First, I should point out that I have been trying to work a quote from The West Wing into a blog for some time now, so mission accomplished. Secondly, for those of you who, unlike me, may not have an unhealthy relationship with this particular Aaron Sorkin production, it seems only fair to explain what the hell I’m talking about. Post hoc ergo propter hoc is Latin and means: after this therefore because of this. This is usually not the case in most scenarios, but I think when it comes to this particular topic it actually holds some weight. 

So what’s the point? It’s no secret that when HIV hit North America it affected the gay male and other men who have sex with men community the hardest, and today HIV still disproportionately affects gay men and other men who have sex with men. Why? Is it because “God Hates Fags”? I think not. Is it that since men cannot get pregnant there seemed to be less incentive to use condoms? Maybe. Is it because (some) gay men have anal sex, which is considered high risk due to the possibility of exposure to blood caused by ripping anal-membrane? Partially, I suppose. Or, is it the psychosocial and sociocultural issues surrounding gay men and other men who have sex with men?

Let’s face it. We live in a culture that hasn’t exactly been “all about the gay”. We’ve been ostracized, criminalized, sterilized, and lobotomized (shamelessly plugging my own blog). As Safren et al point out in Mental Health and HIV Risk in Men Who Have Sex with Men,

Young men’s development is influenced by many contextual factors, including socioeconomics, race/ethnicity, and familial variables. However, sociocultural pressures, including the pressure to meet socially valued masculinity norms (not the least of which includes heterosexuality) also affect the development and behavioral patterns of MSM. Masculine Socialization Stress results from the ‘shaming and other punishment of gay males for failing to achieve masculine ideals’… (Page 3)

Sociocultural pressures to conform to norms, and institutionalized homophobia have long-term lasting effects on gay men and other men who have sex with men. These effects increase the chances for substance use and abuse, high-risk sex and other risky behaviour. These risky behaviours increase the chances of HIV transmission, resulting in a population disproportionately infected and affected by HIV. What just happened here is referred to as a syndemic, a series of social situations that influence how disease impacts groups of people. So, gay men and other men who have sex with men are treated poorly by society. This treatment increases their likelihood to engage in risky behaviour, and then this risky behaviour increases the likelihood of contracting HIV.

First, my apologies, academic articles tend to be rather stuffy and, well, boring, and for that reason I don’t usually use them in my blogs. However, I admit that I don’t know very much about syndemics and so ‘outrageous Matt’ hid behind the coattails of stuffy, boring Matt. Don’t worry, I’m back now. I often tell people that pretending to be straight was the single most exhausting thing I’ve ever done, and I was a Milk Man!

Pretending to be someone you’re not involves constant consciousness. For me the questions of: “Is this how a straight guy would stand?”, “Is this a word a straight guy would use?”, “Do I look like I’m too eager? Should I look like I care about stuff less?”, and so on were forever running through my brain. This is not only ridiculous, but also a disservice to straight people. However, I was raised in a place where it was perfectly acceptable to (among other things) bar same sex couples from getting married or adopting, so being “straight” was not only easier than telling everyone I’m gay, it was a survival technique. In addition to being exhausting, pretending to be straight did little for my self-esteem.

I would argue that these factors are pretty common components of the syndemics affecting gay men and other men who have sex with men, and are not unique to me. They’re how I found myself in a situation where I was so thrilled to be getting attention from someone who knew I was gay and still liked me that I was willing to throw caution to the wind and commit to some risky decisions.

A single blog entry is not enough space for me to even begin to explore this massive topic, but as soon as I started to research it my brain instantly exploded and I needed to share what I had read with everyone. I haven’t even touched on how other groups of people are affected by this and other syndemics with respect to HIV. What about youth, women, cultural minorities? AH! So much information! Methinks this an introductory piece that needs to be continued, because right now I’ve missed my posting deadline by about a day. I will say that while HIV is certainly not as cut and dry as post hoc ergo propter hoc; there are certainly some contributing factors that happened before the discovery of HIV that work towards propagating more HIV.

