Vaccine Alert issued by Toronto Public Health.

Invasive Meningococcal C Outbreak among Men Who Have Sex with Men (MSM) in New York City: Recommendations for Travel

April 18, 2013: An ongoing outbreak of invasive meningococcal disease serogroup C has been occurring among men who have sex with men in New York City. Since 2010, there have been 22 cases reported: one in 2010, four in 2011, 13 in 2012 and four in 2013. Seven men have died, including three of the last five cases. The age range of cases is 21 to 59 years, and 50% have been Black, 27% White, and 18% Hispanic (any race). Twelve cases were HIV-infected, of which five have died. Cases of meningitis have also been reported in MSM in California.

The New York City Department of Health is recommending meningococcal vaccine to the following New York City residents:

• All HIV-infected MSM
• MSM, regardless of HIV status, who regularly have close or intimate contact with other men met either through an online website, digital application (“app”), or at a bar or party 

The Public Health Agency of Canada (PHAC) is not aware of any cases among Canadians related to this outbreak. Toronto Public Health has also not seen any cases related to this outbreak. Please call Toronto Public Health if you think you have a suspect or confirmed case of meningococcal disease to TPH's surveillance unit at 416-392-7411 during work hours (8:30am to 4:30pm, Monday to Friday) or at 3-1-1 after hours.

The National Advisory Committee on Immunization (NACI) recommends use of the quadrivalent meningococcal conjugate vaccine (Men ACYW-135 – Menactra or Menveo) to travelers where the risk of meningococcal transmission is high. NACI also says vaccination should be considered for individuals with HIV.

Toronto Public Health recommends physicians offer meningococcal conjugate ACYW-135 vaccine to MSM who are planning to travel to New York City and who are either HIV-infected or who may have close or intimate contact with other men met either through an online website, digital application (“app”), or at a bar or party in New York City. Note that this vaccine is not publicly funded for this group.

More information:

Toronto Public Health Immunization Information Centre:

416-392-1250 or email This email address is being protected from spambots. You need JavaScript enabled to view it.

New York City Department of Health alerts. 

Canadian Immunization Guide on meningococcal vaccines.

Being an HIV advocate means straddling two different, diametrically opposed worlds.  Engaging in battle on two fronts, much like a war, I advocate for both HIV+ (us) and HIV- people (them).  Each battle has it's own challenges and rewards, some of them immediate but most of them are unknown or more long-term in the rewards. 

It is sometimes hard to juggle two hats - fighting for those with HIV and fighting for those who do not have HIV.  Both groups of people have their separate challenges.  

People who perceive themselves to be HIV-negative (one in five do not know they have HIV) often believe they are not at risk for HIV.  HIV is something from the 80’s, they say.  I can just take a pill and be fine, they say.  I am not someone who could get HIV, they say.  But all of these assumptions are false, based on ignorance or they chose to keep their head in the sand.  HIV is something that happens to “those people” (you can fill in the blank here with gay, sex worker, drug addict, homeless person, etc.) and they go to extreme mental limits to make sure nobody thinks they are one of “those people”.  Ignorance is only bliss until you get HIV, then... 

...then you become one of “us”.  All of a sudden all of your assumptions go out the door.  You are pulled roughly and violently into the world of HIV, your head no longer in the sand.  Like a grim rebirth, at the moment of your diagnosis you become someone else.  Your soul is laid bare, your very self begins to crumble in upon itself, and microscopically you begin to become repaired, each new particle of yourself knitting itself into a new Phoenix.  It may take years to rise up from the ashes of your old self.  It may happen immediately for the few and for the determined and for the strong.  

When you as an “us” becomes the new “us”, you become what was known to your former self as “them”.  And a funny thing happens...one day you realize the barrier you erected between “you” and “them”, though it is a very tall and very thick wall...that wall is composed of sand.  Being diagnosed with HIV is a huge tsunami, impossible to ignore, definitive in its power to transform. 

Advocating for myself as a person with HIV means I want to ensure I am safe, protected, and that I can always get my medications.  I definitely see the need for eliminating HIV criminalization, expanding access to lifesaving medications, and for reducing the still-awful stigma of this virus.   Becoming someone with HIV has added whole new dimensions to my life that were not there before, words such as “disability”, “Ryan White”, “adherence”, and “deductible”.  I suddenly pay very close attention to the fine print of any insurance plans I am able to choose from at work.  For me, I always look to see what kind of prescription coverage is offered, as that is my absolute main concern.  At one place I worked at for years, our HR decided to change insurance companies.  My monthly out of pocket expense for my meds shot up from $100 to $400 a month.  I paid more for my medicine than I did for my rent.  Needless to say, I had to go back on Ryan White to afford them, which always makes me feel guilty because there is a waiting list for ADAP in most states. 

