Rethinking what we know, Part One
Birch reporting from the B.C. Gay Men’s Health Summit Vancouver, BC November 1-2, 2012
Where’s our provincial strategy for gay men’s health? Where’s our money for gay men’s wellness? Where’s our outrage?
The re-frame of how smart queer men look at the health and wellbeing of our complex communities however is shifting. The focus on our ‘behaviour’ takes a backseat while the ‘drivers of the epidemic’ takes the wheel.
No Magical Bullet: moving forward with HIV prevention and gay men in BC.
[Moderated by Travis Hottes, BC CDC with Mark Gilbert, also from BC CDC, Chris Buchner, VCH; Olivier Ferlatte, CBRC; Kevin Say-Moore, Living Positive Resource Centre, Kelowna]
This plenary session offered an overview of general summit themes. Mark Gilbert carefully laid-out comprehensive and accessible research that asks us to reconsider the social determinants of health (Summit theme). Rather than look at these determinants as a passive process, the emerging, more dynamic descriptor amongst some epidemiologists asks, what sustains and drives the epidemic amongst us?
“We are 1% of BC and 40% of new infections. Where’s the money! We need an outcry. HIV does discriminate!” (Ferlatte)
Gay men have proof of social, medical, employment, research and health funding disparities. Funders will be informed by this research. Will they listen? Will they act? Not without a big queer, multi-pronged push.
The stats: ‘critical but stable’
Gilbert: The trend is not changing for us globally. As the number of HIV infections drops overall, MSM rates remain elevated at 54%. The ongoing mystery is how to reduce incidence of HIV among gay men. We need to take stock of recent trends and consider what we know about factors that influence the HIV epidemic in gay men in BC. What keeps us in this holding pattern?
“Recent data suggest individual-level risks might be insufficient to explain the high transmission dynamics evident in MSM outbreaks.” (Gilbert)
He suggests transmission events need to be considered as concentric circle which includes networks and behaviours as well as relationships and community. Structural and social factors are interrelated. More social support does works.
Bring a friend to get tested
Looking at youth in BC reveals protective factors that reduce risk of HIV including “family caring and support, inclusive and safe schools, attitudes of friends/peers, meaningful extracurricular activities. However, these still many not be sufficient to offset the increased risk.”
In 2007 we spent 40% of our down time with other (generically labelled) MSMs. In five short years that figure radically dropped to only 25% of us spending most of our free time with our own kind. (Globally, queer spaces are vanishing rapidly). Syndemic theory reveals that marginalization (harassment, physical violence etc.) leads to development of psycho-social difficulties that ‘snowball’ into more HIV infection. The more inter-related psycho-social issues = more UAIs, skin on skin sex.
HIV does discriminate - always has, always will
Gilbert: “Dynamics and influences on HIV transmission in gay men are similar yet fundamentally different from other populations affected by HIV in BC. Influences on HIV trends do not operate in isolation, but intersect and can be additive, and vary regionally. Gay men in BC are not a uniform population and are comprised of diverse social and sexual groups.”
Our multi-faceted identities (sexual, racial, economic, physical, emotional, community, HIV related) determine different behaviours. Research employing theoretical models of syndemics and intersectionality (looking at the whole picture -more on this next posting) reveal that focusing on individual behaviour limits data, community uptake and programming.
No time off for good behaviour. And yet, despite condom-message fatigue:
- three quarters of gay men almost always to always use condoms;
- 68% HIV negative men use condoms;
- 63% ask about HIV status;
- in 2008; 72% of gay men in Vancouver who self-identified as Poz indicated that they were currently taking ant-HIV meds.
- 71% had previously tested, mostly in the past two years.
- While as of 2009 19% of us still didn’t know about their HIV status.
Can we do better? Doesn’t it seem that, as gay men, we have to be perfect, the ‘best little boys in the world?’ Never good enough, is it? Why are we more likely to be diagnosed with acute HIV compared to other people newly diagnosed with HIV in BC? If we have the same amount and type of sex as straights, but the chances of infections are so obviously higher, something structurally important is being overlooked or ignored. Unless of course, we have internalized the dangerous behaviour-bent message: we deserve it.
Where do we go from here? Demand What We Need.
