March 13, 2013 - 11:00 pm

Things are really progressing, the tattoo is getting seen by more people and the responses are all, er, positive ;-)  I am becoming more and more comfortable wearing it and the feeling of empowerment continues to build, which is a great feeling! 

I should recap my original experience googling "biohazard tattoos," as it wasn't pretty. The Internet is both a wondrous and sometimes hideously ugly place. 

When I did the google search I was looking not only for images but various opinions as well and was struck by the ignorance and one-sided descriptions of poz people wearing biohazard tattoos. The nicest made reference to someone wearing this tat saying, "He's either a hardcore social reject or he has AIDS!" One of the meaner descriptions went much further: 

"In the gay community it has apparently become a beacon for someone with AIDS. If this is true, again, while the idea of TRUTH IN ADVERTISING is laudable, it may also be a banner of honesty that eliminates any chance of finding a partner, unless of course that partner was LOOKING to catch HIV. In my opinion, this tattoo should be done away with in favor of having the phrase INFECTIOUS WASTE tattooed directly on the forehead." - Urban Dictionary.com 

In the face of such open ugliness (though doubtful this cretin would have dared to say the above to me in person) I was less than thrilled with the idea of putting this tattoo on my body; but I also felt a burning need to stand up to such ignorance and dispel these insane points of view. 

I have no tattoos presently. I have wanted to do a very special one, with deep spiritual importance to me, for years but just haven't found the right artist to draw the design. In the case of the biohazard tattoo I know exactly what I want, even the size (the original tat was 60mm but am ordering a new set of the temps with it nearly 75mm in diameter, I am hoping it will look fuller on my chest and less like a badge) so there is not a lot of debate with the artist, simply, "I want this, how much and how long?

I refuse to ask about the pain as I know it will sting like a bitch!.  I was present when my ex got an Egyptian scarab beetle with wings of an eagle spread wide across the top of his back. The places where the bone is right beneath the skin are supposed to be intensely painful and indeed his shoulder blades and especially his spine, across which much of the detail of the beetle was done, was crazy painful for him. 

That shouldn't be an issue for my chest but I am not big on pain or permanent marks, so tattoos of any kind are quite a stretch for me.  Add the apparent stigma that comes with this particular tattoo and it gives me serious pause; hence the need to run this temporray tat experiment prior to making such a commitment. 

March 14, 2013 - 7:00 pm

Still really eager to get the opinion of other poz guys, I left work early and traveled 75 minutes across the city to finally make it to the Being Alive meeting, “The Young and the Restless” attended only by poz guys.  The apprehension of attending this meeting really ate at me during the drive over. I had way too much time on the road to think about it; tried listening to Pandora Radio but my brain just couldn't stop going over it. 

What if they hate it, what if they are scared of it or of me for being so forward? What if it proves to alienate the very people I seek to make a real connection with? Maybe it totally turns off a potential friend or even a life partner - argh damn this brain of mine. Where is the off switch? Yet I know it's just working overtime trying to protect me from feeling the pain of rejection by reviewing all the possible outcomes (my engineering mind hates surprises), unfortunately it’s only succeeding in stressing me out. At some point one just needs to throw caution to the wind, step off the deep end and start paddling for dear life; this is definitely one way to really feel you are alive. 

(Quick disclaimer, I will write only about my specific experience and some of the general comments made by those in attendance, to preserve the privacy of this meeting and out of a very deep respect for all who attend; they are a great bunch of guys and I applaud them.) 

The group was actually quite small, only a handful of guys but at some level that made it easier. We chatted a bit amongst ourselves waiting for the facilitator to arrive and I began to feel my uneasiness subside.  When the facilitator arrived he sat closest to me and asked if I could start the "check-in" process.  For the uninitiated "check-in" is where each individual is asked how they are feeling and what is going on in their lives. Cross talk or interrupting someone during their check-in is highly frowned upon, as the point of this exercise is to allow attendees a chance to be heard. 

I told everyone my name and went right into why I was attending the meeting. I explained about my experience reading the disclosure article, the anger I felt regarding the issue of disclosure but also how it ignited an internal conflict which no longer allowed me to feel comfortable hiding in plain sight. Coupled with being newly single and faced with having to deliver the bad news to prospective boyfriends, I need a way to once again show solidarity to the community as well as make it easier to disclose. 