Part of me finds it so much easier to fight on the side of those with HIV.  It seems easier to me to fight for more funding for HIV, to help people newly diagnosed just feels like more of a good deed.  It is definitely more appreciated.  I get more immediate satisfaction by being a resource for the newly infected. 

But the other part of me, the part that drives me the most, is the part of me that wants to fight for others, “them”...those who do not have HIV.  I want to do everything possible, shouting from the rooftops at the ignorance and complacency that causes HIV infections to rise every year.  I want more than anything for people to stop doing the things that are dangerous.  I want those who still have a choice to have the options available to them to be able to make a choice.  I guess you could very well call me an advocate for HIV negativity. 

Advocating on behalf of those who perceive themselves to be HIV- always feels like I am alone in a stadium, shouting loudly to the empty seats.  People who think they are HIV- close up when you say “HIV”.  The word conjures up the image of sex, gay or straight.  It conjures up images of needles stuck in someone’s arm.  It conjures up images of starving African children with their famine-swollen stomachs and their skeletal faces.  It forces someone to come face-to-face with mortality, another subject to be studiously avoided at all costs.  

The silence of the HIV-, especially in gay males, is deafening.  It is much easier for someone to convince themself they are not one of “those” people than it is to admit to themselves how many times they had unprotected sex last year.  But if you mention HIV to them, like a key unlocking a door, they remember that night they had sex without a condom...but wait, “he told me he was clean, so I don’t have to worry about THAT time”...or that other time...or that other time.  Like the emperor and his new clothes, they convince themselves they too are fine, nothing to worry about, now stop talking to me about HIV. Let’s talk about Lady Gaga instead.  

This is an edited version of an article originally appeared on Jason’s own blog, Embracing Pozitivity, here.  

About the author: I am 38, gay male from Knoxville, TN who is not ashamed of my HIV+ status. I am optimism personified. I am strength realized. I am just me. 

Website: embacingpozitivity.blogspot.com.Twitter @jjemcdonald

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

How do you start the conversation with somebody when you're disclosing to them?

Well, for me, it's actually been pretty easy. Because I don't know if I copped out. I mean, I posted it on Facebook, and I have a blog. The blog is now at almost 15,000 views. Then being on the cover of the magazine here, locally. Everyone here, as far as the gays in town, they're all aware. I guess some of them are probably tired of me talking about it.

But there's other things that I had to think about. I have a company and I have a staff, and we have interns and that sort of thing. And so I've made it a decision again -- it's not my legal responsibility -- but I made a decision that I was disclosing to everyone.

You know all the pink stuff, the marketing for breast cancer awareness? Susan G. Komen for the Cure? People walk around and they say stuff like, "I'm a survivor of cancer." Or, my mom -- I've done MS Walks with her. And it's very easy for her to tell people that she has MS. I see it real similar, that it's just a disease that I'm fighting. There's no cure yet, and there's no vaccine that works 100 percent yet. So I'm just on a journey, just like other people; but it just happens to be that what I'm fighting is HIV.

It is so important to me for people, and particularly -- and that's where my heart is -- ifor Nashville, because this is my home; I've lived here for 10 years. So it's so important for other people that have HIV that in any way feel like they're scared or feel less or whatever. I want them to know that they're still the same person, that they're OK, and it's going to be fine. So that is really the bottom line on all of it.

The benefit for me, with the way that I disclosed, and that I've told everyone and I've told them so quickly was that I haven't gone to the bar or to the club or whatever here, and knew that people were talking about me, about something that they haven't heard from me about. So I don't feel uncomfortable going out now. And I'm sure there are people that are going to say things. But I've tried to be honest and I've tried to be transparent.

And some people have called me brave, which I don't think at all. I don't think that what I'm doing, or what I've done and what I'll continue to do, is brave. But if it helps one person or two people here feel like they're OK, then that's enough.

A good example of that is I got a call, a couple of weeks after I released the blog, from someone -- and I couldn't even tell you who it is now -- but they called me. It was a 22-year-old here in my city that had just found out a couple days before they called me that they were HIV positive. And they contemplated committing suicide because of it. And they happened to see someone reposting my blog on Facebook and they read it. Then they felt compelled to call me.

From there, I talked to him for just a few minutes. And he said that because of the blog he decided to tell at least one of his friends, or a couple of his friends. So now he's fine, you know? He didn't commit suicide.

I don't think that I had anything to do with that, except that I know that's what people feel, or that's what people have told me that they have felt immediately. And so if my being able to talk openly about how I contracted it, and what I'm going through, and how I feel, and all those things, if that helps other people then it's worth it to me. Because I'm in a position where I can, you know? I have a strong support group around me. My family means the world to me, and they're OK.

I don't think you give yourself enough credit. It sounds like you saved that boy's life. Would you say that's the best response you've gotten from sharing your status?

