Inside tbe world of drag

Most of you know me as DJ Relentless, but I am also known as Jade Elektra and I just spent Easter Weekend in Chicago competing in The Miss Continental Elite Pageant. As an out HIV-positive person, it was really a great weekend for me to represent Canada in my first national pageant.

Ever since I came out on the gay scene back in Tampa in the mid 80's, the drag world has always been a major fascination for me. I remember going to The El Goya and seeing my first drag show that featured Joey Brooks, Stephanie Shippae, Bobbie Lake and Gilda Golden. These were the performers who would mold my view of what it meant to be a female impersonator. Glamorous and larger than life. I knew after that show I wanted to be an entertainer.

Back then, there was a talent show on Mondays at a place called René's. This bar was known for producing some of the top title holders. Tiffani Middlesexx, Tiffany Arieagus, Mahogany, Chena Kelly, Lakeisha Lucky, Esme Russell, Dana Douglas, Dana Manchester, Patti Cakes and countless others were headliners there. They had the best talent show in town. Queens would come from Miami and Orlando to make an impression and win $100. Many of today's top legends got their start in that talent show. René's could make or break you. 

First Steps

A wonderful hostess named Tony Rose watched my first attempt at getting attention with a concept number of Stephanie Mills' cover of "How Come You Don't Call Me Anymore". I am very glad that no photos have surfaced. I had no idea how to do make up or that I really needed a wig to cover up my jheri-curled hair (remember it was the 80's). But I guess Tony saw some potential in me and pulled me aside after one of the most humiliating nights of my life. She told me that I should show up early the next week and she would help me with my make up. She gave me my first Millie Jackson record, "Live & Uncensored" and told me to learn something off this. She surprised me the next week with not only doing my make up, but also donating my first drag outfit, a simple white Dynasty dress (at least that's what I called it) and a wig. She was my very first drag mother. They don't make 'em like that anymore. This was back when the older queens would teach the younger gyrls the way. God, I miss those days. 

I came up with some of the new crop of gyrls back in those days. Simplicity Hart, Tomeka Love, Donna White, Regina Rheal, Natasha Richards, Tiffany McCray, Syreeta Montiel, Crystal Clear, LaTonya Rogers, Monique LaBelle  and Ebony (my first drag name before becoming Jade Elektra in 1992) were names that dominated that Monday night talent contest. 

With all the tutorials on YouTube and shows like Drag Race, the young gyrls today think they don't need a guiding hand. And all the bad habits and horrible attitudes that RuPaul's little creation has spawned has straight audiences and younger gays believing that this is the future for drag, that your fifteen minutes are your ticket to stardom. But like Madonna said in her interview on Anderson when asked about reality TV celebrities "It may get you in the door, it doesn't guarantee you will stay at the party". And no truer words were ever spoken.  

The Pageant

So, being a contestant in The Continental Elite Pageant was an honour. When I walked into registration at the Park West Theatre and saw Dana Douglas I became a little drag kid again. I remember when she won Miss Continental in 1987. I remember her performance of "Black Velvet" at The Miss Florida pageant that year with this amazing long train to her dress. I began talking with her, thinking she must be a judge, or there to help organize the pageant. But when Jim Flint and Ginger Grant called everyone over to sign up she came over as well. I knew right then that I was looking at this year's winner. This was drag royalty. It would not matter if I had jumped through hoops of fire or what any of the other gyrls were doing - this was the winner for 2012.

After watching and listening closely to the whispered conversations, I learned that some of these gyrls had been in this pageant system for years. Unfortunately I believe they are stuck in it.

Now...anyone who knows me knows that I don't mince words. So, if you are easily offended or you can only see your point of view, I suggest you stop reading right now. Because I am about to tell you what I really think about the Continental pageant system along with most pageants. This is no different than the ballroom scene. These people spend thousands and thousands of dollars to enter these competitions and for what? At the end of the day what does it all mean? Absolutely nothing outside of that circle. They lure you in with the glamour and glitz of what you see on stage, but all the stuff that goes on in the background would probably make a sane person say I will have nothing to do with this.

I also think of the pageant system as a pyramid scheme. Someone on the top of the pyramid is making money off all the people who are involved. Kind of like how RuPaul is making all the money from Drag Race and the contestants are left fighting to be on that show to get a chance to be in the spotlight. And just like the mafia, they take care of their own. Once you are in the family, you are always in the family. But if you don't get accepted into the family, you are encouraged to come back and try again. They might dangle a small prize to keep you interested, but make no mistake....they want your time and money.

Augmentation

Back when I was coming up on the scene, bar owners and promoters would help the gyrls get their breasts done and any reconstructive surgery you would need to be the next beauty. For a while there were a few who wanted to make me into the next Stephanie Shippae. They would have paid for everything if I gave them my youth and innocence. But the one thing I always enjoyed at the end of the show was taking all that stuff off and being Alphonso King Jr. My motto was and still is "If I can't take it off at the end of night, then I don't need it."

