On April 5, 2013 I took my first dose of Truvada as pre-exposure prophylaxis (PrEP). 

So many questions were swirling in my head at that point, and had been for weeks and months. As I was about to swallow my first pill, I gazed outside the window and wondered…

• How did I end up in this situation where I feel like I need PrEP?

• How is it possible that it was this easy for me to access PrEP when so many people don’t have access to ARVs to stay alive?

• How did I go from being a major PrEP skeptic 4 years ago to actually taking PrEP now?

• What would people think if they knew I was taking PrEP and therefore by implication putting myself more at risk than I’d even been willing to admit to myself?

• Will I be taking this pill every morning for the rest of my life?

• Will I start taking more risks than I did before?

• Will I experience side effects?

• When will this damn winter end? I know this is Canada and everything, but enough already with the grey skies and slush and dreariness.

To find clues about how I got here and how long I might need PrEP, I took a sexy stroll down memory lane. Or as I like to call it…

My Sex Life: A Tale of HIV Risk in Five Phases

Phase 1: “In the Beginning”, lasted 8 years. I grew up in Moncton NB, (right) a small town on the East coast of Canada, and stayed there until my mid-20s. Let’s just say there were not very many opportunities to participate in activities that would have put me at high risk. This was pre-interwebz and smartphones, folks. In a town with one gay bar. I don’t do bars. Ever. All my experiences were very low risk. I didn’t even want to experiment with high risk behaviours. I was much too scared. I watched my father, an out gay man, progressively get sicker and eventually die of AIDS, desperately gasping for breath in his last hours, right in front of my eyes. I was 18 when we learned he already had AIDS and he died when I was 20. Trust me, this leaves an indelible impression on a young gay man who is just beginning to have sex, and who has not even come out yet. I did come out very shortly thereafter, and I ended up in a long-term relationship pretty much immediately.

PrEP would have made no sense for me then. I didn’t even need condoms. That would come later.

Phase 2: “Spreading my Wings”, lasted 9 years. I moved to the Ottawa/Gatineau region where I still live now, a sprawling metropolis compared to what I’d known until then. I was here by myself for a while. I decided it was time to explore and play around. Even after my partner joined me. But I was still not at high risk for HIV. This was largely because I was frankly uninterested in activities that would have put me at high risk. Partly out of personal preference. Partly out of concern about “bringing something home” to my partner (oh ya, I was suuuch a considerate adulterer!). Partly because at this stage my fear of getting HIV still considerably outweighed any desire to do anything even moderately risky.

PrEP would have made no sense for me then. I didn’t even need condoms. That would come later.

Phase 3: “Letting Loose”, lasted 1.5 years. After the end of my 14-year relationship, I decided it was time to explore and play around even more. Not that I’d been an angel before. Far from it. But now I was ready for some adventure. Through it all, I can honestly say that I managed to maintain absolutely 100% condom use. Each and every time. How did I manage that? For one thing, while my fear of getting HIV no longer outweighed my desire to explore activities that happen to be more risky, it still was strong enough to reinforce my resolve around condom use. It also helps that negotiating, convincing, or cajoling are rarely required when you’re almost always the one actually wearing the condom.

PrEP would have made very little sense for me then. That would come later.

Phase 4: “The Dark Ages”, lasted 1.5 years. Through a very severe depression, there was nothing going on. Nothing.

PrEP would have made no sense for me then. I didn’t even need condoms. That would come later.

Phase 5: “The Renaissance”, lasted 5 years. I was back to a life of adventure as a single gay man in a mid-size city, and on very frequent travel. At first, I still managed to maintain 100% condom use. But gradually, over the course of the last 2-3 years, I started to veer away from 100% condom use for reasons that I will explain in my next installment. As a sneak preview—it has to do with the current state of knowledge about HIV transmission, and, well… because sex feels better without condoms! *GASP* Stay tuned for the shocking next episode.

So now, for the first time in my life, at the age of 43, and after 25 years of active sex life (minus a brief depression-induced hiatus), PrEP makes sense for me. How long will this new phase last? How long will I be on PrEP? I don’t know. But luckily it exists and I can access it.

***

There are a million other things I have to say about PrEP. Well OK, maybe only half a million. But luckily others have already addressed many of them, and have done it so eloquently. I encourage everyone to check out the following remarkable first-person accounts:

• Len Tooley did a series of interviews on PositiveLite.com.

• Jake Sobo has been writing a whole series of articles on his blog, “My Life on PrEP”.

• Several other first-person accounts can be found right here on the “My PrEP Experience” blog.

Len and Jake are so friggin’ smart and insightful and articulate, I want to marry both of them. It has been a tremendous source of help and support to read the thoughts of everyone who shared their stories publicly. A big hairy thanks to Jim Pickett for starting the “My PrEP Experience” blog because he recognized that amidst all the heated debates and discussions and policy decisions about PrEP, we weren’t hearing the voices of real-life flesh-and-blood people actually using PrEP.