It's funny, but I have been flooded with different stories of people. And so some of the best responses to me are people that have been living with this disease for 15 years or 20 years, and they come and say, "Thank you. I haven't been in a position where I could really talk about it like you, but thank you. It makes me feel a little bit more normal at least." Just as a whole, that's the stuff that feels good.

But there have also been a couple of bad things. I got a really nasty e-mail from a previous pastor. He told me everything that he thought about why I got the disease, and how I'm living with it, and all that stuff.

Then, you know, there's thedirty.com, which is a funny website. Somebody posted something not pretty about me on there, basically saying that I'm trying to get fame from this, or monetize this. And that's not the case at all. I haven't made any money from talking about my status, and I wouldn't.

But all that is to say that there's good and bad, but the great things have far outweighed any negative that could ever come at me.

What did your youth pastor say to you, and how did you react?

Basically what happened is that I released the blog, and then the pastor saw the blog and sent me a very long email, basically saying that it's unfortunate that I contracted the disease, that he saw the disease as a direct result of me living a sinful lifestyle from my sexuality, and that God really wants to love me, and so I need to repent and turn away from all of this stuff. Just a religious rant. But the hard part for the email was that it was really tied in with some things that were very personal to me that he really used as weapons -- the fact that I had been molested as a kid, and the fact that the pastor's oldest brother passed away from HIV, and that sort of thing.

He was trying to do exactly what he thought was right, which was to email me and tell me that I'm wrong and that I'm sinful. Although I disagree, adamantly, with every theology that he discusses in the email that he sent to me, I really truly believe that his heart was in a place where he thought he was doing the right thing. So I don't hate him or despise him, but I did respond to him via a blog.

I basically just told him that HIV was not a result of God being angry at me, and that eventually I would be in heaven and that I'm OK.

I did rebuke him a little bit, in a nice way. I told him that this was the absolutely wrong email to ever send to someone that's recently infected, and especially someone that's recently infected and then trying to talk about it in hopes of decreasing stigma and also furthering the discussion of prevention in others. This is totally the wrong tone. And so I responded in that way. But I haven't directly spoken or had a conversation at all with that pastor. And I don't really want to.

He sent me the email but I responded to him in the only way that I knew how at the moment, which was via my blog. But I did disguise his identity so hopefully he hasn't gotten any hate mail, or anything.

But, you know, it was totally the absolutely wrong thing to ever say to someone, particularly someone that's recently infected.

Let's talk a little bit about dating and relationships. Has being positive affected your dating life or your sex life at all?

During the three weeks that I was waiting on my results, that constantly came over my mind. I was absolutely scared that I would never be loved again. I felt that maybe that the gays in my town would think that I was used goods. I had already come out of the closet about sexuality, and that had limited the people that would want to date me. And then now that I'm HIV positive I was like, wow, that even makes the pool even smaller. Because I thought that only someone that was HIV positive would even want to date someone, you know, like me. I was real nervous about that.

The other thing that was really hard is that during the middle of finding out, I had met someone that I hadn't been intimate with, but I'd seen him out several times, and was really kind of digging this guy. And the thought of having to tell him that I was positive: I just knew that he would run away. So I was kind of preparing myself for that. 

I didn't actually call him and tell him that I was positive. We hadn't have sex or anything like that, and so I didn't have to tell him anything. But he is a friend of mine on a social media; and so when I released the blog on my Facebook, he saw it. And he actually called me and he said that he wanted to see me. And I said OK. We met, and he told me that it was OK.

I think the coolest thing that could ever happen for someone that is positive is if someone that is negative just wants to date them. I think that is the coolest thing, and one of the bravest things, in the middle of all this. With that said, of course dating and relationships and that kind of stuff is overwhelming. I mean, when do you disclose to someone? Do you get them to really start liking you before you tell them? Or do you tell them from the very beginning, when they have absolutely zero invested? I don't know. I think that's a question that keeps going. 

Obviously, I've researched and looked online. There are tons of people that only want to hook up with someone that is DDF (or disease-and-drug-free); they would never want to date somebody that was positive. I've seen stuff online, blogs and forums where people are saying that positive people should only date positive people so it will quit happening. That was something that I was really concerned about. It was a decision that I had to make, because I didn't know how he would react, or anyone else would react. But I decided I was OK with being alone the rest of my life if I could talk, if I could tell my story, and if I could in some way decrease the stigma and then further the discussion of prevention. That was more important. And so I had to be OK with that. But it worked out really well for me. So I'm dating somebody that I've been dating for over a year now.

We've already established that on top of that, you also have a very close and supportive family. Did your relationships with them change at all after you disclosed to them?

The only thing that changed was that the first several weeks after I told them that I was positive, they wore me out with phone calls and text messages, asking how I was and how I was feeling, and that sort of thing. So it was appreciated, but I finally had to tell my family: "Listen, you don't always call me every day anyway. So you still be you, and I'm still me. We can talk; but you don't need to ask me every day how I'm feeling, and if things are OK. Because I'm fine." But besides that -- which is, obviously, appreciated -- my family really rose to the occasion and have been amazing supporters for me.

