Exactly twenty years ago, in the first three months of 1993, more than thirty men in care of Her Majesty’s Prison Glenochil (Scotland) (below, right) were on heroin, sharing needles and syringes. During a prison-wide HIV testing campaign, it came to light that 12 of the men had become HIV positive as a result. 

Today, twenty years on, HIV treatment has radically improved the health and longevity of people living with the virus. For anyone receiving an HIV diagnosis in the early 1990s, however, prognosis was poor and society less than accepting, especially of men infected through sharing needles in prison. When an official report of the outbreak warned of the risk of spread from the ‘Glenochil twelve’ they were unaware just how prophetic their words were of what was in fact a human tragedy.

In one case at least, the infection of a partner would trigger the first trial in the UK of someone with HIV for ‘reckless and culpable behaviour’. The High Court found the accused, Stephen Kelly, guilty and returned him to the custody of the prison service in whose care he had contracted the virus in the first place. Implications for him, his partner and family were disastrous, and created a knock-on effect among people with HIV. A string of other stories was related in a tabloid newspaper a few years later, naming individuals and their closest connections, while also feeling entitled to breach intimate details of the men and their families.

The first report globally of an HIV outbreak in one of Scotland’s prisons created a stir. Even with the well-known high rates of injecting among the young men and women of the housing estates on the edges of Scotland’s biggest cities, it was headline news when it broke.  Drug education measures for drug users in prison had been insufficient to protect the ‘Glenochil twelve’.  A subsequent enquiry by the Scottish Affairs Committee of the House of Commons (London, HMSO 1994) concluded that anything between 22 and 43 inmates might have been infected, while another 258 were missed from the study having been released or moved to another prison with the six-month study period.

Outside prison, in contrast, a raft of measures including needle exchanges had started to turn around an epidemic of HIV infection that had peaked in 1986, six years previously. Day to day, the majority of drug users in communities would have made use of these harm reduction measures. Once behind prison gates, however, inmates addicted to heroin found a different set of rules.

In a rapid response, prison authorities introduced counselling on admission, detox and rehab, and eventually sterilising tablets to clean syringes and needles. Syringes and needles themselves, however, were excluded. They still are.

The official report at the time recommended ‘urgent measures’ to prevent further spread among prison injectors. (Taylor and Goldberg, BMJ, 1996). Experience in the community was clear.Harm minimisation through provision of needle exchanges, oral substitution treatment with methadone, support on release, and good links with community and health agencies would mirror strategies in the community from which prisoners came and where they were accustomed already to protective measures. For those twelve men infected in Glenochil, in 1993, time in prison had taken them right back to experience the self same conditions that had fed the epidemic a decade before.

Now, 20 years on, what has changed? Pressures have increased with soaring occupancy rates. The majority (64%) of people entering prison have used drugs in the previous twelve months, and many (39%) worry that drug use will be problematic on their release.  Positive advances have been made in prison drug policy. Provision of clean needles and syringes, however, remains taboo to Scottish prisons.

Proposals to pilot a needle exchange in 2009 were met with threats of a walk-out by the Scottish Prisons Officers’ Association. Despite having been Scottish Government policy stated in its Hepatitis C Action Plan (2006), the pilot remains in the red zone. In response to SPOA concerns for its members, the SPS undertook a thorough study and concluded, “It is important that, where possible, inmates of prisons have access to the same services in prison that they would have if they were living in the community”.

It was also found that needle exchange schemes in 46 prisons in four other European nations had successfully reduced rates of HIV and Hep C. Despite similar safety fears expressed by Scotland’s prison officers, no single instance of use of needles as weapons had been recorded. Where these schemes have been stopped, it has been due not to opposition from staff, but to political interference. Indeed, whereas 85% of staff in the European study had opposed introduction of the schemes, 100% wanted them kept when politicians closed them, a remarkable change based on direct staff experience.

As long ago as 2001, a review of the HIV strategy in Scotland received evidence from the then SPS Medical Adviser on HIV prevention and concluded, “We recommend that the Scottish Prison Service considers whether it can do more to reduce the potential for HIV transmission in prison”. SPS Standards currently support an enlightened approach to drug use in prison. Harm reduction is integral, taking the form of substitute prescribing, harm reduction packs, condoms, lubricant and dental dams. In some prisons, there is even a needle replacement scheme at reception and the offer of sterile injecting equipment on release.

The one gap is in provision of clean needles and syringes during custody itself, and it seems that the whole project is off the agenda.

It might be argued that not only are needle exchange schemes unacceptable to prison officers, they are no longer necessary due to the success of other existing educational and harm reduction measures in prisons.

This latter point was scrutinised by the same researcher and her team as reported on the original Glenochil outbreak. This time, the primary focus was on Hepatitis C not HIV. This study, published in the latter part of 2012 found that the rate of illicit injecting drug use and of HCV in injectors in Scotland’s 14 prisons is the lowest in the literature. This is due in great part to drug treatment in Scottish prisons, including harm reduction.

It found, however, a 3% incidence of Hep C in the prisons during the period of their study, meaning that Hep C transmission occurs within prison. The researchers conclude that although the risk and rate of exposures to Hep C, including injecting, during current imprisonment was low, risk accumulates the longer someone is in prison.