I remember my first year in New York City I met a queen named Consuela. She was taller than me (I'm 6' 4") and had these insanely huge implants. At that time I was a DJ at a tranny hooker bar called Sally's on 43rd Street. Consuela got really drunk one night and came over and talked to me as I was packing up for the evening and what she said has always stayed in my head. "If I knew what I know now, I would have never done any of this to myself. You are so lucky. Stay just the way you are. It's not cute waking up at 40 to find that not even 7-11 will hire you."

So, what do you do when you have altered yourself so much that you are unrecognizable and you have implants and facial hair? You are stuck in that life for the rest of your life. Unless you have had some of the best doctors over the years (which most of these gyrls have not) you are probably not healthy from the silicone injected into your body. And the one thing that was really clear is that the Continental System is for transsexuals. Boys who do drag are cute, but they are looking for all the augmentation. Outside of my friend, Scott Cooper, who is still a boy and has not had any work done, I believe that only transsexuals have been winners of Miss Continental. But where is the line between female impersonation and transsexualism? 

Now, don't get me wrong....I love these drag conventions. You get to see all the people you haven't seen in years. And the energy is great. Of course a few folks were trying to get me to join the other pyramid scheme, Miss Gay USA (which I'm told is strictly for female impersonators). And although I have been around these queens for years and around the pageant scene in the background as the DJ who mixed their talents or did the voice-overs for them, I have never really lusted after these titles. I have a few titles and a few crowns from randomly entering a pageant here and there, but I have never felt that these titles have defined me as Jade Elektra. In fact, the highlight of this past weekend in Chicago was getting to perform as Billie Holiday on the Park West Theatre stage. That was absolutely wonderful. I felt completely at home on that stage. And it confirms that I am heading in the right direction with my career as a recording artist and vocalist. Hopefully one day someone will come across the DVD of that performance and say "Wow...where is that queen now? That was a talent!" Because let's face it.....someone doing a live vocal performance in character is not in the same category as a glamazon standing there lip-syncing with back up dancers. Apples and Oranges. I knew that going in, but I wanted to let people know that I was there. And no disrespect to any of the gyrls, but my vision for myself is a lot bigger than this circle. 

To have people come up to me after my talent and ask me if I was really singing or where did that voice come from was my crown and title. No one had ever done a Billie Holiday impersonation at Continental. It was an real honour to have a former Mr. Continental, Antonio Edwards whom I have known for years, come up to me and say"I knew you could sing, but I never knew you could sing like that".  It really made my evening. And hopefully I have opened the door for future impersonators to take a chance on live talents.

I would like to see more classic drag come back. There's only so many music videos that can be recreated on the drag stage. There's so much more out there than the Top 40 that is being rammed down our throats. I sit back and watch all these young ones killing themselves to be exactly like the gyrl sitting next to them in the dressing room. They want to out-do the next one. Well, you can't do that by doing the same numbers you saw on YouTube over and over. You have to be creative and strive for something different. And stop dumbing down the performances. You are in a unique position to educate your audience as well as entertain.

You've got to listen to the ones who were here before you. Their wisdom is very valuable. I try to tell the gyrls I work with simple things that would help them on stage and in life, but most are not listening. I just hope that they don't fall into the trap and lose themselves in this world of drag. If you meet an older queen, sit and talk with her instead of dismissing her.

But back to story of The Baton...

The finals . . 

So, it is the night of the finals at The Baton. There are twelve contestants and we come out in orange presentation. It all seemed surreal to be standing on the most famous drag stage in America. In my heart of hearts, I was hoping that my talent had gotten me into the Top 8 at least. They start giving out awards for best interview, best swimwear, best evening gown and best talent. My name is not called for any of those. They start calling the Top 8 and as they skip over me an epiphany comes to me. "Thank God I am not in this". If I had won any of those things I would be obligated to come back again. But you have to pay your dues with this pageant system, to build your brand with Mr. Flint before you get his seal of approval. And at registration he gave a speech about he might end the Elite pageant if there are not 20 or more contestants next year. Of course Dana Douglas is the perfect candidate to go out and sell the Miss Continental Elite pageant to promoters and bars across the country. This is how the business works.

So, I was very grateful that I did not place and did not make the Top 8. I am free! All I have to do is step down as Miss Toronto Continental Elite in November and I am done.

The drag world still fascinates me. What motivates a man to put on a dress and act like a woman? There are a million stories and reasons why, but for me it is an extension of who I am as a man who has embraced his feminine side and still treasures his masculine side.

