This article was originally published in TheBody.com here

An undetectable viral load: the point at which HIV, though still present, cannot be found in a person's blood with the most sensitive tests available. It's a powerful concept with profound implications to the life of a person living with HIV (and his or her partner). However, according to CDC's treatment cascade, for a host of complex reasons, 75 percent of people living with HIV in the U.S. have not reached the point of viral suppression. (Among some specific groups in the U.S., that number is even larger.) For many of those that have, reaching that point was a major milestone in their lives. We asked people living with HIV to contribute thoughts and stories about getting their own viral loads to undetectable.

Minister Rob Newells, Oakland, Calif.; Diagnosed in 2005

Reaching undetectable never seemed like a significant milestone to me. I waited for my CD4-cell count to drop below 400 (about 18 months after my initial diagnosis) before I made the decision to begin antiretroviral therapy. My viral load, which was never extremely high, has been undetectable on every test since I started HIV meds in 2006.

For a long time, I thought viral suppression was a normal result of taking the medications. I expected nothing less. The HIV treatment cascade was a visual wake-up call that I am in the 25 percent minority. Clearly, we have much more work to do to increase retention in care and adherence to the medications that both improve the health of people living with HIV/AIDS and help to prevent transmission of the virus.

Meta Smith, Baton Rouge, La.; Diagnosed in 2001

At the time I was told I was HIV positive, I was placed on meds and did not have any idea how being undetectable would help me. When I had been on the meds for at least three months I returned to the doctor after lab work and was told I was undetectable. I knew I was feeling better after the meds; but after being told what undetectable was and how it would affect my life, I need to say I was on TOP OF THE WORLD and have stayed that way since then. It meant the world to me and changed my life, for the better. I got busy living.

Nelson Vergel, Houston, Texas; Diagnosed in 1986

I'm on the last combination I can try. I take a lot of pills. ... There's a part of me that's been very frustrated, extremely frustrated, with the fact that I've had it really hard when it comes to HIV. I've never had an undetectable viral load until three years ago ... Twenty-six years with virus in my blood, no matter what I did, no matter how many conferences I went to, no matter how many papers I read ... I felt like a loser, like a failure -- really, they call us "failure patients."

Watch Nelson's full "Day in the Life" video.

Bernadette Berzoza, Denver, Colo.; Diagnosed in 1989 

Over the past few years I have really fought and struggled to get my viral load down. It's been 23 years that I have been positive, and in the beginning it was just keeping your T cells up. Then the viral load was added. I was so freaked out when they told me my viral load was in the millions and we needed to change my meds to get it to undetectable. I did what was recommended but it wasn't working for me as they thought it would.

Read Bernadette's full story of getting her viral load down after many years.

Joe Ohmer, Bronx, N.Y.; Diagnosed in 2002

Eight months after I was diagnosed with HIV, my gastroenterologist that was taking care of my liver issues did some blood work, and my HIV viral load was undetectable without any medication. I didn't realize that that was anything significant or insignificant at the time, until maybe eight or 10 years later when my GI doctor mentioned it to me. I went on a regimen of Epivir (lamivudine -- also used to treat HIV, in different combinations with a higher dose) and Hepsera (adefovir) for my hepatitis B, which since I've been on it has been undetectable as well. Except for one blip, my HIV viral load has been undetectable.

Recently, my GI doctor, who's the same one who saw me initially, brought up that I was undetectable before I went on any regimen.

Read the rest of Joe's unusual story of being undetectable without medication.

Melissa Baker, Mechanicsville, Va.; Diagnosed in 2007

I was diagnosed August 2007. By January 2009, I made the count-dependent decision to start meds. It took me longer than three months to become undetectable. If it had taken me any longer my provider was going to change my regimen, fearing a possible resistance. The day I heard "undetectable" finally came before he had to, and my virus has remained undetectable since. :) I was ELATED!