Scotland has an internationally recognised reputation for the success of its pragmatic drug policy in tackling HIV. This has not stalled in our prisons, with excellent treatment and support from local specialists and voluntary agencies. Local NHS Boards now provide prison medical services. NHS Forth Valley, where Glenochil is situated, hosts the largest number of prison establishments of any NHS Board area, and is an example of positive change in the relationship between prisoners’ health and prison.

There is a renewed opportunity to revisit a pilot of prison-based needle exchange schemes in a less threatening context.

Based on all of the evidence, policy, and the real risk of exposure and infection, Scottish prisons must introduce needle exchange schemes to complete its strong harm reduction approach. It is long overdue, two decades after the notorious Glenochil outbreak.

This article appeared in ‘The Herald’, 08/03/2013

Republished from Roy's own blog scottfreehiv here.

I’m writing this as I’m desalinating from spending the day at the Dead Sea. For years I’ve hear of this wondrous place where one’s body becomes a floatation device.

At first when I arrived I thought I’d get a friend’s cousin in Tel Aviv to be my guide. As it turns out I’m having a Tel Aviv fling over the course of this month. Nothing serious, like planning a long distance relationship. I’m pretty sure as much fun as it is, the expiry date will be the moment I board the plane. Nonetheless, it is quite nice. It has been well over a year and a half since I’ve actually spent the night with someone. Twice in one week is a miracle, and very nice. 

We met because of a profile on the local gay site. He’s the only one so far I’m met. But over 70 messages later, I’ve been deprogramming myself from the old negative message track in my head, that is: I’m getting old, I’m not in shape like I used to be, I don’t have much to offer.

In Toronto the stand-up schedule does mean that time to meet guys is limited, let alone have anything sustainable. Also I tend to go from 0 to 60 to co-dependency mode in about three seconds. Even here, what I tell myself is go be independent and plan out what I want to do, and figure out where this other stuff can fit in. If not I turn into this big needy blob. But at least I can recognize it, which is why I have my next four or five days all planned up.

Weirdly though, the morning after spending the night together, I felt sad. Maybe because I know this is just a fleeting moment in my journey. Perhaps it’s a reflex from all those “paid” overnights. I started to wonder, “Have I become one of those guys who used to arrange nights with me due to the big gaping hole of intimacy in my life”.  A Chihuahua, after all,  can only do so much.

I did tell him I’m positive after hanging out a bit. I’ve since learned that this is something not many guys do here. But I had to. I’m just a Google away from him finding out anyway. Besides I can’t relax and feel authentic if I’m hiding something.

It was not a problem. Even when he asked whether doing such and such thing is safe, he was so cute and sweet about it.

Tonight I’m meeting with pretty much the biggest and most long term activist in Tel Aviv. Surprisingly enough, up only until now, he’s been the only public out positive person in Israel. There is a lot of work to do. He tells me that they have about six guys who are going public, which is great. A little context in which I disclosed.

My fling and I met up yesterday early and drove to the Dead Sea to his special spot. Not only did my dream of floating in the Dead Sea come true, I was doing it in the arms of a guy I really liked. It was this rare romantic moment. And then I blew him in one of the hot springs, just before a bunch of Haredim (Ultra Orthadox) men came down. This was the one time I was happy that they made the girls stay away at the top of the hill as we were butt naked floating in the water.

I panicked a little. I thought, “Please don’t bring the girls down!” Once I realized they weren’t coming down I was OK. I hear stories about the ultra-religious freaking out about stuff and wondered if our gayness was going to evoke a rant or something. It became clear everything was OK, though.

My camera got a bit mucked up so my photos (above right) aren’t too clear.

I’m off to a Storytelling Slam tonight about food, something about which Israelis are passionate. Then tomorrow night I’m going to attend the Tel Aviv’s gay men’s choir called Gayzmers.

On Friday I’m working out the details to head over to Jerusalem to meet a couple I know from Toronto who are studying here. Once a month there is a very musical and joyous Kabbalat Shabbat (the welcoming in of Shabbat). It is supposed to be very cool, and it’s looking like it will pan out.

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

PositiveLite.com says why this article is important. This article is particularly important for those of us following the notion of treatment as prevention and in particular the concept of the “HIV treatment cascade” that CATIE’s James Wilton described here. An important part of watching the treatment cascade at work is the need to follow – even encourage – the passage of people with HIV through the continuum which begins with detection and proceeds to a suppressed viral load.  In the case of those living with HIV in North America, the number of those “virally suppressed” is estimated at 28%, the figure used in the CATIE article, with the statement that Canada  "may be similar".

The following article is important in that it questions whether using a 28% figure for the virally suppressed here is accurate. Certainly PositiveLite.com suspects that the previously quoted figure does not reflect the situation in Canada. However no reliable data exists here and research needs to be initiated to confirm the extent of treatment penetration and to enable monitoring of  future treatment as prevention initiatives that are bound to take place. 

Several presentations at the recent 20th Conference on Retroviruses and Opportunistic Infections in Atlanta suggest that previous estimates of the proportion of people with HIV in the USA who are on antiretroviral therapy (ART) and with an undetectable viral load may have been too low and may be closer to the proportion virally suppressed in Europe.

Background: a walk through the cascades

The “HIV care cascade” is a way of calculating what proportion of HIV in a country or community is on ART and virally suppressed. Having a high proportion of people with HIV with undetectable viral loads is generally seen as critical to the success of ART to prevent HIV transmission and as an important component of programmes to reduce HIV incidence.

