Introduction
Across the world in March of 2020, the colloquial usage of the word pandemic skyrocketed upon the initial discovery of the novel coronavirus that causes COVID-19. The several years in the fight against COVID has set a modern-day precedent for what a pandemic looks like in our world. The constant debates around dissemination of resources, vaccination policy and an overall overhaul of public life have left governments and persons in common with only one thing— how in shambles we all are. The uncertainty, the illness, the isolation, even the mortality was foreign to many; however, for the LGBTQ+ community, dealing with these emotions related to the long-standing fight against HIV is nothing new.
HIV, or Human Immunodeficiency Virus, is a virus that attacks and destroys CD4 T lymphocyte cells ( referred to as just “t-cells”), or the body’s infection-fighting white blood cells. Without them, it’s difficult to fight off infections, illness and even cancer. Untreated HIV is the virus that causes AIDS, or Acquired Immunodeficiency Syndrome, which causes rapid decline and destruction of the immune system. Despite HIV being formally declared an epidemic in 1981, in lower-income nations, queer communities and, particularly, the intersections between them— HIV is still a crisis.
From transmission to treatment, HIV and COVID-19 are two very different viruses, but both are indicative of human reaction to major viral outbreak. COVID-19 is the greatest example, since the HIV/AIDS crisis, of two pandemics overlapping. The timeline, universality and intensity of COVID make it an ideal reference point for hypothetical future pandemics as a source of comparison to the long-standing HIV epidemic. With climate change and the rise of animal-human interaction, our future with pandemics is not ending anytime soon. HIV research and innovation has been decades-long and highly stigmatized, and in years-coming, research predicts that the resources required to conduct this work only seem to slim out. Matters of public health are matters of people. Queer and marginalized communities worldwide have to monitor community practice and destabilize stigma through education in order to combat the effects of a changing Earth and unequally disseminated medical resources; ultimately with the goal of keeping queer sex (and culture) safe and alive.
HIV History and Stigma
From Princess Diana’s handshakes to ACT UP’s worldwide proclamations of “Silence = Death” and what a 1988 edition of the science journal, nature, describes as, “Seven years into the AIDS epidemic, US President Ronald Reagan appears still not to have resolved his ambivalent attitude towards AIDS, nor to have found any way to balance conservative and liberal opinion other than by inaction.” (Nature Publishing Group, 1988); the HIV epidemic has been shrouded in controversy in the world’s social, biological and institutional landscapes. Despite a person’s susceptibility to HIV through many means (e.g intravenous drugs, from pregnant parent to child or contact with a HIV-positive person’s bodily fluids), attribution to the spread of the disease remains imbued solely with the community of men who have sex with other men, referred to as MSM. Even today, MSM are more greatly affected by HIV across the world, in which the estimated lifetime risk for HIV infection among MSM is one in six (as compared to their male and female heterosexual counterparts at one in 524 and 253 respectively). Yet, constant associations between the two in popular culture and media discourse, creates tangible stigma and further marginalization for queer men, rather than societal goals to eradicate the disease altogether.
Looking deeper into the intersectionality around those who live with HIV, race plays a great factor into current HIV positivity rates. HIV Epidemiological Update in 2004-5 found that the prevalence of HIV infection amongst Black MSM was 46%— more than double of their white counterparts (at 21% respectively).4 These racial divides in transmission extend far beyond purely the American perspective, but into a larger world framework. HIV transmission is still present in countries that have criminalized LGBTQ+ populations, often existing at higher rates. Nigeria, for example, has adopted the ‘Same Sex Marriage Prohibition Bill’5, which prosecutes same-sex marriage and supporters of such, yet has the highest HIV burden in Sub-Saharan Africa which accounts for 67% of HIV cases observed globally today.6 Stigma, as through legislation and culture in Black-American communities and African countries, serves as a catalyst for the continued HIV infection of Black men around the world. For queer Black men and all those MSM alike, these negative associations surrounding the disease have created complex and deeply rooted stigma and have long impacted MSM’s ability to receive adequate preventative care, STI testing and medication.