Reggie Smith, Atlanta, Ga.; Diagnosed in 1984

After being sick in 2005, I have been taking the antiretroviral combination that has kept my virus at undetectable levels, and allowed me to enjoy really good health. With God's grace, and enough desire to live well, I have been able to adhere pretty well to this regimen. My oldest granddaughter was 2 years old at the time. Now she is 9, and I have two other granddaughters, a grandson, and a set of boy/girl twins! I play softball and golf, take flying lessons, I am of service to my community, and I am blessed to share my experience and hope with you.

Read Reggie's full story of coping with being tired of taking HIV meds.

Lillibeth G., New York City; Diagnosed in 1992

When I was told my viral load was undetectable I felt 100 pounds lighter. My greatest challenge was getting to an undetectable status. I had multidrug resistance so getting to undetectable was a milestone.

I was diagnosed in 1992 and it was difficult for me to adhere to my treatment since I was in denial and angry at myself (I should've been more selective of my partner). During one of my doctor visits he found a clinical trial I was able to join for both Isentress (raltegravir) and Intelence (etravirine). I was determined to bring my viral load to undetectable since I have so much to live for; I needed to live for my son, my mom (she was alive at the moment), myself most of all; I have things to do, people to educate. After a 17-year fight, I got the GOOD news: "I'm undetectable!" It makes me feel so alive.

I have a whole new look at life: I'm going to live; I have a fighting chance. Now I can talk to others about the importance of getting to that point -- it gives you hope. I'm always smiling and laughing; life is so different for me now -- I have HOPE.

Pastor Andrena Ingram, Philadelphia, Pa.; Diagnosed in 1989

THAT was another day, I remember with clarity. Waking up and dreading my doctor's appointment, because I knew I was going to get my blood-work results, and because I was about sick and tired of injecting myself. I was tired of Fuzeon (infuvirtide, T-20), I was tired of medication, I was just tired of it all.

I sat down in her office, and she pulled out my chart and looked at the labs, and smiled. I was like ... OK, what is my CD4? And it had been explained to me months before that they were beginning to look at this thing called "the viral load" ... and how that was more important than the CD4 count. She told me what my CD4 count was, which had peaked a bit ... but she was still smiling. And then she said: Guess what Andrena? Your viral load is under 50 copies! She was cheesin'! Grinning from ear to ear! I still didn't understand what that meant, until she stopped grinning long enough to tell me. That it meant that the virus in my body was undetectable …

Even though she explained it to me, I still didn't quite get it, until a few days later ... my mind had to process it. It meant that the Fuzeon was working. It meant that I was NOT gonna die (anytime soon). ....

I was ecstatic!

Read Pastor Ingram's full story of getting to undetectable.

Shannon Southall, Denver, Colo.; Diagnosed in 1992

February 1996, four years after being given my HIV diagnosis, I found myself lying in a hospital bed, and hearing that I now have AIDS. My CD4 count was 131. I needed to add more medication. When I was initially diagnosed in 1992, I had 896 CD4 and my first doctor put me on AZT monotherapy. After a friend found an infectious disease specialist I was switched to Zerit and Epivir.

Now lying in the hospital my doctor came in and said there was this new drug available called Crixivan and he strongly recommended that I add this to my current regime. My viral load was 159,000 and these new meds show that they can reduce the virus in my system, therefore prolonging my life. So of course I said yes. By August, my viral load was undetectable, less than 200, and my CD4 count was finally up over 200. ...

A few years ago I started to wonder about switching or stopping meds for a while. Then I met the man who would become my husband. He is HIV negative and I know that keeping my viral load down is crucial to maintaining a healthy sex life and reducing the risk of transmission to him.

Read Shannon's full story of 21 years on HIV meds.

I hadn't talked to my cousin David in close to fifteen years.  This phone call was a flashback to when we were both living in Manhattan in the 1980’s and our frequent dinners eating cheap Chinese, talking non-stop and laughing with our mouths full of food. 

We had an unusual way of deciding who would pay for dinner. He was a commercial photographer and we'd meet at his studio in Manhattan’s Photography District, near the famous Flatiron Building.  

We’d hang out on a corner of Broadway for five minutes and have a contest. Whoever spotted the most cars filled with Hasidic Jews heading downtown to Brooklyn would get a free meal.  No doubt this sounds odd if you don’t know Manhattan, but there are lots of Hasidim especially in that part of the city and because of their close-knit community – both at work and back home – cars filled with bearded men in black hats were not quite but almost as common as taxicabs. 