The care cascade calculation takes into account that having a high proportion of people with HIV essentially non-infectious is dependent on a chain of events happening, all of them at high frequency:

• A high proportion of people with HIV need to be diagnosed, which implies frequent testing among high-risk groups;
• A high proportion of the diagnosed need to be engaged in care, which suggests an easily-accessible healthcare system for all;
• A high proportion of those in care have to be on ART, which suggests guidelines with high CD4 count thresholds for care (or none), and few financial or availability barriers to ART;
• A high proportion of those on ART have to be virally suppressed, which suggests high adherence rates, good monitoring, and appropriate prescribing. 

Reports in the last two years appear to show a large gap between the US and Europe in terms of the proportion virally suppressed. Last year at the IAPAC summit on antiretroviral-based prevention Dr Valerie Delpech of the UK’s Health Protection Agency showed that in the UK 53% of gay men with HIV have an undetectable viral load. Preliminary data suggest that the figure will be very similar for HIV-positive people in general, and indeed another study at the International AIDS Conference suggested that because incidence in gay men is higher than in other populations, the proportion of the HIV-positive population in general that is virally suppressed may be quite a lot higher than this, despite their tendency to be diagnosed later.

In contrast, two similar calculations for the US by the Centers for Disease Control have suggested that only 28%, or even 25%, of people with HIV are virally suppressed and even fewer of the most vulnerable groups, such as black gay men, heterosexual men and young people.

France, the UK and the US

A clue as to why, so far, ‘cascade’ calculations for the US have come out with such lower figures came from a study of the care cascade in France (Supervie).

This study, based on a large cohort of patients with HIV, calculated that 52% of people with HIV in France are on ART and with an undetectable viral load, and 56% of gay men, a little higher than the UK.

It estimated that 81% of people with HIV in the country are diagnosed (better than the UK estimate of 76%); found that 92% of those are in care; that 81% of those have been taking ART for more than six months; and that of them, 86% have a viral load below 50 copies/ml.

Counter-intuitively, the group with the highest rate of viral suppression is people who got HIV through injecting drug use, 66% of whom have an undetectable viral load; but this is because, as in the UK, France has done a good job of bringing down HIV infections in injecting drug users to a few per cent of the total, so most IDUs form an ageing cohort who are already in care. However IDUs also formed a disproportionately large part of the small number of people who are diagnosed but are not in care.

The French researchers cited the country’s health system for its relatively high number of virally-suppressed people. The French system is not free at point of demand and is insurance based; but unlike the USA, with some residency exceptions, people with HIV are entitled to recoup the cost of all their medical care.

Why are the US results so different? In most respects, the US health system actually performs just as well. For instance, in both countries, 81% of people with HIV are diagnosed; and though France performs better when it comes to the proportion with a viral load below 50 copies/ml (86% in France versus 77% in the US), in the US, more people with HIV who are in care are on ART (89% in the US versus 81% in France). 

The big difference is the number who are linked to, and stay in, care after diagnosis. In France 92% of the diagnosed are linked to care (and an even higher proportion in the UK); in the US study cited, only 51% of the diagnosed thereafter attend clinics regularly.

Are the US calculations wrong?

Why? The assumption has been that inequalities built into the US healthcare system are to blame.

In the US, health care for HIV is covered by a complex system of healthcare benefits and entitlements. About a quarter of people with HIV are classed as uninsured, and people with HIV in general are 56% more likely to be uninsured than the general population.

The uninsured can still get HIV treatment via state-run AIDS Drugs Assistance Programs, which are funded by federal money under the Ryan White Care Act. In the past, a number of state ADAP programmes have run short of money and have sometimes placed people in need of HIV therapy on waiting lists.

The 2010 Affordable Care Act (‘Obamacare’) mandates that employer and private insurance schemes must cover long-term medical conditions and provides for the creation of insurance markets (state- or federally-administered) which will start in October, with a bridging insurance plan already in place. It also requires states to expand Medicaid, the main provider for people with disabilities, but the Supreme Court struck down federal powers to fine states that refused to comply.

What this means is that while the vast majority of US citizens can access HIV treatment, getting it is complex, can require satisfying stringent criteria, varies hugely by location, may be covered by several different schemes, often requires co-pays, and is currently in a state of flux. It also enshrines socioeconomic inequalities, with black people with HIV twice as likely as white people to be on ADAPs. There has been an assumption that this resulted in actual gaps in HIV care coverage.

However several studies from the US presented at the recent CROI conference suggested that instead it forced people to move from one provider to another or to space out medical visits.

Defining ‘retention in care’

The definition of ‘retention in care’, as used by the Centers for Disease Control paper that came out with the figure that 25% were virally suppressed, was the proportion of adults with HIV who received at least one medical care visit between January and April 2009.

When this finding was presented at the International AIDS Conference last year, it was suggested that many people on stable ART might attend appointments less often.

A study presented at the recent CROI conference (Horberg) by Kaiser Permanente (KP), the US’s largest private not-for-profit provider of HIV healthcare, suggested that the CDC ‘cascade’ calculation may considerably underestimate the proportion of people who are virally suppressed.

In particular, the CDC assumption had been that people who were not ‘retained in care’ could not be taking ART, but this might not be the case.

KP used its own database of 16,816 patients, which, because it provides coverage in general to the less-deprived populations, was largely male (87%) and older (average age 48 and 29% over 55). No data on ethnicity or sexuality were given.

