Shaping the Meaning of HIV for Men who have Sex with Men:
Perspectives in Contemporary HIV/AIDS in Los Angeles
WORKING NOTATIONS/DRAFT
REVISION: October 3, 2005
Tyler P. Haugen
California State University, Northridge
Department of Sociology
18111 Nordhoff Street
Northridge, CA 91330
(818) 677-3591
STATEMENT OF THE PROBLEM
Today, the World Health Organization (W.H.O.) estimates that “42 million people worldwide are living with HIV/AIDS” (p. 2). While seventy percent of those who are infected are living in Sub-Saharan Africa, there are still estimated to be 950,000 US residents living with HIV infection (p. 2). AIDS is now the fifth leading cause of death in the U.S. among persons aged 25-44 and the leading cause of death for African Americans in this age group (p. 2). Optimistic news was released when it was found that in the U.S. AIDS related deaths fell almost 70 percent from 1995 to 2001 (p. 3).
While some recent statistics released by the Centers for Disease Control (CDC) from 2000 provided hope that HIV and AIDS was to soon be eradicated in the United States, by 2002 it was found that certain populations [such as men who have sex with men (MSM)] within the United States have rapidly growing HIV rates. According to the CDC (2002), persons aged 25-34 represented 28% of all new diagnoses of HIV/AIDS in the United States (p. 6). In addition to age, the category of sex became a dividing line for new HIV infection. In the United States, males accounted for 71% of all new HIV/AIDS diagnoses among adults (p. 6). Upon further analysis of the recently HIV infected male population, mechanism of exposure became a critical concern. Of the five categories of exposure identified by the CDC, including injection drug use, heterosexual contact, male-to-male sexual contact which occurs in conjunction with injection drug use, and “other” (such as hemophilia and blood transfusions) all categories saw a decrease from 1999 to 2002 with the exception of male to male sexual contact (p. 10). Male to male sexual contact in the United States spiked 17.06% from 1999 to 2002, see Table 1. Further, when comparing the United States to California, (all sexes and exposure categories), California has seen an increase in HIV/AIDS of over 226% from 1999 to 2002.
Table 1. Estimated numbers of diagnoses of HIV/AIDS for adult male and adolescent males, by year of diagnosis and exposure category in the United States.
Year of DiagnosisExposure Category / 1999 / 2000 / 2001 / 2002 / Change ’99-‘02
Male-to-male sexual contact / 9995 / 10519 / 10974 / 11701 / +17.06%
Injection drug use / 3029 / 2940 / 2715 / 2757 / -8.98%
Male-to-male sexual contact and injection drug use / 1066 / 962 / 948 / 943 / -11.54%
Heterosexual contact / 3237 / 3252 / 3191 / 3234 / -0.09%
Other including hemophilia, blood transfusions, and other non-reported risk / 166 / 167 / 167 / 164 / -1.20%
Source: CDC (2002: 10).
Table 2. Estimated numbers of diagnosis of HIV/AIDS for all men and women of all exposure categories, by year of diagnosis, California versus the United States.
Year of Diagnosis1999 / 2000 / 2001 / 2002 / Change
’99-‘02
California / 2274 / 2537 / 3521 / 5155 / +226.70%
United States / 25174 / 25522 / 25643 / 26464 / +4%
Source: CDC (2002: 10) & California DHS (2005: 2).
While nationally, there has been a mild increase in the amount of HIV & AIDS diagnosis in recent years (1999-2002), California has seen a major increase in the numbers of HIV & AIDS cases reported (CDC 2002: 10 & California DHS 2005:2). To further narrow down the frequency of HIV & AIDS in Los Angeles, the most recent data from the Los Angeles County HIV Epidemiological Program must be used. In reviewing that data, (see Table 3), from 2002 to 2003, new diagnoses of HIV in Los Angeles County shot up from 1199 cases in 2002 to 7100 cases in 2003. While the cases of HIV decreased a bit from 2002 to 2003, they were still over double the amount of cases from 2002, resulting in a 242.54% increase in HIV cases in Los Angeles County from 2002-2004.