That's wonderful. Can you tell me a little bit about your background? Where did you grow up?

I grew up in West Tennessee, in a small town called Jackson. It's between Memphis and Nashville. A lot of people know Jackson for one reason, really: My hometown has gotten hit by tornadoes a lot.

It's a very small conservative town. I never hooked up or anything in my hometown; that would have been way too weird and that sort of thing.

When did you tell your family that you were gay?

I moved to New York right after high school, to go to an acting school. That was the first time that I had voluntarily had sex with a guy -- a terrible experience, by the way -- then I moved back.

I kind of dated a couple people after I moved to Nashville for college. I first told my sister, when I was around 24, that I was gay. And she was fine with it. I hadn't told my mom and stepdad, or my stepmom or my dad, yet.

So I went home one Christmas the year after I told my sister. My mom, again, has MS. We were in the bathroom, and she was getting ready or something. She asked me, "Are you dating anyone? Because I never hear you talk about anyone." And I kind of smiled, and I said, "Yes."

And she said, "OK. Well, do you want to tell me about it?" I started telling her about it. But it was very generic; but still, to me, it was obvious that it was about a guy. So I thought I had come out to my mom.

So she would call me for the next six months, and we would talk about the person that I was dating. But I didn't realize: Because of her medicine she was on, she didn't remember that conversation, and she didn't realize that I'd come out to her. And so for six months, we had talked on the phone and she would ask about whoever I was dating. But it would always be, you know, "How is your friend So-and-So?" And so I just assumed she just wanted to call him friend, which was fine. But she really thought it was a friend.

There was a day that I realized absolutely that it wasn't clear to her that I was gay. And so I had to come out to my mom a second time, which is funny.

How I came out to my dad is, I had called my stepmom. I told her. And I told her to tell Dad. An hour later he called me and asked me if I needed to tell him anything. And I said, "Nope. You probably know everything."

He said, in his Southern way -- he's a fisherman; he's a tire salesman -- the nicest thing that he could say was: "You could kill someone and I'd still welcome you into my house." Which makes other people laugh; but that's totally my dad's character. So I knew it would be OK.

But since that time my sister has come to visit; I've taken her out to the gay bars and she obviously has met who I was dating and that sort of thing. My dad and my stepmom: I convinced him to let me take them to a drag show, and to the gay bar. And they know who I'm dating, and who I've dated. My mom is the same way. It's awesome, because it's completely open.

The one thing that's cool now is that my mom sent me a text the other day saying Obama is backing gay marriage. And I was, like, "Yeah. That's really cool."

And she said, "Yeah."

And so I sent her a text message -- something like, "So, are you ready to walk your son down the aisle one day?"

And she replied back: "Absolutely." Which was just a cool text to see from my family. But, yeah. I'm completely out of the closet about my sexuality and, I guess, my status.

When did you know you were gay, yourself? And was that difficult?

It's always a funny question to think through. I remember when I was a kid, and I don't know the age -- 5 seems to be the right one to say -- but I remember playing with the neighbors, the little boy next door; I remember kissing him. And that obviously is not what other kids do.

But also, we lived in a small town. I had girlfriends, and I really liked them. But it wasn't ever where I wanted to go home and sleep with them, or anything. You know, we were just friends, I guess.

What I explained earlier about when I was younger and was molested: That was when I was older. I was, like, 10, or 11, or 12, or something like that. It was a family member. But as far as knowing I was attracted to guys, it was early on. I remember kissing that boy.

Do you want to talk about the molestation at all?

I'm really OK with it now. It was a situation where it was a family member and I was told that this is what guys do, you know, when they're older. And so when I say molested, there wasn't ever anything violent or anything like that. But I absolutely was taken advantage of as a young person. And that should not ever happen by an adult, obviously.

But in the same instance, although I've kind of blocked those circumstances a little bit, the fact was, moving forward, that I don't think that that had any influence on me being attracted to guys.

Do you know what happened to that family member?

No. I told my family and my sister, and then there was a kind of division that happened in the family because of that. Years after -- I think I was 18 when I finally told them what had happened -- there was a lot of anger. I talked everybody down. I said, "I'm really the only one that has the right to be mad, and I'm not mad. I'm fine. And that's that."

The thing is -- I don't want to give too much information -- that some families have uncles that aren't legal yet. So they may be 10 years older, or something. But it wasn't like a fully grown adult.

There was nothing else that needed to happen. I'm completely fine with it. I've forgiven him. I mean, I'm not going to go to dinner with him, probably. I don't go to extended family reunions, anyway.

Let's talk about health care and treatment. What has your health been like since your diagnosis?