KP used a broader definition of ‘retained in care’ (at least two visits in a year) and below 200 copies/ml as its definition of viral suppression. It also used a single measurement of viral load in any one year as its definition of viral undetectability rather than two consecutive ones.

Using these more liberal criteria, its estimate for the total number of diagnosed patients virally suppressed, at least in KP patients, was 60.2%. If the CDC estimate of 19% for the proportion of people with HIV who are undiagnosed is added, this would become 51% of all people with HIV – quite similar to France and the UK.

However the actual Kaiser figures for filled prescriptions and for viral undetectability showed that more people were prescribed ART and were virally suppressed than were defined as being ‘retained in care’. Using the proportion of all patients with a viral load under 200 copies/ml at the last test as its criterion for viral suppression rate, rather than the proportion counted as ‘being in care’, the result was that  80% of diagnosed KP clients with HIV were virally suppressed. Extending that to the whole population and adding in 19% undiagnosed, that would mean two-thirds of the HIV positive population had an undetectable viral load – or would do if they were all like KP clients.

Seattle: adding in the lost-to-care

The KP paper may overestimate the proportion of people in care and virally-suppressed as much as the CDC underestimates it, but a study using real figures from Seattle (Dombrowski) supported its findings to some extent.

This found that diagnosis rates were similar or higher than the CDC estimate. But it also did something the CDC did not, which was that by using data from real-life case investigation of people who apparently dropped out of care, it determined that about 10% of people classed as not receiving care had in fact moved out of area or away from the providers included in the study, and were in fact in care. It also found by investigation that another 10% of people who were listed as not being ‘retained in care’ because they did not have a CD4 or viral load test result recorded, were also in care: the issue in these cases was to do with medical note recording or of physicians deciding to monitor less often, not actual attendance.

Using these figures the Seattle team calculated that 79% of all people with HIV living in King County, Washington state (Seattle’s county) were linked to care as opposed to 66% in the CDC calculations, and 71% retained in care as opposed to 35%. This meant that the proportion of people with HIV who were virally suppressed was 57%, as opposed to 25% in the CDC figures. Again, very similar to the European figures. 

New York: increases in viral suppression

Similar figures were obtained by a study from New York city (Stadelmann), although once again, these local figures may not be representative of all areas.

This paper used as its definition of viral suppression two successive viral load results under 400 copies/ml in a year, not dissimilar to the CDC studies.

However it did not assess linkage to or retention in care, and thus made no assumptions about whether only people classed as being retained in care could be assessed for viral load suppression.

It found that 52% of diagnosed HIV-positive people in New York were virally suppressed. If the estimated 19% of undiagnosed people is added in, this becomes 44% - lower than in Europe but a lot higher than the CDC estimate.

These figures are from 2010-2011 and represent a considerable increase from 2006-2007, when 38% of diagnosed, or 31% of all, people with HIV had an undetectable viral load.

The New York study also assessed the proportion of diagnosed people with persistently high viral loads (two successive measures of over 100,000 copies/ml), and who would therefore be very infectious. It found that this proportion had declined from 7.4% of diagnosed people with HIV in 2006-2007 to 4.6% in 2010-2011. This does not imply a proportional decrease in very high viral loads in the whole HIV positive population, though, as high viral loads in the undiagnosed would be unaffected by ART.

Health inequalities had their effects on viral load undetectability: whereas 20% of the HIV positive population was white, white people formed only 9% of those with a persistently high viral load; conversely, though 45% of the patient population was black, they formed 54% of those with a persistently high viral load.

Conclusion

What these papers show in general is that the complexities of the US healthcare system make it very difficult to measure the true proportion of people with HIV in the country who are taking ART and are virally undetectable. The proportion may be much higher in some areas and for some populations, and the criteria used by the CDC may be too strict, especially as we move to less-frequent monitoring.

But it also shows that even in areas with good coverage, health inequalities remain.

References

Supervie V and Costagliola D. The Spectrum of Engagement in HIV Care in France: Strengths and Gaps. Twentieth CROI conference, Atlanta. Abstract 1030. 2013. See poster here. 

Horberg M et al. HIV spectrum of engagement cascade in a large integrated care system by gender- age and methodologies. Twentieth CROI conference, Atlanta. Abstract 1033. 2013. See  poster here.

Dombrowski JC et al. An encouraging HIV care cascade: anomaly, progress or just more accurate data? Twentieth CROI conference, Atlanta. Abstract 1027. 2013. See  poster here.

Stadelmann L et al. Changes in HIV Viral Load Suppression among HIV+ New Yorkers, 2006-2007 to 2010-2011. Twentieth CROI conference, Atlanta. Abstract 1032b. 2013. See abstract here.

This article first appeared on ConnerHabib’sBlog here. Republished with permission.

You can follow Conner on twitter at @ConnerHabib

Why do porn actors kill themselves?  Who is responsible?

Whenever a porn star – especially a gay porn star – commits suicide, theories show up, and people act very, very certain about them.  Arpad Miklos, who was as much as a porn “star” as anyone can be in a time when we are hyper-saturated with porn, killed himself on February 3rd, 2013, at the age of 45. As usual, many people felt sure they knew why he committed suicide, without much evidence. It was drugs, it was studios not treating him well, it was the feeling of dehumanization, it was the vague but all encompassing “porn industry” that did it, it was the feeling of being hollow, it was his loss of validation after being a star for so long.