Table 3. HIV Cases 2002-2004 by Year of Diagnosis and Report. Los Angles County.
Year of Diagnosis2002 / 2003 / 2004 / Change
’02-‘04
Los Angeles County HIV Cases / 1199 / 7100 / 4107 / +242.54%
Source: Los Angeles Department of Health Services/Public Health (2004).
In looking at the population demographics of new HIV cases within Los Angeles County, the LA County Department of Health Services (2005) reported that males accounted for an overwhelming 84% of all new infections. Of those, White males accounted for 5082 cases, or 36% of all new HIV infections, more than any other racial category within Los Angeles County from 2002 to 2004. The second most prevalent racial category in new HIV infections for Los Angeles County from 2002 to 2004 was Latino males at 4849 cases, or 35%.
With the national increase in HIV among MSM from 1999 to 2002 as shown above, and the very poignant increase in HIV cases among White and Latino males in Los Angeles, this research project will seek to better understand what meanings and perceptions males who have become infected with HIV in the past six years (1999-2005) have about the disease. This project will then begin to explore what HIV means to men who are HIV positive and how the meanings of HIV come to play out in shaping sexual relations.
REVIEW OF LITERATURE
Impression Management
For the purposes of this research on HIV and specifically social interactions with regard to risky sexual behavior, it is most appropriate to take a symbolic interactionist perspective. The social interactions which guide behaviors, specifically those which can lead to risk sexual behavior are often shaped by the meanings assigned to those behaviors. Specifically, Goffman (1963) and his theories of stigma and impression management encapsulate much of the interactionist theoretical perspective on HIV and social interactions.
A central premise to understanding Goffman’s work is the idea of impression management. Impression management is the way an individual guides and controls the impression others have of him or her. Goffman (1963) insists that as a human whenever we are in the presence of others we are engaging in impression management. Goffman asserts that our impression management is done through performances, which include all the activity of an individual which occurs during a period, “marked by his continuous presence before a particular set of observers and which has some influence on the observers” (p. 39). Essential to this definition is the importance of the audience and therefore impression management happens while in the co-presence of others. For gay men with HIV, impression management can be a key to maintaining a “normal image” as dictated by society and avoidance of being deemed as deviant (Herdt 2001).
In seeking to control any potential stigma attached to HIV, Goffman would argue that we rationally calculate what information others learn about ourselves in an effort to minimize negative stigmas (Goffman 1963: 41). In line with Goffman’s argument, Herdt (2001) argues that fear of stigmatization shapes social interactions because individuals will use avoidance to ignore their HIV status, therefore never discussing it with their partners. Herdt further concludes that because we do not know how a potential partner will react to finding out HIV status we will simply avoid the issue all together to escape from the potential negative effects.
Stigmatization- Generalized
Lee, Kochman and Sikkema (2002) reported that the stigma which surrounds persons living with HIV is profound. They found that the level of stigma in the United States did decline a little in the past century but eighteen percent of American’s still believe that people who contracted HIV through sex or drug use received “exactly what they deserve” (Lee, Kochman & Sikkema 2002: 309). They concluded four reasons why the stigma with HIV is so great; the first reason is that the disease is perceived as the responsibility of the infected person because the means of contracting the disease are perceived to be voluntary and avoidable. The second reason is that the disease is perceived as a condition that is fatal and unchangeable, regardless of new and innovative medications. A third reason for the stigma is that HIV is contagious and therefore others fear it. The fourth reason for the stigma may not play a role for all HIV positive individuals, but for those who display outward signs and symptoms of disease the stigma is increased. Lee, Kochman, and Sikkema (2002) conclude that the stigma of the disease is really a combination of stigmas which are attached to the disease of HIV and the idea that HIV is connected to homosexuality.
