And the love, whatever it was, an infection.—Anne Sexton
Introduction: MSM = HIV?
It is universally acknowledged that the HIV/AIDS pandemic has been one of the most destructive public-health emergencies in human history. Famously called “the plague” early on by no lesser authority than Larry Kramer, the virus and syndrome of human-acquired immune deficiency is normally seen as a scourge laying waste to human life. Moreover, more sensitive recent HIV-surveillance methods indicate that the incidence—the annual rate of new infections—and, hence, the scope of the epidemic is greater than the Centers for Disease Control and Prevention had previously calculated, rising from an estimated forty thousand new infections each year to a figure closer to sixty thousand newly infected people in the United States alone since the advent of the pandemic.1 According to the CDC report, despite the tremendous treatment successes, more people are becoming in fected than ever before. What are the implications of a global epidemic raging stronger than ever before, perhaps infecting more people worldwide than ever before, while those infected by HIV now stand a better chance of living a “normal” life than ever before, thanks to the relative efficacy and accessibility of HIV/AIDS treatment, at least in the West?2
This is one of the evolving contradictions in the “epidemic of significations,” to borrow Paula Treichler’s phrase, that HIV/AIDS un leashed on an unsuspecting public in 1981. First affecting the so-called “4H” groups—homosexuals, heroin addicts, Haitians, and [End Page 82] hemophiliacs—HIV/AIDS now weighs heavily on heterosexual communities of color. This expansion of the populations affected by the epidemic has shifted the ground of public-health activism within the community originally most active in battling governmental indifference to the ravages of AIDS: gay and bisexual men, which the CDC now terms merely a “subpopulation” ensnared in the cruel probabilities of HIV transmission.3 Evolving from “gay cancer”—the so-called “GRID,” or gay-related immune-deficiency—to an equal-opportunity vector of transmission, HIV/AIDS is no longer a gay disease, or even a Western one.
There is a paradox, therefore, in the extent to which prevention science has focused and continues to focus on the population construct of “men who have sex with men” (MSM) almost to the exclusion of other segments of the overall population. The visibility of public health campaigns targeting MSM maintains a social contract between sexual behavior among men and HIV transmission, despite our knowledge of HIV as an equal-opportunity pathogen transmitted almost as likely through vaginal as through anal sex. It is ironic that we continue to worry about the high rates of infection in MSM communities, particularly among younger men and MSM of color, according to the latest epidemiological studies.4 There is a whole lot of public hand-wringing over MSM—specifically, hand-wringing over increasing incidence rates within this population, precisely despite decades of focused HIV-prevention efforts dedicated to diminishing the impact of HIV/AIDS within communities of gay and bisexual men. Despite the global face of the epidemic, it seems, MSM remain the epicenter of the epidemic and the public discourse that surrounds it.
As neutral public-health parlance for gay- and nongay-identified men whose HIV-risk behavior is homosexual sex, “MSM” indicates the evolution and the lack of evolution, simultaneously, of our public imagination regarding—literally looking at—AIDS. As a cover for “gay and bisexual” without seemingly reducing the behavior to sexual identity as such, the public health discourse on MSM continues to center on the elevated risks of HIV transmission between men. These risks, it seems, are constructed as greater than those linked to heterosexual contact—unless, of course, said contact depends on an MSM vector of transmission: the so-called “down-low” brother carrying the virus into the general population. There is a triangular nature to this [End Page 83] transmission scheme, whereby homo-sex is the agent of contamination infiltrating supposedly HIV-naïve populations of heterosexual women (and, coming full circle, heterosexual men). This epidemiological transmission plot seems familiar and this...