Struggles in the Implementation of Contemporary Medical Innovation
PrEP, or Pre-Exposure Prophylaxis, is a broader term referring to the usage of medication as a precautionary measure to prevent the spread of disease in those who have not been exposed to a virus or other disease-causing agent, but of larger medical organizations and colloquially it is used in reference to the antiviral medication used to mitigate HIV spread. It has been largely successful in this task, yet many barriers stand in its way to becoming widespread amongst MSM populations. Firstly, to exemplify the effects of stigma on PrEP usage, despite in clinical trials PrEP reaching 99% efficacy in stopping HIV spread7, in a 2022 Lancet Public Health study done on the real-world effectiveness of PrEP, “PrEP effectiveness was significantly reduced in people younger than 30 years (26% [–21 to 54]) and in those who were socioeconomically deprived (–64% [–392 to 45]), both of which groups showed low amounts of PrEP consumption and high rates of PrEP discontinuation.” Despite PrEP’s existence, structural impediments like lack of insurance to cover PrEP’s cost, greatly impede the working and lower-classes from being able to access preventive care. In many countries (or their smaller counties, provinces or states) political controversy often bars queer people from accessing sexual health care, “to have an impact in decreasing HIV incidence, clinicians will need to be willing to prescribe PrEP.”
Yet, beyond sociopolitical conflict, there are epidemiological struggles in being able to disseminate HIV preventative and curative care. The first findings of the SARS-Cov-2 virus, which causes COVID-19, stopped research in across all other medical fields, “many clinical research projects ground to a halt as clinicians were redeployed to COVID-19 wards, and lockdowns prevented face-to-face appointments. These trials included large, national and international studies investigating treatments for chronic diseases that themselves cause millions of deaths each year.” The “Dusseldorf Man” is the 5th person to be cured of HIV on Earth with an intensive stem cell transplant process. Research into HIV cures, vaccination and other forms of care has been a long-term and worldwide process—one that has produced results, but can come to a halt with the discovery of other potentially catastrophic viruses, like COVID-19. Managing the livelihoods of those with HIV, even with the presence of other widespread diseases, cannot come to a halt. As greater ecological changes (e.g climate-change-motivated animal migration) on Earth increase the future possibility of prevalent epidemics and pandemics in our lifetime, populations with greater communal exposure to the disease (i.e MSM or queer men) cannot rely on solely medical intervention to support the mitigation of HIV.
Cyclical Environmental Burdens
Beyond epidemiological effects, in both medical innovation and patterns of human behavior, growing climate and environmental changes are affecting the spread of HIV. Climate change can motivate the migration of animals in the same way it can humans. Sub-Saharan Africa, who is combating HIV at a greater-level than most parts of the world, is also slated to see 86 million people leave their native countries as climate refugees by 2050, due to water shortage and crop productivity. The act of escaping extreme temperatures, harsher weather, even famine and drought, decreases proximity between populations and ultimately expands the larger world sexual disease network. It’s also important to note the presence of survival sex work existing within this population. For migrants moving to countries under capitalism, there are greater risks of community-based and personal cases of food insecurity— part of operating underneath this structure is engaging sex work. Spreading disease through sex expands far beyond romantic relationships, but into the economics of the impoverished.
Environmental issues also exist within the sphere of medical innovation. There are many struggles in the development of an HIV vaccine as “the virus itself integrates into host DNA… we can’t use that [live attenuated vaccines] for HIV because of the concern that live attenuated virus could integrate into the [host cells’] DNA and elicit disease.” Researchers are looking into the development of monoclonal antibody-virus treatments as an alternative way of developing a HIV vaccine, which is a process of isolating broadly neutralizing antibodies, synthetically creating them and putting them into vaccines. This promising research introduces a new (or old) problem: storage. Mass storage and deep-freezing of vaccines has the potential to spike CO2 emissions. As observed in Germany by the vaccine creation and distribution of COVID-19 vaccines, “Until now, one million doses of two mRNA vaccines have been injected in Germany and has emitted 1100 kg CO2, due to the different freezing temperatures of vaccines and their cold supply chain” These figures are for a single country and only across one vaccine that requires two doses and optional yearly boosters. The research into a PrEP method of vaccine development finds that recipients would need to receive an injection every three to six months in order to maintain its efficacy. This increase in the number of vaccines needed over time to keep populations safe sits alongside the large amounts of microplastics and other bio waste created in the packaging and facilitation of vaccines. This contributes to higher volumes of waste in marine landfills and greenhouse gas emissions. In both matters of the personal and biological, forced migration and the HIV spread resulting from can be observed as a result of climate change, and solutions for mitigating it contribute to worsening climate change overall. A cycle has been created, but what can be done to break it?