Then I showed the tattoo. Only half the attendees were certain what it meant, some had remembered seeing it before while others had no idea.  Some of the guys are newly poz and are just coming to grips with all that entails so a biohazard tat disclosing their status is the last thing on their minds. 

Once I explained that it indicated I was poz they were all quite cool with it. One guy said he would never do it because it would be a daily reminder of all the bad choices he had made that lead to him being poz. This really touched me and I told him I have felt the very same way for many years. 

I was 42 when I got diagnosed and frankly I was bitterly angry to have contracted HIV so late in life when my future seemed set, but leave it to my own shortsightedness and the universe to throw a monkey wrench into my seemingly perfect world. You would think that sometime in the last six and a half years I would have resolved this anger. However, being in a relationship with my partner who was originally neg and later poz, I was able to avoid ever really addressing it. So until just a month ago I would have been "Hell to the NO!" and thought anyone suggesting such a tattoo to 'memorialize' my infection was clearly unhinged or totally out of touch with just how angry I was both at myself and my crappy luck that I got infected. 

I related most of the above to the group but added that I was beginning to see things very differently. Moving to acceptance and showing open solidarity to my poz brothers and sisters were now my goals, to let go of my anger and finally own the disease that had owned me, my future and my happiness for so many years! 

Some guys expressed how the disease is more a mind fuck than a true threat.  For me the idea of accepting it appears to be the only real way to address this issue and achieve some peace of mind. 

None of the guys had any negative comments or expressed horror with regards to me wearing it so my first reveal to an all-poz crowd was a great experience.  The group continued on with check-ins and later discussed various topics, warmly supporting each other through the issues we face being poz. I know that it's damn scary -  at least it was for me - and you may not think you need to attend such a group but if you have never been to an HIV support group you are seriously missing out!  Please do the legwork, find a group that works best for you and get up the courage to attend.   

Over the 90 minutes we went from anger to laughter to near tears and back to laughter again. It was a very heart warming and unexpected cathartic experience which I highly recommend, regardless of your situation! 

To be continued . . 

It’s four am and I’ve just split the nail of my middle left toe on the bed post. I need to write before I forget, before I fall back asleep. Later in the morning my husband will follow a thin trail of blood into the kitchen and see scrawled on the top of a pile of scrap paper typically reserved for our grocery list:

“We eroticize death and forgetting. The forgetting of gay men.” He’ll ignore it, flip the page and write in neat capital letters, ‘MILK.’

I’m on stress leave. Gay for pay, I’m the men’s wellness coordinator for a sizable region, the one poz fag on staff at an AIDS Service Organization. There may be a handful of us littered across the country. The job’s impossible. I love it. It inspires, consumes and confounds me with its boundarilessness. Here I’m a performer in multiple roles: peer counsellor, activist, administrator, event organizer, retreat leader, campaign marketer, writer, editor, facilitator, mentor, mentee, researcher, lecturer, administrator, community educator, community member, formerly sexually active man, gay park garbage picker upper, condom and pamphlet distributer, trouble shooter, administrator and pot-luck host. For now, I’m home again for a few weeks getting back into my own skin.

The below isn’t professional. It’s personal.  Because it was once about community. Impacting external factors of the last few weeks include (and please forgive this pre-dawn listing):

1. The murder of a 2 Spirit friend. Dolan Badger spent much of his adult life fighting the plague. The little that we know is that he was killed without a weapon by some 22 year old (one might imagine) troubled twink. I will write more  later to honor Dolan;
2.  A new young gay activist and friend institutionalized himself in the psych-ward for several weeks after an unsafe sex event precipitated by a fight with his homophobic mother; 
3. Another wiredly-talented mid-twenties fag friend (and non-ASO service user) finally shocked himself out of a three week suicidal depression & daily sexual binge thanks to the terror and guilt-riddled pleasure of a condom-less fuck;
4. Another young person snapped, “You didn’t invite women to your event!” It was a town hall meeting on men’s sexual health. I’m left to wonder does this righteous anger represent a welcome change in the anti-oppression guard despite the fact that the organizing event committee had over 150 person years of social justice work under our belts compared to their feisty few years.  I heard one youth say: “We weren’t around for AIDS. Today we’re concerned about safety regarding race and sexual politics.” This both frightens and excites me as they are picking up where conscious gay men were cut off by AIDS.
5. A neighbour tells me of her 17 year old nephew coming out in a small town to a mother furious about giving birth to ‘that,’ while all his father wants to do is throw up in disgust, “Who would ever choose that lifestyle?” he demands.
6.  And to bottom it all out, an hour before a fun-loving, educational queer inclusive event,  a mid-fifty year old gay man, someone I would compassionately consider a survivor, emailed to inquire, “What the fuck are you gay men up to now? Why can’t you just be normal like everyone else!” Later he wrote, “They’re all just waiting for us to die, anyways.”