To be continued. . . 

About the author: Marc-André LeBlanc has worked in the community-based HIV/AIDS movement for 20 years.  He does community engagement, capacity-building and policy work related to biomedical HIV prevention research, both in Canada and globally. He is a co-founder of International Rectal Microbicide Advocates (IRMA), serves as secretary on their steering committee, has authored two reports on the global state of rectal microbicide efforts, and leads IRMA’s global efforts to ensure the safety of sexual lubricants. Marc-André loves movies. He got a film studies degree while working full-time, just for the sheer fun of it. He is now leading advocacy efforts to get ice cream and popcorn recognised as new basic food groups in Canada’s Food Guide

This article first appeared on My PrEP Experience here. 

This article by Michael Carter first appeared on aidsmap.com here.  

Aidsmap.com reports taking HIV pre-exposure prophylaxis (PrEP) does not lead to increased levels of sexual risk behaviour among gay men, investigators from the United States say.

Taking HIV pre-exposure prophylaxis (PrEP) does not lead to increased levels of sexual risk behaviour among gay men, investigators from the United States report in the online edition of the Journal of Acquired Immune Deficiency Syndromes. Numbers of sexual partners fell, as did the proportion of men reporting unprotected anal sex.

“We found no evidence of risk compensation among at-risk MSM [men who have sex with men] initiating PrEP,” comment the authors. “Mean numbers of partners and the proportion of men reporting UAS [unprotected anal sex] decreased significantly from baseline during 24 months of follow-up.”

PrEP is an emerging HIV prevention technology. It involves HIV-negative individuals taking daily antiretroviral therapy to reduce their risk of infection with the virus. In 2010, results of the iPrEx trial involving gay and other MSM showed that daily PrEP with Truvada (FTC and tenofovir) reduced the risk of infection with HIV by 44% overall, with high efficacy seen in people with the best treatment adherence. Although the results of PrEP studies involving heterosexuals have been mixed, the United States Food and Drug Administration approved Truvada for use as PrEP by adults with a high risk of HIV infection.

However, there is concern in some quarters that use of PrEP may lead to increases in sexual risk behaviour. Mathematical models suggest that even modest increases in the proportion of gay men reporting unprotected sex could wipe out the beneficial effect of PrEP at a community level. However, the precise impact of PrEP on sexual risk taking is highly controversial.

Data gathered during a PrEP safety study allowed investigators to explore the impact of PrEP on the sexual risk behaviour of HIV-negative gay men with a high risk of infection with HIV.

A total of 400 men were recruited to the study between 2005 and 2007. All reported anal sex with another man in the preceding twelve months. The study was double blind and placebo controlled. Participants were randomised either to start treatment immediately or to wait for nine months. The men were interviewed at baseline and then every three months about their sexual risk behaviour and use of recreational and erectile dysfunction drugs. The study lasted 24 months.

At baseline, the men reported a mean of 7.25 sexual partners in the previous three months. This fell significantly during follow-up to a mean of 6 partners between months 3 and 9 and a mean of 5.71 partners between months 12 and 24 (p < 0.001). These declines were similar in the immediate- and delayed-treatment arms.

The mean number of reported HIV-positive partners or partners of an unknown status fell from 4.17 at baseline to 3.51 partners between months 3 and 9 and 3.37 partners between months 12 and 24 (p = 0.01). There was also a significant fall in the number of reported partners believed to be HIV negative.

Use of poppers (p < 0.001), erectile dysfunction drugs  (p < 0.001) and a higher perception of the efficacy of PrEP (p = 0.04) were all associated with reporting higher numbers of sexual partners during follow-up.

At the start of the study, 57% of men reported unprotected anal sex in the previous three months. The proportion fell to 48% between months 3 and 9  (p = 0.001) and to 52% between months 12 and 24 (p = 0.03).

The proportion of men reporting unprotected sex between months 3 and 9 was similar between the immediate- and delayed-treatment arms.

There was also a fall in the proportion of men reporting unprotected sex with an HIV-positive partner, from 29% at baseline to 21% between months 3 and 9 and 22% between months 12 and 24 (p < 0.001). Declines in unprotected sex with HIV-positive partners were seen in both the immediate- and delayed-treatment arms.

Factors associated with reporting unprotected sex during follow-up included younger age (p = 0.01), use of poppers (p = 0.02), erectile dysfunction treatments (p < 0.001) and methamphetamine (p < 0.001).

Participation in the study did not lead to an increase in the number of reported episodes of unprotected anal sex, which remained steady between months 3 and 9 and months 12 and 24 in both the immediate- and delayed-treatment arms.