Education, Access and Change
With all of the epidemiological and environmental challenges that the world’s HIV epidemics present, MSMs, particularly those in lower-income countries, can no longer rely solely on medical intervention to mitigate the spread of disease to themselves and their surrounding community members. Living in this world landscape, all people must fight for improvements in universal sexual health education, changes in social behavior and equal contraceptive access in order to keep safe HIV-predisposed populations.
Sexual health education is a highly debated and politicized topic in many parts of the world. With most United States teens becoming sexually active around 17, having adequate sexual education prior to this is paramount in keeping younger populations safe from sexually-transmitted infection, pregnancy and other social and medical struggles. While the vast majority of secondary schools teach sex ed (93%), the content of these programs is not standardized, particularly as it relates to geographical politics. A study performed by researchers at the Guttmacher Institute, found that teaching abstinence as the only form of preventing pregnancy and STI contraction is taught in the American South at almost double the rate of the Northeast (30% to 17%) respectively. Particularly as it relates to MSM’s transmission of HIV, the same study showed sexual orientation (homosexuality) was taught in 39.5% of Southern schools and barely above 50% of schools in the West and Midwest of the United States. This data also represents the United States– in countries with greater criminalized LGBTQ+ populations or strict religious governments, all people (those queer and not) often do not have the privilege to have sex ed in schools of any kind. Religion, local and federal politics and personal ethics are often conflated with science in regards to the dissemination (or lack thereof) of medically-substantiated sexual health information.
In addition to access to information, people need access to physical aids in maintaining their sexual health. Contraceptives are banned or stringently restricted in countries like Nigeria, The Philippines, and Indonesia. These numbers also largely coincide with regions of the world facing rising numbers of HIV; the Philippines, which sports the lowest usage rates of condoms in the entirety of the country, is “one of seven other countries in the world where HIV cases have risen by 25 percent, or even more, since 2001” (World Population Review, 2023). Similarly to sexual health education, religion and moral objections are being conflated with legislation of public health. Abstinence-only sex education, or no sex education at all, does not effectively decrease the number of teenagers having sex, it only renders them uneducated on their health and bodies; preventing them from knowing the contraceptives that will keep them safe. Grassroots organizations are beginning to do this work independently; The Condom Collective is an effort created by Advocates for Youth based out of the United States in which 1,000 university students across the country are sent 500 condoms to distribute across their respective campuses. Yet, despite the debates around reproductive health in the USA, condoms are available around the country; these efforts need to be expanded on the international level to address the rising rates of HIV (and other STIs) in many developing countries of which contraceptives are largely inaccessible.
The dating app Grindr and its derivatives have served as pinnacles for modern-day homosocial interactions, making it easier than ever for MSMs to get in contact with fellow community members— and their diseases. Yet, the omnipresence of social media provides advocates with an opportunity to better inform people of how to maintain their sexual health.
Instagram, TikTok and even dating apps, like Grindr and Tinder, need to be utilized, not only, to tell people to get tested for HIV and other STIs, but also, to show them how and where to get tested. This also needs to be paired with a change in community behavior. PrEP is not a replacement for condoms, particularly when having multiple consistent sexual partners, but something to be used in conjunction with external contraceptives. Queer communities are often wrongfully stereotyped by their usage of alcohol and drugs, like amyl nitrite or colloquially– poppers, yet much of queer nightlife incentivizes drug use, often as a vehicle for sexual activity. These substances impair both one’s ability to give consent and be proactive about contraceptive usage; community-wide efforts need to be made to encourage sobriety in these spaces and between sexual partners.
Conclusion
The complex relationship between HIV and sustainability efforts proves the importance of adopting holistic and community-based praxis to address the many challenges posed by both issues and the people that rest at their intersections. By acknowledging and addressing the symbiotic relationship between the health of the environment and the health of the human body, we can work toward a future of finding effective HIV interventions whilst also promoting environmental sustainability. Collaboration among public health practitioners, environmentalists, policymakers, and community leaders, via mass media and publicized, accessible marketing platforms is essential in forging innovative solutions that not only mitigate the impact of HIV but also reach those who need it most. In all of the continued struggle to balance the epidemiologic, environmental and social implications of HIV epidemics, the modern day finds us better equipped for the struggle. Yet, navigating the HIV crisis works only if individuals and organizations, particularly those of high-income class and country, find ways to be sustainable in other parts of life and leave the environmental effects of medicinal research and maintenance to take up the brunt of our ecological impact. Ultimately, we’re navigating the sustainability of humans. Disease is a matter of all people, not those of a select community, as it will take all of us to eliminate it.
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