When work and personhood are so seamlessly woven fresh spaces between a) what is known and b) what is possible are achingly needed. My mind and body became oppositional forces numbing down my usual bravado.

Back to me

Usually, challenges invigorate me. However, these shoulders are narrower than I often pretend.

I am a middle-aged positive gay man who outlived any understanding of what that used to mean. Even my gratitude for the blessing of survival has no ‘where’ to be shared except in my heart and in this intolerably dimming realm of memory.

This work is inspired and haunted by ghosts. I attempt to introduce tenacious young queer men to these complex queer spirits while simultaneously ‘protecting’ their bright dreams from their gay ancestor’s darker fate. What is lost is the cause. Where is the call to this once proud movement’s temper? Will young gay men ever feel alive in a fight that is about claiming place in their world? Or is the contest of this generation so global that self-identity has become obsolete?

Forgive me, stress makes for bad armchair philosophizing. Perhaps the trans/cis-gendered generation knows better what I’m attempting to say here.

This winter my social immune system plummeted. The virus of homo-hate wormed itself past worn thin defenses. Between the chat-line vitriol of gay men championing criminalization of their poz brothers for non-HIV disclosure, an avalanche of disturbing statistics and the recent barrage of anti-gay global politics, a cloudy mental horizon eclipsed my occasionally abrasive sunshiny personality. How have people done this for years?  I lost sight of any vision. Is all this drama or lack thereof thickening the scar-tissue over my emotional core or rather an ego tenderizing workout for the soul?

Or is this timeout an emergent sign of budding consciousness, an awakening from the inherited shockwaves that I share with all gay men; just a peeking out from behind pain, assumed privileges and heterowashed legal rights? What has caused me prior to this job to ignore to the point of amnesia what just happened so very few years ago? The too muchness of it all; the need to move on; the need to find joy despite what happened? How are you all doing? Our once slap-ass community is sagging in its mid-life crisis.

Am I then, as a member of this trauma frozen gay movement finally thawing out? Are the horror and joy stories of my faggot mentors finally sinking in? Re-sensitization is a uniquely painful process. I have taken longer walks, deeper breaths. I want to find joy because of what happened. That feels more honoring of us all.

While at home, I am revisiting the pressures of being the good (gay) boy. Never allowed to be sick as a child, I prided myself for winning annual year end perfect attendance badges. Never raised nor educated to consider the people I must have infected, I toughed it out no matter how ill I got.

Pre-HIV, youthful guilt is also resurfacing with bizarre memories of the sterile early eighties house I spent my disappearing youth in. We had plastic runners covering much of the Canadian beige carpets and stretched thin, glossy plastic suffocating much of the furniture. When my siblings and I walked over exposed parts of the carpet while sneaking a peek at ‘re-run’ TV we promptly got on our hands and knees and swept away our tracks before my recession burdened parents got home. I learned to break family rules and not get caught.

After only two years at this job I’m challenged to take this sick leave now. It’s sad comfort to hear that other gay friends and colleagues, all solo agents of gay men’s health, once housed inside a radically different ASO culture than the one we first knew, have had to take ‘timeouts’ as well. Perhaps it’s time for a younger man to sit in this chair. Or is it time to reclaim and/or change how we think of gay men’s realities? How can we conceptualize queer health all together and get more sexual and gender fluid diversity to claim our shared place at a future-now table, a wellness we we grow together?  Who is already starting over?

Can we chat next month?

Enough. At times like this I’m gently and lovingly reproached as having a hero complex. Just writing that makes me want to spew more guilt, hilarity, desperation and repressed sadness. Having created and fed on drama most of my life, I use to think of myself as immune to it. If nothing else this Virus has taught me otherwise.

It’s these 4 a.m. voices in my head that remind me of the necessity of self-care as a gay man. These sad and frightening notions demand the attention of a more disciplined writer. However, I’m willing to embrace some space from a job I still want to consider a small but necessary part of a larger movement.  Like the disappearing images of a dream for the moment I’ll let go of analyzing what woke me up.