I am unfamiliar where other people are in their journeys with self-identification and I am not advocating that it is necessary or even required, but for me, I found that if I was going to be trusting someone with my body and waned them to keep me safe, then I would want them to know I may have limitations that may not otherwise be noticeable from the outside.  That is a choice I made around the five-six year mark of being HIV+ when I took up this physical practice of yoga.  It was a style of heated yoga that aroused my personal interest for two major reasons: I wanted to detox some of the chemicals I was taking (both prescription and “prescription”) and it was three blocks from my home.  I was probably in one of the worst shapes of my life.  Not just physically unfit, but my diagnosis was in transition back from having full blown AIDS and slowly on the mend.  I didn’t have much energy or the ability to move around too much and the idea of being in a gym environment scared the crap out of me.  Images from Grade 9 gym still haunted my mind’s eye and my low ideals of my body didn’t help either.  Ofcourse crazy me chose a style of yoga that has a giant wall covered with mirrors!  Oh ya!  There I am fully in reflection and there is everyone else.  No hiding in this room!!

I went to Bikram Yoga Danforth, which eventually became Moksha Yoga Danforth and I was there at the start of a newer style of hot yoga: Moksha Yoga. I went with my roommate at the time on a Friday evening Karma class.  A karma yoga class is a regular class but instead the money isn’t paid to the studio but given as a donation to a local charity.  Honestly, I was scared.  I remember filling out the release forms and coming to health things and pausing and trying to figure out if I should say something or not.  I figured that I should, not so much that I wanted people to know, but hopefully to give me a future excuse not to have to try so hard in case it kicked my ass, and not in a good way. 

The class was hard.  I had never sweated that much in my life.  I seriously started to reconsider long shorts and a thick cotton t-shirt.  There was so much sweat.  It burned my eyes.  I could swear people were staring at me but they weren’t.  This wasn’t like gym class.  Nobody turned and looked at me or made fun of me as far I can tell.  The person I was sort of following in front of me seemed to send out nice thoughts and glances, if she was even ever really looking at me.  I had the same feeling about my teacher (who would one day become a friend and colleague).

The postures were hard.  I hadn’t really moved like this before.  Some of them were just awful, but some were actually wonderful.  I remember enjoying backbends from the beginning – which I found out later many people dislike.  They seemed natural for me; perhaps it was the high-like feeling I got when coming out of them! LOL!  Who knows?  Before I knew it, we were on the floor and that brought some relief but we kept on sweating.  I looked over at my roommate and he was struggling too.  That made me happy.  He’s younger and way more fit then me so if he’s finding it hard then it suddenly made it OK for me.

I looked around and other people were sweating a lot too.  I wasn’t the only one.  I was not alone.  Eventually the class lead up to us finally getting to lay down at the end and the lights were dimmed.  The teacher asked us to send a thank-you out to those that helped us practice and I thought of the really fit girl in the front row who I stared at for a majority of the class.  I thought of my roommate who came with me because I couldn’t have come without him.  I thought of the teacher for being kind to me.  She said some quote and I can’t remember the words of what she said but I remember the impact it had on me.  I felt rested.  I laid there in the dimly lit room with all these people and felt rested.  I wanted more.

I ended up coming back.  I signed up and things went from there.  I eventually got to a point where I didn’t care as much about the clothing and my outfits became less clothing oriented.  I remember the day I took my top off for the first time.  It is really the first time I had ever done that in public as an adult.  I even swam with my shirt on at that point.  But it was just so hot and I’m like “nobody cares what you look like” and just did.  It was freedom.  Eventually it led me to skimpy Lululemon Hot yoga shorts.  I still have the original pairs today (side note: Lululemon makes incredible clothes that last a long time).  Things changed.  I moved up to the front row one day.  Here I am, in a room full of strangers – many of them women, contorting my body, practically naked, sweating like a pig, in front of a full wall to ceiling mirror with the lights on and I feel good about myself.

I participated in their first 30-day challenge.  The goal was to practice yoga everyday for 30 days and see how many you could do.  This seems hard, but not completely unattainable.  I was already coming a few times a week and thought I would try.  Ted and Jess, my teachers encouraged me to try and see what I could do.  And I believed them.  I tried.  I made it up to about Day 27 before I had to bow out.  I figured though, that for someone who was dying less than a year prior, I should be awarded some extra credit and so it didn’t seem like a fail but a victory.

There was a party to celebrate the start of Moksha and this new journey for the studio and I was there in the beginning; not exactly the splendor of health but I was there.  Moksha was and has been cited for their environmental conscious but importantly, from a yoga asana perspective, as being accessible. It was open to all – which included me.  I have never really been included in something like this before and it was nice.

Several years later, I was in a matted basement on the Westside of the city doing my Moksha yoga teacher training.  And those same teachers who encouraged way back then were here again, encouraging me to follow this path and I did.  Training was grueling.  It was two practices a day in the hot room and long hours.  I was up at 5am, six days a week and burning out fast.  One morning while on a subway, I prayed.  Or perhaps you can call it questioned.  I closed my eyes and tilted my head upwards and said inside my mind quite audibly “Why am I doing this!?!”  I was so upset and ready to quit.  Then I opened my eyes.  And there on the wall of the subway was a post-it note.  To this day I have never seen another post-it note ever on the subway, but in the heat of my questioning, there it was.  The post-it note read “The possibilities before you are INFINITE” I cried.  I looked around, peeled it down and took it with me.  I have carried it around in my wallet ever since and have never looked back. 

