There’s an old war story about working as a community organizer in the early years of the AIDS epidemic. During a meeting in which the U.S. Centers for Disease Control and Prevention was showing off a new education initiative aimed at African Americans, an activist complained that none of the posters targeted gay men. Not so, the CDC officials eagerly pointed out–one depicted a man shadow boxing with a caged canary. This, they said, would surely indicate his homosexuality.
The idea is laughable today, when you can find HIV prevention workshops on how to safely engage in anal fisting. But as we plow into the epidemic’s third decade, still facing an estimated 40,000 new infections each year, a dangerous confluence of scientific fatigue and right-wing invigoration is bringing public health policy to the verge of a national déjà vu.
The Bush administration has launched an unprecedented number of high profile audits of community groups working with gay men, charging them with misusing federal funds by “promoting sexual activity.” Nationwide concern over this increased government hostility to admittedly provocative work exploded into alarm in April, when the CDC announced it was changing its HIV prevention funding priorities.
Traditional HIV prevention aims to educate an entire community, instilling the value that anyone who’s sexually active or using injection drugs is at risk, and encouraging behavior that reduces that risk. Last year, the CDC spent roughly $400 million on such campaigns, directly financing community-led projects and funneling additional funds through the states. But the agency now says this brand of “primary prevention” has failed.
The problem, CDC maintains, is that not enough people know they are HIV positive. The agency estimates that almost a quarter of a million people are walking around unknowingly infected; New York City epidemiologists say 25,000 of them live here. One much-discussed study found that nine out of 10 twenty-something black gay men who are positive don’t realize it. So the feds want local health departments and community groups to focus on the basics: zero in on pools of people likely to contain a high percentage of positives, test them, then trace their sex and drug-use partners.
Once those positive people are identified, groups can still sit them down for the more traditional prevention work–ranging from offering information on how the virus is transmitted to counseling in order to decrease risky behaviors. This approach works best, argues CDC’s HIV-prevention chief, Ron Janssen, when applied to HIV-positive people. He points to studies showing that efforts to change risky behavior among those who are negative work only about 20 to 30 percent of the time. Meanwhile, research shows a 60-to-80 percent return on work to prevent risk behavior among people who have tested positive–people who are necessarily involved in any virus transmission.
“It’s very science-based,” concludes Janssen, one of the plan’s chief architects.
All of this would make perfect sense if HIV prevention had ever been solely about science, or even public health. But the epidemic’s easiest targets are poor people of color, and the road to behavior change for people in this demographic, be they positive or negative, is a long and winding one that may not even pass through the testing stage.
“The things you have to put in place really speak to social services,” insists Harlem United’s impassioned prevention director, Soraya Elcock. To address risk behavior, her clients first have to deal with housing crises, detox and food shortages. “And that’s the funky dynamic,” she says. “That’s why it’s hard for public health dollars to go to it.”
Because of the epidemic’s unique history, prevention also involves wrestling with a community’s political and social values as much as its health–the disease, after all, was originally dubbed Gay Related Immune Disorder. “I’m not just changing your behavior; I’m working on a whole community,” says Elcock. “I’ve also got to get grandma to change the way she feels about the gay boy who’s her grandson. Because if he’s still living in shame and secret…he’s gonna go to the park, suck a little cock and come home and pretend.”
Elcock’s character choice is not rhetorical. He’s the prototypical target for today’s most aggressive and cutting-edge prevention campaigns: young, black, gay and closeted. Epidemiologists warn that HIV is galloping forward in this population at a speed akin to that in southern Africa, and the CDC has floated the notion that these men may at least be contributing to the skyrocketing rates among young straight black women as well.
The primary mission of Brooklyn’s People of Color in Crisis is to craft prevention campaigns for this population. In August, it sponsored a weekend’s worth of black gay pride events–from a beach party to a drag ball–all excuses to get 10,000 men in one place not just to conduct HIV tests, but also to work on their sense of identity and self-worth. Year round, the group offers programs like couples counseling and safe sex workshops, and every dime of its money comes from federal funding–money that is now supposed to be used for narrowly focused efforts to identify positive people and link them to treatment.
Local health departments can choose to ignore the CDC’s new priorities. But the funding pool for community-led projects is now much more restricted. For instance, the roughly $90 million budgeted by Congress to fund groups doing prevention work with people of color directly this year is being redirected to the new initiative. Funding sent through local governments must also support work in epidemiology and other essential public health efforts.
But what troubles people like POCC director Gary English most is the climate in which these changes are taking place. POCC is the latest in a series of community groups working with gay men in large urban areas to become ensnared in what many see as orchestrated federal harassment, led by conservative politicos anxious to return to the days of shadow boxing with canaries.
Last year, egged on by Indiana Republican Rep. Mark Souder, the Department of Health and Human Services accused a 19-year-old San Francisco prevention program of “promoting” sex–in violation of rules governing the use of CDC dollars–with workshops on topics like having “safe and friendly relations” with
hustlers. Undeterred by vocal protests from all over the country, HHS launched similar investigations of groups working with gay men in Washington, D.C., and St. Louis. Then, this June, POCC discovered CDC officials were asking the same questions about an email POCC sent out soliciting proposals for a workshop on “erotic sex.”
Defenders of these programs say campaigns targeting sexually active gay men, particularly young ones, only work when they discuss sex in the language and context of real life. In fact, the CDC’s own compendium of model programs highlights such a project, one targeting young gay men in Oregon. The participants’ reported incidence of unprotected anal sex dropped by a quarter after a series of workshops that included tips on making safety sexy. “You don’t get HIV from a smile,” English scoffs. “You get it from sex. It’s unprotected sex, and we need to talk to people about it.”
But the Bush administration’s HHS is peopled with decision makers who have long said otherwise. In April, news broke that federal grant officers were advising researchers not to include phrases like “sex worker,” “anal sex” and “needle exchange” in their proposals. The new Presidential Advisory Council on HIV/AIDS is stacked with some of the nation’s strongest proponents of abstinence-only sex education. Its chair, former Oklahoma Rep. Tom Coburn, once argued the CDC was engaging in criminal behavior by promoting condom use despite what he insists is proof that it is an ineffective way to block sexually transmitted diseases.
“So the CDC is coming out with this whole testing campaign,” warns English, “I think because it is being partially driven by the right wing. The CDC wants to do something safe.”
The CDC’s focus on changing the behavior of positive people and finding their partners is also disquieting. In 18 states, people who know they are positive and don’t disclose it to their sex partners can be jailed–whether they’re having protected sex or not, and regardless of whether the virus has been transmitted. And the same Bush advisors who have challenged cutting-edge prevention campaigns have long called on public health officials to demand people with HIV take greater responsibility for their actions.
Concerned Women for America is among the new CDC initiative’s most vocal supporters. Joe McIlhaney, the favored researcher of the abstinence-only movement, congratulated the CDC for “being dissatisfied with the status quo.”
“You hear people on the right say, ‘This is great,'” acknowledges the CDC’s Janssen. “And that creates great concern in the community.” Janssen spent the summer traveling throughout the country, trying to convince community leaders that his agenda is distinct from that of the right-wingers they fear. “People think it’s the sex police,” he sighs. “I agree that this is the political environment that we live in. But that’s not what is driving this initiative.”
But to Harlem United’s Elcock, even if the initiative is well-meaning, it still marks an unfortunate retreat: Moving HIV from being a problem for everyone to deal with back to one that only diseased individuals need to worry about. “We have done a lot of work to make people feel we’re all at risk in some way,” Elcock insists. “If, at the end of the day, people want to say that all prevention did in its old paradigm was put AIDS awareness out in the world, that was major enough.”