On the phone we spoke for nearly an hour, catching up on the last fifteen years. Work, his kids, my writing, our parents, the old days, the recession - and then he asked about my health and I told him how good it was.  

"Do you know how lucky you are," he said, repeating it twice. I readily agreed, knowing that he too had many other friends who died hard deaths. We acknowledged the unfathomable randomness of life.  We discussed my great fortune and other friends, those who had it all only to be struck dead, without warning – Jake while windsurfing, Stan a vicious type of brain tumor, others from car wrecks, kidney disease and other maladies.  

I don’t always feel lucky so the reminder was a gift, one that I’ll take as I head back to New York for my 30^th college reunion in June.   

I’m excited to go. I’m looking forward to it, but wish I had more on my resume. Among the friends I’m excited to see for the first time in decades are a U.S. Congressman, a lawyer who is one of the leading activists in the fight for marriage equality, successful artists and professors too.  

And me, a writer who spends too much time not writing, with declining freelance revenues that have led me to anxiously scour Craigslist looking for more catering work, gladly serving and bartending even though I’m making the same hourly wage I made when I catered between jobs in the late 1990's.  

Swiss Chard Beggar’s Purse, Maam? 

I like the work if not the pay, but passing kobe beef sliders, swiss chard beggar's purses or pouring cocktails isn’t a bad way to make things happen. I’m proud of my resilience, my ability to put things together to pay the rent even while I am occasionally embarrassed by seeing people I know who are surprised to see me holding a tray of champagne at a wedding reception.   

After all I’m the guy who drove a taxicab in New York City after graduating from college with honours. The guy who never worried much about earning money for the future, a creative sort, who didn’t fit in the box.  

Sometimes I can’t sleep and lie awake worrying about everything from the NY Mets bullpen to what will happen when I’m too old to work. I wish I’d done things differently, made more money and saved it, bought a house, wore suits to work, could take vacations every year. Was my lack of concern about money because my upper middle class upbringing left me deluded that things always work out or because I thought I’d be dead before I reached 40? 

Would whoever threw up in my bed clean it up? 

A month ago I lost my black necktie, the one I need for catering and was enraged at my carelessness. It would cost me another $7.99 at Ross Dress for Less to get a new one; that’s half an hour’s pay. I berated myself for the stupidity. My fury got worse. The only one Ross had in stock cost $16.99, $18.48 with tax. Determined not to spend that much I spent two hours scouring half a dozen thrift shops looking for a bargain before I returned to buy it.  I found the missing tie the following week.   

I frequently joke that I have my retirement plan almost in order. It has four parts, and three are taken care of. The three pieces in order are a hot plate, a space heater and an inflatable aero-bed. The only thing missing is a friend with a garage I can live in that has an electrical outlet that can support all three appliances without blowing a fuse. I'll be the old guy sweeping the sidewalk in front of their Victorian, whom the neighbors bring leftovers too and kindly listen to my stories about the old days, before getting away relieved. 

In college, early in my freshman year, I earned the nickname "Ralph". If you don’t know the slang, to ralph is to vomit. By October I had twice thrown up and blacked out.  When I was told I was the one who puked in the shower I thought it wasn't true because the guys in the dorm figured I was wimpy and would clean it up without much debate. The second time I woke up on a Saturday morning smelling of vomit, furious about the fact that someone threw up in my bed. 

When my roommate said it was me I didn't believe him.  After all I wasn’t a big drinker, had never listened to Neil Young before college and wasn't a sloppy drunk. 

Of course I was the culprit.  But lucky for me, my stomach couldn’t handle too much booze and despite the roster of world-class drunks on both sides of my gene pool I was spared the family affliction of alcoholism.  

Though spared the fate of becoming a drunk, the nickname lasted all four years of college. There were people who thought that was my name, including Fran, one of the nicest of the sweet ladies who worked in the dining hall. 

On graduation day she was beaming as she gave me a hug. 

