Don't test, don't know: The danger of denial

1 in 5 MSM has HIV — 44% unaware

Results of a new analysis of 21 major U.S. cities from the Centers for Disease Control and Prevention indicate approximately one in five (19%) men who have sex with men (MSM) in a study is infected with HIV, and nearly half (44%) of those men are unaware of their infection.1

This research serves as a reminder that HIV remains a serious health threat among gay and bisexual men in America's major cities, says Amanda Smith, MPH, an epidemiologist in the CDC's Division of HIV/AIDS Prevention and lead author of the paper. The analysis, a review of data from the 2008 National HIV Behavioral Surveillance System, found a high prevalence of HIV among MSM of all races. However, black men who have sex with men were the most affected; 28% of black MSM were infected, versus 18% of Latinos and 16% of whites, Smith states.

A troubling fact: the CDC research also suggests that a high proportion of MSM who were infected were unaware of their illness. In fact, nearly half (44%) of MSM who were infected in the study were unaware of their infections, says Smith.

HIV exacts a devastating toll on men who have sex with men in America's major cities, and yet far too many of those who are infected don't know it, said Kevin Fenton, MD, director of CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, in a statement accompanying the new research.

"We need to increase access to HIV testing so that more MSM know their status, and we all must bring new energy, new approaches, and new champions to the fight against HIV among men who have sex with men," Fenton says.

The new statistics underscore two important points for clinicians who work with MSM, says Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University in Atlanta. They are: Talk with patients about the importance of learning their HIV status, and counsel on the need for consistent condom use for disease protection.

The study provides additional insight into the populations of MSM most in need of HIV testing and prevention, says Smith. Among racial/ethnic groups, black MSM with HIV were least likely to be aware of their infection (59% unaware, compared to 46% for Hispanic MSM and 26% for white MSM).1

While those gay and bisexual men under age 30 had lower HIV prevalence than older men, they were far more likely to be unaware of their HIV infection, states Smith. Among MSM ages 18-29 who had HIV, nearly two-thirds (63%) were unaware of their status, versus 37% for men age 30 and older.

Among young gay and bisexual men, young MSM of color were less likely than whites to know they were HIV-infected. Among HIV-infected black MSM under age 30, 71% were unaware of their infection; among HIV-infected Hispanic MSM under age 30, 63% were unaware. This compares to 40% of HIV-infected white gay and bisexual in the same age group, says Smith.

The study's finding of low awareness of HIV status among young MSM is not surprising. CDC officials note several factors might lead to low awareness among young men, who might:

  • have been infected more recently;
  • underestimate their personal risk;
  • have had fewer opportunities to get tested; or
  • believe that advances in HIV treatment minimize the threat of HIV.

For young gay and bisexual men of color, discrimination and socioeconomic factors such as poverty, homophobia, stigma, and limited health-care access might present obstacles to testing and care, CDC officials say. Jonathan Mermin, MD, director of CDC's Division of HIV/AIDS Prevention, in a statement accompanying the new research, said, "For young men who have sex with men — including young men of color who are least likely to know they may be infected — the future is truly on the line. It is critical that we reach these young men early in their lives with HIV prevention and testing services and continue to make these vital services available as they become older."

Testing is the key

The CDC estimates that the majority of new sexually transmitted infections are transmitted by individuals who are unaware of their infection, and studies show that once people learn they are HIV-infected, most take steps to protect their partners. Because undiagnosed infection likely plays a major role in HIV transmission, reaching younger MSM with regular HIV testing is critical, CDC officials state.

The CDC recommends that gay and bisexual men of all ages get tested for HIV at least annually, or more often (every three to six months) if they are at increased risk, such as those with multiple or anonymous sex partners, or who use drugs during sex.2 Such stepped-up testing is imperative. In the current CDC study, 45% of HIV-infected MSM who were unaware of their infection had been tested in the past year, says Smith.

In April 2010, the agency announced a new three-year, $31.5 million expansion of its testing initiative. Funding for the new phase of the initiative is expected to total approximately $142.5 million over the next three years and will be provided to state and local health departments across the country to increase access to testing and early diagnosis of HIV. The initiative, originally designed to increase testing and knowledge of HIV status primarily among African-American men and women, will now reach more U.S. jurisdictions and populations at risk. These include gay and bisexual men, as well as male and female Latinos and injection drug users.

Smith says, "Here at CDC, HIV prevention for MSM of all races remains a top priority. Supporting HIV testing has long been a critical part of our testing efforts, and the recent three-year, multi-million dollar expansion of our successful HIV testing initiative will enable us to target our testing efforts to increase access to HIV testing and diagnosis of HIV to even more individuals at highest risk, including gay and bisexual men."


  1. Centers for Disease Control and Prevention. Prevalence and awareness of HIV infection among men who have sex with men — 21 cities, United States, 2008. MMWR 2010;59:1201-1207.
  2. CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 2006;55:RR-14.