Our HIV Crisis?
2 CommentsThe minute he placed the wooden phallus on the table, giggles erupted and eyes widened. “Let’s talk about condom usage,” announced the seminar leader to a roomful of freshmen last August. “Remember when you’re putting it on, you want it to look like a sombrero, not a beanie.”
His co-leader chimed in. “Gently roll it down and pinch the tip of the condom. If air gets in, you risk breakage.”
When the momentary entertainment subsided, the phallus quickly disappeared to avoid distracting the freshmen, and the two student-leaders moved on to a different topic: “What are some methods of birth control?”
This scene has become a hallmark of the opening days of the academic year. Amid nightly meetings with freshman counselors, far too many extracurricular introductions and countless workshops, a laugh is always guaranteed at one point during final, fast-paced days of August: when the mock penis appears.
However, at a school where 28 percent of male students report having had same-sex romantic or sexual interactions, the scene above takes on a different tone when accounting for a morbid fact: From 2001 to 2011, the Centers for Disease Control and Prevention observed a nearly 133 percent increase in HIV incidence among gay men aged 13 to 24. Many of these young men contracted the virus due to lax condom usage or the failure to take similar precautions with respect to their sexual health.
When informed of these trends, the workshop leader, who wished to remain anonymous, responded: “I suppose the laughter would stop if you prefaced the condom demonstration with that statistic.”
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An individual’s risk of contracting a sexually transmitted infection is largely a function of his or her sexual network — essentially a social network defined by the sexual relationships in a given population — and his or her own behavior.
One might expect such networks to be relatively insular at a school that calls its campus a “bubble.” But Michael Rigsby, Yale Health’s medical director, is quick to acknowledge that Yale’s sexual network extends far beyond the edge of campus.
Rigsby says the average student overlooks certain groups that nevertheless comprise an integral part of Yale College’s sexual network. These include students in the graduate and professional schools, some of whom have a decade of sexual experience over their undergraduate partners and are more comfortable with risk-taking behavior; citizens of New Haven, brought closer by anonymous hookup apps like Grindr and Tinder; young alumni who return to campus from metropolitan areas for various events; and even New York residents, as students tired of the local scene might train in to the city for a night of fun.
As a network stretches to include more at-risk members and becomes more connected, the chance of STI transmission increases. This is especially true for gay and bisexual men, who are limited to a much smaller population of potential sexual partners. A simple dorm room fling one night might not be as innocuous at second glance.
Misunderstandings of Yale’s own sexual network certainly raise eyebrows, but health providers like Rigsby express greater concern over the cohort of young gay men who take up residence in New York City full-time after graduation. Their anxiety is not unfounded, as one Yale College 2014 graduate, who wished to remain anonymous to share a personal experience, knows firsthand.
“It’s actually difficult to talk about Yale College and HIV education because I recently needed to begin a round of PEP [post-exposure prophylaxis, a course of drugs taken to prevent HIV contraction after potential exposure] and will start Truvada when the drug course is over,” he says. “At Yale we live in such a pristine version of what the real world is. You’ll never encounter on campus the man who says he’s slipped on a condom but really never did, only to tell you that he is HIV-positive but undetectable as he leaves.”
Luckily for the recent graduate, who is currently without health insurance, he was able to start a round of PEP through a makeshift support network and Gay Men’s Health Crisis. Their resources put him in contact with a team at Mount Sinai Hospital studying the treatment.
When he went to the pharmacy to pick up his prescription, he remembers very clearly the pharmacist asking for insurance information. When he told her he didn’t have any but presented a voucher, she sighed, saying, “ Thank God — this just got picked up to $1,700 a course.”
“The conversation around gay men’s sexual health was lacking on campus, and I was honestly surprised how unprepared I was to have conversations about HIV when I needed to,” he continues. “Everyone is on PrEP and everyone is neg in New York City according to common wisdom — it’s crazy the amnesia we’ve thrown ourselves into for the sake of comfort.”