There was a fall in reported episodes of unprotected sex with HIV-positive partners from two in the previous three-month period at baseline to 1.37 between months 12 and 24 (p = 0.05). This was the case for both the immediate- and delayed-treatment study arms.

In contrast, the number of episodes of unprotected anal sex with partners thought to be HIV negative increased between baseline and months 12 and 24 (2.75 Vs. 4; p = 0.01).

“These changes may represent a possible increase in seroadaptive practices, in which men preferentially have more episodes of UAS with assumed HIV-negative partners,” comment the authors.

They also note “men in this study received risk-reduction counseling, condoms and lubricants, regular HIV/STI testing, and linkage to prevention services…which may explain the observed risk reduction and could explain the observed risk declines and could mitigate any potential for risk compensation.”

Despite this, the investigators were encouraged by their results, which they believe “provide important information on changes in risk practices among MSM in the US initiating PrEP in a clinical trial setting”.

Reference

Liu AY et al. Sexual risk behavior among HIV-uninfected men who have sex with men (MSM) participating in a tenofovir pre-exposure prophylaxis randomized trial in the United States. J Acquir Immune Defic Syndr, online edition, DOI: 10.1097/QAI.0b013e31828fo97a, 2013.

This article by Gus Cairns first appeared on aidsmap.com here. 

Increasing HIV testing frequency, and giving everyone antiretroviral therapy (ART), would not in themselves reduce HIV prevalence in US gay men, a mathematical model suggests.

These measures would produce, in the model’s baseline scenario, a 34% reduction in the cumulative number of new infections and a 19% reduction in cumulative deaths by the year 2023. This would lead to the annual number of new HIV infections in gay men almost declining to the annual number of deaths, but not quite.

The model therefore predicts that HIV prevalence would continue to grow in US gay men, albeit very slowly. This remains the situation under a number of different scenarios; even if every gay man took an HIV test every year, and everyone diagnosed with HIV started treatment within six months of infection, infections would still slightly outstrip mortality.

The model also finds that universal treatment would lead to a doubling in the prevalence of multidrug-resistant HIV, although this would not lead to an increase in deaths or progression to AIDS.

However this particular output from the model derives from data on the prevalence of primary HIV drug resistance that is more than seven years old and 'MDR' means any resistance to two of the three main classes of HIV drug that were well-established at this point, not resistance to all options currently available.

The model’s assumptions

The model was devised by researchers at the University of Southern California. It includes a number of parameters regarding the gay male population in Los Angeles, such as HIV incidence, the proportion of people in primary infection, the proportion diagnosed, the proportion diagnosed on treatment, and the proportion who progress to AIDS – although it does not directly input a figure for the proportion who have an undetectable viral load (virally suppressed).

It also inputs variable figures for the per-partner risk of HIV transmission in gay men, the frequency of HIV testing in gay men, the adherence rate in people taking ART, and the rate at which people acquire drug resistance.

These figures are all derived from observed trends in HIV infection in Los Angeles gay men between 2000 and 2010.

The researchers perfected their model by testing different combinations of inputs against the observed figures and repeatedly discarding ones that came out with results that didn’t match what actually happened over the previous decade, until they achieved the best fit.

The researchers than tested what would happen to the rates of new infections, the proportion of people with HIV who are not yet diagnosed, the proportion on ART, deaths, progression to AIDS and multidrug resistance, if they increased the frequency of testing and/or reduced the gap between infection and treatment in gay men.

Currently, in Los Angeles, gay men have HIV tests, on average, every 4.4 years. The researchers used the model to find out what would happen if this frequency was increased to every three years, every two years, and every year.

The average time between HIV infection and starting ART in gay men has been calculated as 2.5 years. The researchers modelled what would happen if this was reduced to one year or to six months.

Other figures fed into the model included the cumulative number of new HIV diagnoses, AIDS diagnoses and deaths that would occur by 2023 if nothing changed: 54,000 new infections, 49,000 AIDS diagnoses and 42,000 deaths. The current proportion of people with HIV who are undiagnosed was set at 20%.

The proportion who enter treatment with 'multidrug-resistant HIV' (MDR-HIV) was set at 3.1% which would have increased by 2023, even if nothing else changes, to 4.8%. This figure derives from data that was becoming out of date when it was published, and in addition, the model's definition of ''MDR-HIV' includes virus that today would be sensitive to a wide range of new drugs. See below for more on the model's assumptions about MDR-HIV.

The model’s predictions

At the time the model was first devised, the US Department of Health and Human Services (DHHS) HIV treatment guidelines still recommended that ART be started when a person’s CD4 count falls below 350 cells/mm3. So the first thing the modellers did was to model a scenario in which the only thing that changed was that all those diagnosed started ART according to this recommendation. This single change led to a 6% cumulative reduction in HIV infections and deaths and an 11% reduction in progression to AIDS over the next ten years. The proportion of people undiagnosed would fall to 18.5% and the proportion with multidrug resistance would increase to 6.1%.

