It was my first year attending the Gay Men’s Health Summit this November (the 8th annual organized by the Community-Based Research Centre for Gay Men’s Health) and the organizers dished out an impressive program.

While efforts to de-stigmatize HIV testing have been encouraging everyone who has ever had sex to get tested (an important effort!) HIV remains a heavy burden for the gay community, an issue conference organizers insist needs to be brought into the light. While in Vancouver it is estimated that 1 in 1,000 people have HIV in the general population, when you look at just the gay male population, the number is 1 in 5. Needless to say, it remains as important as ever to gather to discuss how HIV is a key health concern for the gay men’s community. To keep the discussion going, I connected with Jaime Forrest (below left), the coordinator of the Momentum sexual health study, to hear his reflections on what was presented at the Summit.

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Andrea Langlois (AL): What does this year’s summit theme “Reconsidering the social determinants of health” mean to you?

Jamie Forrest (JF): Reconsidering the social determinants of health is about highlighting and recognizing the important social drivers of gay men’s health inequities. We are not all equal in our risk for any given health condition. There are social, cultural and economic factors that make us all more or less susceptible to illness. Research and practice that ignores this, by not considering the unequal distribution of access to resources and knowledge that protects our health, will be flawed in its approach. This year’s conference importantly reminded us that broadening the discourse to include elements of the social determinants of health framework is crucial to working towards a better and more holistic understanding of gay men’s health.

AL: A new (to me at least!) acronym that got more action than others at the Gay Men’s Health Summit was “UAI.” What does this acronym mean and what does it say about the focus of some HIV prevention research?

JF: Yes, the acronym “UAI” definitely was floated many times at the Summit! The acronym UAI stands for Unprotected Anal Intercourse. The term UAI historically comes from the field of epidemiology, the study of population health. In epidemiology, researchers use UAI as an outcome measure when trying to better understand what factors are associated with transmitting or acquiring HIV. However, this is an imperfect measure of risk of transmission. There are many forms of unprotected anal intercourse that vary in risk. Controlling for relationship status and sex with regular versus casual versus anonymous partners as well as partner serostatus is therefore important for researchers to account for in describing risk associated with UAI.

AL: Methods for measuring sexual altruism and HAART optimism were presented by Allan Lal and Ashleigh Rich, and Sarah Chown provided an overview of what gay men’s health literature says about resilience – what do these approaches offer to researching the social drivers of HIV within gay communities? Or not?

JF: Let me first remind folks that HAART optimism is the belief in/reliance on new HIV treatments, and how a lowered perception of risk may be associated with increased risk behaviour. I think that HAART optimism and resilience can be linked in a number of complex ways. Sarah Chown told us that resilience can be a strength in some contexts but can heighten vulnerability in others. In terms of exposing people to vulnerability, hiding behind optimism of HIV treatment and prevention innovations may be an effort to shield ourselves from actual sexual risks. For example, a belief in HIV treatment as a prevention tool may lead to reliance on “low viral loads” or as protection from transmitting HIV. More importantly though, we learned from these presenters that the ways in which we express HAART optimism and resiliency are both complex and unique and we must consider this when understanding sexual health in our communities. There was certainly agreement at the Summit that HAART optimism and the concept of “resilience” can serve to depoliticize gay men’s needs and that building resilience at the community level is an essential component to prevention.

AL: This year’s Summit included workshops on rebuilding the grassroots gay men’s health movement (Robert Birch) and several presentations mentioned the importance of community in building the health of a community, does this represent a shift in the direction of health programming for gay men?

JF: Community, in a broad definition, has always played a crucial role in the gay men’s health movement, but there are still ways in which our strength as a collective will accomplish more than our individual parts. This is especially true in a changing social landscape where gay men are more geographically decentralized than ever before. To keep our community movement building, we need to adapt to the new ways that gay men are seeking out others, and to pay attention to what gay men are looking for when we do this. Better community programming will need to include participation online, including social media and networking sites and mobile apps. Community building will also require us to take a more inclusive approach to gay men’s health that includes the social, sexual, mental and physical health domains important to gay guys today.

AL: In his plenary presentation, Dr. David Brennan spoke about health outcomes associated with viewing pornography, and Jody Jolimore from the Health Initiative for Men, Robin Parry from Qmunity and Del Stamp from Priape Vancouver shared thoughts on barebacking in porn. What can we conclude about porn and gay men’s health?

JF: Porn is a part of nearly every gay man’s life. Dr. Brennan shared research findings that show some positive outcomes associated with viewing pornography, such as a decrease in sexual risk that may be associated with viewing certain porn at particular ages of development, but that there may be some negative body image associated outcomes as well. Robin, Jody and Del’s panel engaged the audience in thinking about bareback porn, both professional and amateur, and the influences that watching porn may have on a person’s engagement in sexual risk. My conclusion is this — as something so much a part of every gay man’s world, we must continue having conversations about both the positive and negative outcomes associated with the frequency and content of the porn we watch.

AL: Okay, now just for fun, what was the social highlight of the Summit this year? On the fashion front I definitely saw a lot of checked shirts and skinny ties!