Conversations about sexual health are difficult enough to have with peers. And, as this recent graduate knows, they are sometimes impossible to have in an honest, open way with new sexual partners without a tactful strategy in mind. He admits that his experience is not ubiquitous, but he feels it is nevertheless representative of a reality check that awaits many as they transition from a sheltered place like Yale to the real world.
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Thirty years after doctors first observed AIDS in the United States, Yale continues to play two roles in the fight against the disease: As a research university, it must search for more effective treatments and eventually a cure. As a home to young, sexually active students, including a sizable gay population, it must care for its own. Although the University plays the former role as well as any other institution, how to best achieve the latter remains unclear.
“We’ve all been trying to figure this out since the earliest days of the AIDS epidemic,” says Rigsby. “Of course universities will continue to do research. But we should also always be open to doing more.”
According to Rigsby, at the peak of the crisis, the University viewed itself as the primary diagnostic and treatment facility in New Haven, then a hotspot for HIV/AIDS among intravenous drug users. And in 1997, Yale took a huge step in combating the crisis by establishing the Center for Interdisciplinary Research on AIDS.
CIRA’s mission statement is inspiring: “To support innovative, interdisciplinary research that combines behavioral, social and biomedical approaches, focused on the implementation of HIV prevention and treatment and the elimination of HIV disparities.” But Gregg Gonsalves ’11 GRD ’18, an AIDS activist and current lecturer at Yale Law School, feels that the University’s research efforts to eradicate HIV/AIDS aren’t necessarily paralleled in the resources it provides students. This has become particularly problematic as HIV incidence continues to increase among young gay men.
Gonsalves isn’t the only faculty member who worries about HIV awareness among the college’s young men. History professor George Chauncey ’89 tackles the subject candidly in his course “U.S. Gay and Lesbian History.”
“At some point I realized my students knew almost nothing about HIV/AIDS,” he says. “It was hard to believe because any gay man or lesbian woman my age lost friends, former partners or partners” during the first wave of the epidemic.
Chauncey says conversations with students over the years revealed a startling ignorance of how much damage the disease caused and can still cause. “I had a sense that people were beginning to think, ‘Oh, it’s not that big of a deal if I get infected,’” he says. “Of course, I have HIV-positive friends who are now living long, healthy and fulfilling lives, but that comes at a significant cost. A good number of young men don’t understand that.”
Every fall, Chauncey gives a lecture chronicling the AIDS crisis, paying special attention to Yale and the young men who died in the epidemic. At the close, after a notice that he is shifting from the role of professor to that of “gay uncle,” Chauncey urges a packed auditorium to always practice safe sex, no matter what urges arise.
“In the midst of the crisis, there was an incredible self-discipline and collective decision that we had to take care of one another,” he reminisces. His lecture on AIDS, other than serving its academic purpose, is the latest iteration of that same self-discipline, but this time he directs it at a student population he feels is in need of guidance.
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Students arrive at Yale from a wide variety of backgrounds and with equally variable knowledge of sexual health. Some benefited from comprehensive sexual education programs in their time prior to Yale, while others received abstinence-only sexual education or none at all.
Given this disparity in baseline knowledge, professor Kristina Talbert-Slagle, lecturer in epidemiology at the Yale School of Public Health, feels colleges like Yale can help loosen HIV’s grip on the gay community. “Universities need to provide appropriate, thorough sexual education to all students,” she says. “All students should have ready and ongoing access to accurate, supportive, nonjudgmental, easily accessible information to help them have healthy sexual lives and reduce the risk of HIV transmission.”
Dr. Andrew Gotlin, chief of student health at Yale Health, says Yale considers its students’ sexual health a top priority, regardless of their orientation. While students might be more familiar with some services, like providing birth control and other contraceptive options for women, the University also offers services targeted toward its MSM (men who have sex with men) community.
In addition to providing free HIV testing for all students, Yale offers consultations and prescriptions for Truvada as PrEP (pre-exposure prophylaxis), a pill taken daily to prevent the contraction of HIV. Those who have potentially been exposed to the virus through sexual contact, like the recent alumnus, are treated with the same urgency as someone experiencing a heart attack.