I can’t claim any special knowledge about his death, I didn’t know him very well. We met in passing on a set; he’d just finished a scene, and I was about to start mine. He was huge and handsome; I’m not saying anything new. If you met him, you were impressed by his smile and his body and his presence. Looking at him almost made you feel a sense of unbalance in the world, like his handsomeness and flawless physique were proof of some deep inequality between people. But then you’d forget that feeling and be drawn back into the intense attraction.

He gave me a kiss and his phone number and asked me if I’d like to spend time with him later that night. My scene ran over schedule, and I was exhausted, so I told him I couldn’t meet. We communicated a few more times over the years by text and phone, and that was that. I mention all of this to say: I don’t know his motivations or who he “really” was. We kept passing through each other’s lives without ever truly meeting.

But others who knew him even less than me flooded twitter, wrote articles, posted to facebook about what had happened. The theories appeared as soon as the news did. It was immediate, like flies to a corpse. Theories arrived before grief, before honor and love and the experience of loss. When a gay porn star dies, instead of an outpouring of grief, what we are usually witness to is a buzzing.

All of this is to say that not even death can trump many people’s confused and hostile attitudes towards porn and porn performers. That is how deeply injured we are as a society when it comes to sex, exuality, and love.

***

It’s natural to turn events like suicide into cultural concerns.

Tragedies are supposed to pose questions to us – the feelings of discomfort that sadness brings can create meaningful action. But these actions are always most effective when we don’t bypass grief and compassion to get to them. Unfortunately, the people that make up the largest group involved in porn – the viewers and consumers – may not understand what it’s like to be a performer or to work for a studio. The porn industry remains obscured by unexamined attitudes towards sex. So compassion isn’t always available.

There’s a general confusion for outsiders about performer motivations for making porn, how much money they make, what happens during a shoot, what health and safety precautions are in place, how a scene is organized, what it feels like to be a crew member and more. The result is that a monolithic image of “gay porn star” and the “gay porn industry” is formed.  But unlike ideas of other industries – banking or agriculture, say – people’s perceptions are colored by a broader societal confusion: a difficulty in thinking and communicating clearly when it comes to sex and desire.

This confusion is generated by many factors, most importantly by social and cultural institutions that have historically leveraged sex as a way to control people (I address some of those forces here, and will write more about them in the future).  Because these forces create pressure and guilt around sex, when someone like Miklos, who had sex publicly, kills himself, people tend to think he was sad because of his public sex life.  They don’t focus on the fact that he was trained as a chemist nor do they ask what his relationships were like or if he was generally happy. Instead, a knee-jerk reaction links his sadness with porn.

People want to know: How was porn involved in this death?

This isn’t a totally unfair question, but when left unrefined, it’s not a good one; it’s misguided at best, damaging at its worst. Aside from not taking all the other factors of Miklos’s death into account, it’s misguided because it’s not nearly a deep enough or complete enough question. It focuses too much on the performer as victim and not enough on sex in society, nor how the porn viewer receives porn and thinks about porn performers, or how sex is legislated, or what our unquestioned assumptions about the “porn industry” are.

The porn performer is, in general, not a victim. This image of the performer as starting porn because of bad circumstance or compulsion is largely a lie (perpetuated, in part, by confused critics of porn). Part of this false image comes from the idea that porn performers just “fall into” porn or that they’re “discovered” by unscrupulous studio moguls with big, villainous mustaches. But the majority of would-be porn performers now approach studios, not vice versa. They’re seeking porn work for different reasons. Some of those reasons are aligned with the performer’s heart and integrity, others are not, but almost none of the reasons merit the label “victim,” at least not for deciding to be in porn.

The result is thousands of healthy, thoughtful, happy porn performers in gay and straight porn that haven’t killed themselves. And their ways of enacting being a porn performer are very different. There are performers that make one movie to try it out. There are porn stars who make a career out of it like Miklos did, appearing for years in different movies by different studios. There are performers who shoot scenes with their boyfriends and post them to XTube; there are performers who wish they could make more.  There are people who long to be in the porn industry but can’t break into it, or are too afraid to start.

Many (though not all) have other jobs: Along with porn stars who are also escorts and personal trainers, I know gay porn stars who are lawyers, farmers, doctors, meteorologists, and artists. Some don’t have much overhead at all because they live with their parents, who know what they do and are proud of their children.

While there may be some vast archetype that encompasses all porn stars, there’s no such thing as a typical “gay porn star.” We’re all different.

So sadness and mental health problems are not an industry epidemic – that perception is inaccurate, as is the notion that porn stars don’t have any other skills or feel compelled to do porn out of a lack of options.  Such statements simply aren’t true.

Of course, some performers do have mental health problems. Some are suicidal, some are drug addicts. The same is true for lawyers, farmers, doctors, etc. who are not porn stars.

If we strip misconceptions away, we still have a question of porn and mental health before us. But it appears in in a refined version, a version that makes sense. We can ask ourselves, what are the specific pressures of being in gay porn?  How can we make those pressures less of a burden?

***

None of the pressures that face porn stars are exclusive to porn – many of them face mainstream actors and athletes, for example. One of the main problems is the constant inflation and collapse of a performer’s ego.