In less than a year I was teaching FT and I haven’t looked back since.  Who knows what can happen right.  I wasn’t the model student, but I tried.  They created an environment that allowed me to feel safe enough to try without judgement and I am grateful for that.

As I write I hope that my students know that they are always welcome, regardless of anything they perceive to limit or keep them separated, that they are always allowed to be included.  If you are thinking about this style of practice as a possibility for you but think its daunting or that perhaps you cannot, think again.  Let the teachers and staffs know your situation.  It has been my experience that not one community in this yoga world I have been a part of has ever excluded me based on health.  If you’re inflexible, in bad shape, in poor health and may possible have a bad attitude, you’re welcome here.

I am in the hot room often, several days a week.  It isn’t the only style I teach anymore and my practice and teaching have broadened to include and encompass a variety of offerings, but my home is always in a Moksha space.  In the yoga world, it was in Moksha that I learned how to fly free.

Metta 

This article has been hard to write for many reasons, the biggest of which is that it hits close to home. I do want to stress that I am not a licensed therapist nor have I had any training on this; these are my own thoughts, feelings, and opinions.

My family has a history with depression. Luckily I can say with the exception of my mom’s uncle, we are still all here today and doing a lot better.  I’ve tried to kill myself twice because I was unhappy with where my life was going, because I was dealing with being gay.  My sister tried to kill herself when she was younger, my cousin used to cut herself, and my mom’s uncle shot himself.

Depression affects us all; most of what we see and come into contact with falls into "situational" and "clinical". Situational depression is a depression that occurs in response to a specific set of external conditions or circumstances.  Clinical depression is a condition identified by loss of energy and ability or desire to function, poor sleep or appetite, and/or exaggerated feelings of hopelessness and discouragement.

The reason why I wanted to write this is because I have been trying to help Lisa, a friend in Germany, who has been going through life events that caused her a lot of pain and sadness.  In February, Lisa’s best friend Chris killed himself after finding out he was HIV-positive and left behind his partner, Tom.

Chris felt guilty about being HIV-positive; he cheated on Tom and may have infected the guy he cheated with.  Instead of dealing with the issue, he was so ashamed of what he did he decided the best way to deal (or not to deal) with it was to end it all.  He wanted to end the guilt.

Tom was lost without Chris and tried to kill himself on multiple occasions. He had been staying with Lisa and her family so she could keep an eye on him in hopes that he would get better and not try to cause himself any harm.  Lisa was determined not to lose Tom and tried to stay at Tom’s side 24-7.  However, this is unrealistic in any scenario, and not healthy for her or her family.  Lisa was starting to feel the effects of Tom’s depression; she wasn’t able to sleep, cried a lot, while lying in bed holding Tom, and started to withdraw from her family.

Last Wednesday morning, I received word that Tom was finally successful at committing suicide; he took advantage of Lisa’s absence from the house and took his car for a ride into the side of a bridge. Lisa was only gone for an hour, and when she returned home she noticed Tom’s car was gone.  Two hours later, the police showed up at her house to tell her the horrible news.

In a two-month span, Lisa lost two friends. Now she is feeling like somehow she has let Tom down for not being there to make sure he wouldn’t succeed in his plans.  However, this was not Lisa’s fault or in her control; Tom made up his mind long before Wednesday that he was going to kill himself and no matter how much Lisa and her family were there for him he was going to follow through with it.  Lisa is now starting to understand that; and with the help of her husband, she is starting to get things back to normal. It’s going to be a tough road for Lisa but she has the support of wonderful people in her life and my thoughts and prayers are with her.

My view on suicide has changed a lot since I tried to kill myself.  I now see it as a cowardly, selfish thing to do. A person attempting suicide wants the pain to end so bad that they never look or think about what they are doing to others around them, like their family and friends. 

However, this wasn’t a thought that came to me quickly.  While I was locked up I was able to see how my actions affected those in my life. The first time I tried committing suicide, I just wanted the pain to subside. I don’t think I was really planning on causing myself to die; I mean it in the sense that I tried to end my life.  After weeks of watching movies/TV, I was released.

The second time was a lot different; I took a lot of pills and chased them down with a bottle of my favorite champagne. By the time the paramedics arrived, I was barely breathing; they had to insert a tube into my throat.  While one was trying to get the tube in, another had to sit on my chest to hold me down.  After a few days in the ICU, I was transferred to Beaumont Psychiatric Hospital.