“Ralph you were one of the nicest kids I ever met.  I hope life treats you well.” 

It has. Even if I’m passing trays of champagne and sleeping on an inflatable mattress in someone’s garage when I'm old it has treated me very, very well.  

Oh yeah and if you need to borrow a black necktie, let me know.  I’ve got an extra.

The challenge for the new Safe Sex 2.0 effort will be trying to capture the attention span of someone who lives life and thinks in 140 characters. In this Internet age, we in the HIV+ and HIV- community (basically that is everyone) have been given the dual-edged sword of the internet as a tool for advocacy and outreach.  The internet is definitely useful in finding the answer to almost anything, and it has exponentially increased the means by which information can be disseminated to the masses.  However, the internet has also created vast, huge, and deep canyons between us, where we are only as connected as our wi-fi signal allows us to be. 

Back in the “old days”, we in the older gay community used to go to gay bars.  At those gay bars there were bowls of free condoms.  They were right there on the bar or by the door so that they were always on hand. Back then, we cared about protecting our community.  Back then it was not as controversial or offensive to talk about or insinuate safe sex. Safe sex was viewed as a normal, healthy part of the greater gay conversation. 

At some point though, this changed. Bars are no longer the meeting places of gay men.  Grindr, Scruff, and Adam4Adam have taken their place. Face to face caring was replaced by the cold glow of a computer screen.  Our community became diffused and fragmented and it dispersed like smoke in the wind. There were always those that didn’t go to the gay bars, just as there are those who do not go online today, but they were in the minority I believe.  

Our sense of community has been replaced by a transactional approach, where one’s personal opinions seem to trump the collective wisdom that has been tempered by experience.  Collaboration and compromise have been thrown down the toilet, to be replaced by the louder squeaky wheel of personal, selfish freedoms.

Now, if you were to talk about safe/safer sex or condoms, a method that is clinically proven to reduce HIV and other STDs, you are yelled at, or someone posts a pages long diatribe about how out of touch you are, and how it is their God-given right to have unsafe sex. They pull one tenuous statistic (that successful HAART treatment prevents 96% of HIV transmissions) and they have built an amendment to the sexual constitution, much like gun proponents clutch onto the 2nd Amendment. They ignore the fact that an undetectable viral load in the blood is NOT equal to an undetectable viral load in semen or in anal fluids/tissues. 

And so, the uninformed and unwilling shun proven methods of safety: condoms, HIV testing, non-sexual forms of intimacy.  (Apparently in the age of Grindr, intimacy seems to be an outdated concept as well.)  And then when they contract HIV, they then have this sense of confusion and incredulity, knowing in the back of their mind that they knew their risk all along but chose to ignore it and live in the moment.  There is even a hashtag for that, #YOLO (You Only Live Once).  

Because one in five urban gay men do not even know their HIV status, it is imperative to again find a way to encourage HIV testing and to advocate condom use. People proceed with actions based upon their perception of risk, as opposed to the actual risk at stake.   Stigma is still very high and the pervasive HIV stigma within the gay community (as well as outside of the gay community) prohibits those at the highest risk for HIV from getting tested. When those at highest HIV risk continue to contract the virus year after year after year, there should be a more aggressive approach to HIV testing and condom use.   

It is ironic that studies have shown that when a person is diagnosed with HIV, that person’s sexual behavior becomes safer. They care more about not wanting to infect others. But on the flip side of that is the callous carelessness that pervades young gay men, who believe their greatest source of angst is over what to wear to a Lady Gaga concert.  These guys repel conversations about HIV/risk/safety like Teflon repels an egg.  If you try to mention HIV, they all the sudden stop texting you back, or they fade from your Facebook...they become silent and they disappear.  

I believe there needs to be a new call to action, one in which the new ways of the internet and the social media expertise of the young are merged with the proven, effective methods of prevention.  And through all of this we must figure out how to burn of the fog that has settled on everyone regarding HIV:  for the older people who are tired and exhausted from 30+ years of advocacy and for the young, know-it-all youth who live in ignorance and bliss.