JF: Skinny ties were definitely in this year, Andrea. Next year, I’m hoping to see more suspenders and bow ties at the best-dressed academic conference in BC. The social highlight of the conference has always been the wine night after the opening. It’s a great opportunity to connect with great folks doing great work in gay men’s health across Canada. Another great conference under our designer belts!

Questions? Feedback? Get in touch!

Andrea Langlois

Community-Based Research Manager  This email address is being protected from spambots. You need JavaScript enabled to view it.

Follow Andrea on Twitter at @PAN_CBR

This article first appeared on the website of the Pacific AIDS Network here. 

The following was transcribed from the taped broadcast on the CBC Q web site.  You can hear the broadcast by clicking on the June 28 show here. 

The CBC is Canada's publicly funded broadcaster. Q is the daily morning arts, culture and entertainment talk show hosted by Jian Ghomeshi.

This is how Jian opened today's show.

Opening music . . .

Jian Ghomeshi: Well, hi there.

Happy Friday.  And it’s high time for Pride, in Toronto that is.

There are many celebrations and events in the LGBT communities of the world at different points in the calendar, but this week, it is Toronto’s turn. And, as you may know, the Toronto Pride celebrations are the biggest in the country and recognized as one of the major events of their kind on the planet.

Everything comes to a colourful crescendo. I’ve often called it the best day of the year. A sense of collective, family, love, pride and awareness of community.  And in that spirit, maybe it is time to reflect on the past year or so in LGBT culture and politics.  It’s been quite a period, capped by U.S. president Barack Obama’s endorsement of same-sex marriage – a big first – some would say an overdue endorsement, but maybe also a decisive one that not everyone was expecting.

There’s been the continuing expanding embrace of LGBT by corporate interests, not only in their canny sponsorship of big Pride celebrations but in ad campaigns and product tweaks, from the Oreo with the rainbow filling to J.C.Penney Father’s Day ads with the two dads. And be honest; no doubt it may be in their economic interest but it still feels like a major step for the corporate world, the normalization of cultural diversity and LGBT.

There has also been significant movement to save the lives of young people who are facing the prospect of bullying, isolation or even suicide because of their sexual orientation on the spectrum. Dan Savage’s “It Gets Better” campaign and the ”You Can Play” project in professional sports have come to international prominence. And comprehensive ante-bullying legislation for schools here in Ontario has been passed, even in the face of the headline-grabbing debate between church and state over the status of gay-straight alliances.

We must not forget more stars coming out too – and in pages of the comics, Green Lantern.

It’s been a banner year in many ways. But as we also know, there are still haters, bullies, others out there who would stand in the way of basic human rights for every citizen. Maybe, though, there has been more good news than bad on this file lately. You know, it’s kind of serendipitous that Toronto’s Pride festivities and parade in particular will fall on Canada Day this year.

As we celebrate the birth of our nation, call Pride a reminder, perhaps, of the importance of embracing our closely held Canadian values of diversity, of respect.  Here’s to welcoming openness, to tolerance and celebration – in a country of rainbow colours through and through.

I’m Jian Ghomeshi.  Happy Pride, kids!

Newly updated US treatment guidelines are recommending antiretroviral treatment for all people with HIV infection, rather than starting at a particular CD4 range. But for those about to start treatment and their doctors, it’s not quite that simple; the strength of the recommendations varies by category of patient. Here is how a simplified scale looks:

• CD4 count less than 350 – strong recommendation
• CD4 count 350 to 500 - strong recommendation
• CD4 count over 500 – moderate recommendation

Regardless of CD4 count, initiation of ART is strongly recommended for individuals with the following conditions: pregnancy, a history that includes an AIDS-defining illness, HIV-related kidney disease and HIV/hepatitis B virus (HBV) co-infection. The guidelines also include an early treatment recommendation for anyone at risk of transmitting HIV to partners.

You can read a summary of the recommendations, including changes to existing guidelines, here or read the  full guidelines here.  

In contrast, recently issued draft British HIV Association treatment guidelines continue to recommend treatment when the CD4 cell count falls below 350, although treatment may be started earlier in people with hepatitis B or by people concerned about the risk of transmitting HIV to partners.

Canada has no national guidelines at present, a reflection of our provincially administered healthcare system, but our practice tends to follow the US guidelines.   BC and Quebec have their own guidelines.  But it’s likely that these new US guidelines will be influential in affecting treatment decisions here and around the world.

In Ontario, the advice you will receive currently depends, at least to some extent, on who is your doctor.  Some (many?) doctors are now suggesting treatment immediately on diagnosis, with the consent of the patient, of course. Others are suggesting holding off.  But clearly there has been a move towards earlier treatment for some time, driven in part by the evidence of better clinical outcomes   for those who start earlier, and in part perhaps by concerns about the perceived need to curb secondary infections that the treatment as prevention advocates frequently cite.  More on that later.

The issue of when to start treatment has been controversial. Previously, for instance, the panel that decided on the US guidelines was divided.