This hospital was no joke (or at least the section I was in) -- there were people that were not just suicidal but crazy on a whole new level.  If I wanted to shave I had to go to the nurse and get a razor and shave in front of an orderly, then return the razor to him so he coul give it back to the nurse.  There were therapy sessions, both group and one-on-one, that we had to attend as part of treatment.

During one visit my mom said, “When you were in San Francisco, you were worse off and you never did anything like this; why are you now?” She got me thinking because she was right.  When I was in San Francisco, I was sleeping out of my truck, in homeless shelters, even on the street -- yet I never tried to hurt myself. This had to be the lowest point in my life. I started to see what my actions were doing to my family; I missed the birth of my nephew because I was feeling sorry for myself.

As days passed, I started to listen to the other patients' problems and issues in group therapy. There was a gentleman in his late 60’s, there because he wanted to kill himself. His partner had died 5 years before and he was tired of being alone. His friends were all gone and he was in bad health due to HIV and diabetes.  All he wanted to do was see his soulmate again.  He tried to kill himself by taking one of his insulin needles to pump air into a vein to cause a heart attack.  He passed out from the pain before he could accomplish this goal.

Another patient, a mother of three, was laid off work and she was having a hard time finding a job about the same time her husband was released from prison. He started using and dealing drugs and infected her with HIV that he contracted in prison.  She decided to turn to prostitution so that she could feed her kids. Once she received notice that her HIV was now full blown AIDS, she turned to heroin and purposely overdosed so she would not have to face her children.

While hearing these stories I started to ask myself, “What the hell am I doing here?” The therapist asked me what I did that got me sent there. I stated this was my second time trying to commit suicide by overdosing, I felt like that my life was going downhill fast, I didn’t know who or what I was, and I saw myself as a failure, both as a marine and as a human.

As time went on I started to realize that everyone in the hospital with me was completely different, yet we all made decisions based on our own circumstances. During the visitations, I saw how each person’s family acted, who visited, and who didn’t.  It started to make me realize that no matter what, I have my family and that’s what life was  - having loved ones close to you.

From that moment on I decided to take the negatives and turn them into positives. I missed my family, I wanted to see my nephew, I wanted to get out of that hospital and start turning things around.

I still struggle with depression. To say that I’m fixed is far from the truth. I’ve learned ways to cope with my problems and issues, though.  When I look back on my time in Beaumont, I’m thankful for having been there and going through what I did because I realized that nothing is that hard to deal with when I have family, friends, and loved ones around.  If I was successful in ending my life, I would not have seen my nephew or niece, I would have never met so many wonderful people in my life, and I wouldn’t be here writing this and sharing my experiences or helping others through theirs.

Never give up hope

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To continue where I left off in part 9 of my story, which you can read here, the decision was made to seek to remain in Canada as a Conventional Refugee, thanks to the information shared with me by the man I had fallen for during (Toronto) Pride 2011.

I returned home and began to discreetly wrap things up, all the while maintaining contact with the list of references provided to me by my new boyfriend.  I reached out to folks at the 519 Church Street Community Centre and the Metropolitan Community Church  who in turn connected me with a great lawyer. The support I received from them was overwhelmingly positive, much like the support I received from my partner and unlike the negative feedback I received from my gay relative here in Canada. One of his opinions was that people from our country “don’t succeed” with such claims. But despite his negativity, I decided to proceed.

In less than a month I returned to Toronto. I was scared shitless but optimistic at the same time. Here I was making a break for it from the years of bullshit and turning a new yet uncertain page of my life. I didn’t know what to expect. A few days after I arrived, I formally made the claim at the Citizenship and Immigration Canada (CIC)   office. It was a two-part process that included having to be interviewed by an immigration officer to ensure that I met the requirements. That in itself was terrifying, to say the least. I then had to complete a medical exam in which the results would determine if I’d be eligible to work while I wait for my refugee hearing.

Since the results of this exam would take a few months, I decided to use this time to tend to some much needed mental self care. I started by touching base with the program coordinators of the refugee support group, Amongst Friends, at the 519 and by way of referral from the very support doctor that performed my medical exam, I went to an HIV specialist. After all, I had no clue what was going on with me medically. I then enrolled in an excellent program by the AIDS Committee of Toronto (ACT) geared specifically to HIV positive gay men - Gay Poz Sex (GPS). Joining this program was one of the best decisions I’ve ever made. It literally gave me the tools needed to start unpacking the side effects of the homophobia I faced. It also gave me some much needed practical Canadian HIV 101. Like the fact that I must disclose my status to anyone I wanted to have sex with prior to doing so. (Editor's note – where there is a “significant risk” of transmission.) This law doesn’t exist at home. In fact if I disclose my status, I’d probably have my ass kicked, among other things.

The more I learned about the HIV community/movement, the more I felt the need to get involved. I then started volunteering for ACT and, from a connection made through the GPS group, I was given the opportunity to have a voice through PositiveLite.com. Apart from my new activism stripe, I continue to meet with the facilitator of the GPS program after it wrapped up to continue unpacking my mental issues. These private sessions are a now weekly part of my life.