January was a total wash for me. I was completely sick, and not feeling great. I finally saw a doctor on Valentine's Day. The reason why my viral load was so high at the beginning, readers may or may not know, is because I found out so soon. It's been remarkable -- and those are the words that physicians have used -- being able to really track my process and my progress, particularly because of the vaccine study. They've had my blood work and have been viewing everything when I was negative, through seroconversion, all the way through now being four or five months into being infected.

It's been interesting. I've had; every two weeks or so, I've had CD4 counts and viral loads, which is way more information that I would ever suggest anyone ever have. But that's just the way that it's worked out between doctor visits or vaccine visits. My viral load came down, and it's come down even more.

I have made the decision right now, in consultation with my HIV specialist, to not begin medication, as my viral load (at last test) was 1,102 and my CD4 count is 730, with great percentages.  

It's important to understand that although I am not on medication, that I consider myself in therapy and in treatment. This discussion of being "on" therapy and "on" treatment leaves out a very attentive, concerned and responsible group of individuals -- like myself -- that, at the given moment, are not taking HIV meds.

Deciding which medication, if any, that I will choose at the exact moment that I feel is best for me, personally, is just that: a personal medication decision I will make based on my body and health, consultation with my doctor, and the current information and research that appears to apply to me. I'm not a one-type-fits-everyone kinda guy. But just because I'm not on medication, doesn't mean I am not taking this as seriously as others.

To be continued . . . 

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This article by Roger Pebody  first appeared on aidsmap.com here.  

The majority of American gay men in relationships say they establish a ‘sexual agreement’ with their partner, both to minimise HIV risks and to maintain the quality of their relationship, according to research published online ahead of print by the Journal of Sex Research last month.

However, partners do not always agree on whether they have an agreement, on whether it was explicitly discussed, or on what sex is allowed with other people. And the agreement had been broken by one or both partners in just under half the couples studied.

The study has also found that around a quarter of the HIV-negative men who have casual sex attempt to 'serosort' or use 'strategic positioning' when doing so. However, regular HIV testing was far from universal in this group, making such practices potentially unreliable.

“From a public health perspective, we need to encourage gay couples to have more honest and explicit discussions when establishing and honouring sexual agreements,” commented Dr Jason Mitchell of the University of Michigan, who conducted the research. “Sexual agreements are not only advantageous from a prevention standpoint for couples, but the agreement can also help strengthen their relationship.”

A sexual agreement is made between two individuals, and concerns what sexual behaviour may occur within and outside their relationship. Some agreements may simply clarify that sex is not permitted with other people. Other agreements may concern the relationship being ‘open’ to a lesser or greater extent. Many couples use agreements, in part, to limit their risk of HIV infection.

A couples study

Jason Mitchell’s study recruited both partners in couples and compared their responses, rather than relying on just one partner’s perspective. Men were recruited to this cross-sectional online survey via adverts on Facebook in 2011 – the advertising was targeted to reach individuals whose profile information indicated that they might be a man in a relationship with a man. The first participants provided the email address of their partners, who were then contacted and asked to complete the survey.

The study recruited 722 men (361 couples). This was a predominantly white (77%) and relatively well-educated sample, with a mean age of 33, all living in the United States. Couples had been together for an average of an average of five years; three-quarters were living together.

One in eight men had been diagnosed with HIV. Half of them were in a relationship with another man with HIV, and half with an HIV-negative man (i.e. in a 'serodifferent' or ‘serodiscordant’ relationship).

Most men reported that they were HIV negative. (Just 3% of the sample reported that they did not know their HIV status.) However, one in five of the ‘HIV-negative’ men had not tested since the beginning of their relationship, and on average, HIV-negative men had last taken an HIV test two years ago. There was considerable diversity in the men’s HIV testing practices, with a minority testing much more frequently than others.

On average, men said that they had discussed their HIV status 12 days into the relationship, and this occurred before the couple started having unprotected sex (a mean of 81 days into the relationship). However, when the couple made a sexual agreement, this typically occurred much later – 174 days into the relationship. 

Agreements

Although seven in ten men reported having a sexual agreement, this perspective was not always shared by the man’s partner. In 57% of couples both men agreed that they had a sexual agreement, but in 25% of couples, one man thought there was an agreement, while his partner said that there wasn’t.

Amongst those couples who agreed that they had agreed, 58% said that there had been an explicit discussion, while 11% reported that their understanding was more implied or assumed. In a further 31% of cases, one partner had thought they had had an explicit discussion, while his partner thought that it was implicit.

For 56% of men who thought they had an agreement, it was that the relationship was monogamous.

For a further 41%, the agreement was to permit sex with casual partners, but with some rules or guidelines. For the last 3%, there was an open relationship, without any conditions.

Responses detailing what was permitted for those with open relationship guidelines showed that around a quarter actually permitted unprotected anal sex with casual partners. While the data shows that some couples had different rules for receptive and insertive sex, and for withdrawal before ejaculation, respondents were not asked whether there were conditions based on the partner’s HIV status and seroadaptive behaviours.

