Written by Geng-Hui Lin
Image credit：Photo provided by photographer, Chieh-An
The Human Immunodeficiency Virus (HIV) epidemic has been a worldwide public health issue since the 1980s. In Taiwan, according to the data from Taiwan’s Center for Disease Control (CDC), over 80% of new HIV cases are transmitted by unprotected sex between men (usually by condomless anal intercourse). This indicates that men who have sex with men (hereinafter: MSM) are the main population at risk of HIV in Taiwan. HIV has existed in Taiwan for decades, and much progress has been made in HIV prevention and treatment. As a result, public perception of the condition has also improved. However, despite all this progress, one key issue remains. This is the generation gap and related generational prejudice in HIV treatment in Taiwan.
Taking a Brief Look at the HIV “Generation Gap”
The HIV generation gap, which refers to the differences in beliefs, attitudes, values, and behaviours related to HIV, is now a well-established phenomenon in many countries, especially economically developed countries. Unfortunately, in Taiwan, this concept has not yet been widely discussed. This gap may derive from the different life experiences relating to HIV between different generations, as such life experiences reflect personal histories and the influence of HIV policies and interventions.
When we look back over the last few decades, there have been several important events in the history of HIV treatment in Taiwan. We can see this in implementing anonymous HIV testing services in 1996, free access to highly active antiretroviral therapy (HAART) in 1997, and the harm reduction policy. Further still, there have been dark moments, such as when a city councillor proposed that people living with HIV must all get a tattoo of ‘A’ on their private parts in 1992. These events helped shape the generational perception of HIV of those MSM who grew up as these policies were enacted. Taiwan’s MSM population can be roughly divided into two generations: the younger and older generations. MSM’s who were younger than 18 in 2005 grew up with proper HIV treatment and care as HAART had been provided free since 1997, and the HIV cases management program had been launched in 2005. A previous study even described MSM in this generation as ‘Medical citizens’ in terms of their higher familiarity with HIV issues and higher engagement in HIV related services. Public health researchers and practitioners have argued that the younger MSM generation are no longer as worried about HIV because of the advent of antiretroviral medications (ARVs) and the reduced social stigma surrounding the disease. Young MSM’s also have a lower self-perceived HIV risk than old MSM probably, because HIV has been seen as a manageable chronic disease. Also, some young MSM engage in more and higher HIV risk behaviours due to the rise of ‘party culture.’
For those MSM who grew up before 2005, data suggests that they feel ashamed to talk about HIV because of the social stigmas they had experienced or keep their distance from HIV related services due to their perception of the disease. Previous studies show that the older MSM generation have a deep fear of HIV, for they grew up in an era when little was known about HIV. HIV was often considered a death sentence during their formative years. In Taiwan, HIV used to be nicknamed ‘愛死病 (death by love disease),’ Àisǐbìng, which is pronounced very similar to the preferred 艾滋病 Àizībìng.
From Generational Gaps to Generational Prejudice: Taiwan’s PrEP Program
Although HIV treatment is improving every day, however, the new HIV policy has not only overlooked the generational gap but has even enforced age-based barriers to access. Pre-exposure prophylaxis (PrEP) is an antiretroviral medication taken by HIV negative people before having sex to prevent them from contracting HIV. It has been a recommended option for comprehensive HIV prevention strategies since the 2000s. In Taiwan, the PrEP program was launched in 2016. According to the information about the program announced on the CDC’s website, to participate in the PrEP program and receive a subsidy, MSM should have a high HIV infection risk and be under 35. Objectively, the age limit echoes the HIV epidemic in Taiwan, as in 2021, 45% of new cases were recorded in the 25-34 age bracket. This said, almost 30% of new cases were found in those above 35 years old in 2021
Compared to HIV risk, which is assessed through responses to a CDC survey, age is a relatively inflexible criterion for MSM’s who want to obtain PrEP through Taiwan’s PrEP program. There are ways to be categorised as an elevated risk for HIV infection depending on your answers to the CDC’s HIV risk assessment. As a result of these criteria, although some MSM’s over thirty-five have been enrolled in the program, access and availability remain mostly limited to those under this age. This leaves older MSM’s as outsiders to the program, unable to enter.
What Should We Do with the Generation Gap Over HIV Among MSM in Taiwan?
There is a generational gap in attitudes and perceptions; such a gap is reified through policy boundaries and thus gets formed into generational prejudice. My goal in pointing this out is not to blame one generation or the other but rather to refocus our attention on how health policies and care systems can compound social gaps. Ideally, policies should be used to alleviate such gaps. Even if younger MSM’s are at higher risk of new infection, health policy needs to be cognizant of the differentiated life experiences of various parts of the MSM community. Older MSM’s grew up with less access to treatment and greater social stigma. Policy should be focused on bringing them into the care system, not on keeping them out in the dark.
I thus believe that removing the age limit for Taiwan’s PrEP policy would be a positive start for decreasing current generational prejudice. Instead, we should focus on assessing individual patients’ risk instead of using age as a marker. However, such a shift would only be the beginning of addressing such generational prejudice. We need interventions beyond policy changes to truly tackle this prejudice. Creating a greater dialogue on the issue of generational prejudice MSM is critical for helping us understand how to properly understand the age in the context of epidemic data and the real lived experiences of MSM’s. This dialogue should be achieved through outreach to existing MSM organisations and communities. Community organisations play a key role in strengthening the bonds of MSM across all generations and can thus be a useful partner in helping to tackle generational prejudice. Through greater cooperation and dialogue between medical institutions, policymakers, and queer communities, we can allow communities to actively bring older community members into the healthcare system and, crucially, make them feel welcome within the system.
It is not too late to act to eliminate this generational prejudice. Break down the wall and build bridges instead.
Geng-Hui Lin (he/him/his) is a master’s student at the Institute of Health Behaviors and Community Sciences, National Taiwan University. He is interested in studying MSM health, LGBTQ health, and HIV prevention through the scope of behavioural science. Geng-Hui also identifies himself as a member of the LGBTQ community.
This article was published as part of a special issue on “Queer Taiwan”, find all the articles here.