Report of the 20th Conference on Retroviruses and Opportunistic Infections (CROI) of a presentation by Susan Buchbinder . 

Reports of the HIV ‘cure’ of a baby in the USA have attracted global attention. My guess is that although this provides further support for the concept of cure, and will add momentum to research, it will make no immediate difference to mothers and their babies. Once more information emerges from the conference, I might return to this topic.

Reading other conference presentations, there is information on prevention that is of immediate strategic relevance.

In her presentation on “HIV Prevention Research: What’s Next?” Susan Buchbinder highlights evidence that provides a useful guide for action.

Networks - again

In HIV, size matters. HIV prevention work must address the influence of sexual networks and the numbers of sexual partners on HIV transmission. The point here is that even a small increase in the mean number of partners a person has in a community leads to a massive degree of interconnectedness of networks. The flip side is that if we can reduce that number of sexual partners, the potential for rapid spread is also massively lowered.

The data presented by Buchbinder is taken from Carnegie (2012) which modeled a population of 10,000 in which 44% had one sexual partner in the year, and 56% had two or three partners. In this case, there was only a 2% interconnectedness through networks.

Immediately that percentage with two or three partners increases, so much the greater is the interconnectedness. Relatively small increases of 4% having two or three partners bump the interconnectedness to 10%. If 64% have two or three partners, it rises to 41%. At a 68% of individuals with two or three partners, interconnectedness rises to a massive 64%.

According to McDaid’s (2012) most recent bar-based study, 11.9% of gay men interviewed had more than six sexual partners in the previous 12 months. Of those who had never tested, 24.1% reported a high-risk event of unprotected anal intercourse in the previous 12 months.

Disparate efficacy

It has been reported previously and I have commented on the steadying of rates of increase in new infections globally. After the peak in the mid 1990s, there has been a decrease of 25% in new cases, attributable to a variety of factors including the effect of treatment on infectivity. It might be too early to identify such a trend in the UK, but from what we understand, a plateau overall in rates of diagnosis of HIV conceals a worrying disparity between populations most affected. Whilst new heterosexual infections have reduced, in contrast among men who have sex with men they have increased. The same is true in the USA, Sub-Saharan Africa, and Latin America.

In the USA, more detailed analysis reveals the impact not only upon MSM but also upon black MSM, particularly in the South which represents nine of the ten areas with highest fatality rates, mirroring high rates on HIV incidence. Globally, HIV rates in MSM are 50 times higher than in the population generally. Geography, race and sexuality matter in this context.

Focus of prevention as well as of public interest upon sero-discordant couples reveals an assumption that this is the major source of new infections. In fact, within Sub-Saharan Africa, the majority of men infected acquire their HIV outwith their primary relationship. Women on the other hand are more likely to become infected within their relationship. Risk strategies and messages need to be different. Reaching and influencing men is key to prevention.

The high rates of HIV in MSM and the disparate risks between men and women in heterosexual relationships cannot but be linked. Legal and safety barriers for men who have sex with men are all the greater with the current anti-gay politics and laws being debated and passed in many African nations. This serves to increase infectiousness because African men are less likely to test or to go on treatment. At the same time secrecy and fear drive men’s sexuality underground and out of reach of prevention.

Real life science

The research priority currently is in treatment as prevention. Not only do we know that in specific circumstances an undetectable viral load reduces infectivity, but that statistically the same treatment is as effective as condom use in HIV negative individuals.

The best research results are reported in highly controlled trials. Less promising are the Fem-Prep trials and a trial recently with MSM in Chicago. The differences are not in the drug formulations or the kinetics and dynamics of the drugs, but in adherence to the demands of a strict regimen. Without good adherence, poor concentration of drug reduces its effect on viral load and therefore on infectivity.

The rate of adherence in the Chicago MSM study was found to be only 20%. The most likely explanation is that instead of taking the drug Truvada regularly every day, men were using it occasionally and only when they anticipated having sex. This is difficult to establish without some way of reliably linking time of medication to the time when the men had sex.

Efforts to improve adherence are looking at interventions such as texting, not to remind individuals when to take the medication, but to establish what kind of support might be needed at different times. A comparison with texting to remind people when to apply sunscreen ie when the sun was out, found a better response for the sunscreen than for anti-retrovirals. In other words, getting your shirt off and slapping on factor 25 is less stigmatising than swallowing down Truvada before unprotected sex with a positive partner!

Better cover

The standard and effect of research from the USA is outstanding, related primarily to the power of the dollar and the prestige of its academia. Sequestration of their budgets is likely to knock this primacy, but even more worryingly, it will hit hardest those who are without a good insurance policy in one of the few Western or indeed medium resourced nations with no universal health cover.

For prevention to be effective, it needs to use various drivers. We see clearly that the effectiveness of biomedical interventions such as treatment as prevention and more detailed action such as PEP and PrEP depend on a host of other factors.

If for example, 80% of those diagnosed with HIV are on ARVs and diagnosed at or around a CD4 count of 350, then modeling suggests a major impact on transmission. Treatment of all people with HIV was credited with the promise of the future elimination of HIV at last summer’s Washington 2012 international conference. In the cooler and more reflective Atlanta of March 2013, optimism might be as lively, but hope faded in light of the reality on Capitol Hill. In Scotland, the 80% point is exceeded by our HIV clinics, yet we see rates of HIV continue to rise. Fall in condom use has already been suggested as a major factor. In addition, however, the fact that 50% of new infections are diagnosed below the 350 CD4 count level, and half of them below 200, adds to a tragic Sisyphean effort of never quite getting the boulder to the top of the hill.

Summary

Mainly structural and socially determined factors negatively affect our prevention efforts. Buchbinder summarised in the following five points:

• Understanding and addressing disparities
• Understanding drivers, design and test interventions for largest impact
• Identifying new PrEP agents, delivery and scalable, durable adherence interventions
• Integrate clinical trials, ecological studies and mathematical modeling
• Scale up, measure impact, correct course

This article first appeared on Roy’s own blog scotfreehiv here. 

This article by CATIE’s James Wilton and Logan Broeckaert first appeared on the CATIE  website here.

Une version française est disponible ici.

We have known for years that antiretroviral therapy can significantly improve the health outcomes of people living with HIV. More recently, research has revealed the important role that antiretroviral therapy plays in preventing the transmission of the virus. As HIV treatment and prevention have converged, attention has turned to how well we are engaging people living with HIV in the continuum of services, including testing, care and, ultimately, effective treatment. The concept of an HIV treatment cascade has emerged as a way to identify gaps in the continuum, which are preventing people from realizing the treatment and prevention benefits of antiretroviral therapy.