For the moment I will close the lid of my computer and take another winter’s nap before a much needed celebratory spring rut. 

This title quote comes from a February, 2013 interview with Morrissey, by Amy Rose.

For those of you who are asking ‘Morrissey? Who?’ he was the lead singer of The Smiths in the early 80’s before going solo in 1987. The group was massive and yet had a cult status and the same could be said for Morrissey himself. The personification of an anti-hero and the absolute antithesis of those we would call superstars today, Morrissey’s angst-ridden lyrics spoke to a whole generation of bedroom-bound teens and young people. Strewing gladioli over his audience and singing songs with titles like ‘Heaven Knows I’m Miserable Now’ and ‘Meat is Murder’ he struck a chord with those who felt alienated from the mainstream and still has one of the most loyal fan bases of any of his generation. People literally swear that he saved their lives!

I never got Morrissey and probably never will and although I admired his daring as a gay entertainer, I couldn’t cope with the relentless depression. but then again, I was also the wrong generation and looked at the bleakness of 80’s Britain and the rise of the ‘loads of cash’ generation more with cynicism than despair. Nevertheless, he became a cult icon and considering the fact that he hated the very idea, success like that can’t be denied.

However, in this recent interview, he comes out with some pretty controversial statements, the validity of which you will need to decide for yourselves. One of these is the theme of this article:

“War, I thought, was the most negative aspect of male heterosexuality. If more men were homosexual, there would be no wars, because homosexual men would never kill other men, whereas heterosexual men love killing other men. They even get medals for it. Women don’t go to war to kill other women. Wars and armies and nuclear weapons are essentially heterosexual hobbies.”

Has he got a point? I believe we’d really like to think so. In the best of all possible worlds, LGBT people are non-aggressive, pacifist and have no secret longings to play with war toys. I’m not sure Jeffrey Dahmer, Huang Yong, Fritz Haarmann  and many other serial killers would agree but maybe psychopaths are cases apart and can’t be said to be representative.

However, surely most people would find Morrissey’s statement naïve to say the least? LGBT people are surely as susceptible to rage and violence as anyone else. Because we are more often than not victims of violent crime doesn’t mean that we wouldn’t kill under the right circumstances. Surely history has taught us that if you scratch the surface of a human being in certain situations, any person can quite easily revert to the animal and behave like the beast. Every civil war in the last fifty years has shown how easily people can turn on their neighbours and slaughter them because of their different beliefs. It’s an instinctive kill or be killed drive that often stems from following the herd.

Why should LGBT people be any different? We don’t have a peaceful gene that distinguishes us from the rest of society. Enough gay men and women join the armed forces, or the police, or criminal gangs; are we saying that they would eschew violence when required in their line of work? No of course not, so what on earth is Morrissey on about?

There isn’t a shred of evidence to prove that children who are brought up to be gender neutral in respect of their toys (no toy guns, tanks, swords, bows and arrows etc.) grow up to be any less susceptible to aggression and violence than others. Girls are no less prone to aggression if they are denied Barbie’s and Cinderella costumes. That said, they, may well be more tolerant and less inclined to gender stereotypes but despite what Morrissey claims, I don’t believe that aggression is a gender stereotype; it’s a universal human instinct that is easier aroused in some than in others.

To underpin his argument by claiming that women don’t go to war to kill other women is just too simplistic. As more and more women find their way into armed forces across the world, they will inevitably end up indulging in same-sex killing because it’s part of their job and like all human beings, integral to their nature. Apart from the legendary Amazons, all-female armies haven’t existed, although historically, many cultures have had female military detachments within the main army. That however, is a social construct and nothing else. When women are forced to raise the children and be housekeepers; fighting is left to the men. Male pride has denied female warriors their chance because males have traditionally been the hunters and physically stronger but whether that’s nature or nurture is open to debate.

There are two other reasons why I disagree with Morrissey’s idealism. Anger management in the LGBT community is one of the largest topics of discussion on therapists’ couches. Repressed frustration; anger at stigmatisation and unfair treatment; aggression through guilt or even illness (as with people living with HIV, cancer, hepatitis and more) are growing problems amongst the LGBT community. I would claim that there is nothing wrong with that. It’s a perfectly natural reaction due to stress from outside influences. If LGBT people were really non-aggressive by nature, that wouldn’t happen because we’d all look at life’s setbacks with a Zen acceptance. Rage against the machine is a universal reaction to injustice and LGBT people are as entitled as the next man to do it and they do! 