I wish I had the answer on how to do that, because until that answer is figured out, I fear we will again see a rise in HIV infections.  I believe the coming storm will rival the pre-HAART era. Before HAART, people died because there was no medicine.  Now, I believe stigma and indifference has become just as deadly as those early days. 

About the author: I am 38, a gay male from Knoxville, TN who is not ashamed of my HIV+ status. I am optimism personified. I am strength realized. I am just me.

Website: embacingpozitivity.blogspot.com.Twitter @jjemcdonald 

Click here to read the first installment.  

On April 5, 2013 I took my first dose of Truvada as pre-exposure prophylaxis (PrEP). How did I end up in this situation where I feel like I need PrEP?

As I mentioned in my previous post, a look back at the phases of my sex life gave me some clues about why PrEP makes sense for me now. After more than 20 years of being sexually active, I only recently found myself veering away from perfect 100% condom use.

How did that happen?

Ironically, this is in part because I’ve been working in HIV for 20 years, including the last 10 years focussed on tracking biomedical HIV prevention research. I know what the research is telling us about HIV transmission. I know what proportion of new infections is driven by people who are undiagnosed. I know what undetectable viral load means for transmission risk.

I started serosorting, but not in the conventional sense. More and more, I’ve been dividing guys up into 3 categories.

1. The first category is small. With HIV-negative guys I know and completely trust, we arrive at a form of negotiated safety—if we have been tested for HIV and all STIs recently, and not yet had sex with others, we usually have condomless sex.

2. The second category has been steadily growing—positive guys. We have discussions about treatment, viral load, STIs and decide how to proceed from there. Sometimes without condoms.

3. The third category is basically everyone else—HIV unknown or undisclosed, and HIV-negative men I don’t know well. I consider guys from this third category as potentially being in the acute infection phase, whether they know it or not. This is the category of men with whom I am most adamant about condom use. All too often, their prevention strategy is dubious at best (e.g., “r u clean? how big r u? wanna bb?”). If I see another highly stigmatizing "disease free"/"no poz" message on an online profile, meant to be some kind of stand-alone, ill-informed HIV prevention strategy, I might reach through the screen and cyber-throttle someone.

So gradually, I’ve found myself feeling much less worried about having condomless sex with a positive guy after a conversation with him about treatment and viral load and STIs than about having condomless sex with a guy who says he is negative, but could be in the acute infection phase with sky-high viral load without even knowing it.

Paranoia? Rational, effective, evidence-based risk-reduction strategy? Both? You be the judge.

But let’s be honest. I also started “slipping up” more and more often because, well… sex feels better without condoms. *gasp* That’s right folks. Sex without condoms feels freaking amazing. You heard it here first.

So while I still maintained a relatively high rate of condom use, I found myself having condomless sex every once in a while. Of course, I also know how effective inconsistent condom use is over time (i.e., not very).

An illuminating peek inside the Little Black Book

Three years ago, I started to keep track of my sexual encounters in a proverbial little black book. (OK fine, it’s blue and has a Global Campaign for Microbicides logo and a Rectal Pride for Microbicides sticker on it. It’s super pretty and seemed appropriate). Every time I have sex, I write down what we did, what I know about my sex partner’s HIV status, and whether or not we use condoms. Yup, every time for 3 years. I do this partly so I have very accurate information at my fingertips to relay when I get tested for HIV and STIs. Partly so I have very accurate information at my fingertips when I start to worry. I can look at my list since my last tests and say: look, you had this many encounters, this is what you did with whom, this is how often you used condoms, and this is what you know about his HIV status. Sometimes that helps alleviate the occasional panic attack and insomnia. Sometimes.

I had never seen myself as being “high risk” for the first 20+ years of my sex life. But I’ve been working in HIV for 20 years. So I know the behavioural characteristics of “those people” at high risk. Armed with about 3 years of hard data about my own newly evolving behaviour (i.e., my stylish little blue book), I decided to look at it objectively.

• Multiple sex partners? Check

• History of STIs? Check

• Partners of unknown or HIV-positive status? Check

• Inconsistent condom use? Check

Well then. It’s hard to ignore what this spells.