This article takes a closer look at the cascade, why it’s important for HIV prevention and how it can be improved.

Steps in the HIV treatment cascade

Antiretroviral therapy is normally considered successful when it reduces the viral load of a person living with HIV to undetectable levels. Research shows that people who have an undetectable viral load in their blood are more likely to live a long and healthy life1 and are less likely to pass HIV to others.2

For a person living with HIV to achieve an undetectable viral load, they need access to a continuum of services: HIV testing and diagnosis, linkage to appropriate medical care (and other health services), support while in care, access to antiretroviral treatment if and when they are ready, and support while on treatment. This sequence of steps is commonly referred to as the HIV treatment cascade or the HIV care cascade. Unfortunately, the cascade isn’t seamless and some people “leak” out and are lost at each step, due to barriers to getting tested, staying in care, and starting or adhering to antiretroviral treatment. These barriers include:

• poor access to services;
• stigma and discrimination;
• poverty, food insecurity and homelessness; and
• mental health and addiction issues.3

As a result of these leaks at different points in the continuum, only a small proportion of people living with HIV are engaged in all the steps needed to achieve an undetectable viral load. For example, in the United States it is estimated that only 19% to 28% of people living with HIV have an undetectable viral load (see Figure 1).4,5

Figure 1. Engagement in the HIV treatment cascade in the United States

Source: Adapted from the Centers for Disease Control and Prevention – Morbidity and Mortality Weekly Report, December 2nd, 2011.

There are currently no official estimates for the number of people engaged in the treatment cascade in Canada; however, preliminary data suggest that there are also significant leaks in the cascade in Canada and that the proportion of people with an undetectable viral load may be similar to that in the United States6 (although it likely varies across regions and for different populations).

Patching the cascade to improve treatment and prevention

Poor engagement of people living with HIV with healthcare and social services limits the effectiveness of our HIV programs and our response to the HIV epidemic. Increasing the number of people engaged at all levels of treatment and care may both improve the health of people living with HIV and reduce new HIV transmissions. Increasing engagement in the cascade requires programs that address the multiple barriers.

However, we do not know what the “ideal” cascade should look like and aiming to get everyone living with HIV on successful treatment is not realistic, nor would it be ethical. It’s critical that efforts to better engage people in services do not come at the cost of individual rights and that we make sure clients and patients are ready and willing to take each step. To ensure informed consent, the risks and challenges that come with testing positive for HIV and starting treatment need to be explained to clients and patients before they make these important decisions.

Let’s take a look at each step of the cascade, its importance for treatment and prevention, and how we might be able to better engage people in each step.

HIV testing and diagnosis

An estimated 26% of people living with HIV in Canada do not know they have HIV.7 Reducing the number of people who are unaware of their HIV status requires increased uptake and frequency of HIV testing.

Increasing the frequency and rates of HIV testing will help diagnose people sooner after they have become infected with HIV. Currently, many people in Canada are not learning about their HIV status until late in their HIV disease, when they start to develop symptoms or opportunistic infections.8 At this point, antiretroviral treatment can help improve their health, but not as effectively as when treatment is started earlier.9,10 Furthermore, research suggests that a disproportionate number of HIV transmissions originate from people who are unaware of their HIV status because they are less likely to take measures to prevent transmitting the virus to others 11 and are more likely to have a higher viral load, particularly if they have recently become infected and are in the acute stage of HIV infection.12 Earlier diagnosis is therefore important for both the health of a person living with HIV and for preventing the transmission of the virus.

These are some of the interventions being used in Canada to promote HIV testing and diagnose people earlier:

Campaigns to improve awareness of HIV risk and encourage people to get tested regularly. Campaigns such as Get on it in Ontario, Find out where you stand in Montreal, and What’s your number? and Hottest at the Start in Vancouver encourage gay men and other men who have sex with men to test regularly for HIV. Some of these also aim to improve awareness of acute HIV infection and its role in HIV transmission.

Improving access to more acceptable types of HIV testing, such as point-of-care (POC) antibody testing and peer testing, to increase options for people who want to get tested. For example, POC testing is now more widely available in large Canadian cities. Peer outreach and testing in gay bathhouses is offered by some organizations, such as Toronto’s Hassle Free Clinic. In Montreal, the SPOT Project offers gay men anonymous HIV rapid testing and counselling as well as a full range of tests for sexually transmitted infections (STIs) from a storefront site.

Improving access to tests that have shorter window periods and can detect HIV infection earlier than antibody tests. These tests can help identify people in the acute stage of HIV infection. For example, P24 antigen testing has been used in Ontario since 2010 and a pilot study using nucleic acid amplification (NAAT) testing is currently underway in Vancouver.

Making HIV testing a routine part of healthcare to increase the number of people offered an HIV test. For example, Vancouver is scaling up HIV testing; primary care facilities, acute care hospitals and a few dental clinics in the city are now routinely offering HIV tests to patients.

Integrating HIV testing with testing for other STIs. Some organizations, such as the Hassle Free Clinic, offer an HIV test to anyone seeking STI testing. This greatly increases opportunities for HIV testing since people are more likely to seek testing and treatment for other STIs than for HIV.

Enhanced partner notification services to better identify and diagnose people who may have been exposed to HIV. Some regions, such as Vancouver, are re-examining how they perform partner notification to improve the effectiveness of the service.

Linkage to care and support

Linking people who receive a positive diagnosis to accessible and culturally appropriate care and support services is important to ensure that people living with HIV enter the next step of the treatment cascade. Research shows that delays in linkage to medical care after HIV diagnosis are associated with faster disease progression.4 Interventions that currently improve linkage to care in Canada include the following:

Referral systems that link people diagnosed with HIV into care. For example, the Manitoba HIV program, which provides a wide range of integrated care and support services at two sites in Winnipeg, has a referral line for people who test positive. This line can be used by the healthcare provider who performed the test to refer newly diagnosed individuals to the Manitoba HIV program for care.

Improved outreach interventions. For example, the STOP Outreach Team in Vancouver uses case-management to connect people with complex needs to the most appropriate service or program and ensures strong engagement in care before discharging them from the team’s caseload.