Far more couples allowed oral sex and masturbation.

Open relationship guidelines were not just about the risk of infections, but also about intimacy and context. Having sex with a casual partner on more than one occasion, physically sleeping together and dating were all permitted by half or less of couples, whereas threesomes or group sex were allowed by 81%.

Men’s motivations for making agreements were not just about minimising the risk of HIV or sexually transmitted infections, although this was the most common primary reason, cited by 23%. Other important reasons included wanting monogamy or exclusivity; fulfilling sexual desires; establishing guidelines so as to manage expectations; and building and maintaining trust.

Jason Mitchell did not analyse motivations by type of agreement, but in a separate study, another group of researchers previously found that the themes of trust, honesty and strengthening the relationship were predominant in the motivations both of men with open agreements and men with monogamy agreements.

Breaking agreements

Looking at couples, including those with an agreement to monogamy, in 46% of cases, either one or both partners had broken the rules at some point during the relationship.

But in the previous three months, 80% of couples had stuck to their rules. In 15% of the couples, one partner had broken the agreement, and in 5% both partners had.

The main reasons for breaking agreements were sexual frustration and the ‘heat of the moment’. Only a minority of men (30%) told their partner that they had broken the agreement. Reasons given for not disclosing included not giving the partner a reason not to trust the respondent and fearing that this could lead to the relationship ending.

Risk reduction strategies

In a separate article, published in AIDS & Behavior in December, Jason Mitchell has also reported on the risk-reduction strategies employed by this group of men, both inside and outside of their primary relationships.

He was interested in strategies such as serosorting, strategic positioning, 100% condom use and taking undetectable viral load into account.

This analysis is especially interesting because Mitchell actually asked respondents whether they had used strategies to reduce their risk of HIV or sexually transmitted infections. In contrast, most other studies on this topic have examined the pattern of men’s sexual practices with partners of different HIV statuses, and attempted to infer whether there was a strategy in place or not.

It therefore hasn’t been clear from previous research whether the conscious and deliberate use of strategies such as strategic positioning is something widely practiced by gay men, or just a minority pursuit.

For this couple-based analysis, those couples in which both partners had diagnosed HIV were excluded. Participants were asked about strategies used in the last previous three months – they could name more than one strategy, either because strategies were combined, or because different strategies were used in different situations.  

Always using condoms for anal sex, or always doing so with an HIV-positive partner, was reported by a minority of men. Within the main relationship, 15% of HIV-negative couples (i.e. in which both partners thought they were negative) always used condoms, rising to 38% of serodifferent couples (i.e. in which one partner had HIV and the other did not).

When having sex outside the relationship, 38% of men always used a condom for anal sex.

Only having oral sex and never anal sex was reported, for the main relationship, by 23% of HIV-negative couples and 31% of serodifferent couples. This strategy was more commonly reported for sex with casual partners – by 51% of men.

'Serosorting' (having unprotected anal intercourse [UAI] with a partner because he was thought to have the same HIV status) was reported by 66% of HIV-negative couples. Moreover, this was also reported for sex with casual partners, by 27% of men.

‘Strategic positioning’ (only having UAI with the HIV-positive partner in the receptive role) was reported, for the main relationship, by 32% of serodifferent couples. During casual sex, it was also reported by 23% of men.

Having unprotected sex because the HIV-positive partner was either taking HIV treatment or had an undetectable viral load was reported by 24% of serodifferent couples.

It was much less commonly employed as a strategy with casual partners – by 1% of men in an HIV-negative couple and 14% of men in a serodifferent couple

Finally, it’s important to note that a significant proportion of men did not have a risk-reduction strategy at all, especially with their main partner. One of the answers men could choose was ‘‘regardless of HIV-status, we never use condoms and ejaculate inside’’.

For their primary relationship, 24% of HIV-negative couples and 22% of serodifferent couples chose this answer. It was also chosen by 9% of men having sex outside the relationship.

Overall, having unprotected sex within the main relationship (in the last three months) was reported by 87% of HIV-negative couples and 69% of serodifferent couples. Moreover, for 16% of couples, there had been unprotected sex both with the main partner and at least one casual partner during the same time frame.

Improving the quality of agreements

Clearly, with a number of couples permitting unprotected anal sex outside of the relationship and with a significant minority of men breaking agreements in one way or another, there are risks that HIV can be brought into relationships.

The research highlights a number of other limitations of some men’s sexual agreements, in terms of the frequency of HIV testing, the discrepancy in partners’ perceptions of whether there is an agreement and what it entails, and the quality of communication following breaks in an agreement.

This suggests that HIV-prevention interventions which support men in strengthening their relationships and in making better agreements would be warranted.

One such approach that is being piloted is couples voluntary counselling and testing, in which couples take an HIV test and receive the results together. The focus of the counselling is not on past sexual history, but on how the couple wish to manage the risk of HIV in the future. Quantitative and qualitative research suggests that this is an intervention that many men in relationships would be interested in.