Secondly, if you go into any gay social situation, you will encounter the same aggression towards other like-minded people as in the heterosexual community. Okay, it doesn’t often end in killing but neither does it amongst heterosexuals. The aggression is there however. Look at gay humour. Bitchiness can be cruel, direct and words can hurt, even when cloaked in humour. It’s generally a safe escape valve. In the heterosexual social environment, that may end up as a full blown argument, with a physical fight as a result but they don’t have the humour as a catharsis. However, take both situations and move them one step further and violence can be applicable to both groups.

Morrissey’s main point I suppose is that LGBT people would never go to war because they don’t love killing like heterosexual men do. That supposes that heterosexuals enjoy killing as a hobby and gay people don’t. Sorry but where’s the proof and is that anything more than pure stereotyping? If we take an honest look back at our childhoods, I’d wager that we got the same perverse satisfaction from squashing the poor fly or spider as the rest of humanity.

Anyway, men or women don’t go to war of their own volition, politicians, political idealists and religious leaders do. Their armies are professional employees who are ordered to do a job but the orders come from above and we know there are enough LGBT people in the corridors of power!

Okay, you might assume that LGBT people are less inclined to become soldiers, policemen, or other positions who occasionally need to implement violence but is that because that’s their nature, or is it because they aren’t accepted in those jobs thanks to their sexuality?

I would claim that actually, LGBT people are just as violent and able to kill as their heterosexual counterparts. Put any man or woman in a situation where it’s kill or be killed; protect your loved ones, or give them up and fight for what’s right, or surrender. I believe that the human animal in us all, fuelled by the adrenalin in us all, will then kill or maim if necessary.

I’m not saying that Morrissey’s talking out of his ass and he’s entitled to his opinion but I do believe he’s way off the mark with this one. That said, if any one of the generation who, locked in darkened rooms and overwhelmed with depression are prevented by his words, from taking out their frustrations on society in ways that have dominated recent headlines, then I’ll be the first to bow down and join the ‘Morrissey for sainthood’ movement.

One hundred and eighty degree turns happen in a variety of ways. Sometimes we seize the steering wheel of our lives and in one fell swoop travel along an opposite path.  Other times, we take the turn slowly, one degree at a time, gradually realizing the path we are on leads nowhere and we need to go off in radically new directions. That’s been the case with my realizing that most of my once fervently held objections to treatment as prevention, in 2013, make much less sense than they once did.

Why? In the last decade, our knowledge of disease progression has changed as has how much we know about the impact of ART on our ability to transmit the virus. But treatments have changed too, and so has my own willingness to look at both sides of the argument, to weigh them against each other and to make informed choices which recognize, above all, a shifting environment.

As well, the realist in me tells me that when it comes to HIV prevention, the status quo isn’t working. I respect those who work in the prevention community. But, to be blunt,  those who continue to play with the same old tricks – plugging condom use when we know the limits to their efficacy in real life situations, trying to effect behavioural change with the odd stray missile thrown at the social determinants of health  - are playing in the wrong sandbox. Let’s not fool ourselves. None of these things will stop the epidemic. We need new tools.

Enter my new friend, treatment as prevention.

Accepting it as a valid, in fact necessary, tool hasn’t been a slam dunk.  My early introduction to it left me decidedly unimpressed.  At the Canadian AIDS Society (CAS) eight years ago I echoed the concerns of the Quebec caucus who first bought the issue of treatment as prevention to the floor, concerned at the notion of people being put on treatment without informed consent and with no demonstrable benefit to their health. If memory serves me I moved a motion that was approved at a CAS AGM condemning treatment as prevention - and in fact was instrumental  in drafting a highly critical position paper when I was subsequently elected to the CAS board.

Fast forward a few years. I was still a treatment as prevention doubter in January 2012 when, through my work for PositiveLite.com, I nervously picked up the phone to talk with Dr Julio Montaner, the distinguished former head of the International AIDS Society, now heading the British Columbia Centre for Excellence in HIV/AIDS.  Montaner is of course a leading expert on, and advocate for, treatment as prevention. His arguments though, have not persuaded all in the HIV/AIDS movement, notably many people living with HIV/AIDS. 

Going in to that long conversation with Montaner, which you can read in two parts here and here I had real reservations as to whether treatment as prevention was ethical or even good for people living with HIV, yet alone effective. I’ll get to how I’ve processed those issues since, but let me first say a few words about Montaner.