If average testing frequency increased to one test a year, then the cumulative number of new infections by 2023 would fall to 35,800 (a 34% reduction), of new AIDS cases to 30,000 (a 39% reduction) and of deaths to 34,100 (a 19% reduction). This would reduce the number of people unaware of their infection very considerably, to only 4%. But the proportion of people with multidrug-resistant HIV would increase to 9.1%.

If, in addition, the gap between HIV infection and treatment initiation was reduced to one year, this would lead to a 42% reduction in cumulative new infections and a 28% reduction in deaths, and if reduced to only six months, to 47% fewer infections and 34% fewer deaths. But the proportion of people with multidrug-resistant HIV would increase to 11.9% and 13.7% respectively under these scenarios.

The modellers found that HIV testing and putting more people on treatment were not synergistic – in other words, that they worked independently to reduce HIV infections and deaths, but did not reinforce each other’s effects. Increasing test frequency from every 4.4 years to annually, for instance, resulted in an absolute 28% reduction in cumulative new infections regardless of the length of time between infection and starting treatment. Conversely, reducing the gap between infection and treatment from 2.5 years to six months resulted in a 13% reduction in new infections, regardless of testing frequency.

Cautions, caveats and conclusions

The modellers do make one other crucial assumption: they assumed that when gay men become aware of their HIV infection, they very considerably reduce their sexual risk behaviour. In the model the researchers reduced the likelihood of someone transmitting HIV by an average of two-thirds post-diagnosis, a figure based on US studies. These reductions have not necessarily been matched by figures from other parts of the world, and the researchers found that sexual risk behaviour was the assumption fed into the model that had the biggest influence on cumulative new infections.

The researchers do point out that their model lacks certain subtleties. Firstly, it doesn’t attempt to stratify HIV risk in different age groups, ethnic groups, or by risk behaviour – it assumes all sexually active gay men are approximately at the same risk of HIV. Secondly, it does not add in any allowance for the possible future use of pre-exposure prophylaxis (PrEP). And thirdly, they point out that "mathematical models are only as good as the available data used for the parameters and calibration".

It is also interesting that they use estimates of the average time between diagnosis and treatment as their parameter for the influence of treatment on prevention, rather than using the more direct figure of the estimated proportion of people with HIV with an undetectable viral load. They explain that this is because we do not have high-level evidence for the efficacy of viral load suppression as a prevention measure in anal sex. However, they do feed in an assumption that anyone starting treatment at a CD4 count over 350 cells/mm3 who mainains adherence becomes 96% less infectious.

The researchers suggest that, given that starting people on treatment earlier leads to a prediction of higher rates of multidrug-resistant HIV, and given that increased testing and more treatment do not seem to be synergistic, it might be better to concentrate on getting people to test more frequently rather than treating everyone diagnosed.

The finding that the number of patients with MDR-HIV will increase, however, is based on very old data. The figure of 3.1% the model uses for the proportion of people who start therapy with MDR-based HIV is derived by taking the median figure for primary MDR resistance from a single review (Van de Vijver) which was published in 2007, and includes no data collected after 2005. Even in this review it was noted that MDR resistance was lower in other parts of the world than the US. In addition, it was just after this point that studies started to find that drug resistance in people with HIV was starting to decline, and epidemiologists soon confirmed that it had in fact been doing so for several years (see Health Protection Agency). This trend has been sustained in more recent studies.

This brings the finding of the model that each 10% increase in average testing frequency, or each 10% decrease in average time between infection and starting ART, leads fairly consistently to a 0.45% absolute increase in the proportion of people starting therapy who have MDR-HIV, into some question.

In addition, however, they also use an outdated definition of multdrug resistance, namely resistance to two of thre three drug classes in use at the time of the 2007 review, nucleoside and non-nucleoside reverse transriptase inhibitors (NRTIs and NNRTIs) and protease inhibitors (PIs). Even this review noted that it was not taking into account resistance to the then-recently developed fusion inhibitor enfuvurtide (T-20, Fuzeon). Since then ARVs of two other classes (integrase inhibitors and CCR5 inhibitors) have been developed, as have a number of drugs of established classes that work against HIV with resistance mutations to those classes.

However, even with their own assumptions about resistance, the researchers found that the development of multidrug resistance actually had relatively little clinical effect and that even projecting the model into the far future, which would lead to a 23% rate of multidrug-resistant HIV, would not lead to more HIV cases or deaths than we have currently.

The model includes, buried within its parameters, a number of other interesting assumptions, which are not entirely explained. It assumes, for instance, that if people start therapy at a CD4 count over 350 cells/mm3 their adherence rate will be just under 90% but that if their CD4 count is under 350 cells/mm3 their adherence rate will be nearly 99%. It is not clear what data these inputs are based on.