Retention in care and adherence support

Once linked to care, a person needs to be supported and monitored and receive counselling to determine when they are ready and eligible to start treatment. Once a person decides to start treatment, remaining in care is important so a person can be supported with adherence and receive ongoing viral load monitoring to ensure that their treatment is working.

Appropriate care and support for people living with HIV may include a wide range of services in addition to medical care, such as mental health and addiction services, adherence support, affordable housing and prevention counselling. These services can improve the quality of life of people living with HIV, address the underlying reasons people may drop out of care or find it difficult to adhere to treatment, and improve sexual well-being. Research shows that a combination of medical care and additional types of care and support improve the health outcomes of people living with HIV13 and make them less likely to engage in behaviours that can lead to HIV transmission.14

Recently, the International Association of Providers of AIDS Care released guidelines for healthcare providers that contain 37 evidence-based recommendations to improve retention in care and adherence to antiretrovirals.

• Interventions and services are offered across Canada that keep people engaged in care and help them access treatment, adhere to their medications and prevent the transmission of HIV.
• Intensive case management approaches can improve engagement in care by providing tailored support to individuals who need it. For example, the Manitoba HIV program proactively follows up with people who entered the program but have been lost to care and provides highly individualized services to people who have a history of lapses in care.
• Maximally assisted therapy (MAT) programs deliver daily treatment and support services to their clients. For example, the Positive Outlook Program at Vancouver Native Health Services and the MAT program at the Downtown Community Health Centre in Vancouver both provide assistance with daily treatment adherence and comprehensive support to their clients.
• Peer navigator programs train HIV-positive peers to offer services to people living with HIV who face multiple barriers to engagement. For example, Positive Living BC’s peer navigators provide tailored support to people who need it. They do this through community outreach and at the Immunodeficiency Clinic at St. Paul’s Hospital.  
• Programs that offer psychosocial supports, such as housing and food security programs, can reduce structural barriers to engagement in HIV care and treatment. For example, La Corporation Félix Hubert d’Hérelle in Montreal, the SHARP Foundation in Calgary, and many others across the country offer housing and housing supports to people living with HIV. A Loving Spoonful in Vancouver offers 1,200 meals a week to people living with HIV.
• Programs that support people living with HIV to live healthy sexual lives and incorporate prevention as part of their overall health and well-being. For example, the Poz prevention program at Toronto People With AIDS Foundation provides peer consultations, training for service providers and group discussions on sexual health and HIV prevention.

What can you do?

Public health authorities, healthcare providers and frontline service providers all have a role to play in making services more accessible and providing people with ongoing care. 

Patching the leaks in the cascade may require new interventions and new partnerships and/or the re-conceptualization of how services are integrated and linked with other services. It may also involve changing how services are evaluated. 

Key questions to ask yourself and your organization are:

• How can your organization better engage people living with HIV in the treatment cascade?
• What additional services could your organization provide to improve engagement in one or more steps of the cascade? Can you learn from what other agencies have done? Would it work in your region?
• What initiatives or partnerships could you develop to connect people living with HIV to your services? What initiatives or partnerships could you develop to connect your clients with other relevant services in your community?
• How can you evaluate whether your clients are entering the next step of the cascade? 

As we work to improve engagement in the treatment cascade, it is critical that human rights are respected and that people living with HIV and at risk of HIV are empowered through information to make decisions about testing and treatment that are right for them. This includes information about the legal requirement to disclose prior to some sexual activities.

Improving HIV treatment and prevention

Each step in the cascade is important for improving the health of people living with HIV and preventing new transmissions. The idea of a treatment cascade is useful for conceptualizing how services are linked and for identifying gaps that need to be addressed. At the same time, it has several shortcomings. First, it represents care for people living with HIV as a linear process, which we know isn’t always the case. For example, a person living with HIV may fall out of care or stop treatment for various reasons, they may move backwards or forwards at different points along this continuum, or they may receive healthcare for many years without starting treatment. When developing programs and services, we need to take these realities into account. Secondly, the concept of a treatment cascade does not include prevention as a component of an effective response. As a model of care for people living with HIV, it indirectly reinforces the false view that the responsibility for HIV prevention rests solely with people living with HIV. In fact, prevention is a shared responsibility and all people, regardless of serostatus, have an important role to play. Additionally, treatment as a mechanism for prevention is only one of several effective prevention strategies, all of which, when appropriately combined will provide a more effective response to the HIV epidemic than any one strategy alone. We should no longer do prevention work in isolation of those working in HIV testing, treatment, care and support, as they are all reinforcing elements of an effective response to HIV.

While each organization has a role to play in improving care for people living with HIV, we also need to look at the issue from a systemic level. How can we, as policymakers, service providers, healthcare providers and people living with HIV, improve services for people living with and at risk of HIV? We need to identify gaps and ways to improve care in conjunction with the community, to ensure that a person can effectively navigate their way within the healthcare system. Fragmented, stand-alone programs and services need to be linked to ensure that people living with and at risk for HIV have access to services that can support their care. 

In September 2013, CATIE will host a national forum called New Science, New Directions in HIV and Hepatitis C. This forum will provide an opportunity for frontline workers to come together to learn about new directions in service provision, share programming experiences and strategize about developing more integrated approaches to treatment and prevention.

Resources 

TreatmentUpdate – HTPN 052: The trial that changed everything

Prevention in Focus – Detecting HIV earlier: Advances in HIV testing

Prevention in Focus – Recently infected individuals: A priority for HIV prevention

Prevention in Focus – The STOP HIV/AIDS Project: Treatment as prevention in the real world

References

1. Nakagawa F, Lodwick RK, Smith CJ et al. Projected life expectancy of people with HIV according to timing of diagnosis. AIDS. 2012 Jan;26(3):335–43.

2. Cohen MS, Chen YQ, McCauley M et al. Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine. 2011 Aug 11;365(6):493–505.

3. Hull MW, Wu Z, Montaner JSG. Optimizing the engagement of care cascade. Current Opinion in HIV and AIDS. 2012 Nov;7(6):579–86.

4.a. b. Gardner EM, McLees MP, Steiner JF et al. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clinical Infectious Diseases. 2011 Mar 1;52(6):793–800.

5. Vital signs: HIV prevention through care and treatment--United States. MMWR Morb. Mortal. Wkly. Rep. 2011 Dec 2;60(47):1618–23.

6. Adam BD. Epistemic fault lines in biomedical and social approaches to HIV prevention. Journal of the International AIDS Society. 2011;14(Suppl 2):S2.