As I said in my interview, he‘s a passionate man. One to one, he speaks with excitement born of frustration. But the thing that impressed me most was how so much of our conversation was rooted in his obvious burning sense of justice, of civil rights, of the conviction he has of what is the right thing to do. Far from down treading on patients’ rights, for instance, he was vocal and insistent about the need for informed consent and hugely concerned about disparities in access to treatment and care.

He’s also very persuasive, both in his manner and in his arguments. More of that later.

In any event, I wanted to look at the commonly used arguments against treatment as prevention, ones which I once upheld, and share why there has been a shift in my appraisal of them since those early days at CAS. Beginning with . . .

1.Let’s not start treatment earlier than we absolutely have to . . . 

There is an oft expressed concern, or was, that HIV treatments are toxic. If this is true, why expose the body to HIV meds longer than necessary? Montaner makes the point that while not perfect, treatments have improved considerably. More importantly, he suggests most everybody will need to start treatment sooner or later; delaying a few years until the immune system is showing signs of collapse results in a only a few year's respite from meds out of what will almost certainly be many decades of treatment. Blunt words, but I found that argument quite persuasive.

2. There is no demonstrable benefit to the patient to starting treatment early.

There was always the belief, now the certainty since HPTN052  (CATIE dubbed it “the trial that changed everything”), that antiretrovirals could have a marked impact in reducing one’s ability to transmit the virus. Experts now believe that benefit can, in the right circumstances, be as effective as condom use.  That’s powerful. But whether there any other benefits has been a thorny subject. The evidence now seems to firmly suggest there are. The negative impact of inflammation, for instance, even when CD4 counts are holding strong, has been well documented. As CATIE’s James Wilton said to me in a recent interview  . . . 

“More and more research is showing that even early on in the course of HIV infection the virus can begin to cause long-lasting and permanent changes to certain organs and the way the immune system works.  Research is also showing that uncontrolled HIV replication causes ongoing inflammation which may lead to premature aging of the immune system and accelerated development of age-related conditions such as cardiovascular disease.”

The botton line? Others may, but I’m not prepared to ignore the evidence that, simply put, starting treatment early really is better for us.

3. But what about side effects if I have to start treatment now?

When I started advocating against treatment as prevention at CAS, going on treatment was full of problems for many. It's way less problematic now. In fact many who’ve  started on one-pill-a-day treatments like Truvada, a particularly well tolerated medication, will answer “what side effects?”  But the fact is if you are going to experience them, and I hope you won't, that’s not likely to change whether you start treatment now or later.

4. But what about long term side effects? Those treatments may look safe now, but side effects can often emerge over the longer term.  Why encounter that prospect earlier than you might need to.

This is a variation on 1. above and for many years, I felt it to be a very persuasive argument. After all I suffer from both lipodystrophy and peripheral neuropathy, the latter very badly, consequences of talking medications whose latent side effects came as a surprise to all. So yes, I know side effects can happen downstream.  But this argument is not so much an argument against treatment as prevention as treatment in general.  So while I don’t discount this argument entirely, I’ve learned to put my faith in the fact that modern day meds are better than those that have caused myself and others grief in the past.  And, you know, sometimes, as throughout the history of HIV treatment, we just have to take a chance, recognizing that few things in life are certain.

5. People are going to be given treatment against their will because someone decides it's best for them.

First of all, suggesting treatment be offered for a condition not long after diagnosis is hardly exclusive to HIV – think cancer – and there are always dangers inherent in this process. Informed consent is the issue as is the opportunity for coercion. It’s tricky to ensure informed consent happens always, but certainly not insurmountable – and that’s where we can and must do the work.  Says  CATIE’s James Wilton  . . . 

“It’s important that people living with HIV have constructive and meaningful discussions with their healthcare provider before they make the decision to start treatment. These discussions need to explore their readiness to start treatment, the risks and benefits of initiating treatment and what the evidence does, and does not, tell us. Ultimately the decision needs to rest with the person living with HIV. The tools we need are those that support the doctor-patient relationship to ensure informed decision-making and treatment readiness. CATIE has developed several of these tools, such as an HIV treatment talking tool (Your Doc Talk), treatment videos (Starting HIV treatment: Personal Stories), A Practical Guide to HIV Drug Treatment, and workshops. Some of these tools are available at http://www.catie.ca/en/starting-treatment.”