On the social side of things, I’ve been slowly starting to come into my real self. I now love all things gay. It’s a bit difficult to go from closet case to gay and proud but I’m working on it. Like anyone my age, I enjoy hitting the bars/clubs in the village from time to time and checking out the eye candy in the Church-Wellesley village. I’m still navigating my way through the maze of making friends but I do have a few genuine guy friends for which I’m more than thankful.

Though I’ve been finding ways to occupy myself, I still have the ‘what if’s’ thoughts that causes a panic. Like what if things don’t go well and I have to return home? It’s inevitable for anyone in my shoes not to have these thoughts but thanks in great part to ongoing counselling and the support from those around me, I’m slowly learning to counter those negative thoughts with positive ones.

I was lucky enough that after I received my work permit earlier this year I was able to find full-time employment in a field that I’m familiar with. Through my volunteer duties and participation in different LGBT support programs, I was able to see that you actually can live a normal life with HIV. With that in mind, I’m planning to finally pursue my educational and career-related goals. I gave up on them after my diagnosis but I’m ready to move forward with my life. I’m more than just HIV positive.

Within a few short months, I’ve been able to accomplish things that I never would have thought possible if I were still in my country. I’ve been able to put a totally different spin on my life and possibly my future, if granted permission to remain in Canada. Though it’s daunting, and despite the difficult moments that come with being a refugee claimant, I’ve been able to see tremendous results from simply taking a stand.

The Warnings

“I’m surprised there isn’t a greater sense of urgency about this in the community” said  Dr Kevin Fenton of the US Centers for Disease Control, speaking at the International AIDS Conference in Mexico in 2008.

He was talking about a study that showed that more than one fifth of HIV-positive gay men attending a STI clinic in Amsterdam had hepatitis C, compared with only one in 250 negative men; numbers had risen by 50% in the last year.

A year later, aidsmap.com reported that Hepatitis C infections (or HCV) among gay men with HIV represent a growing epidemic of an STI that, like HIV, is both chronic and potentially fatal.

Here in Canada, CATIE sounded alarms too. In a 2011 report published in Spring last year zeroing in on MSM (men who have sex with men, a term which includes gay men), they said “effective messaging for communities at risk” was needed  and that “service providers needed to be aware of the particular risk of sexual practices in the MSM community that can lead to  the transmission of HCV.”

A recent article "Sexual Transmission of Hepatitis C among HIV Positive Men in the U.S. and Australia" in HIVandHepatitis.com  reported “nearly three-quarters of new HCV infections among HIV positive gay and bisexual men in the U.S. are likely due to sexual transmission, according to an analysis described in the January 31, 2011 advance online issue of Clinical Infectious Diseases. An Australian study published in the same issue found that "sexual transmission accounted for a majority of cases among men who have sex with men, but injection drug use also played a role. These findings suggest that HIV positive people who have risky sex should undergo regular hepatitis C testing. “

This PositiveLite.com article looks at the community response to the issue of sexual transmission of HVC in gay and bi men in Canada. The picture that emerges is one of poor reporting mechanisms, warnings ignored - and inaction.

The Epidemic in Canada

How is the overall  HCV epidemic panning out in Canada? A Hepatitis C surveillance report from the Public Health Agency of Canada  (PHAC) covering the period 2005-2010 says that the number of new infections generally in Canada decreased from 13,107 in 2005 to 11,357 in 2009. The report states that the majority of new HCV cases are among people who use injections drugs (61%).  Of other  transmission routes, it says “sexual transmission of HCV is uncommon in the general population when compared to other modes of transmission. However, it is becoming widely recognized as a growing public health problem among HIV-infected individuals. Co-infection with HIV and other STIs, unprotected sexual intercourse and “HIV serosorting” (i.e., the practice of selecting a sexual partner based on concordant HIV infection status) increase the risk of HCV transmission."

The same report also provides an indication of how many people are infected in Canada. It was estimated that by 2007 a total of 242,521 Canadians were infected with HCV. Almost one quarter of Canadians infected with HCV are unaware they are infected.  Importantly, the document does not report HIV co-infections, nor does it report the incidence of HCV in MSM.

Sexual transmission of HVC in MSM

Researchers Tohme and Holberg report that “several longitudinal studies of HIV-infected MSM totaling more than 12,000 person-years of follow-up have shown that these men are at much higher risk for sexually acquired HCV than HIV-uninfected MSM.  Likewise, a large cross-sectional study in Amsterdam reported that HIV-infected MSM were almost 43 times more likely to acquire HCV infection than HIV-uninfected."

It went on “The real risk for sexual transmission appeared to be predominantly related to HIV infection: of all the practices considered in this review, the clearest and least equivocal risk behavior was unprotected sex between HIV-infected partners, particularly HIV-positive MSM.”