I like to think I’m at least moderately intelligent. I know how HIV is transmitted. I know how effective condoms are.

I like to think I understand the consequences and the stakes. Yes, people living with HV are doing much better today. But I saw my dad die of AIDS in front of my eyes. I saw countless other friends, colleagues and clients become HIV-positive or die of AIDS. That leaves an impression, to say the least.

I like to think I’m a responsible person. I get tested frequently. I stay informed.

I like to think I have high self-efficacy. I have several years of experience using condoms consistently, and I am more often than not the one wearing the condom, so little to no negotiation is required.

I’m not depressed. I never drink. I don’t so drugs. My judgement is not clouded by any of those.

I’m not in denial. I know that the combination of inconsistent condom use, multiple partners, history of STIs and having partners of a different/unknown HIV status is a very strong predictor of seroconversion over the course of a few years.

If all of this doesn’t make me an ideal candidate for consistent condom use, I don’t know what more it would take, short of using Super Glue to permanently bond a condom to Mr. Happy.

Yet here I am.

So as a smart, responsible, well-informed, sexually active gay man with good self-efficacy and good access to healthcare and accurate information, I’ve come to the conclusion that PrEP makes sense for me at this point in my life. I don’t know how long this new “PrEP phase” will last. But I am glad it is available to me while I need it.

To be continued . .

About the author: Marc-André LeBlanc has worked in the community-based HIV/AIDS movement for 20 years.  He does community engagement, capacity-building and policy work related to biomedical HIV prevention research, both in Canada and globally. He is a co-founder of International Rectal Microbicide Advocates (IRMA), serves as secretary on their steering committee, has authored two reports on the global state of rectal microbicide efforts, and leads IRMA’s global efforts to ensure the safety of sexual lubricants. Marc-André loves movies. He got a film studies degree while working full-time, just for the sheer fun of it. He is now leading advocacy efforts to get ice cream and popcorn recognised as new basic food groups in Canada’s Food Guide

This article first appeared on My PrEP Experience here. 

A decade ago, Dr. Susan Cochran at UCLA’s School of Public Health published  findings from a comprehensive study conducted on the mental health of gays and lesbians. In the November 2002 issue of American Psychologist, Cochran’s conclusions on depression were depressing themselves: gay and lesbian youth suffer from higher rates of substance misuse than their heterosexual peers; LGBT folks need to utilize mental health professionals more than heterosexuals; and, gay men seem to experience recurrent, debilitating bouts of depression more than almost any other group in the overall LGBT community.

Confirming these findings, Michael Kerr writes on a study conducted in 2009 that reinforced Cochran’s findings, pointing out that “research shows that things are even worse for [LGBT] people. Depression affects LGBT people at much higher rates than the general population.”

In addition, Northwestern University’s IMPACT Program focusing on LGBT health asserts, based upon an even more comprehensive study last year, “Taken together, these results indicate health disparities for…LGBT youth are strong and pervasive. Due to the presence of these disparities at such a young age, they are likely to influence to health and well-being of LGBT [individuals] throughout their lifespans.” 

I can always tell when I’m letting my own depression get the better of me because of the responsive actions of my friends. Truly, my better angels prod me to be nicer. More specifically, there’s a small group of friends I’m lucky enough to have, people who are quizzically good-natured in spite of the arguably self-centered nature of mankind, who either directly say to me “Be nice” or who implicitly say this by responding to my gruffness and misanthropy with emailed pictures of llamas visiting elderly hospice patients for pet therapy. Based upon the amount of animals I’ve looked at lately, I must conclude that I am in a very bad place emotionally. And, admittedly, I am.

Yet, I do not feel utterly hopeless about my future nor do I not have a long list of blessings in my life: in fact, I have a better life than most of the billions of homo sapiens walking the planet. Instead, I am tired.