However, even though some of its parameters are based on somewhat out of date findings, this model, by basing its assumptions carefully on what has actually been observed to happen in gay men, may avoid exaggerated predictions of the success of ‘test-and-treat’ for which some other models have been criticised.

Reference

Sood N et al. Treat and treat in Los Angeles: a mathematical model of the effects of test-and-treat for the MSM population in LA County. Clinical Infectious Diseases, early online publication, doi: 10.1093/cid/cit158. See abstract here and supplementary data here (requires payment). 2013.

Van de Vijver DAMC, Wensing, AMJ and Boucher CAB. 'The Epidemiology of transmission of drug resistant HIV', in Hahn B et al (editors), HIV Sequence Compendium 2006/7, pages 17-36. Thoretical Biology and Biophysics Group, Los Alamos National Laboratory. LA-UR 07-4826. 2007.

Health Protection Agency. HIV drug resistance in the United Kingdom: data to end of 2005. Health Protection Report 1(31): 2007.

This article from This Positive Life by Warren Tong first appeared on TheBody.com here.

How did you find your HIV physician?

The vaccine program that I've been talking about at Vanderbilt, they're really connected with Nashville CARES. As a small business owner, I'd really supported all the events that the organization does every year; I've always been involved in that. I didn't ever think that I'd be a client.

I went over there, and they gave me a list of people; and then I just called around. And I found a doctor. It's been amazing. I think that the physician is kind, is warm, and is also very knowledgeable.

Little things: They said that there's more studies going on about just the neuroscience kind of stuff that goes on with your brain right after you get HIV. I remember during that amount of time, through January and half of February, that there were times I couldn't even remember conversations that I just had. And so there was a short-term memory kind of loss. My physician was able to talk to me about that. Because that's an area where more research is being done. She's always traveling to these conferences, and that sort of thing.

It's been awesome. I have a fantastic doctor! She's understanding, patient, informative, motivating and the best choice for me for treatment. At one of the visits -- you know, when I got to 550 -- I was really aching to discuss treatment. Based on the current numbers, I have made the personal decision not to begin medication -- however, I am also involved in a couple clinical trials that allow me to have access monthly to my viral load and CD4 numbers. Based on this participation and the volume of real-time numbers, I am comfortable making the decision to choose a path that is right for me.

But my hope is that they come out with like a once-a-week kind of pill at some point, because I'm absolutely terrible, even about taking a multivitamin every day. So I've been trying to do better. My physician has given me an exercise, to try to take a multivitamin every day at the same time. She's trying to prep me for when I have to start taking meds. But I'm just hoping that the longer that we wait, as long as my health is OK, or stable, that something new will come out.

How do you think you'll deal with adherence, once you do start treatment?

One thing that I have been real honest about, with all my physicians, is that I am a drinker. I like to have drinks when I go out a couple times a week. I've always been nervous that if I'm supposed to take a pill at 11 and I'm out till 3, whether I'm going to remember when I get home, or when that has to happen. I know there's tons of different little options, and different ways to do it.

But it's just going to be a commitment, once I'm at a position where I need to take medication. I've always been like that. I've never wanted to take any kind of medicine unless I just absolutely had to. But once I'm at that point that I'm going to have to, then it's just going to be a change of priorities. Then I'm just going to make it happen. So I'll probably use every one of those tools.

What do you do to keep healthy?

I eat healthy. I was smoking a pack of cigarettes a day. I've really cut back those. I'm not like a Nazi about it, where I won't ever have a cigarette. I'll have one if I'm out with somebody. But that was really an important discussion with my physician -- that I needed to quit smoking. So that was something that I did. And we discussed openly about me and my drinking. Then they were looking at my blood, and my liver, and making sure everything with that is fine.  

Also, knowing when to say no. If I'm tired -- and there were times that, within that six-month period, I was just kind of tired, and worn out from life. Before I was infected, I would just keep going and keep going. I wouldn't really take care of myself in that way. Now I've really learned how to say no. So if I can't do something, or if I just don't feel like it, for whatever reason, then it's a no.

I know everyone says exercising is important. But I'm not someone that is ever going to go to a gym; it's just always awkward for me to go to a gym. So I'll run. Or it's little things. Like, I live on the fifth floor of my condo, and so I don't take the elevator. I do the stairs.

I don't know if that answers your question. But there's no magic thing, I guess. That's what I'm doing. And I feel good. So . . .

That's good. Little tips here and there always help.

Well, I also think that a lot of what I've gone through is mental, you know? I decided how I was going to attack this disease. I decided how I was going to tell people. And I did it on my terms. Little things used to really bother me. I'm one of those people where everything can bother me. But since January 2012 I just don't let that stuff bother me, you know? If I can't change it then I can't worry about it. So I think that's part of it, too.