Stigmatization- Sexual Partners
Serovich and Mosack (2003) found that males infected with HIV were often unlikely to tell their casual sex partners their HIV status. They found that 23% of those who were HIV positive told none of their casual sex partners, 40% told some, and only 37% told all (p. 73-74). In examining the reasons for disclosure or non-disclosure of HIV status, Serovich and Mosack (2003) concluded that the more the HIV infected person trusted and felt there was potential for a meaningful relationship with their partner, the greater chance they would tell that partner their HIV status (74). In further analysis with their participants Serovich and Mosack (2003) found that the shame and stigmatization was the largest factor underlying disclosure and non-disclosure (p. 76). Similarly, Wolitski et al. (2001) reported that stigmatization not only impacts disclosure but also intervention and prevention measures as a whole.
Drug Therapy and the Meaning of HIV
Glassner (1999) found that Americans often base their actions and beliefs on the idea that they live in a culture of fear, one in which violence runs high and everyone should be afraid of everyone else (p. xii). Blau (1964) argues that our daily social actions are based on rational choices in which we weight the alternatives and then take action. The problem recently with HIV and AIDS, is that people no longer fear the disease (Holtzman et al. 2001). Holtzman et al. (2001) primarily identify that people no longer fear HIV or AIDS because of two reasons, the first is recent advancements in HIV drug medications and the second is that recent advertising campaigns have downplayed the adverse health effects of HIV.
One of the primary concerns over the shift in HIV perceptions have been the advancements made in HIV medicine. Highly active antiretroviral therapy (HAART) has been a relatively new advancement in HIV treatment, but one that gives many the hope of living for decades (Katz, Schwarcz, Kellogg, Klausner, Dilley, Gibson, McFarland 2002). According to Katz et al. (2001) they found that the concern over this medical advancement is that people perceive that even if they do contract HIV, they can simply take a few pills and be just fine. Further, those who are already HIV positive were less concerned over transmission of the disease to others (p. 392). Another concern over HAART is that biologically, HAART drug treatment does reduce the HIV viral load in a single drop of semen and therefore some believe that it is okay to engage in unprotected sexual behavior because the risk of transmission is low (p. 388). Katz et al. (2001) conclude that because of the recent advancements in HAART there have been increases in risky sexual behavior that they suggest are equal to or greater than the beneficial impact of HAART on per contact HIV transmission rates (p. 392)
Finally, there are also some HIV positive males who engage in risky sexual behavior simply because of a “nothing to lose” perception (Wolitski et al. 2001). Part of this perception is that the highly active anti-retroviral therapy (HAART) medications are a “fix” for the HIV disease and that with their advances a cure for HIV is in the near future (Wolitski et al. 2001: 884). Wolitski et al. (2001) feel that the perception that HIV is no longer a real threat not only sends the message to already infected individuals that HIV is a less life threatening disease, but also for those who are HIV negative, there is a perception that even if infection does occur, a simple pill or two can fix it (p. 885). They felt these perception were directly linked to increases in unprotected sex among men who have sex with other men (MSM), citing that 22% of MSM in their last study reported not knowing their sexual partners HIV status prior to having unprotected sex (Wolitski et al. 2001: 884).
The Prevention Campaigns & Perceptions of HIV
Another area which has led to a shift in the lack of fear surrounding HIV among MSM is advertising (Holtzman et al. 2001). First, Holtzman et al (2001) found that in a survey of sexually active persons (ranging from 18-49 years old) the majority had a very misguided perception of their risk of contracting HIV. Only 4.1% of those in the study actually admitted that they were at any personal risk for contracting HIV, while in reality nearly one half of the respondents had engaged in some form of risky sexual behavior (p. 1883). The question of why people had misconceptions then was addressed. Holtzman et al. (2001) first identifies that part of the problem with HIV is that Americans are no longer seeing huge numbers of people dying from AIDS (primarily due to HAART) and the prevention advertising they do see only suggests the promise of hope and a healthy life, not death as was the case in most of the early 1990’s (p. 1882).
Further, age was also found to be related to effectiveness of HIV prevention campaigns (Wolitski et al. 2001: 884). They found that some youth experienced a “burnout” on AIDS and HIV campaigns, citing that many of the advertising campaigns were outdated or over simplistic. Benotsch, Kalichman and Cage (2001) argue that even when younger people do internalize HIV prevention campaigns, the messages they receive are often only a necessary component for prevention but not a sufficient one (p. 182).