7. Government of Canada Public Health Agency of Canada. HIV/AIDS Epi Updates—July 2010. [Internet]. Available from: www.phac-aspc.gc.ca/aids-sida/publication/epi/2010/2-eng.php

8. Althoff KN, Gange SJ, Klein MB et al. Late presentation for human immunodeficiency virus care in the United States and Canada. Clinical Infectious Diseases. 2010 Jun;50(11):1512–20.

9. Li X, Margolick JB, Jamieson BD, Rinaldo CR et al. CD4+ T-cell counts and plasma HIV-1 RNA levels beyond 5 years of highly active antiretroviral therapy. Journal of Acquired Immune Deficiency Syndromes. 2011 Aug 15;57(5):421–8.

10. Siegfried N, Uthman OA, Rutherford GW. Optimal time for initiation of antiretroviral therapy in asymptomatic, HIV-infected, treatment-naive adults. Cochrane Database of Systematic Reviews. 2010 Mar 17;(3):CD008272.

11. Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. Journal of Acquired Immune Deficiency Syndromes. 2005 Aug 1;39(4):446–53.

12. Miller WC, Rosenberg NE, Rutstein SE, Powers KA. Role of acute and early HIV infection in the sexual transmission of HIV. Current Opinion in HIV and AIDS. 2010 Jul;5(4):277–82.

13. Giordano TP, Gifford AL, White AC et al. Retention in care: a challenge to survival with HIV infection. Clinical Infectious Diseases. 2007 Jun 1;44(11):1493–9.

14. Metsch LR, Pereyra M, Messinger S et al. HIV transmission risk behaviors among HIV-infected persons who are successfully linked to care. Clinical Infectious Diseases. 2008 Aug 15;47(4):577–84.

About the author(s)

James Wilton is the coordinator of the Biomedical Science of HIV Prevention Project at CATIE. James is currently completing his master’s degree of Public Health in Epidemiology at the University of Toronto and has completed an undergraduate degree in microbiology and immunology at the University of British Columbia.

Logan Broeckaert holds a Master’s degree in History and is currently a researcher/writer at CATIE. Before joining CATIE, Logan worked on provincial and national research and knowledge exchange projects for the Canadian AIDS Society and the Ontario Public Health Association.

Len Tooley is a relatively young, HIV-negative gay guy who works in downtown Toronto as a gay men’s health promoter and an HIV educator, tester and counsellor. As a way of helping him stay HIV-negative, his family doctor prescribed him Truvada as pre-exposure prophylaxis (PrEP). 

In the first part of his interview with me, which we published two weeks ago, Len talked about what motivated him to go on PrEP. Last week he discussed the conversations he had with his family doctor about PrEP, his experience of actually taking Truvada every day and how he feels about asking his drug plan to cover its cost. 

This week, in the third and final part of our interview, Len responds to those people in the gay and HIV communities who are critical of negative guys like him who decide PrEP is right for them, about why he decided to talk publicly about being on PrEP and what he would say to others who are considering this option as a way of staying HIV-negative.

 ***** 

John: Len, I’d like to start off this third part of our interview by asking you to to respond to some of the criticisms we’ve heard about PrEP.

As you know, not everyone thinks that HIV-negative guys like you should be prescribed anti-HIV drugs but should, rather, depend on condoms to keep them and their partners safe.  Some people hold very strong views about it indeed. For example, freelance journalist David Duran has written, in an article for the Huffington Post entitled Truvada Whores, that “having unprotected sex and willingly taking that risk because you're on an easy, preemptive treatment regime is just plain stupid”. 

Len: My first reaction is - Wow! That’s a lot of judgment and shaming to respond to. Maybe I should get a t-shirt made that says “Truvada Whore” on it.  Sticks and stones may break my bones…. 

Seriously though, I wish that I could be 100% certain that even if I used a condom every single time I had anal sex I wouldn’t get HIV. I also wish that condoms could be made out of a magical material that didn’t have any texture, scent, colour or substance – but I know that not all my wishes can come true! 

But I’ve had to admit to myself that I’m not perfect at using condoms 100% of the time, and, because I’ve been working as an HIV tester and counsellor for so long, I know that a lot of gay men that I provide HIV testing to aren’t perfect either. And that’s not because we’re not trying, it’s because we’re not robots. I can also admit that condoms aren’t some invisible barrier that doesn’t impact the quality of my sex life at all. Condoms aren’t easy to use, and for me (but not for everyone), they make sex a lot more difficult. I wish it wasn’t so, but alas, it is. 

I also know that if I were to do every single thing I could possibly do to prevent HIV and STI infection I would not be enjoying sex very much at all. If I were to do only things that were “no risk” or “negligible risk” that would mean, for example, that I would have to use a condom even if I was giving a blowjob to a guy I was on a date with. It’s low risk to get HIV from giving oral sex, but when you’re having sex in an epidemic, low risk really doesn’t mean no risk. I’ve had to give HIV-positive results to guys who were certain they hadn’t had any unprotected anal sex, some of whom could even pinpoint the exact partner and blow job they’d given that had led to seroconversion symptoms shortly after. Their stories have really stuck with me, because they taught me that for guys in my world low risk really doesn’t mean no risk. I don’t really want to give blowjobs with condoms. So while statistically the risk is low for oral sex, I know that I could still end up with HIV anyway. This really made me re-think my relationship to risk and where I stood on things. And it also makes me aware that even if I’m only giving blowjobs, I still have to be vigilant about HIV because I could be one of those guys – I’ve seen it, so I know it isn’t impossible. The stress and anxiety that I was living with around getting HIV really impacted my life and it was something that affected every experience I had with other guys I was dating and/or having sex with. 

John: One of our regular contributors on PositiveLite.com, Dave R, worries, among other things, about possible resistance to Truvada, one of the most highly prescribed antiretroviral medications, developing down the road due it being used as PrEP. 

Len: The question of drug resistance is definitely a challenging one. If I ever were to test positive, I would want to be able to take the most tolerable drugs possible, and Truvada is one of those drugs. I decided that this is a consequence that I will have to deal with, and a risk that I will have to take. If anything it gives me all the more incentive to manage my risk for HIV as carefully as possible, to get regular HIV tests done, and to stick to my medication schedule as closely as possible. 