Once, after shooting a scene for a studio I hadn’t worked with before, one of the staff enthusiastically invited me to the “family.” He told me how great I’d done and how excited he was to work with me again. I was in a towel, exhausted, and happy to hear the news. We were interrupted by a phone call. He answered and entered into an urgent sounding discussion with a performer on the other end. The studio just couldn’t hire him, the employee said, for the rate he wanted. Then he relayed to the performer, studio by studio, how much other studios were paying.  It was significantly less than I’d been paid for work that day. I felt a little sad for the other performer, but didn’t think much of it. I became friendly with everyone at the studio, and we’d talk outside of work, too.

Months later I was the performer on the receiving end of this conversation. Another staff member of the studio had warned me that I was “fat” and that I was asking for too much money. My appearance hadn’t changed since they’d last hired and praised me. If anything, I was more toned. I explained that I was only requesting the same rate they’d always paid me. He went down the same studio-by-studio list, detailing rates, saying that everyone was paying less now. But the rates he quoted were incorrect. I knew that now, because I’d worked for everyone on his list, appearing in a scene for one of them just a week ago. It was a canned speech, created to dock performers’ pay.

Why was someone who I thought was my friend lying to me? The first answer that comes to mind isn’t quite right: money. Such a simple answer doesn’t explain why we couldn’t have had an honest conversation about money, rather than one coupled with insults and constructed to intimidate me in to accepting less.

Another time, I saw a hopeful newcomer come to the set for some preliminary casting photos. A director photographed him, and gave him many encouraging words when they were done. When the aspiring performer left, the director started complaining about how fat the guy was.

“What a fucking slob,” he said in front of me and the other performers hired for the day. Everyone was quiet.

“Did you tell him he wasn’t ready?” I asked, finally.

“No, he should have known,” he said.

There’s a fear among many performers that what we hear from employers is not reflective of how they actually feel, and this fear is, at least in part, justified by stories like these. I’ve heard these complaints echoed again and again by other performers.  On top of this, like many entertainment-related businesses, porn studios are extremely busy but often disorganized. Not hearing back from a studio in a timely manner after initial emails or calls creates a flashing anxiety; is it because they’re ignoring you, because they forgot, or are they simply, reasonably, busy? Until you learn how to navigate it, all this puts you in a weird split state. Are your employers your smiling and nodding friends or are they harboring thoughts about you that they’re not expressing?

Again, this isn’t a complaint confined to the porn industry – it’s a problem with many American business models, where honesty and forthrightness are not properly valued. But in porn, it’s compounded by the fact that these concerns mix into performers’ anxieties about their bodies. Every porn performer I know has at least some fear of how the public will receive our bodies or how “fat” or “skinny” or “small” we look, even though we may not be fat or skinny or small by any means (and if we are, that brings in a separate set of societal issues). This situation isn’t made any better by unscrupulous internet commenters and bloggers, who are happy to leave the cruelest comments they can think of under photos of our naked bodies.

***

Seen in this light, working in porn has a healthy aspect and a dark shadow.

Porn is healthy for a performer to the extent that it allows him to detach, rather than immerse himself in his body.

***

Porn offers an amazing opportunity to think about your body. You have to think about how it looks, what food to put into it, what exercises to do to refine it, how to relax it, how to take care of it.  You even have to consider that other people may not like your body, no matter what you do. Your dick might be too small (or too big!) for them. They may not like your face or think your abs are undeveloped. In porn, you have the opportunity to hear these complaints and to love yourself anyway. It’s very freeing if you can achieve it. When you can think about your body, you create a loving distance from it, a detachment. It becomes an honor to have a body when you know it’s only an aspect of your being.

One happy and surprising side effect being in porn has had on me is that it’s loosened up my response to societal standards of beauty, allowing me to see who I actually find attractive. Before porn, I found myself having a reflexive response to men with huge pecs and six pack abs. If a huge guy walked into a bar, I (along with a lot of the other patrons) would turn instinctively to look at him. Maybe I’d compare myself or other guys at the bar to him. After being paid to have sex on camera with men like that, the feeling has totally left me. Sometimes I’m still attracted to men who fall into society’s standard of beauty, but it’s not reactive. Being in porn, being detached from my body, has helped me see the real contours of my desire and attraction, rather than conforming to what I’m told to think is attractive.

The same detachment is what allowed me to hear from the studio owner that I was “fat” and not breakdown, or to read mean-spirited comments on blogs, or to resist the command to do steroids from another studio worker. My body is linked to my worth, but it’s mine, after all. I’m a caretaker for my body. The more detachment I get from it, the more clearly I see that. I can feel this way most of the time now, but I still dip into the shadow every once in awhile.

The shadow side is that, as a porn performer, you can begin to completely identify with your body. You can think it’s who you are. You can stumble off to the gym and onto the set and through parties and bars, cutting off your mind from other aspects of experience. When you’re in this immersed state, an internet commenter or mean-spirited blogger or tactless industry employee calling you fat can feel devastating.

This is problematic enough, but it becomes crushing when you start to believe that your body is all you have to offer. While I think most arguments about objectification are shallow, I also notice how porn performers can limit their own freedom and destroy their happiness by equating their bodies with their worth (and their worth with how much people are willing to validate their bodies by paying to film them.)  This is where a cliche comes from, the one where the ex-porn actor says desperately, “But porn is all I know!” How to perform on camera is never all anyone knows, but being in porn creates the possibility of that self-delusion.