Information on Yale’s HIV prevention resources, though, isn’t broadcast regularly to the public.
Although not an official arm of Yale Health or the Yale administration, the student-run organization Community Health Educators conducts mandatory sexual health seminars for freshmen when they arrive on campus each fall. These seminars, scheduled by the Yale College Dean’s Office, try to shrink the information gap about sex — according to Talbert-Slagle, this is a key step in any STI prevention regime.
CHEs make an effort to include healthy living tips for men who have sex with men: the seminar begins with a segment on sexual diversity and ends with a warning against heterosexism, the tendency to view sexual relationships through a solely heterosexual lens.
However, the community workshop leader, who volunteered with CHE this past year, feels that the group falls into the same trap it warns against.
CHE presentations emphasize the contraceptive uses of condoms rather than their disease-prevention uses. For example, the transition between the “STIs” section and the “Protection/Contraception” section reads:
“We just talked about STIs, one risk of sexual activity. What’s another physical risk of sex — some heterosexual sex in particular? (Unwanted pregnancy!) Now let’s talk about how to protect ourselves against STIs and unwanted pregnancy. Though this might seem irrelevant to those of you who are abstinent or who have same-sex encounters, this information can still be useful sooner or later.”
And the portion on what to do if a condom breaks reads:
Q: “People can find themselves in situations where a condom wasn’t used or breaks. Then what?”
A: “Emergency contraception or Plan B helps prevent unwanted pregnancy.”
As the workshop leader notes, key facts about the spread of HIV are conspicuously absent from the script — in fact, the acronym HIV appears only once in the entire document. And strategies for how to respond to condom breakage during anal sex, where there is no risk of pregnancy, are nowhere to be found.
Corinne Ruth ’15, a CHE during her first three years at Yale, feels that the focus on pregnancy and the simplicity of the seminars is perhaps a product of mission creep. CHE was not founded to educate the Yale students, she says, but rather middle- and high-school aged students in New Haven.
As Ruth notes, a group formerly existed under the official Yale College banner — the Peer Health Educators — to tackle issues of sexual health, consent and substance abuse among Yale students. But when the college formally introduced Communication and Consent Educators to help reform the campus sexual climate after a Title IX investigation, the group went defunct. No peer-led organization as intimately linked to the University has filled the void left by its disappearance.
Equipped with a modified script crafted in conjunction with the YCDO, the CHEs step up once a year to educate Yale’s freshmen. But this year, due to a shortage in facilitators, several CCEs had to help guide 20 of these seminars after receiving only two hours of training.
It should surprise few, then, that a group created to educate New Haven adolescents sometimes struggles to offer comprehensive sexual education suitable to the needs of college freshmen, particularly at a school known as the “Gay Ivy.”
If any advanced information on HIV prevention for MSM makes its way into a CHE seminar, the workshop leader and Ruth say, it would likely be because a freshman counselor interjects to comment on it. There is no directed discussion on Truvada for PrEP, nor is there any advice on whether to seek emergency medical care after condom breakage with a partner of unknown HIV status.
Other University resources similarly fail to address MSM-specific health issues adequately.
In a pamphlet passed out to freshmen counselors titled “Man to Man: Tips for Healthy Living for Men Who Have Sex with Men,” HIV makes two appearances, under the headings “Discussing Sexual History” and “Know Your Status.” Both times the term appears in parentheses, seemingly as an afterthought, and in neither instance does the pamphlet offer recommendations on how frequently to get tested or how exactly to discuss one’s sexual history with a partner.
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If, as some believe, Yale does a subpar job at preparing its young gay students to tackle issues of sexual health head-on, it probably doesn’t result from a dearth of clinical resources. It just doesn’t make a concerted effort to communicate LGBT-specific risks and resources to the student body when it mandates their attention. Other would-be educators suffer from different problems.