This article first appeared on the blog of AIDS New Brunswick here. 

You can follow AIDS New Brunswick on twitter @AIDS NB

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.

Panel reflections:

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 . . 

“Are there enough Gay Dollars for HIV Prevention?” http://cbrc.net/resources/2012/are-there-enough-gay-dollars-hiv-prevention

A lot has been written about how we process risk lately – how we take risks all the time based on a calculation of what we know, what might happen, and what are the likely chances of that happening. 

It’s being increasingly pointed out that we make risk calculations every time we cross the road or board an airplane.  So do people who cross Niagara Falls on a tightrope.  So do people who have sex, with or without condoms.

The HIV landscape is changing around us, so that talking about risk has never been hotter. In part that reflects our ability to treat HIV often quite successfully. Often routine suppression of  viral load, the Swiss statement and then HPTN 052 which followed  have all necessitated thinking about the risk of transmission, and how that risk is processed and communicated, for instance. Things are different now.

The concept that we all take risks, everyday in our lives and “is sex any different?”  is being widely talked about.  Here’s what one of our writers, Michael Bouldin, said recently ”It’s not that we don’t know what constitutes risky behavior; it’s that it’s simply not possible to always avoid it, or in a given moment even desirable. Walking a red light can get you killed; it can also get you to a job interview on time.”

Megan DePutter, another PositiveLite.com writer and the Poz Prevention coordinator  at an Ontario ASO, recently developed this theme further: “The risk of an accident likely trumps the risk of acquiring HIV by unprotected sex. The number of car accidents per year far exceeds HIV infections, yet people get into their cars every day, buckle their seatbelt as a matter of harm reduction, and go ahead with their day without thinking, calculating, or questioning these risks, let alone judging others who also put themselves at risk by being on the road.  But many of these HIV negative car drivers would not carry this same approach to sero-discordant sex, even though it could be argued that a car accident could potentially have worse consequences than HIV acquisition and that missing out on a great love or even great sex would be a tremendous loss.”

Knowing what the risk is.

The recognition that we all take risks and why is HIV any different – has until recently seldom been reflected in HIV prevention messaging, and has arguably been its biggest failing. But let’s be clear.  We sexual health “consumers” DO need to know if there is a risk and, better still, what that risk is. In fact let’s talk odds, let’s talk percentages, let’s talk probabilities. Whether we also need to know  - or be told - HOW to process that risk, e.g. “wear a condom every time” is  a moot point.  Perhaps a more effective approach is talk about choices, as some service providers are doing. More on that later.

But choices are at the heart of every sexual deed, aren’t they?.Sometimes we make them in advance – carry a condom in our pocket and use it, come what may.  Sometimes they are made in the heat of the moment.   Sex is a messy business, not at all rational when it comes down to it and whatever factual information we have and decisions made about how we will act on it, all this can of course, be tossed aside when the lights go out.

Sometimes decisions to take risk can become more deliberate.  Tim Dean in his book “Unlimited Intimacy, Reflections on the Subculture of Barebacking” says of the decision-making process in the barebacking subculture ”after two decades of safe-sex education, erotic sex among gay men has become organized and deliberate, not just accidental.”

There is of course much literature to suggest that at least a little bit of risk taking is a good thing in life.  Goethe said “The dangers of life are infinite, and among them is safety.”  General Patton, of all people said  “Take calculated risks. That is quite different from being rash.”  And let’s hear from T. S. Elliott “Only those who will risk going too far can possibly find out how far it is possible to go.”  So clearly risk is part of our culture, and in many circumstances, lauded.