References

Mitchell JW Characteristics and Allowed Behaviors of Gay Male Couples' Sexual Agreements. Journal of Sex Research, online ahead of print, 2013. (Abstract here)

Mitchell JW, Petroll AE Patterns of HIV and sexually transmitted infection testing among men who have sex with men couples in the United States. Sexually Transmitted Diseases 39: 871-876, 2012. (Abstract here)

Mitchell JW HIV-Negative and HIV-Discordant Gay Male Couples' Use of HIV Risk-Reduction Strategies: Differences by Partner Type and Couples' HIV-Status. AIDS & Behavior, online ahead of print, 2012. (Abstract here) 

Saturday, April 13, 2013 – At the Canadian Association of HIV/AIDS Researchers conference in Vancouver AIDS ACTION NOW! led people living with HIV, researchers, and doctors to stand in solidarity and call for members of the Canadian HIV research community to stop acting as paid expert witnesses on the side of Crown prosecutors in HIV non-disclosure trials. 

Over 50 demonstrators stood behind a sign that said: “HIV is not a crime. AIDS Profiteering is” during Dr. Robert Remis’ (below, left) abstract presentation. Dr. Remis is a prominent epidemiologist who is responsible for Ontario’s provincial epidemic surveillance, and is also a paid expert witness for the Crown in many HIV non-disclosure trials.

AIDS activists have been increasingly angered at the perceived conflict of interest practiced by this scientist and that he financially benefits off the lives of people who are prosecuted in relation to HIV non-disclosure. In one case, Remis’ testimony in the pre-trial led to charges being increased from assault to aggravated assault. Remis is also a member of the Canadian Association of HIV/AIDS Researchers and was an abstract reviewer for the conference’s Epidemiology and Public Health Sciences track.

Jessica Whitbread of AIDS ACTION NOW! stated, “We are calling on HIV scientists and doctors to take a moral stand and stop perpetrating HIV stigma against those of us living with HIV. If we are to end stigma and HIV criminalization we need to act in our own movement first.”

The protest was silent and strong with members leaving their seats in the front row to come and join the demonstration. One member of the audience who joined the demonstration stated, “When I looked back I saw a dense wall of fierce women activists and it gave me the chills to know how powerful they were. Then I got up and joined them.” Another member of the protest said: “We need to stand for something or else we will compromise for anything.”

Demonstrators handed out a flyer that said:

Dear Doctor,

It’s your duty to actively oppose the criminalization of people living with HIV.

Use your title and platform to promote science, reason, and social justice. Speak out against the further marginalization of populations you serve and study.

Criminalization perpetuates stigmatizing misinformation, fear, and hatred. Testifying in support of prosecution appeases oppression. You know that this miscarriage of justice contradicts science and public health so retaliate.

Strongly advocate for universal access to HIV education, testing, and treatment, and say NO to the criminal prosecution of people living with HIV!

Sincerely,

Integrity

Like an onion, there are many layers to HIV-related stigma.

Stigma can be internalized, directed at oneself, or it can manifest outwards.  Like an interstate, stigma can also move in both directions at the same time.  Consequences of stigma can impact a person, a relationship, or a community. Like an elevator, stigma can move up and down the age scale. The impact of stigma can have physical, emotional, and social effects on both HIV- and HIV+ men.

It seems to me there is a growing and widening divide between HIV+ and HIV- men.  Like an infection, it seems to be only getting worse.  

I find myself being a part of the very stigma I detest,  I have become an oxymoron and my behavior has become hypocritical of what I know to be right.   I would much rather become friends with someone with HIV than someone without HIV. For me, friendships with HIV- men too often become mentally exhausting; I get tired of the endless HIV-related questions, the answer to which they should already know or could easily Google: 

“Can I get HIV from sucking dick?  Can I get HIV from kissing?  Are you going to die?”

Ignorance and laziness are two qualities I detest.  I don’t believe an HIV- person should become concerned about finding the answers to such questions only after meeting someone who has HIV.  I feel like someone without HIV just doesn’t get it.  And yet...I feel a separate yet equal responsibility to share my knowledge when such questions are asked.  I feel frustrated and yet worrie, that if I do not answer their questions then they might not ever take the time to find out otherwise, and thus by giving into my frustration I could very well be allowing them to live in dangerous ignorance. 

In my experience, the one way to drop a grenade on a potential platonic gay friendship is to disclose your HIV status.  All of a  sudden the fear of guilt by association comes into play.  I believe HIV- guys fear others will think they themselves are HIV+ just by being friends with or dating someone with HIV. Both HIV-positive and HIV-negative men screen prospective social or sexual partners for compatibility, either in a platonic or sexual sense.  Disclosure of HIV within the gay community begins the process of “AIDS apartheid”.  