A French 2006 report warns that “Increase in the incidence of acute HCV infection in recently HIV-infected patients confirms the shift in sexual behaviour in recent years, especially in HIV-infected MSM. Repeated testing for HCV antibodies should be carried out in HCV-negative HIV-infected patients and specific recommendations about protected sex should be clearly provided.”

Clearly the dangers for gay/bi men, and HIV-positive gay/bi men, have been red-flagged for some time.  Are there resources for gay/bi men which address this danger?  

CATIE, in their Focus On Prevention, Spring 2011 edition has an excellent article  “Sexual transmission of hepatitis C: Are HIV-positive gay and bisexual men at risk”  which outlines  the role of service providers specifically relating to the MSM.   Here is what CATIE says. “Service and healthcare providers need to increase HCV testing in men who may be at risk of HCV from sexual transmission. When offering testing for HCV, service providers should also discuss transmission risks and harm reduction strategies. Front-line community workers can play a role in educating and encouraging men living with HIV to test regularly for hepatitis C and other STIs.”

The CATIE article goes on “Numerous studies tell us that a higher proportion of HIV-positive MSM are living with HCV infection than HIV-negative MSM. This suggests that there may be something about HIV-positive MSM that makes them more likely to become infected with HCV. However, it should be noted that not all studies have shown that HIV-positive MSM are at higher risk, so some controversy continues in the medical field.”

Testing for HCV Co-infection in People living with HIV

Why the fuss? Men and women who are living with both HIV and HCV face greater health and social challenges than those who are living with HCV or HIV alone. Each infection makes the other one worse. Those who have acute HCV infection are commonly asymptomatic, which poses a challenge for identifying new cases, other than through testing.

So although HCV is a common and serious co-infection among people living with HIV, it often goes undiagnosed.  In a recent large scale study in Florida, researchers found that of a total of 14,291 HIV+ patients studied, only 51% had been tested for HCV. The report highlights the great challenges in identifying and treating HCV with many healthcare providers and adds “there is a great need to educate infectious disease providers on HCV treatment for co-infection.”

That’s a US example, but is this disturbing situation present in Canada?  It’s impossible to confirm or deny. There is just no data available on whether the recommended HCV testing of HIV+ patients has in fact happened. So in the absence of Canadian co-infection testing data, the most relevant data seems to be from the US, and also perhaps from the UK.

(I should add that at my Positive Care Clinic, Hep C testing, if not performed annually, now seems to be the norm at least once.)

In the UK, the National AIDS Trust  has zeroed in on HIV and HCV co-infection. It’s 2012 report recommends “regular screening for hepatitis C for people with HIV. This should be promoted and encouraged as early diagnosis and treatment has a high response rate.”

The report says of the UK situation “There is an epidemic of hepatitis C among HIV positive gay men. 7% of HIV-positive gay men are co-infected with HCV. Infections are largely due to sexual risk factors, but drug use behaviours may also have a role.”

The UK report states HCV testing is recommended for anyone diagnosed with HIV and also at least annually, since there are immense advantages to being diagnosed with HCV co-infection early.

The UK report makes interesting observations about prevalence in the IDU versus the MSM community. "There is considerable disparity between risk groups. Some 83% of HIV positive injecting drug users are co-infected with HCV, whereas the co-infection rate in HIV positive gay men is 7%. Whilst this is a much lower prevalence rate than amongst HIV positive injecting drug users, given the large numbers of HIV positive gay men there are more co-infected gay men than there are co-infected injecting drug users.

British HIV Association (BHIVA) guidelines also recommend that all patients with HIV should be screened for hepatitis C at the time of their HIV diagnosis, with annual follow-up screening thereafter. More frequent testing is recommended for individuals with a higher risk of hepatitis C infection, including HIV+ gay men with 'risky sexual behaviour'."

A BHIVA audit in 2009/10 found that just 66% of HIV+ patients had an annual HCV test.

The UK report says “Prompt diagnosis of hepatitis C is especially important as the provision of therapy during the first year of infection can yield cure rates of up to 80%. By contrast, the response rate to treatment for chronic HCV is approximately 40%. The prevention and treatment of hepatitis C is a priority for people with HIV. Liver disease caused by hepatitis C is an important cause of death in co-infected patients. Moreover, co-infected patients have a significantly shorter prognosis than HIV positive people who do not have hepatitis “

As to the US situation, a search of the internet reveals a number of community responses to the issue of HCV and gay men's sexual health, such as this one from Project Inform in San Francisco.