Buchner: We’re all on team Gay Men’s Health. Behavioural science cannot do it all. Strategies around behavioural approaches have not lead to behavioural changes. Let’s be cautious about data that it isn’t working. There is no single approach, we need a multi-layered approach:
- we must increase frequency and convenience of testing;
- work with the multiplicity of demographics;
- let go of duelling research agendas and the competition for $$; work in partnership;
- engage an ecological model inclusive of macro level policy, legislation, schools, parenting, criminalization for non-disclosure, invest in social marketing, education and programs; from the bio-medical level to making condoms more available, STI screenings, ‘treatment as prevention’, Pep and Prep, we need a comprehensive coordinated approach -- no one is better than the other.
Ferlatte: Gay men are complex. We need to bring our complexity to regional analysis. I’ve heard that “Gay men have been researched to death”--I’ve not see anyone die yet! We do NOT have enough data. We lack evidence and insight around HIV prevention. UAI. UAI. UAI. We know so little about social contexts of intimacy, gay relationships, we pay poor attention to the social determinants of health. [He angrily sights one paper published by a senior researcher in our own community that states gay men have failed to respond to the HIV epidemic. Ouch!] Fired up, he marches on: “We are not seeing HIV funding for our populations! Only 10% of ACAP goes to our community. How can they get away with underfunding us? ACAP funding might be decimated in 2 years - we may not see any $ outside of Vancouver!”
Sayer-Moore: We see discrepancies in services for gay men outside of the Lower Mainland. We have little sense of social support. We have a higher perception and experience of homophobia, as a result our communities cannot activate toward health and wellbeing. Divisions in small communities are more deeply felt amongst (and against) gay men. We need testing in public health offices. How do we close the gap between the medical community and what the community feels it needs? Structural and social factors are interrelated - no one container includes us. Community activation all comes down to $ and other barriers to health care, including homophobic physicians and social conservative bias.
Ferlatte: What factors are blatantly missing? What works in HIV prevention? We don’t know what works! We lack insight about what else works as a prevention strategy.
Buchner: MSMs in BC are overburdened, over-identified by ‘behaviour.’ Let’s unpack: ‘What is behaviour?’
Question: If you were to recommend a new policy or program, though it may be difficult, what would it be, what would it look like?
Ferlatte: Here’s the big issue, - we have never had a provincial strategy for gay men’s health, NO $, - minor initiatives aren’t sustaining, medical interventions have limited impact; interventions need to address our forms of vulnerability. We need to engage community better; prevention needs to come from gay men ourselves. Why have gay men become so passive, like clients and babies? We need a strategy that respects that not all gay men are the same. (Note: Ferlatte’s not blaming the victim rather asking us to focus on structural homophobia and its punative neo-parental relationship to our populations).
Buchner: What haven’t we been doing as well as we could: promotion of condoms, the basic building blocks, including huge gaps in testing. We have this sense that testing relies on the individual putting themselves in the hands of a health care provider. Provide routine access across the total system of care. With this caution: with the Supreme Court ruling on criminalization lots of people are re-examining what our testing procedures mean.
Gilbert: we need levers that draw more deliberate connections between different governmental departments. The approach must look at trends as opposed to cross sectional data to strengthen our arguments. Trends in resource allocation need to be exposed forcefully. Trends in psycho-social support in treatment and care, prevention needs to be integrated with treatment and care. We need to claim it back. We need social mobilization of our gay communities: we need to be brave enough to tell that story. Qualitative data is needed to capture our stories. Definition of prevention is differently defined from funders and community.
Audience: How do we advocate around policy? Gay men pay premiums too, yet we have unfair distribution dollars for our health.
Audience: Thin gruel’s been given to us. Where can we take this information? The political need is to use this data as the leverage. Community does rise up. Intervention in the gay community are very reasonably priced (i.e. HIM, Vancouver’s Health Initiative for Men). We must broaden the audience of who gets this information. We must think very broadly.
Clearly we need to take our power back. As a community rich in experience and diversity we must resist the medical, the legal and straight assimilation of our identities. We have got to create and express our own vision of who we are. In the next article I will focus on a few Summit presentations that offer us a multi-directional map.
For a conference-related article that determines gay men are better educated, but make less money go here. Also . .