men’s heads.
Getting Tested When AIDS Was a Death Sentence
How it FELT to know, why it’s different today
That’s the narrative that most North Americans and Europeans are familiar with. Worldwide, however, HIV is primarily transmitted by vaginal sex. A very large majority of people in the world with HIV became infected by heterosexual transmission.
According to data collected by the US CIA, in large parts of sub-saharan Africa, HIV prevalence ranges from 10% to more than 25% of the adult population. Almost all of those infections are attributable to penis/vagina sexual transmission.
In the United States by contrast, HIV prevalence falls somewhere around only 0.3%. While a majority of the people infected are gay men, the numbers are tiny compared to places where the epidemic is raging.
Click here to see a nation-by-nation breakdown of HIV adult-population prevalence.
Total numbers of people living with HIV —
According to UNAIDS, the United Nations agency tasked with coordinating an international response to the epidemic, most people with HIV live in sub-saharan Africa where 25.5 million people are HIV positive.
Only 2.1 million people in the US and western Europe combined are positive.
What do the numbers mean?
Even if every case of HIV in the US and western Europe resulted from men having sex with men, the overwhelmingly heterosexual epidemic in Africa still accounts for over 10 times more cases.
Additionally, in the United States and Europe combined, there were 72,000 new HIV infections in 2016, with something like 80% of them probably the result of men having sex with men.
In Africa, there were over 1.2 million new HIV infections, almost all of them resulting from men having sex with women.
So, if somebody were to tell you that the HIV epidemic is mostly not about gay men, they’d be correct.
So, why is the US different?
Why were gay male communities harder hit by HIV than straight communities when the epidemic began? This is a really important question with implications for how we can end the epidemic once and for all — at home and abroad.
The answer probably isn’t what you think —
It’s common knowledge that the disparities in prevalence rates result entirely from the higher risks of anal sex compared to vaginal sex. Anal sex is riskier than vaginal sex; that’s why so many gay men and transgender women became HIV positive.
That common knowledge makes sense and sounds entirely reasonable, but it happens to be wrong — not supported by data.
First, look at southern and eastern Africa today. HIV prevalence there is tragically high. Almost all of it is due to vaginal sex. So vaginal sex clearly works well enough for transmitting HIV.
Second, epidemiologists tell us that while anal sex is riskier for HIV transmission than vaginal sex, that higher risk cannot explain the huge differences in infection rates in the 80s and 90s.
The math doesn’t work, not by several orders of magnitude. The disparities in risk ALONE don’t explain what actually happened in the United States and Europe.
So what does explain it?
Gay male populations in the 1970s began to concentrate in major US cities and to become very insular and dense. Lots of gay men were packed into “gay ghettos” or tightly networked in small gay communities in cities that didn’t have actual gay neighborhoods.
Lots of men had sex with the same men — before anyone knew a deadly virus was loose among us. I understand how it happened, because I lived through it. Let me tell you a personal story to illustrate.
It all started at a gay bar —
I was a very young man, still a teenager, but I had finished Marine Corps boot camp, started college, and was feeling fit and fine. Ready for romance.
The Question Mark Bar and Grill in downtown Des Moines was just a small, smokey dive with a sticky dance floor. It was Shangri La to me, a gleaming, pink-neon paradise of freedom and erotic possibility.
The night in question started well. Some kids my age were ooh-ing and awe-ing over the muscles I’d grown over the summer. I was enjoying my new-found tequila-drinking skills.
We hit the the dance floor as a group, buzzed and a little high on sexual possibility. When we ordered fresh drinks, the bartender pointed out a pair of tall, handsome men in Stetsons sitting in a corner.
“Look, girls, you see them two over there? In the ten-gallon hats?”
My buddy Bobby whistled softly. “See em? That one’s a total hunk. Yum.”
I agreed. They were tall, lean, and dressed like cowboys. Best looking guys I’d seen all night. Bobby looked all set to walk over and throw himself at them.
The bartender reached out and grabbed him by the shoulder. “Listen up and listen good. Them guys are here from Texas. Dallas.”
“So?” I complained, pulling his hand off Bobby’s shoulder, “Big deal!”
I took the opportunity to draw Bobby in a little close. I wasn’t all that thrilled that he was so eagerly into the Texans.
He relaxed into me.
“You guys know about that thing, right?” The bartender just kept going. “That gay sickness thing? They call it GRID, sumpthin like that. Stands for something gay. It’s bad.”
Bobby tensed up. I could feel his spine stiffen like a rifle. “That’s right! Yeah. Gay dudes in big cities are getting it. A bunch of guys died even. Like gay cancer or something.”
So we stayed away from the Texans.
That’s where I was when I discovered AIDS, not long after the doctors did.
Four of us went to a cheap motel later. I had sex with Bobby without a condom. What were those? Straight guys used them so their girls didn’t get pregnant. We swapped partners a couple of times.
Gay cancer was in Texas and in California. We were just a foursome of wholesome Iowa boys.
What did we have to worry about?
To end HIV, UNAIDS and the US CDC target at-risk or insular communities with information about safer sex, testing, and treatment. Treatment as prevention is the key, because condoms haven’t been enough to end the epidemic.
HIV is still circulating, and while new infection rates are starting to come down in Africa and have plummeted in the US, they remain stubbornly level, and are even rising in some at-risk populations
Enter PrEP, stage left —
PrEP is an antiretroviral drug that prevents HIV infection almost all the time. Public health authorities strongly urge people at risk of HIV infection to use PrEP, which consists of one pill a day of a drug combination called Truvada.
PrEP is a crucial component of the new US CDC strategy to end HIV. Condoms still matter a lot. Safer sex is important for protecting against HIV and other sexually transmitted infections. But condoms haven’t been enough.
PrEP works, it’s safe, and where it’s been made readily available in at-risk populations, new infection rates have plummeted.
Truvada as PrEP is a public health success story. We can end the epidemic if we strangle the circulation of the virus, and the CDC is working to do exactly that. Much of the battle involves identifying and effectively targeting close-knit communities of at-risk people
In the US, much of the battle is in southern states and rural areas, where new transmissions have never been effectively suppressed because of obstacles like HIV stigma, homophobia, transphobia, racism, and lack of access to healthcare.
Ending HIV means getting testing, treatment, and PrEP to the right people at the right time. Epidemiologists are confident. They say we can end HIV and save total health care dollars if we can harness the political will.
Are you at risk for HIV?
PrEP is not right for everybody. It also doesn’t mean you can stop using condoms. Hepatitis, syphilis, and drug-resistant bacterial STIs are no joke.
But if you’re a man or a transgender woman who has a lot of sex with men, PrEP could be exactly what you need to stay free of HIV. Click this link to learn more.
If you already have HIV, click this link and learn how you can live a long, full, loving life. HIV is not a death sentence. Treatment works. With condoms and PrEP, the day is coming when nobody will need treatment.