Founded in 1980, the LGBT Co-op at Yale defines itself as a community-building and politically minded organization intended to represent queer and LGBT-identifying students on campus.
According to former co-coordinator Alex Borsa ’16, the Co-op tackles numerous issues in any given year. While student leaders recently have adopted a politically inflected agenda, fighting for mixed-gender housing and promoting trans rights on campus and elsewhere, the Co-op itself is many different things to many people — a necessity given the diversity of its membership.
Unfortunately, Borsa says, even the recognized mouthpiece for LGBT issues on Yale’s campus struggles to communicate with the larger student population. The primary mechanisms for spreading information are posters and the group’s panlist, which consists of 450 students and is annually purged of graduating seniors.
Relying on an opt-in email list and flyers is less than ideal, Borsa admits, particularly when it comes to issues relating to gender identity, sexual identity and sexual health. “There are a significant number of people on this campus who, if we were to advertise an HIV-testing drive like we did a few weeks ago, would greatly benefit from the service,” he says. “But because the flyer has a big rainbow on it, some people won’t pay attention. A lot of students don’t think they need it or don’t readily identify as LGBT.” Borsa adds that this group of people naturally includes MSM.
Maria Trumpler, director of Yale’s Office of LGBT Resources, acknowledges a similar problem in getting information to those who could use it: Are there people on this campus who should utilize the office’s resources but will never walk through the doors? “Of course,” she says. “It’s hard to accept, but we won’t reach everyone.”
Trumpler explained that, like the Co-op’s mission, the resource office’s job is complicated by the diversity of needs among Yale’s LGBT population.
“For some people, if HIV happens they might not think it’s the biggest deal,” she says. Others might feel inhibited sexually out of fear. Conversations on the topic, she believes, are most effective one-on-one, rather than in the form of community guidelines that might reach people at different stages of their sexual lives. For an intervention targeting risky behavior — whether for unsafe sexual practices, substance abuse, or any number of issues — to be successful, it must be tailored to the individual.
Borsa’s and Trumpler’s experiences highlight two challenges in communicating effectively to queer students about sexual health: Not only must any effort effectively target a population that is not readily identifiable (and, at times, purposefully eschews a non-heterosexual identity); it must also present the information in a way that makes the recipient feel it is relevant to them. If, like Chauncey and others worry, students don’t grasp the risks and challenges of HIV, there is little chance of inspiring healthy habits among them.
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Any medical professional will tell you that behavior change is the hardest thing to inspire in an individual. Smoking, drinking, eating, sex — they’re all similar in this respect. In 2015, the behavior many young gay men find hardest to change is their failure to adequately protect themselves from HIV. Some know better and simply don’t care. Others haven’t the slightest clue of the threat that HIV continues to pose. Some simply make careless mistakes. But they all risk the same fate.
The AIDS epidemic shook an entire generation of gay and bisexual men. Unfortunately this cultural history — this gay cultural history — cannot be transferred like that of other groups, in stories of shared experience from father to son, from mother to daughter.
Strategies of survival in the past and resilience in the present — informed by cold, hard statistics and health strategies — find no home in the traditional forum for educating youth: our own public schools. So many young men arrive at Yale, either clueless or careless, and the vast majority are left alone, continuing on the trajectory they began when they first walked onto Old Campus.
Must each of these men confront the virus alone, in the most personal way?
The answer is a firm “No.”
Many people want to help, but they need support and direction from the Yale administration.
Avenues to communicate knowledge and promote resources are in place, and a student body capable of engaging with them is waiting. We must adapt our current introductory health programming to include LGBT-specific issues like HIV.
But we cannot stop there.
Given Yale’s unique familiarity with HIV/AIDS, we must remake ourselves into a model for the rest of the country, tackling difficult issues like discussing sexual history and HIV status with partners, regardless of orientation.
We must empower young men and women to carry these skills and this knowledge into their communities when they leave campus as Yale College graduates.
We must recognize that this is our HIV crisis.