I guess the only other thing I would say again (I know I said it before) is that taking an HIV medication every day at the same time without fail is not a simple task. It really takes a commitment. But I’m really motivated to do so, because I do indeed hope to stay HIV-negative. I’m not great with routine, I’ll admit, but for me taking a blue pill at the same time every day, while difficult, is much easier than dealing with the anxiety and guilt of not being a perfect condom user. I want to stay HIV-negative, so I make the adjustments necessary to adhere to the prescription as best as possible. 

John: That’s very helpful, Len, to hear your responses to those who criticize negative guys on PrEP. Yet here in Canada, it’s not just community members who have expressed these kinds of concerns. Professionals, too, are undeniably divided about PrEP and treatment as prevention generally, arguing over whether they work or not, even though both were among the major focuses of last year’s International AIDS Conference. Why is Canada such a divided country on these things, do you think? 

Len: That’s a really difficult question to answer, John. I think that, as should be expected, nobody wants to jump the gun and start making decisions based on what they feel is not complete evidence. So scientists, politicians, and healthcare professionals may be worried that implementing a new technology, that we aren’t 100% certain of, is a dangerous proposition. 

But science will never be perfect. And as a fellow “PrEPer” Jake Sobo noted in his blog, back in the day when gay men took it upon themselves to have “safer” sex (by using condoms) rather than have no sex at all, they were doing so without evidence that condoms were 100% effective. I’m in a situation where I can’t be 100% sure I will never get HIV unless I’m abstinent, so I don’t have the same standards as scientists, politicians or healthcare professionals might – since I don’t have the luxury to. 

I understand that those who are hesitant about PrEP feel they are taking the most conservative, cautious and appropriate actions. But at the same time I feel that for me, the evidence that exists is good enough to be confident that if I do it right, PrEP can have a significant impact on my chances of not getting HIV. 

On another note, there are a number of poz guys that have taken Truvada and experienced horrible side effects of the medication. I’ve spoken to a few of them who had very strong (negative) feelings about the idea that I would take the drug if I don’t actually “need” it. I can understand where they’re coming from, for sure, but I felt I needed to see for myself if such would be the case. It turns out that for me, there weren’t any side effects – at least there haven’t been any so far. The only real effect PrEP has had so far is to allow me to be a little less guilty, feel a little bit less shame, and be a little more confident, about the sex I have. 

John: Why did you decide to talk publicly about your decision to go on PrEP? 

Len: John, I talk to a lot of gay men both through my work doing HIV testing but also socially. So I know how many of us struggle with being – or trying to be – perfect condom users. I also know that the majority of guys simply don’t know that PrEP is even a possibility, period. If I had the opportunity and privilege to read and learn about PrEP and decide if it was right for me, I felt that other guys in similar situations should have the ability to make their minds up too. I guess I just felt that it’s time we have this discussion. 

John: What would you say to other guys who are considering PrEP as part of their strategy to prevent getting HIV? 

Len: Firstly, while there are no official Canadian guidelines and even though Truvada has not been “approved” for this use in Canada, it is not illegal for anyone’s doctor to prescribe PrEP. Doctors have the freedom to prescribe drugs “off-label” if, through experience or deduction, they feel it to be in the best interests of the patient. 

Secondly, I want to make it very clear that I have gone out on a limb by seeking out and taking PrEP. I’m aware that this strategy might not completely insure me against getting HIV, and I keep this in mind with every safer sex decision I make. It’s impossible to know exactly how much of a ‘risk’ I’m taking, but for someone like myself who is having sex in an epidemic, sex without risk is more of a dream than a reality. 

Thirdly, while I am taking PrEP every single day, there might be other options in the future. For instance there is one study taking place in Canada right now that’s looking at PrEP called the IPERGAY Trial and it’s centred in Montreal. They are testing the possibility that perhaps PrEP can be taken “intermittently.” In this study, this means starting one day before you might be having ‘risky’ sex, every day while you are having ‘risky’ sex, and then for two days afterward. Other researchers are studying a form of PrEP that can be given as an injection that you get every three months, that slowly releases the drug in your body over time. So the PrEP I am using isn’t necessarily what PrEP will look like in the future. 

And last but not least, it’s important to recognize that I’m only one person with one story. That being said, I have had a unique privilege to access PrEP because of my education, occupation, knowledge, and ability to self-advocate. I’m also a white, gay guy with a university education. While I’m thankful that these have all led me to having access to PrEP, it is problematic that others don’t have access to the same information, and even if they had, they may not be able to access a prevention tool that works for them. 

My story is yet another example of white, gay guys having access to the newest technologies and information, appropriate healthcare, ability/expectation to self advocate, and so many other privileges. It is an injustice that most gay, bi and queer men, cisgendered and transgendered, are living with a healthcare system that doesn’t understand their HIV prevention needs (not to mention their larger healthcare needs), have never heard of PrEP, and don’t have family doctors. Or if they do have family doctors, they don’t feel safe disclosing their sexual and gender orientations to their doctors. And many of us don’t have access to drug plans for even low-cost medications that can make our lives better. This is especially true for the queer folks in our community who don’t have legal status and are really struggling because of it. (No One is Illegal — Toronto is a great group of people working to change that). PrEP is only one small piece of a larger puzzle that our community — positive and negative — has to tackle. 

John: Thank you so much, Len, for sharing your PrEP story with us. 

Len: My pleasure, John!  

You can read the first part of Len’s interview here and the second part here.  

Warning- this post talks about vaginas and pornography and contains some slightly explicit language. Gasp! Anyone who is squeamish, uptight, or related to me can just stop reading right now. Consider yourselves warned.

Lately, I’ve been having a lot of conversations about sex, or should I say a lot more than usual.

Actually, a large portion of these said conversations have been about pornography. I’m not sure how the conversation always seems to go there. Perhaps it is because I’ve been thinking about it a lot more since I took a pornography course during my Masters (expect to see future posts about this). I don’t know, maybe everyone is just dying to talk about porn. I like to think it’s just because I’m relatively open and people feel comfortable talking to me, but I doubt it. More likely it has to do with alcohol. Regardless, somehow the conversation ends up on pornography. Unfortunately, they’re not usually exciting conversations about what we’re into or what kind of porn we prefer.

Lately, the conversation has ended up about pornography as sex ed. Can and should it be used as an educational tool? What effect does watching porn have on one’s sexual development, and of course, is pornography beneficial to women?