The interventions

Against this propensity for us all to take risk in some form or another we have a panoply of interventions designed  so that we don’t. Let’s look first at the traditional approach to HIV prevention, for instance, which seems to maximize risk and thus maximize the need for precautions. Where does that approach come from?  Here’s what one HIV specialist thinks about “maximalist precautions” and why he recommends them. Bernard Hirschel, Head of HIV, Geneva University Hospital said this. "Recommending safer sex  . . practices for all HIV- infected patients, even those with  (an undetectable viral load) is indeed advisable. Imagine, as is likely, these recommendations are not followed. Then, if something bad happens, the onus is on the patient. As physicians, we should always try to shift responsibility for mishaps to our patients, and one of the means of doing so is issuing maximalist precautions. It makes our practice so much easier. “

One hopes he is being flippant or sarcastic or both, but I don’t think he is.  The truth is the practice of medicine inevitability involves liability issues. That fact is seldom talked about or expressed in writing but the idea of "maximalist precautions” underlies almost everything about how medicine, including sexual heath interventions,  is practiced today.

Again, we do need to know the worst that can happen.  If there is a remote possibility, a “significant risk” or even a likelihood of harm to ourselves or others, we need to hear about that, for sure.

Research and risk

Researchers sometimes goes beyond the facts to provide warnings which also reflect a “maximalist precautions” approach to their findings. For example, look at  my article on levels of the HIV virus in men’s semen in  PositiveLite.com here.  This is how the risk was described  in a recent study  I quoted there. “Low seminal HIV titers could potentially pose a transmission risk in MSM, who are highly susceptible to HIV infection. . . Until more information on transmission risk in MSM is available,” the authors write, “it would be prudent to advise sexually active HIV-infected MSM to use condoms and other risk-reduction strategies throughout all stages of HIV disease regardless of HIV treatment status.”

One could pose the question “Is it the role of research to tell people what to do? “ Or is it to provide factual information on which people – service providers and sexual health information consumers - can make their own decisions. Similarly, is it the role of ASOs and other sexual health service providers to tell people what to do, or to provide information so that those who consult them can make informed choices?

Condom messaging

In the past, of course, we’ve been told what to do A LOT.  Here are some examples.

Trojan Commercial: "Use a condom every Time" 

(US) National HIV/STI  Control & Prevention Program: "Use a Condom Every Time" 

FDA 2010 Brochure “A person who takes part in risky sexual behavior should always use a condom.” 

www.positive.org: “Always use a condom.  If you're going to suck your partner's dick (blowjob), put a condom on it first.” 

Messaging like this, with its inherent failure to recognize  the realities of human behaviours, or how and why we process risk, runs the risk of undermining credibility.

Informed choices

This maximalist approach - always do all that you can to protect yourself, all the time - is inevitably starting to wear thin.  Increasingly, service providers are recognizing that messaging has to be much more nuanced, recognizing risk is about the choices we make in life – and in the bedroom .  In the gay men’s sexual health movement, for example, the concept of resiliency brought to the fore by Amy Herrick et al in Resilience as an Untapped Resource in Behavioral Intervention Design for Gay Men is being built on. In particular prevention messages building on gay men’s perceived strengths, which include the ability to make informed choices, are becoming increasingly common.

An example of that approach can be seen in thesexyouwant.ca    resource from Ontario’s Gay Men’s Sexual Health Alliance. Their website says this. “We talk about condoms, and also how to reduce your risk in other ways. . . . We just give you the facts and let you make your own decisions. We all accept different levels of risk every day, and that’s okay. What matters is that we have enough information to be comfortable with the risks we take.”

In any event, we appear to be moving in the right direction.  But just how much do we know about how, when and why we take risks?  Search on the net and you’ll find some research on that, but much less on why we take risks  - sometimes quite  big  risks - when it comes to sexual behaviour, when we might otherwise be risk – averse, for instance. There is even less research relating to specific populations. So clearly more needs to be done there to make prevention work solidly founded on a knowledge of complex human behaviours.

But ultimately, whatever we do can be thwarted and its healthy, I think , to recognize that. Humans take risks, period. And as Denis Waitley said “Life is inherently risky. There is only one big risk you should avoid at all costs, and that is the risk of doing nothing. “