Now, perhaps some of my depression, this tiredness, is indicative of the ennui of our age, of our complete and total dissatisfaction with institutions of power that we are supposed to trust. Indeed, with growing frequency we expose these people and governmental bodies as clownish caricatures of the worst motivations of man rather than accurate reflections of the grotesque, and compassionate, nature of humanity. Instead of allowing for the unpleasantness that is requisite to be labeled human, too often we as gay folks have taken our social lead from the very discriminatory and ridiculous institutions once subjugating us, including institutions rooted in the necessary evil of politics, a field which, upon mention, should elicit nausea in the thoughtful, common man. We have become dismissive, sometimes, of anything that does not fit into our Facebook and online personas, personas who are apparently all very well coiffed, doing very well with that new small business thank-you-very-much, and who are madly in love without any semblance of negativity or strife whatsoever. And, one of the most grave sins as a public figure is, apparently, admitting flaws, contradictions in character, poverty, or sadness.

I need only point out the fact that when I was homeless (a fact most people still are unaware of) very few individuals had the time of day to actually consider for a moment what it meant to worry everyday about how to maintain proper hygiene without showering or how to remain warm and dry at night to demonstrate our society’s general hostility toward unpleasant facts surrounding human nature. Indeed, I myself am guilty of this intolerable sin of selective ignorance; I would much rather focus on my work than consider how to reallocate my own resources to help others out of those figurative holes in which they find themselves.

Then again, life is a consequence of action, so if bad things are happening to people, then these people behaved poorly, right? Unnervingly, this oversimplification is completely contrary to fact; sometimes, bad things happen to good people for no apparent reason whatsoever. And, “bad things” often include, at least in the case of a disproportionately high number of LGBT folks, anxiety and recurrent bouts of deep depression like I’m going through right now.

Most interestingly, I know a great many individuals whose lives are divorced significantly from the general public understanding of who they are as men and women; their collective loneliness weighs on me to a profound degree. Part of me thinks that if everyone was more candid, offered more details surrounding his need to move (from couch to couch, not apartment to house), explained her decline to my dinner invitation (she cannot afford the meal or the inevitable awkwardness when the check comes), provided context to his anxiety (his father has cancer), then we’d all get along better.

Unfortunately, because we live in society and, as such, must navigate society on its terms otherwise we’ll soon stop being mentioned in society pages, we cannot talk about the fact that we are sometimes sad or sometimes poor or sometimes sick or, inevitably as human beings, dying.

Yet, when we provide these details, people are embarrassed for us; they consider such unsolicited personal details as inappropriate or awkward. Rather, they find anything aside from their unsolicited braggadocio, personal “fabulousness,” or maudlin revision of history to fit into a sentimental simplified narrative as completely out-of-bounds. Even worse, they go one step further and, at least in the case of a critic of mine, begin to publicly call you “psychotic” for no other reason than their own apparent pathological discomfort with facts.

Of course, these same folks portray a fabulous image that is completely divorced from the modest reality in existence; but, naturally, this is unimportant to society. Indeed, it is a curious world we live in when facts are presented and those embarrassed by the facts find comfort in dismissing the presenter as psychotic. Then again, I cannot imagine that the King of England felt much affection for Jonathan Swift after “A Modest Proposal” or that Christopher Hitchens received a warm reception from the Vatican after “God is Not Great: How Religion Poisons Everything.”

Inconveniently, these unpleasant components of humanity are inherent to the experience of being alive. Without our downs, we cannot identify our ups. And, there are some human beings with a propensity toward depression; interestingly enough, there seems to be a strong overlap between those with a sincere desire for man to do the right thing and a profound sense of sadness when this does not occur.

The fact that we as LGBT folks suffer from depression higher than straights might just mean that we care a little too much about the world, in that case. And, while that’s a quaint thought, I nonetheless think the reality is much less noble and much more banal. After all, as some of the most talented members of society, we as LGBT folks are, by our very nature, different and more sensitive. 

So, it’s no wonder that we would rather portray an image as well put together, successful, well-decorated, and fabulous. Who’s got time for reality when we’ve got the theatre?

This article originally appeared on Josh’s own blog here. 

My editor asked me to write about the future of prevention. In taking up that challenge, I am discovering that I probably have more questions than answers, but I do have some ideas of the challenges we must meet if we are really going to stop HIV transmission. 