Let me back this up to another conversation I have been having most of my adult life, but especially a lot more lately: vagina confidence. Recently a girlfriend and I were talking about how difficult it is for many women to love their vaginas; as well we were discussing the increasingly popular phenomenon of labiaplasty and vaginal rejuvenation.

While vaginal rejuvenation may sound like a relaxing treatment at some kind of vagina spa, it actually refers to the surgical tightening of the vagina. Labiaplasty, sometimes known as labia reduction, is plastic surgery of the labia (minora or majora), for aesthetic (although sometimes health) reasons and is a growing business these days. One source purports that in the US, this industry is worth $6.8m and that in 2008 in the UK, operations were up 70% compared to the previous year. Vagina modification is a booming business; extremely lucrative for the surgeons, potentially damaging for the recipients. Read any forum and you will find just as many women who are unhappy with the surgery than who are pleased. Besides being super expensive ($2,000+), vaginal cosmetic surgeries can result in infection, loss of sensation, lengthy and painful recovery time, deformities, and permanent scarring, among other “side effects”.

So why, you ask, are so many women willing, even begging, to have this surgery in order to achieve a “designer vagina”?

Many people, including myself, blame pornography and the increasing social acceptance of and access to pornography (although not exclusively). It pains me greatly to say this because I have, for a large portion of my adult life, been an advocate for pornography as positive for women. I do think that porn can be really beneficial for women. Hear me out. Granted, there are tones of different types of pornography, much of which is extremely violent or degrading toward women, which obviously can have the opposite effect. For purposes of this blog, I’m referring mostly about “mainstream” pornography- which generally means predominately Caucasian, largely heterosexual porn (including most “girl-on-girl” as well) all of which of course can still be violent and/or degrading. There are whole other blogs needed to discuss these other categories, as well as the effects “mainstream” pornography can have on people who do not necessarily fit these categories.

Generally speaking, in a society that teaches women to be sexually passive, I think it is good for women to see other women actively enjoying sex, even demanding what they want/like. Porn is a great medium to allow this and to teach women that it is perfectly okay to enjoy sex. Too bad these women are still viewed as social deviants (aka sluts). Unfortunately, because so much of porn is catered to men’s fantasies, it can often really lack in this element of (genuine) female enjoyment (note the absence of the female orgasm in much porn, particularly from cunnilingus).

Sometimes porn can even function in the opposite manner, as will be discussed, teaching women that they should like things that many women don’t, such as cum on the face. Sure, there may be a time and a place, but may I just say - the money shot on the face is not a given and should not be happening unless you ask for it! (also suggesting a need for examples of healthy open communication in porn as well). But I digress.

This is the problem with porn. It has such potential to be educational and positive, but also so much potential to be very damaging. Back to this discussion of “vagina confidence”, I used to think that porn was a great medium for women to see other women’s vaginas and realize that everyone’s is different. Unless you fool around with women, or are super close with your female friends, chances are you haven’t seen many vaginas in real life, given the way our anatomy works. Watching porn could really help women who may be insecure to realize that their vagina is perfectly normal and that there is no “perfect” vagina. However, porn is screwing that up too. With the increases in labiaplasty among porn stars and Playboy’s persistent airbrushing of labia (I read they had a policy against showing labia), we are moving closer and closer to the “designer vagina”; the one-size-fits-all, “flawless”, completely unrealistic vagina. Similarly to how we have an ideal image of the female body, which is completely unobtainable for most women, we now have one of the ideal vagina too. Even one of our largest sources of pleasure is under public scrutiny and judgment. Is nothing sacred anymore? Not even our vaginas?

I recently read a study that surveyed over 400 students in England, aged 14 to 17, about pornography. Apparently, according to this survey, the average teenager claims to watch up to 90 minutes of porn a week. When shown photographs of 10 pairs of breasts, both boys and girls tended to prefer images of surgically enhanced breasts to “normal” breasts. Similarly, they were largely disgusted or shocked by hair between women’s legs. Many girls admitted to having started shaving their genitals because they believed boys expected them to.

Not surprisingly boys also revealed insecurities about the size and shape of their penises, as well as anxiety around performance.

I find this disturbing. What is going to become of a generation of boys and girls raised on porn? While I don’t think this is so much a new phenomenon for boys, I’m guessing that porn as first sex education for girls is increasing. Does this mean girls will grow up thinking shaved vaginas, bleached assholes, augmented breasts, anal, and cum on the face are all a standard, preferred part of sex? How about the fact that virtually no one in porn uses condoms? What chance do our messages of safer sex that my colleagues and I work so hard to promote stand against pornography’s blaring message- unprotected sex is better (and normal)?

And now when girls turn to porn, possibly hoping they will see something that resembles their own, they will find “artificial” vaginas as well. Why wouldn’t they surgically change theirs? Combine that with the countless advertisements that scream at young girls that they are not pretty enough, sexy enough, skinny enough, big breasted enough, tanned enough, etc. and we wonder why so many girls have self-confidence issues.

We are making it practically impossible for women to truly enjoy sex. How are women supposed to “get into it” when not only are we taught that good girls don’t like sex (or shouldn’t admit to it), but we are also too preoccupied with what our ass, hips, breasts, thighs, and now vaginas look like? Perhaps that is the point?

Despite all this, I really do believe that porn can be positive, for the aforementioned reasons. Maybe there just needs to be more amateur porn; real people with real bodies having real sex. Maybe we need to be more open about our sexuality as a society; show more pictures of vaginas. Maybe as women we need talk more openly about vaginas.

We certainly need to nurture confidence among our girls. Perhaps sex ed in school should include various images of various bodies, including genitals. Maybe not being so uptight about even using the word “vagina” would be a start. I’m not entirely sure, but I, for one, am disgusted that girls have yet another insecurity to add to the list. So please, for heaven’s sake, unless you are getting us off- keep your mitts off our muffs. 

It's morning, I open my eyes
And everything's still the same
I turn to the guy who stayed last night
And ask him, "What's your name?"

‘So Many Men, So Little Time’: Miquel_Brown 1983

I must admit, when I read this title quote by the much-lauded, British performance artist and TV personality David Hoyle, I thought it must be something from a late eighties politician and one not exactly gay-friendly. In fact, the very gay David Hoyle said it in 2007, on the day before World Aids Day and on the flyer for a night at the Royal Vauxhall Tavern in London, was added the following text:

 'All over Vauxhall they are fucking without condoms', it reads. 'All over Vauxhall they are dancing till Tuesday morning. All over Vauxhall they are taking G, K, C, V and E [that's GHB, ketamine, cocaine, Viagra and ecstasy]. All over Vauxhall they are dying.'