There has been little reaction to the new US guidelines from the Canadian HIV community to date.  But HIVers from Australia, in the form of NAPWA (National Association of People Living with HIV/AIDS) were quick to state their position.  In a March 28 statement, NAPWA president Robert Mitchell said “It is increasingly clear that untreated infection is bad for the health of people living with HIV, whether their infection is recent or long-term. We also think that people with HIV will value the added benefit of being on treatment in helping reduce the risk of transmitting HIV to others, when used with other proven prevention measures like correct and consistent condom use.”

This two-pronged rationale for earlier treatment contains elements which have been troublesome for people living with HIV in the past.  Over the years, there have for instance been issues raised about the potential side effects from long(er) term exposure to HIV drugs - longer term at least than if treatment were delayed.  Informed consent has also been an issue for some HIVers – nobody wants to be persuaded to start treatment when they are not ready for making that decision. But on this latter point the new guidelines are clear; “patients (who start) ART should be willing and able to commit to treatment and should understand the benefits and risks of therapy and the importance of adherence. Patients may choose to postpone therapy, and providers, on a case-by-case basis, may elect to defer therapy on the basis of clinical and/or psychosocial factors.”

The longer-term exposure to side effects concerns?  I raised this issue with Dr Julio Montaner, a long-time early-treatment proponent, when I interviewed him for PositiveLite.com earlier this year.  Here’s what he had to say about that. “There is no doubt that antiretroviral therapies have improved dramatically. They are simpler, safer and better tolerated. No doubt about it.  Are they perfect? No they are not….However, if we are having a discussion here on whether starting treatment immediately or on a deferred basis, the gap between those two decisions is somewhere in the order of months to a couple of years. It varies from person to person but when we’ve done studies, the rate of CD4 decline in an untreated person is somewhere between 60 and 120 cells per year. If somebody today says ‘no, I’m going to wait,’ what I say is ‘sure, you can defer antiretroviral therapy, no problem, we are not forcing anybody to start treatment.’ What we are saying is let’s have a discussion."

For an expert narrative on the new US guidelines, I interviewed CATIE’s Sean Hosein last week.  He’s an acknowledged expert on treatment issues and I wanted to gauge his feelings on the impact of the new guidelines for Canada.

Sean cautions against interpreting the guidelines as saying that once people are diagnosed they should start treatment then and there. “What this means” he says ”is that there is an opportunity for doctors and people living with HIV to start the discussion about therapy. Given the therapy that we have today, people are going to be taking it every day for the rest of their lives,  and so people have to be prepared for this – ready, willing and able.”

Do the new treatment guidelines represent a major change? Sean thinks so. ”It’s a major change compared to ten years ago, even five years ago, when they were saying ‘let’s wait ‘til the CD4 counts fall’. But what’s happened is that they’re finding that HIV just doesn’t affect CD4 counts. It causes inflammation inside the body that affects major organs like the brain, the heart, the lungs, the kidneys, the liver, the bones  - and so that’s why there is a push to start treatment earlier.”

I asked Sean to what extent the treatment as prevention arguments – which revolve around, in part, reducing the possibility of secondary infections by suppressing viral load to undetectable levels – might have had on the US decision to recommend starting  treatment earlier.  “I think it’s a mix of two things”, says Sean of the new guidelines. “It’s a mix of trying to do the right thing for the individual person living with HIV and also trying to do something for the rest of society in order to reduce the risk of transmissions.” But  of treatment as prevention, Sean cites the cautions in the guidelines about interpreting HPTN 052 results (the much-publicized study released last year which saw a 96% reduction in the risk of HIV transmission in heterosexual sero-discordant couples) too broadly, noting in particular the lack of data relating to MSM (men whoi have sex with men) , an issue discussed in my interview with CATIE’s James Wilton that you can read here.

On the side effects issue, Sean says the environment has changed. ”That argument, I think was important in the 1990’s and maybe ten years ago when the drugs that were used were much less tolerable.  With the drugs that are commonly prescribed today, the regimes are simpler.  There are side effects but they are generally mild and they tend to go away.  It’s true that people haven’t been on the latest drugs for fifty years so in theory there may be problems in years to come. . . . We need long-term studies to monitor people and those studies are underway.”

I asked Sean if the new guidelines are big news for the HIV community.  Sean thinks so. “It’s about strengthening doctor/patient relationships. I would encourage people who have recently been tested to see this as an opportunity to speak to their doctor about starting treatment early.”

Does he think the US guidelines will shift the Canadian response to HIV infection?  Says Sean “I think it will, because it’s good for people living with HIV. It will keep them alive longer.  It’s a good thing.”

I think so too.  Starting treatment earlier is likely a good thing for many people.  Whether the new US guidelines are driven by a desire for better clinical outcomes for people living with HIV or reflect treatment as prevention policies, or both, is almost immaterial.  I say almost because many of us have been vocal about our concerns surrounding treatment as prevention and we are cautious when some of its key tenets appear to go main-stream. But things have changed. Our knowledge of disease progression has changed. Treatments have changed. My own opinions have changed. So yes, I’m with the US on this one.

Let’s hope that Canada follows suit.