The warning comes from three of the researchers who led the CDC's HIV/AIDS efforts in the first two decades of the AIDS epidemic. Lead study author Harold W. Jaffe, MD, was director of the CDC's National Center for HIV, STD and TB Prevention and now heads the department of public health at England's Oxford University.
"'Silence equals death' may unfortunately be regaining relevance for some men who have sex with men," Jaffe and colleagues write in the Nov. 28 issue of TheJournal of the American Medical Association.
That's not to say HIV infection is still the death sentence it was in the mid-1980s. It isn't. And that may be part of the problem. HIV drugs can postpone AIDS for decades. This means the current generation has not had the personal experience of their older gay brethren, who saw HIV devastate their friends and lovers.
"HIV treatment is so widely implemented in developed countries, I think people have begun to feel there is nothing to worry about. That is clearly not the case," Jaffe tells WebMD.
CDC outreach studies suggest that 10% of 15- to 29-year-old men who have sex with men are infected with HIV. More than two-thirds of these men don't know they're infected. And nearly 60% of the men who didn't know they were infected thought they were at low risk.
"These men may not literally be putting their lives at risk. But they are looking at a very serious illness, one that is going to be with them for the rest of their lives," Jaffe says. "You are talking about people having to take drugs for the rest of their lives -- drugs that have significant side effects. It is not acceptable to say, 'I will be infected, but so what?'"
Breaking the Silence
AIDS in the U.S. was first recognized among gay men in the 1980s. It couldn't have happened at a worse time. After a long struggle, American culture had finally begun to accept gay men. There was enormous resistance to HIV risk reduction, which many men saw as a threat to sexual self-expression.
But many gay community leaders spoke out and promoted safe-sex messages. The result was one of the largest and fastest behavior changes in the history of public health -- and a sharp decline in HIV infections among gay men.
These safe-sex messages now are not reaching young men who have sex with men -- especially men who don't consider themselves gay, men of color, and men whose larger communities still stigmatize homosexuality. Such men are far more likely to get, and spread, HIV.
"It is a particular issue for nonwhites, for both African Americans and Hispanics," Jaffe says. "And those are very hard populations to get to, because if you ask them to identify with messages tailored for the white, mainstream gay community, that may not be effective."
What's needed, Jaffe and colleagues suggest, is a new generation of leadership -- both in the public health community and in the communities of men who have sex with men.
"We have to start talking about his. We can't just say the status quo is OK, because it isn't," Jaffe says.
It isn't that gay community organizations aren't active any more. But their focus in recent years has been on advocating for expanded access to treatment and more funding for treatment research.
"Our hope is they will become more engaged in advocating more for prevention and prevention research," Jaffe says. "Where is the kind of advocacy we saw in the mid-'80s for safer sex and in the mid-'90s for treatment? Where is it?"
Jaffe's co-authors are Ronald O. Valdiserri, MD, MPH, former deputy director of the CDC's HIV/AIDS center and now chief consultant to the Veteran's Administration's Public Health Strategic Health Care Group; and Kevin M. De Cock, MD, former director of the CDC's division of AIDS prevention and now director of the World Health Organization's department of HIV/AIDS.