Depending on your viewpoint, this was either in your face, plain speaking by a prophet with street cred or the outburst of a gay artist, exhausted and frustrated by the hedonism of the scene in which he performs?

Let me try to put this in context. The numbers of new HIV infections in the UK have remained more or less the same between 2001 and 2011, despite awareness and sexual health education having reached practically all young people. So somehow, the message which is understood by everybod, is not being translated into action between the sheets. Despite the current youth culture being brought up with the mantra that safer sex saves lives, HIV cases are just as high as 15 years ago and are being fuelled by rampant alcoholism and drug abuse within the gay scene itself.

Now I can’t judge; I was young too once but sex, drugs and alcohol are a powerful cocktail and the potential for harm is self-evident on the gay scene. In Britain particularly, there is a cultural expectation amongst young people, both straight and gay, to get wasted on either drink, drugs or both. Sex is the climax to the evening but by that time, rational thought is by definition diminished.

There has been a spate of drug-induced deaths in gay saunas and clubs recently but even this hasn’t deterred people from giving in to peer pressure and the weight of gay social expectation. More stories are appearing of horrible situations where a partner who has been on GHB suddenly dies straight after sex. Apart from that and despite the lurid publicity many young people also seem to agree with the following from Time Out: 

“Several younger gay men I've spoken to in the past few months have argued that HIV is no big deal. They've heard about combination therapy, they've seen the ads with muscular men climbing mountains and they've jumped to the conclusion that life on anti-retrovirals is one long picnic. There are even the fatalistic few for whom contracting HIV is seen as some sort of rite of passage, or a stepping stone towards having lots of unprotected sex without having to think about the consequences.”

On the other side of the coin, Hoyle’s sentiment from 2007, is echoed in a recent article by Matthew Todd in the Guardian, titled, ‘The Roots of Gay Shame’. He says,

“If you didn't think you were worth caring about in the first place, why would you care if you caught HIV?”

The rise in HIV infections amongst older guys, shows that the problem is not confined to the ‘live hard, die young’ generation. In the older age groups, the causes may lie more in a rejuvenated sex life thanks to erection enhancers than the gay scene in which even the fittest older guy struggles to keep up. The risk taking, though, is proportionately as high. Maybe the older you are, the stronger the feeling that you’ve dodged the bullet so far, why should it change now? My HIV-specialist shakes his head, bemused at the sheer lack of logic regarding new infections in the 45+ groups. After all, it’s not as if they’ve not seen what can happen and no age group is better educated, so what’s going on in the gay psyche, both young and old, that shuts out reason at crucial moments?

"Do we really have an uncontrollable problem that nobody’s talking about?"

Was David Hoyle right? Are we part of a massive, subconscious suicide cult? Do we really have an uncontrollable problem that nobody’s talking about? We can surely assume that if it is happening in UK cities, other urban conurbations across the world will be similarly affected.

It may not be helpful to take the moral high ground either. Many people, will be quick to jump on the ‘serves ‘em right’ bandwagon and people living with long term HIV may also wag stern fingers but it can’t be as simplistic as that. Maybe it’s good that LGBT insiders like David Hoyle, are criticising behaviour from within the scene, however much it sounds like he’s betraying his own by speaking to the world at large. However, he’s not alone. All sorts of people from club owners to social workers are quietly bemoaning the consequences of unbridled hedonism and asking for it to be talked about at least. The point is that it’s not done to be a whistle blower in any social group but in this case something is clearly going on within the scene and could threaten resistance to the virus if it gets out of hand.

To my mind, however tempting it may be to come over as, ‘outraged from Amsterdam’, this isn’t a cut and dried moral issue. Very few people actively set out to catch the virus and there’s never been so much information available on every social platform. So why is a substantial group of LGBT people rushing lemming-like off the cliff despite knowing a hundred reasons not to?

I’ve got to disclaim here: many people go out socially, have a few drinks, meet someone and have safe sex with them – everything in moderation. Not everybody is socially reckless and having unsafe sex; the virus would be out of control if that were true. So I’m not talking about those who follow the ‘rules’ and live fulfilled and happy lives but the rise of a hedonistic culture which leads to a carpe diem attitude and if they get something, too bad. Enough people are spreading the virus to keep the statistics at a stable high. It’s almost as if for every ten converts to safe sex, ten ‘refuseniks’ emerge to take their place and then the stats never improve.

It surely has to be a social issue, with a very strong sexual component attached. You’re bought up in a society that still discourages homosexuality and encourages normality. You discover you’re gay and are immediately confronted with dilemmas over what to do about it. You may have a tough time with your family and at school and via school peer pressure, may take to distractions like drugs, alcohol and smoking even before you hit the gay scene. Heterosexual youth culture sees getting wasted as a rite of passage and then, with hormones raging, you take your first tentative steps onto the gay scene, where your insecurities are quickly masked by the availability of everything in the candy store. You then learn how to mask rational thought with excessive drink and party drugs and before you know it, your trousers are round your ankles, without a condom in sight.

So that’s maybe how it starts but god knows, there are enough social messages and pressures to make you think twice, so why do so many ignore them and wilfully seeking out yet more thrills without brakes. Even ‘normal’ STDs like, gonorrhoea, chlamydia and syphilis don’t stop them in their tracks: antibiotics for a few days and then back on the scene but it’s only a matter of time for many before the law of averages kicks in and hepatitis and HIV take their disease dossiers to the next level. Even then (and here lies the great unspoken problem) people aren’t deterred by disease; as long as it doesn’t kill them, they carry on regardless.

Why do they do that? Very few people can be sanctimonious about it; most people with HIV have slipped up somewhere and not just once and rejected reasonable behaviour. So what drives us to indulge in irresponsible behaviour; irresponsible for ourselves and irresponsible for others?

Maybe we underestimate what my ex-partner used to call, ‘the power of the cock’ and the nature of the sexual act itself. We all know that there’s a point of no return with sex and especially sex with strangers. You’re condom-aware throughout the encounter until the point where you’re going to do it or not and then desire, lust and your sex-drive determine your decision making and sometimes, the sexual urge is just too strong. We’re built that way by nature; remember the original idea was to beat off the competition and procreate like bunnies to extend your own section of the gene pool. It’s one of the most powerful human autonomic reactions and in the moment, very difficult to resist. If you have to break off to put a condom on, not only do you lose the moment and a part of the excitement but you have to have enough willpower to overcome ‘the power of the cock’.