Motivation 

Scary "death" and "doom" messages will not motivate people to take measures to avoid contracting HIV. Fright messages sometimes have short-term effects, but these truly lack credibility in a context where a lot of people (particularly in the gay community) know someone living with HIV and living quite well with treatment. We need to be realistic talking about what it means to live with HIV today. I personally don't look like I'm about to die (not of HIV/AIDS anyway!) and I have a fairly active life, but I wouldn't wish my HIV infection on anyone else. We need to learn how to share our experiences of living with HIV in straightforward, honest ways if we want people to understand why they might not want this virus. 

Risk Assessment 

In all health issues, the quantification of risk is problematic. I have a friend who, in the course of his internship, was sometimes called upon to deliver a prognosis to an ailing patient. "How much time do I have left?" rivalled "What are the chances of the operation not working?" for tops of the unpopularity contest. He was reticent to tell the elderly patient that there was a 4% risk of death in an operation because it was so unlikely to occur and so likely to panic the patient to hear and try to interpret the words. 

How then do we explain that a single act of condomless anal sex with a person with a high viral load might have a transmission rate somewhat less than 1%, but that people still get infected with HIV? I know there has been some degree of reticence to share those percentages of risk because they are so very difficult to wrap our heads around, but that is an attitude that smacks of paternalism. If it is difficult to understand, then our challenge on this point is clear: learn to explain risk in a way that helps people to make informed decisions about their actions. 

A Full Toolbox 

There are many approaches to prevention these days, ranging from motivational counselling all the way to pharmaceutical intervention. We need to figure out which tools work best for which people in which situations. Then we need to be able to make sure that those people have access to the tools they need, understand the strengths and limits of those tools, and know how to use them.

With budgets for prevention stagnant and some new approaches taking up a lot of virtual space, those who make decisions about what to fund might be tempted to put all their eggs in one basket. We have to continue to recognize that there isn't a single approach that will work for all and fight to preserve the diversity of the available tools even as we work to understand them better and to improve them. 

The Pleasure Principle 

Most of the time – if we're lucky – sex is about pleasure. When our prevention messages are peppered with words like "safe" and "secure" or "protection" it shouldn't surprise us that not everyone wants to hear them, or even listen to them. We need to talk more about what to do, and not as much about what not to do. This goes beyond how our messages look (we've learned to make them sexy) right to the core of what they say. 

Since I am given to wild and sometimes inappropriate metaphors, let me just charge headlong into this one: Waterskiing is not all about the life jacket. That life jacket might be an essential tool in the end, depending on how you go about the sport, but the waterskiing is about hanging onto the rope, getting up on the skis (and staying there!), and it's even more about the sun on your face, the wind in your hair and the pure exhilaration of skimming across the water behind a powerboat. We need to focus on that approach when we talk about sex. 

Autonomy 

We need to trust people to make choices for themselves. That means sharing all of the information in the best way to ensure that it is truly understood and letting people determine how they will act on it in their own lives. I would hasten to add that one person's autonomy doesn't trump another's. I'm trying (and probably failing) to make this point not be about disclosure, but if we lived in a world where people wouldn't face unreasonable discrimination after disclosure I would be happy to include it. And when I talk about discrimination, I'm not talking about getting turned down by a potential partner, but about losing a job or not getting one, or about losing all semblance of privacy when the person trusted with the information decides it needs to be shared. 

Back to the autonomy part. People will not necessarily make logical or sensible decisions when it comes to sex and pleasure. We wouldn't be human if we always acted logically and based on the best available evidence. Humans have issues like self-esteem, desires, fears, urges…these all push logic out the nearest window from time to time. Sometimes we make bad choices for ourselves and sometimes we make good ones. Sometimes good and bad are a little difficult to sort out. That doesn't mean that someone else gets a licence to tell me what to do with a willing partner; it means that the prevention challenge is to try to ensure that I have all the information and tools I need to make the right decision for myself, and that my partner has those too. 

I don't know if we'll find the ideal approach to prevention or the means to make sure that the multiple approaches that work the best for now are fully available. I only know that we can't stop trying. One new infection is one too many.