I've stayed really connected with things that really encourage me. I love Steve Jobs, so I was reading his book and his quotes. Getting involved with other people online through social media, just talking to them or checking up on them, and that sort of thing -- kind of investing, virtually through the Internet, in some other people's lives, to just check up on them and see how they're doing. It kind of took the focus a little bit off me and made it more about, you know, this is a crusade for everyone that is going through this.

A large part of the reason why I feel I'm doing OK is the way that I just decided to think about things and be positive. I've always laughed when everybody says, "Stay positive," because I'm always, like "Well, I am positive." But now I just said it!

Let's talk about your work. What kind of work do you do?

I'm a talent agent. I own a talent agency in Nashville. I deal with actors and hosts, children and their parents, for television, film, commercials, music videos, print jobs, that kind of thing.

How did you become involved in HIV? You mentioned doing prevention work before your diagnosis. How did you become involved in HIV activism?

Someone doing outreach about the HIV vaccine program approached me at an event at a bar. I really wanted to do it. Before that, there was a well-known female impersonator in town that passed away, and her name was Bianca. Mark Middleton was his name, and the personality was Bianca.

But she was HIV-positive and she was very, very vocal about prevention and the disease. When she passed away, I got my company involved with her memorial. Doing that really got me connected with people that were very sincere and honest and hardworking, when it came to activism and awareness. That's kind of how it started.

And then at one of those events, I saw information about the vaccine study. They said that they needed HIV-negative people that had sex with guys. And in my way, I was thinking, oh, this is so fantastic. This is my way to give back. So I got involved with the study.

From there I started doing some outreaches with them, looking for other volunteers. But I'm actually really glad that I got involved with the vaccine. I want to say this, because some people may wonder: With the HIV vaccine being studied, obviously, it's not a live virus. There's zero chance to get HIV from the vaccine. The way that I got HIV, even though I was in the vaccine study, was because I was exposed to it.

But once I got involved with that, and then Nashville CARES, and helping them raise funds and that sort of thing, I really fell in love with it. Whether people think that it's God or another power or whatever, I really think that it was orchestrated at the right time. Because I really got passionate about it at the same time that it happened to me.

I'd thought I was invincible. Other people have told me that, specifically: "Josh, we never thought this would happen to you. If it can happen to you, then it can happen to me." And that's kind of been their attitude -- which was surprising at first. But when I sat back and thought about it, it's absolutely true. I felt invincible. And so all of that year that I was involved in prevention and activism and that kind of stuff, it really prepared me to be able to tell my story and, now, raise money.

The last couple months I've been involved with some amazing fundraising people. And I'm proud. We've raised a lot of money in the past couple months for Nashville CARES.

Do you ever get sick of thinking or talking about HIV, or do you think you will?

I think I did. I went through a month in the beginning, to be honest, where every week I was doing something related to HIV or awareness or a doctor's office or something. And so in May of last year I kind of got a little tired. And so I just kind of stepped back a little bit. I didn't post any blog, and kind of stayed off Twitter, and even my Facebook.

Now, looking back at that, it was fine for me. It was a little selfish, I guess. What I'm doing is -- and what we're talking about, all of us -- is so much bigger than any individual person or any of our individual stories. We've just got to keep going and keep talking about it. Because the more we talk about it, the easier it becomes to be talked about.

What do you think are the biggest issues that need fixing in HIV today?

One, I think that HIV is not a "one disease fits all." I think there are regional things to think about. I think that people that live out West, in San Francisco, potentially deal with different issues than someone with HIV in Tennessee. I think that that needs to be approached.

After the pastor wrote me that unpleasant email, it really started making me think, why in the South are we having an epidemic, but we also have the highest number of churches? So there's a tremendous opportunity that is being missed in churches with a captive crowd, if you say, to talk about HIV or STDs [sexually transmitted diseases], or any of that. Some churches are against contraceptives or prevention, I guess. My church that I grew up in wasn't. They were OK with birth control and condoms. But they never talked about sex or disease, or any of that.

And so I think the first thing is to look regionally, maybe, at potential issues. And that's what I've been kind of looking at. I can't speak for anyone else in the country, except, you know, Nashville, or the South, really. Here, the stigma is very strong, still. And I was nervous about that.  

Because we're not talking about it enough, in my opinion, in the South -- HIV and prevention and even early on in schools, besides mixed in with every other STD that you can get -- what I think that it's doing is that it's making it harder to talk about later. When I was growing up, I don't really ever remember talking about HIV or STDs, beyond the one day in health class.

And the way to combat stigma: I was sitting in a group therapy, right after I was infected. Maybe I was a little bit green, and maybe the gentlemen that were in there who have had HIV for years, maybe they were a little bit jaded. But in that group therapy that I was in we talked about stigma. And they kept bringing up stigma, that it's so terrible and hard.