Risk factors

CATIE  reports  “research shows that many of the HIV-positive men who are being diagnosed with hepatitis C have several sexual risk factors in common. These include:

 •  having unprotected (receptive or insertive) anal sex, especially in groups or with multiple partners

 •  rougher sex practices, such as anal fisting and the use of sex toys that can damage the rectal mucosa (the delicate lining of the rectum)

 • sores, chancres, blisters, lesions or other breaks in the skin due to sexually transmitted infections (STIs, such as syphilis)

 • use of recreational drugs during sex”

Of sero-sorting, or poz-on-poz sex, CATIE says “it is not clear if these men are aware of the hepatitis C status of their sex partners. Some researchers argue that social circuits of HIV-positive men that do not use condoms are super-concentrating STIs, which in turn gives rise to hepatitis C outbreaks within these social networks. There is the added complication of HIV causing the HCV viral load to be higher in someone who is co-infected. This further increases the risk of transmitting HCV when two HIV-positive men have sex without condoms.”

The Community Response in the UK

The National AIDS Trust report highlights the response from community groups in the UK. “Valuable campaigns have been targeted at HIV positive gay men to raise awareness of hepatitis C infection and the factors associated with its transmission. In May 2005, Terrence Higgins Trust launched its ‘A, B, C is just the start’ campaign, alerting gay men to the risk of these infections and the steps they could take to protect themselves against it. The campaign highlighted “sharing needles, razors, snorting pipes, unprotected fucking and fisting” as risk factors for infection.

It goes on. “Further work is necessary, such as that already undertaken by THT and GMFA, informing HIV positive gay men of the risks of hepatitis C transmission, with . . . a greater focus on the most significant risks. In addition, complementing this vital health promotion work, HIV clinics need to have clear strategies to minimise hepatitis C transmission (and maximise early hepatitis C diagnosis) amongst their gay HIV positive patients, with consistent testing and counselling processes.

“The failure to prioritise the risk associated with fisting and other sexual activities likely to involve trauma and contact with blood may mean that men are not being sufficiently alerted to what is consistently emerging as a highly important risk factor.”

It also says “Research attention could profitably be devoted to the personal strategies HIV positive gay men are adopting to protect themselves from hepatitis C infection. If anecdotal reports that some individuals are relying on their sexual partners to disclose their infection status prove founded, then there is a clear need for well-focused and targeted information highlighting the unreliability of this strategy.”

The Community Response in Canada

In a word, it’s underwhelming.

There appears to be no data for HCV testing uptake amongst HIV+ patients in Canada. That lack of data cannot be used to assume or even suggest we do not have a problem, when other countries with better research and/or data collection do.

As for programming, it’s clear we as a country are lacking too.  Where are the HCV campaigns aimed specifically at MSM that all the literature, including our own, recommends?

Enquiries of the prevention community suggest that in some, the issue is “more than on their radar”: but that funding constraints combined with inadequate surveillance reporting  have hindered implementation to date. But lack of awareness generally is likely equally as important.

There are exceptions. In BC, Heath Initiative for Men (HiM) has had several columns that contain information about HCV aimed at MSM and poz guys, like this one and this one. 

Conclusions

In a nutshell, we need do to more towards bridging the gaps between recommendations and practice.

The response in Canada, provincially and locally, has been stymied by lack of data as to the extent if the problem. Data drives action; without it there is often none.

We know much too little about the extent of HCV infection in MSM, or co-infection in that group, or to what extent recommended testing is actually happening.  PHAC says this: “better estimates of HCV trends in Canada, including measures of prevalence and incidence of acute hepatitis C, and more detailed data about risk behaviours, would help inform HCV policy by targeting prevention programs toward those at greatest risk for infection.” They are right of course. But research is also needed too, to find out what doctors are doing about HCV testing in their HIV+ patients.

So again, here are the problems

• The lack of data as to the extent of both HCV infection and co-infection in MSM.  Without data there is inaction.
• The  lack of data on uptake of HCV testing in people with HIV in Canada, whereas elsewhere testing rates are clearly  a problem, which lack contributes to potentiailly poorer health outcomes for people living with HIV
• Lack of awareness in health service providers  of the issue surrounding  risk factors associated with sexual transmission  of HCV in MSM.
• The lack of HCV programming  targeted at MSM recommended  by many countries, including Canada

What can you as a person living with HIV do?

Read up on it, particularly if you are a man who has sex with men.  Read the CATIE article as a first step. Then start asking questions.

Ask your HIV doctor or clinic what is their policy regarding HCV testing?  Find out if you were tested on diagnosis and/or annually thereafter. If the answer is no, ask to be tested.

Ask your ASO to see their pamphlets or online material about HCV infection in MSM.  Ask your counsellor/support worker to tell you what he/she knows.

Complain if you are not getting satisfactory answers, or see inaction on this issue. Talk to others.  Raise the issue at HIV conferences and meetings of other people living with HIV.

Advocate for better research.  Gay men are underserved here, and this is an example.

Advocate for better health care relating to this issue in general. The health care agenda has often been moved forward by people living with HIV themselves. This is a prime example where we can do that, by pointing out the gaps between recommendations and practice and asking that they be addressed.