When I was first diagnosed with HIV, I tried to remain within the social scene.  I went to the club, I went to dinner with the gay boys, I did the whole shmooze and social climbing thing.  But too often I became known as “the guy with AIDS”.  Walking into a club or into any gathering with other gay guys, I could tell instantly if they had been gossiping about me. One glance from them and I knew they knew about my HIV status and always there was a flicker of panic as I approached the herd of HIV- guys.  Or the inevitable and too often repeated reaction to my disclosure  “Oh, I will be right back!”, only to see them in a little while, avoiding you like the plague (pun intended).

One can only tolerate or handle such subtle ostracizing before you throw your hands up and ask yourself why you keep putting yourself into a situation where you are shunned and unwanted. 

I often wonder why gay guys perpetuate the very type of stigma and social sorting that we have been victims of by the population at large. One would think that based on stigma from heterosexuals and/or right-wing conservative and/or religious institutions, that gay men would be more empathetic.  One would think they would be the first ones to offer support, friendship, or a shoulder when they learn of their fellow brother’s HIV diagnosis. 

Yet, there still exists a divide within the gay community by which HIV- gay men either explicitly or implicitly blame us for HIV, who still choose to see us as dirty. A glance at any gay hook-up or gay dating website will show you how very frequently one states their desire for a “clean”, i.e. HIV-, person...implying those who are not HIV- are dirty and damaged. 

After repeated rejections, no matter how polite, one begins to realize the hurt of rejection can be avoided simply by withdrawing from the gay world, as it appears there is no room for HIV+ people within the general gay culture. 

Even within the HIV+ gay male community there still exists stigma based on age.  It seems as though the ageism that is present in the gay male population at large (i.e. HIV- men) has bled into the HIV+ community.  A recent blog post by an under-30 HIV+ person took offense and aim at men who became HIV+ in the early years of the epidemic. This young person basically took the position that older gay men with HIV are a real bummer.  He stated that they offend him because he felt as though older HIV+ men were too preachy and he devalued their experience by saying it was time to stop focusing on death.  The generational divide was especially confusing to me as someone whose age falls between twinky  and older. 

Stigma even comes from within.  The very worst stigma I experience is the stigma I throw at myself.  I have gained weight since my diagnosis and since I have quit smoking.  I weigh more now than I ever have in my life and when I look down at my swollen stomach, I feel such a very distinct and visible disconnect from gay culture.  I am the opposite of a mirror image of the physical being I used to be, back before I contracted HIV, back when I was still attractive and could still seduce a man.  The degradation of my physicality has a direct impact on me socially and emotionally.  I never want to go where there are other gay guys.  To see them in their teensy tiny v-necked t-shirts and their super skinny jeans would only serve as a reminder of who I am not.  My social life since HIV is a textbook example of avoidance strategies.  In my current relationship I do not ever want to be intimate with my partner out of self-disgust in my physicality. 

Such serosorting, HIV segregation, or AIDS apartheid can actually place an HIV- in more danger of contracting HIV through infrequent HIV testing, lack of HIV status disclosure, and the continued perception they are HIV-.  One infive gay guys with HIV don’t  know they have HIV.  The culture of segregation and silence perpetuates a horrific catch-22 of HIV infections.  I have heard too often a horny gay boy trust another person’s word when it comes to HIV disclosure.  Believing you are HIV- is NOT the same as actually being HIV-.

I have been in situations (years ago when I was still single) where a guy was more than willing to sleep with me, without HIV ever entering the conversation until I brought it up by disclosing.  I always wonder how often this happens, where someone who assumes himself to be HIV- tells their sex partner they are negative and then they have unsafe sex. Then I wonder if and when that other person contacts HIV if they think back to that unsafe encounter...or do they overlook the encounter because the other guy told him he was negative?  

Serosorting that results in seroguessing is not a safety behavior, it is a grenade waiting to explode...and the explosion of increasing HIV infections among gay men is the result of such silence and guesswork.  This stigma and fear of the negative consequences of an HIV+ diagnosis directly result in avoidance of HIV testing and counseling.  It appears as though many gay guys subscribe to the ignorance-is-bliss philosophy, and to hell with the consequences.

My personal experience in trying to educate gay men about HIV resulted in resounding silence.  Nobody wants to talk about it.  Gay guys become offended if you bring it up, believing you are accusing them of being a slut or drug addict or both, the whole time they themselves are more than likely not practicing safe sex each and every time.  To many of the head-in-the-sand gays, they are not at risk from getting HIV from their unsafe sex.  HIV is what happens to other people.  Until it happens to them.  

This article originally appeared on Jason’s own blog, Embracing Pozitivity, here.  

About the author: I am 38, gay male from Knoxville, TN who is not ashamed of my HIV+ status. I am optimism personified. I am strength realized. I am just me. 

Website: embacingpozitivity.blogspot.com Twitter @jjemcdonald.