And then I just asked a simple question, but it really was a little bit of an epiphany to me before I released my blog. They said the stigma was so bad. And so my follow-up was, well, what have you guys done to combat it? What have you done to fix it? And almost everyone in the room said that they hadn't told anyone that they had HIV. Again, understand some people -- maybe a majority of people -- can't disclose it. I get it. With me, I could.

What was just an epiphany to me: The only way to attack stigma is to talk about HIV, and to talk about it in its face, and show that it's OK. And so those two things, the regional thing and really just keep on talking about HIV, because by doing that, it will become a little more accepted -- not accepted that you want to get it, or that it's OK that people have HIV, but that it's not a death sentence, and that we're not the scum of the earth because we have HIV.

Could you compare how you felt about having HIV when you were first diagnosed, as opposed to now? How has it changed?

I think it has changed. Right after I found out, I was very scared of what people would think. I knew that it wasn't a death sentence and that I would get on the medicine and that though my life expectancy may be shorter than if I was negative, that I would live a long, great life. But I was scared about if someone would love me, and I was scared about what people would say about me.

Right after that, I made a decision that if someone wouldn't love me romantically because of that, that I was OK with that. And I really meant that. I would rather talk about it, about this disease, and attack the stigma, than worry if someone is going to love me, or want to be with me the rest of my life. Because I will be fine.

But coming now, several months later, I respect and I understand the disease a lot more. So my attitude toward that has changed. The thoughts that have started going through my mind now are, you know, disclosure. Why is disclosing or not a criminal act? My mind has just started going down that road. It's not something that I'm going to focus on, but it's just starting to get into the sub-issues; after you get over the big issue of having HIV, it's just how to live with it, you know? Knowing when or not to disclose, or why people choose not to.

But I'm not scared for my life like I was right after I found out that I was positive.

How do you think having HIV has changed you?

It has made relationships that I have with people, in general, more important. It's humbled me tremendously. I mean, I was a cocky bastard. Last year and before that, I was a talent agent and was cocky, and cared less about people and more about myself. This disease really humbled me. I couldn't think of anything worse than contracting HIV, before I contracted it. That was the worst thing in my mind that could happen to me, as a gay man. And then when it happened, it was very humbling.

It was humbling to know that I had to reach out to people to help me, that I needed to go to a therapist and that I needed some of those services that Nashville CARES has provided, that I have supported for years but never thought I would use. So it was humbling, in that aspect.

The other thing is that -- and I don't know if you've heard this before, or what -- but after I found out that I was HIV positive, it made my life a lot richer. Things that don't matter do not matter. Little things don't make me go crazy like they used to. Relationships mean the world to me. My family: It got me even closer to them. So in a weird way it kind of refocused my life into being better.

It's really hard to explain and put that to words, but my life is totally different, in the way that I look at people and relationships; and how I even look at myself is a lot different. I mean, it took a while for me to really be OK with looking at myself in the mirror right after I found out that I was positive. I'm OK with that now. And I feel good about myself. 

What advice would you give to someone else who has just found out they are positive?

If they just found out that they're positive: One, that they are the exact same person they were the hour, the day, the year before they found out that they were positive. That they are still them. Now they just have something that is going to make them choose relationships more carefully and, really, how things are going to be valued.

The one suggestion that I would give is find at least one person that you feel that you can trust, and tell them. Don't try to do this by yourself. Whether it's a therapist, or somebody that truly loves you in this moment. Try to find at least one person to tell that you're positive.

Get online, create an anonymous Twitter account, and find other people like me that are able to talk about it, that you can communicate with, and that it's safe. If you email me anonymously then I'm going to respond. And I won't know who you are but you at least start that chat.

Read TheBody.com. Gosh, I've spent hours on the website. Learn as much as you can about HIV.

But the main thing is that you're still you and that the way that you think about yourself is as important as getting treatment for the disease.

Do you have any closing thoughts, or any takeaway messages you want to relay?

Yeah. First, thank you so much for asking me to just chat with you. Everyone knows their own personal story of the moment they found out that they were positive; and maybe they even have stories like mine, where they know the person that infected them, or that exposed them.

But what you guys are doing is simply amazing. And I know that the three weeks when I was not sure if I was positive or not, I did more research than I'd ever done about HIV. And it's websites like you guys' that I came to, and that I learned the information. And I heard other stories, and I was reading about people. And so, thank you. You know? You helped me tons.

That makes me feel very proud. Thank you for the kind words!

Find Josh Robbins on Social Media

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Check out Josh's blog at imstilljosh.com!

What’s SPUNK! ? 

SPUNK! is a confidential, non-judgmental group for gay, bi, queer and trans men in Toronto who want to talk about drugs, alcohol, sex and PnP. 

Who's Welcome? 

Gay/Bi/Trans/Queer/MSM guys aged 19 and over. 

What is it? 