6. It’s unethical to put public health interests ahead of patient interests by promoting the need to get viral load down at the population level.

First of all, I love that there is an ethical component to this debate; more on that later. But I wouldn’t deny there is certainly meat in the above argument. PositiveLite.com writer Ken Monteith recently said .

“I do believe that a person can validly choose to embark on treatment early, but not in a context where the background information is being manipulated for another purpose. Treatment guidelines are supposed to be about the health of the person being treated, not a pharmaceutical control of that person's sexuality.”

He’s right of course. We need to be vigilant that that doesn’t happen. Certainly treatment as prevention advocates, including Montaner in particular, stress that the decision when to start treatment has dual benefits – better clinical outcomes and reduced ability to pass on the virus to others. We need to make sure, though, that the health of the individual is paramount. I believe we as a community are up to that task.

 And finally . . .7.Treatment as prevention doesn’t work.

Sure it does at the individual level.  On that the verdict is in. But at the population level? Certainly San Francisco, the province of British Columbia and some locales in Africa have claimed success in the form of reducing numbers of new infections. The problem is that treatment as prevention, on a population basis, doesn’t seem to be working in gay men. 

There has been much debate about why, some of it anatomically based and frankly, in this writer’s opinion, bordering on the ridiculous. The saner consensus that seems to have emerged, though, is that  because MSM infection rates are already very high, including in the untested, existing treatment coverage (just 28% in the States, with a similar figure estimated for Canada) testing/early treatment at existing levels is just not enough to bring infection rates down. I buy that, which is why I also buy in to the concept of moving people, wherever possible, along the treatment cascade, a cycle which encompasses detection through to viral suppression that’s outlined here, as handily as we can.

When it comes to MSM, it’s interesting that only some of the more progressive  gay men’s sexual health initiatives have really bought in to the concept of treatment as prevention. ACON, for instance,  out of New South Wales, is a leader in promoting both testing and early treatment with an aggressive (some will say overly aggressive)  target of getting 90% of gay men on treatment.  The language may be too strong for some but it’s beginning to look like these sorts of high levels are necessary to end the epidemic.  Certainly this is what the Brits are saying too. 

Other organizations, particularly in Canada, are less than enthusiastic. There is, for instance, a position paper from the Toronto PWA Foundation from 2010 that you can read here which is complete as to all possible objections to treatment as prevention, but which provides less attention to its benefits. I would like to have seen more balance here.

And there is the rub, isn’t it? Deciding whether new technologies like treatment as prevention including PrEP - even home testing - are to be supported involves weighing the pros and cons, not looking merely at one side of the scale. And in the changing environment in which we live, I’ve come to believe that in the last year or two the scales have been tipped in favour of looking at treatment as prevention, both at the individual and populations levels, as something to be embraced.

Many have made the point, though, that treatment as prevention needs to work in tandem with other prevention technologies, and condoms in particular. They are right, of course. Let’s not go overboard here. HIV-negative people in particular need to be encouraged to use them. Positive folks who are undetectable? The verdict is still out, but I’ll wager that it will come to pass that it’s not just between heterosexual discordant couples where one is undetectable that the chances of transmitting the virus are close to zero.

In any event, you know where I stand now. Know too that in Ontario it sometimes feels lonely to be a proponent of treatment as prevention, but I’m OK with that.  Besides, group think has never been a virtue I’ve bought in to.

One final argument for treatment as prevention I’ll throw in, and it’s an ethical one we seldom hear because – well. we seldom talk ethics. But here’s the thing. Our community has had an amazing record of grappling with the epidemic from within. That’s because we care for each other. We understand community. So we promoted condom use, for instance, when condoms were just a birth control device, even when we didn't like them.  We created an amazing community-based health infrastructure that has become a model for others. Now we have a chance to end the epidemic – again from within.  And people living with HIV now have the power to make that happen.

As I said earlier, it’s become patently clear that existing prevention strategies aren’t cutting it, unless you call containing the epidemic, some of the time, a success. I don’t. For the first time in years, there is a pathway to perhaps end the epidemic but it involves, amongst other things, people living with HIV actively participating. That strikes me as a huge opportunity rather than a threat.

I for one would love to see us seize that opportunity. Why? Many reasons, as you'll see above, but on top of all these - and here comes that ethical thing again - is that I now believe it’s the right thing to do. That's not so strange, is it?

So what do you think is the right thing to do?