It’s good to equate some self-worth with the appearance of your body. Too little emotional and thoughtful investment in our bodies can lead to poor health and compulsive daily patterns. Equating too much self worth with our bodies can do the same, but the damage is often to mental health. We become sensitive, obsessive, or prone to taking mood-altering steroids which for some can amplify the problem.

***

But these are just the pressures porn performers face directly through their involvement in porn.

Since porn is a global phenomenon, watched by millions and millions of people, the largest part of the porn industry is the consumer. Consumers make up a special and powerful part of pornography. Since viewers derive pleasure from porn, they are connected to it, not exempt from shouldering some of the responsibility for the well-being of porn performers.

Despite the global popularity of porn, prejudice against performers has not diminished. Teachers have been fired, simply because they had consensual sex with another person on camera; but no one is prepared to say why being in porn should make someone unfit to teach. Olympic hopefuls with a porn past have been banned from competing under the auspices that they wouldn’t properly represent their country; but isn’t porn part of the country’s culture? Reality TV stars have been disqualified from their shows for being in porn; but pornography was the original reality TV, a blend of real and unreal, and certainly full of performers that people are willing to pay to watch.

Involvement with porn becomes an automatic, unthinking grounds for discrimination. The same people who fire or “out” porn and former performers must have watched porn. But the porn viewer can conceal his/her enjoyment of pornography. So long as this is true, the many people who have masturbated to pornography – and this includes most men and an increasing number of women – don’t have to feel any connection to the well-being of porn performers, who have provided the viewers with sexual pleasure.

All that is a broad, societal issue. But what about smaller, personal instances of discrimination? Porn viewers make discriminate against porn viewers on a smaller scale, through unthinking slut-shaming. But porn performers aren’t just a spectacle, they are, in one sense, the sexual partners of the people who watch them. Their images and actions tie into the arousal and orgasm of the viewer.  Why are we asking, “What is it with gay porn?” but not asking, “What is it with the way society treats people who bring them pleasure?”

These are larger questions that I – and many other sex workers – continue to work through, and that are larger than the scope of this essay.  One of the reasons many sex workers are interested in these questions is because they expose something fascinating about Western culture and sex. But another is that we want to be able to stop this unwarranted discrimination, to be able to be ourselves without reproach or dismissal.

***

So: Why do porn actors kill themselves? is not the right question.  It’s bound to prejudices, misconceptions, and shame.

A better question: What can we do to make involvement with porn easier, less stressful, and healthier?

Each of us, depending on our relationship to porn, can approach this by asking a series of different questions, and by working towards honest answers.

Performers can ask themselves:

• Am I ready to be in porn? Does porn fit into the context of my life and my vision of my future?
• Can I endure the misunderstandings of others without lashing out in anger or being weighed down by sadness?  Will I be okay when my parents and loved ones find out (and they invariably find out)?
• Most importantly, can I maintain the knowledge that I am not only my body, that my body is a part of me, not all of me?

People who work for studios can ask themselves:

• Am I ready to put in effort to deal with performers, who may have sensitive feelings about their bodies, in a gentle way that is at the same time honest and open?
• Am I being honest and open with the performers I work with and hire?
• Am I being transparent (with myself and my performers) about pay and why certain performers are being paid the amounts they are, and why they were hired or rejected in the first place?

Studio employees and owners can also ask performers the questions that performers should be asking themselves:  Are you ready for this?  Can you do this and not put your self-worth into it?  Does this fit into the context of your life? Etc.

Viewers can ask themselves:

• How do I feel about porn performers?
• Am I grateful for the pleasure that porn gives me, or do I feel shame about it?
• If I met a porn actor I liked, how would I react?

Viewers can also talk more openly about watching porn (and sex in general), which will help give voice to just how commonplace a phenomenon pornography is.

Of course, these questions don’t have to be phrased the way that I’ve written them. They don’t have to all be asked at once; any one of them might be difficult to answer honestly. I’m also familiar enough with the many problems we face in pornography – the way it tangles in with some of the best and worst aspects of economics, desire, and shame – to know that questions alone won’t solve all the problems facing us. But asking questions like these can help cultivate more kindness within porn and more acceptance in those outside of it.

When Arpad died, many people rerouted their guilt about porn – stemming from a lack of openness, reflection, and care about sex, pornography, and desire – onto his life. Instead of sympathy, many people projected guilt and shame. It’s up to all of us involved in porn – not just performers, and studio workers, but viewers as well -  to be more loving, open, and honest with ourselves and each other. That way guilt, shame, and confusion can be redeemed and transformed, rather than absorbed by the empty space where a beautiful man used to be.

For John Bruno and Arpad Miklos

About the author: Conner Habib (pictured below and above left) is a writer, gay porn star, and lecturer. His sex and relationship advice web show appears each week on Logo TV's NewNowNext website. He lives in San Francisco where he runs a Rudolf Steiner spirituality and science discussion group.

The Conference on Retroviruses & Opportunistic Infections (CROI) focusses mainly on biological sciences. What can we learn about prevention? 

Nothing is more likely to whip the media into a frenzy over HIV than the word ‘cure’. Over these past few days, reports from a conference in Atlanta of the ‘cure’ of a baby from HIV fuelled numerous media headlines. Since the initial reports, it has become obvious why the ‘cure’ was qualified by the ambiguous ‘functional’, and why inverted commas punctuated the science. Conference attendees now suggest that whilst worthy of further investigation, report of a ‘cure’ is premature.