"All you want to do at that point is have sex; the urge can be irresistibly strong, especially if fuelled by GHB and the rest. It takes a strong mind to unwrap both condom and lube packets and roll it on, with every chance that your bee has buzzed off to another flower . .  "

For many, the very act of putting a condom on is enough to lose them their erection  - and nobody likes that. So although we know we should and must, it’s not easy and your mind has to be at its most rational to do it every time. Put yourself in the situation where you’re on recreational drugs to get you through the night, possibly drunk as a skunk and you’ve exchanged ‘the look’ with a hottie heading for the darkroom. All you want to do at that point is have sex; the urge can be irresistibly strong, especially if fuelled by GHB and the rest. It takes a strong mind to unwrap both condom and lube packets and roll it on, with every chance that your bee has buzzed off to another flower. Morally we all know it’s wrong but it happens and the blame has to be shared between the person himself and the social pressures around him. It’s maybe those social pressures; the drink, the drugs and the social mores, that allow sexual impulse to overcome rational thought but it’s just as likely to be your own biological urges.

I think that maybe if we’re being realistic we will never achieve 100% safe sex behaviour and maybe we should be satisfied if the current HIV new infection statistics for each country remain stable. Aiming for the total eradication of HIV transmission, as HIV organisations trumpeted last year, can only come as a result of a cure or a vaccine because people’s behaviour isn’t going to change, however much you confront them with the facts.

This sort of thinking is, of course, blasphemous in the eyes of health organisations and socially conscious HIV groups. We feel we have to strive for the elimination of HIV but considering social behaviour in certain groups across the world, I’m not sure if we can by trying to change behaviour alone. Moralists can preach that we need to return to taking personal responsibility for our actions but take a step into a modern gay club and you can count on the fingers of one hand how many eyes that stare at you aren’t glazed, or hyper active. Party drugs rule! Pragmatism and not preaching is what we need.

David Hoyle and others see it differently. They believe that there’s something much deeper behind it all. It’s claimed that the apparent lemming-like behaviour amongst our youth groups, stems from shame and self-loathing, rather than outside influences like drugs, drink and hormones. It sounds like a very old-fashioned concept, stemming from the days when staying in the closet was more the norm than the exception. LGBT society was bombarded with messages that it should be ashamed of itself and its behaviour was disgusting to decent, god-fearing folks. It’s not something that you would expect to hear in these days of gay marriage and Gaga birth certificates that prove we were born that way. So what do they mean when they link HIV infection to shame and loathing on the gay scene?

The theory goes that internalised shame leads to compulsive behaviour and this is applied to LGBT people in the following ways:

Children are brought up to believe that sex and sexual relationships are wrong and sinful and gay sex sends you immediately down to Satan’s sin bin.

When they’re old enough to make relationships, society barks at them from every corner like rabid dogs that any relationship they might make has no value and actually causes a breakdown of society.

They learn that some people hate them enough to make their lives a misery of social network sites, or even attack them physically on the street.

They see cases of teenagers killing themselves out of horror at what they’ve become.

So it’s believed that people turn to compulsive behaviours to either compensate for, or hide from, their real selves. People become addicted to drink, drugs, smoking, porn and promiscuous sex, etc. This then leads to situations such as those on the gay scene, where safety is found in numbers and solace in collective substance abuse and sex. These feelings then become so embedded, you hardly know they are there. Becoming infected with HIV becomes a sort of culmination of the lifestyle and when it’s too late to turn back, people get a sort of perverse pleasure in the fact that they were right all along and their shame and guilt has led to this ‘deserved’ punishment.

The British and gay pop singer Will Young claimed recently that his own shame at being gay led to dysfunctional relationships and an addiction to porn. Now Will Young seems like an okay guy and someone fairly typical of his generation but is his claim purely personal or representative of many?

On the face of it, you would think that most of the sorts of behaviour that go on in many areas of the ‘scene’ are hardly symptomatic of shame and guilt. It looks to be more the result of a sort of arrogance and fuck you attitude which young people have had since time immemorial. Add to that the feeling that you’re immortal when you’re young and you have to ask whether guilt plays any part at all, never mind a subconscious collective suicide wish!

That’s the theory and although I may have described it far too simplistically it sums up what many people believe. Although I’m sure that many people carry guilt around with them like a Prada purse and some of them become compulsively obsessive; it by no means explains the problem, except as a sort of moral judgement based on amateur psychology. Why can’t we accept that young straight or gay people these days are just out for a good time because with the pressure that society brings to get a job and have more ‘stuff’ than the next man everybody needs an escape?

"When their own ‘elders’ preach the plague years and bitter experience and every gay site on the planet tells them to avoid HIV by all means possible, of course a percentage are going to rebel and do their own thing . . "

Possibly the only difference between gay and straight twenty-something’s, is that three letter acronym HIV. It’s such a loaded term that the pressure from society that it’s evil and morally reprehensible, leads to what all youngsters have always done; they do the opposite! When their own ‘elders’ preach the plague years and bitter experience and every gay site on the planet tells them to avoid HIV by all means possible, of course a percentage are going to rebel and do their own thing. After all, they’re immortal, right!

Maybe we need a more pragmatic approach to unsafe sex; accept it will happen and aim research at newer and more direct forms of prevention (effective anti-viral lubes for instance). Ease up on attacking the morals of those who indulge in reckless behaviour and concentrate on creating barriers to the virus, while at the same time taking active steps to change people’s recreational stimulant use. Stop treating HIV prevention as a moral issue maybe and concentrate on killing the virus.

It’s no good lecturing young people that they don’t know what they’re getting themselves into because a significant proportion will get themselves into it whatever you do. At the same time, I’d wager there isn’t an LGBT person on the planet who hasn’t felt guilty, or ashamed, or angry at some point, at the cards they’ve been dealt. But by no means have all of them ended up with HIV through reckless living as a result.

The title of this article is a brilliant sound-bite but in my opinion not very strongly grounded in the truth. I’m beginning to believe that the best policy is to mop up afterwards, do our best to give unbiased advice and a safe environment and go for the throats of drug dealers and exploiters just interested in making a buck. It may sound heretical to many but we’re all aiming for the same result it’s just the approaches that are open to debate.