A free and confidential six week group for guys that use drugs or alcohol and want a safe place to talk about the ways that substances impact our lives. Previous group members have found the skills and tools that they learned in SPUNK! to be very useful in their day-to-day lives. It’s a non-judgmental space to set goals of moderation, abstinence, or continued use but with an intention of getting rid of some of the side-effects of use. 

When?           

Tuesday Nights from 7-8:30pm, six weeks in a row, starting at the end of April 2013! 

Where?       

ACT offices, 399 Church Street, Toronto, Ontario 

Why?          

This group was formed as a safe place for GBTQ guys to talk about the ways we use, the reasons we use, and the impacts that substances have on our lives. Discussions of PnP and sexuality, as well as other topics that are specific to our community may be discussed in this group. The group is facilitated by two queer men that will make the space safe for group members to set goals around their substance use, in an effort to reduce unpleasant outcomes. 

What do I do if I'm Interested in SPUNK! ? 

Contact Ryan Lisk, Gay Men's Harm Reduction Coordinator at ACT

416-340-8484 ext. 235

This email address is being protected from spambots. You need JavaScript enabled to view it.

April 15, 2013 - A new study indicates that young men who have sex with men (YMSM) around the world experience higher levels of homophobia, unstable housing, violence, and other factors that hinder access to HIV services, compared to older MSM. Conducted by the Global Forum on MSM & HIV (MSMGF), the analysis shows YMSM fare worse than older MSM in their attempts to access numerous HIV services, including HIV treatment. 

“Existing data indicates that rates of HIV are rapidly increasing among YMSM in low and high income countries alike,” said Dr. George Ayala, Executive Director of the MSMGF. “However, most research fails to disaggregate data focused on YMSM from broader samples of MSM and young people, making it impossible to understand the unique needs of this population. This is the first study to look at these issues among YMSM on a global scale, and the results are alarming.”

The analysis uses data from the 2012 Global Men’s Health and Rights study (2012 GMHR), a multilingual online survey of 5779 MSM from 165 countries, including 2491 YMSM (aged 30 and below). Data from YMSM participants was examined to assess levels of access to HIV services and factors that impact access to services for YMSM. Results are presented in a new policy brief entitled “Young Men Who Have Sex with Men: Health, Access, & HIV,” released today by the MSMGF.

The policy brief reveals that only 33% of YMSM surveyed reported that low-cost condoms were easily accessible, and even lower percentages of YMSM reported easy access to low-cost lubricants (18%), low-cost STI treatment (14%), HIV education materials for MSM (9%), and HIV risk reduction programs for MSM (7%). Of participants living with HIV, nearly half of YMSM with a CD4 count below 350 were not engaged in treatment (44%), compared with 17% of older MSM. Only 38% of YMSM living with HIV reported viral suppression, compared to 73% of older MSM.

Findings also indicate that 20% of YMSM surveyed had no income and 30% had no stable housing, which have both been linked to greater HIV vulnerability and reduced access to HIV services. Compared to older MSM in the 2012 GMHR sample, YMSM experienced significantly higher levels of homophobia and violence. Among all MSM surveyed, homophobia was significantly associated with reduced access to condoms, lubricants, HIV testing, and HIV treatment.

“While homophobia can be damaging to gay men of all ages, it can be particularly harmful to younger gay men,” said Daniel Townsend, MSMGF Steering Committee member. “Like many young people, they often have no income and depend on family for housing. If their family does not understand or accept their sexuality, they risk ending up on the street. Without stable housing or resources, many young gay men face extreme challenges in meeting their basic needs.”

YMSM not only reported greater barriers to HIV service access compared to older MSM, they also reported significantly lower levels of community engagement and comfort with service providers. These factors, along with family support and availability of safe spaces, were associated with increased access to HIV services among MSM of all ages in the 2012 GMHR.

“This data shines light on our collective failure to ensure that YMSM have the resources they need to keep themselves healthy,” said Dr. Ayala. “Moreover, it is a powerful reminder that HIV among MSM is an international development issue, inextricably linked with housing, health, education, and security. Donors and policy makers must treat HIV among MSM of all ages with the same level of urgency afforded to other international development priorities, and they must take concrete steps to ensure that the unique needs of YMSM are accounted for.”

Produced in collaboration with the MSMGF Youth Reference Group, composed of 18 YMSM advocates from 11 countries around the world, the policy brief concludes with a set of recommendations for addressing HIV and its social drivers among YMSM. Recommendations include addressing housing stability and economic dependence, providing comprehensive HIV prevention tailored to the needs of YMSM, improving treatment and care for YMSM living with HIV, taking action to reduce barriers and increase facilitators to HIV service access among YMSM, and supporting YMSM leadership and involvement in the HIV response.

The full policy brief can be found on the MSMGF’s website  here. http://tinyurl.com/br5qn6d.