Less prominent in the media were discussions on the prevention of HIV. On the basis that ‘prevention is better than cure’ I have followed this conference theme from my laptop in the comfort of my Edinburgh living room. For one thing, I prefer to leave complex virology and pharmacology to the scientists. For another, Atlanta is about as grey and cold as ‘Auld Reekie’.

Mixed results

Last summer’s grand and political International AIDS Conference in Washington heralded ‘An End to AIDS’, supplying journalists with a catch-phrase. An exploration of the theme of prevention at the Atlanta conference yields unexciting headlines. It does, however, provide helpful insights.

In the context of what is one of the best conferences focused mainly on HIV science, it is possible to compare biomedical responses with behavioural interventions to prevent HIV transmission. Biological sciences often claim a significant breakthrough, as in the introduction of ground-breaking anti-retroviral therapies. In the behavioural science of prevention you’re up for the long haul of education, engagement, and understanding HIV and protection from a community and individual perspective.

A reality check on ‘End to AIDS’ rhetoric provided useful background to the conference’s assessment of interventions such as Pre-Exposure Prophylaxis, treatment as prevention, and the conditions essential to their success in the long term. By way of comparison, detailed analyses of what drives the HIV epidemic especially among gay men, and community studies suggest a direction for HIV prevention.

A road-test for science

One of the most telling comments was an aside from Thomas Coates of the University of California when he referred to Los Angeles where his research team is based as “like a third world country ….. I kid you not”. In response to a question about how to spend the next few billion dollars, the same speaker quipped, “I think our Congress has decided that the money is not going to be available”. Asides maybe, but another aspect of the reality within which scientific research and prevention are subject to a ‘road-test’.

 “Community-led reductions”, a study presented by Thomas Coates, was a deep disappointment. Reporting on three study sites, the packages tried were little more than the standard community approaches we operate in Scotland. It is true that the interventions applied over three years from 2006-2009 and assessed between 2010 and 2011, yielded a 25% increase in HIV testing and a fourfold increase in detection of previously undiagnosed HIV, as well as reductions in risk especially among those diagnosed positive. These successes are not significant in comparison to experience of the effect of policy and practice changes over a similar period in Scotland.

What Coates called a ‘modest reduction of 14% in incidence’ based on new statistical calculations, however, is worth more investigation. Perhaps one interesting aspect of the intervention was use of mobile outreach and testing buses, similar to that used by the ROAM team in Edinburgh and by the Hepatitis Trust across the UK. His conclusion that his team must ‘achieve the penetration of the community’ should not be misinterpreted.

A drug-based study into use of Tenofovir in a vaginal microbicide and in Pre-Exposure Prophylaxis (PrEP) reported that those receiving the intervention did no better than those on the placebo. Thus, one of the largest trials of HIV drug-based prevention had to be discontinued before it had completed its course. The VOICE study recorded an almost statistically significant greater likelihood of the women on the study becoming HIV positive.

The main reason for trial futility was not drug-related, but on account of low adherence to the regimen. This mirrors results of the Fem-PrEP study and a similar study with young gay men.

Adherence to any intervention, be it condom use or drug-based, is crucial. As mentioned in an earlier report of CROI, intermittent use makes sense for when you’re planning sex, but is ineffective if the power of the intervention depends upon there being sufficient level of drug in the blood-stream to prevent establishment of the infection. Whilst results of broad community-wide, drug-based interventions are disappointing, there might be scope for their use along with intensive support with individuals at greatest risk.

Condom use

was the subject of another detailed longitudinal study, which sought to estimate the efficacy of condom use for HIV prevention among men who have sex with men. Dawn Smith reported a 70% efficacy in condom use, similar to that reported in 1989 by Weller and Ahmed. Of additional interest were the levels of adherence to condom use over time. Long-term, only a minority 16% reported ‘always’ using condoms. Intermittent, ‘sometimes’ condom use, was reported to have no significant effect in preventing HIV. The longer the time-frame studied, the lower the consistency of condom use. This finding attracted a fair bit of interest in conference reports. One must question why.

First of all, the study took no account of the context of condom use, for example, the type of relationship, concurrency, numbers of sexual partners, settings or networks. Secondly, the range used for ‘sometimes’ using condoms went from 1% to 99% with no stratification. It is obvious that the longer one risks ‘sometimes’ not using a condom, say in a fairly representative 50% of per act use, the more likely that infection will occur. It will rise further if 50% ‘sometimes’ shows a further 25% reduction. However, it remains true that ‘always’ is better than ‘sometimes’, and ‘sometimes’ is better than ‘never’ using condoms.

How we report statistics to our communities and their underlying message requires care. Reports of a baby ‘cure’ have resulted in phone lines busy with anxious parents asking when the elusive ‘cure’ will be made available. If we report statistics, and we ought to, we have a responsibility to add sound analysis and relevance to the readership’s real life experience. Meantime, condom use is 70% effective in preventing HIV.

Greater promise in the field of prevention was woven into other studies on which I will comment separately. Meantime, the big message of these studies is that if biomedical science is to be the harbinger of a prevention break-through, it will take time, it has to be in the real world, and it will succeed only in combination with behavioural science and alongside structural and political change. I will also consider these factors and what we might learn.

This article originally appeared on Roy's own blog scottfreehiiv here.