Even those of us who were busy with last minute shopping were very pleasantly surprised at the early Christmas gift that came to us on December 20. The Supreme Court of Canada struck down key provisions of the Criminal code that made sex work more dangerous and made it more difficult for sex workers to reduce their risk of HIV and other STIs. Congratulations to the sex workers and their allies who made this possible!
It made me hopeful that we would start 2014 on the right foot. In that spirit, I thought about how I’d like HIVLand to be different for us in 2014. I’m sure we could easily rattle off dozens of changes we’d like to see. But I decided to limit myself to three things I don’t want to see anymore in 2014, and three things I desperately want to happen in 2014. So here they are in no particular order… out with the old, in with the new.
Three things I don’t want to see anymore in 2014
“Unprotected”. I’ve mentioned before why I dislike this term when we mean to say condomless sex. In today’s HIV prevention context, having sex without condoms does not necessarily mean having sex in the absence of significant levels of protection against HIV. There’s potentially the reduction in risk that comes from greatly lowered viral load, PrEP, regular testing for STIs (and treatment if needed), and a variety of seroadaptive behaviours.
So for the purposes of HIV prevention, the term is all too often imprecise and incorrect. It is fraught with judgement and is not helpful in creating an open discussion that can lead us to identify the best possible options to reduce our risks and to have the types of sex we want.
The debates around PrEP seem to have opened a crack in the door, allowing some of us to “come out” as not always being able to adhere to 100% condom use, for all kinds of reasons. One of those is the desire to have more pleasurable sex. We need to further the discussion about the kind of sex we want in 2014, or our HIV prevention efforts are doomed to fail.
For the purposes of HIV prevention research, the term is highly problematic. Most studies use constructs such as “unprotected anal intercourse (UAI)” which make data and interpretation obtuse. It confounds insertive and receptive intercourse, casual and regular partners, single and multiple partners, and obscures whether a whole range of different risk-reduction strategies are used by study participants, such as negotiated safety, use of pre-exposure prophylaxis, reliance on undetectable viral load, and a whole range of seroadaptive behaviours such as non-use of condoms in seroconcordant relationships, strategic or sero-positioning, and serosorting.
Let’s make 2014 the year we banish the word “unprotected” from our lexicon.
“Clean”. I’m so sick and tired of seeing “clean”, “disease free”, “no poz guys”, and their permutations on dating/hook-up profiles that I practically have a meltdown each time I see them. As Susan Powter used to say: stop the insanity! The fact that this is highly stigmatizing language should be reason enough to stop using “clean” as a stand-in for HIV- and STI-negative. But on top of that, simply typing “clean UB2” in a profile is an ineffective prevention strategy. I don’t really need to explain this any further do I? Good, because my blood pressure can’t handle it.
Whore-shaming. Even the Supreme Court of Canada—not typically known to be the arbiter in this matter—has eschewed whore-shaming. Why so many of us in the gay community and the larger community are still clinging on to whore-shaming as a response to the idea that people want to and can reduce their HIV risk through means other than condoms is beyond me.
Straight men have devised a whole range of options to avoid having to wear condoms and to have the kind of sex they want, i.e. bareback sex. Most of these options have placed an undue burden of responsibility on women by the way, but still, there are options—plural. Why the double standard for gay men or for anyone else who wants to have sex without physical barriers? This is highly anecdotal and I wouldn’t say it’s exactly a trend, but I heard and read several stories in 2013 about guys who said that their sexual partner had removed the condom part way through sex, unbeknownst to them.
In 2014, it’s high time we support receptive partners of all genders in their efforts to adopt prevention options under their control.
Three things I desperately want to happen in 2014
Supervised injection sites. Talk of SISs was all the rage in 2013. 2014 will be a time for action; I can feel it in my bones. Ottawa-based advocates have been fighting to open a SIS in that city. The Toronto Medical Officer of Health recommended a SIS in that city. And Montreal Public Health recently announced it was going to open four of them, including three fixed sites and one mobile site.
You go, girl! You have to admire their chutzpah. In a context where Harper and the Harperittes are trying to pass legislation that will make it nearly impossible for other SISs to open beyond the existing one in Vancouver, Montreal tells the world it intends to open not one, not two, not three… but FOUR supervised injection sites! Delicious. I love it!
PrEP guidance. In 2013, Québec became the first jurisdiction in Canada to issue some interim guidance on PrEP. They should be commended for doing this. I hope others will follow suit.
Frankly, I find the interim guidance to be too timid in relation to gay men. The interim guidance discusses PrEP in relation to the entire population of the province. In that context, it’s not surprising that it says that it does not recommend PrEP in general, and that it should only be considered in “exceptional” circumstances where someone is at high risk. It defines these “exceptional” circumstances as being: 1) gay men who have “unprotected” (GRRR!) anal sex with partners who are HIV-positive or of unknown status, and 2) serodiscordant couples where the HIV-positive partner has a detectable viral load.
As a gay man who has sex in some of Canada’s larger urban centres, I would hardly say that HIV-negative guys sometimes having condomless sex with guys who may be HIV-positive or of unknown status is “exceptional”. If it was we wouldn’t have an epidemic on our hands, people.
This is a missed opportunity. The interim guidance should have had a specific section dealing with gay men, and dealing with other populations at high risk. As it stands, my fear is that physicians will go away with the message that PrEP is only for exceptional cases, even among gay men at high risk. I’m not saying that all sexually active gay men should be on PrEP. Not by a long shot. But being at risk of HIV is hardly “exceptional” for those of us gay men having sex in an epidemic, which is what the interim guidance seems to suggest.
Other bodies and jurisdictions should issue guidance on PrEP in 2014, and ensure that they address the particular needs of those who are most at risk of HIV, including gay men.
A national plan with measurable targets. In the last weeks of 2013, we saw not only the historic Supreme Court decision on sex work legislation and the announcement that Montreal intended to open four supervised injection sites, but the new iteration of Leading Together was also released.
Well OK. Truth be told, I didn’t feel quite the same level of excitement about the new Leading Together as I did for the other two developments.
No disrespect meant to the folks who worked on it. I know and have worked with most of them, and respect their work. An updated Leading Together was highly overdue. And there’s lots of great stuff in there about the need to have rights-based, population-specific, comprehensive approaches. I can only imagine the process required to produce such a document. The fact that the term “harm reduction” appears nowhere is one clue. Actually, I’d rather not imagine what it was like to work on the document. I’m getting nauseous. You all have my deepest sympathies.
Having said that, there are missed opportunities. The breakthroughs we have seen in biomedical research since the last edition of Leading Together are game-changers; as historic and important for prevention as the advent of HAART was for treatment in 1996. These breakthroughs are given a polite cursory mention in sections about context, but then they appear nowhere in any substantial way under the suggested strategies or actions to be taken. Not a word about PrEP or treatment-as-prevention or any other existing or upcoming biomedical intervention anywhere under the prevention goal.
Among the suggested actions to be taken to reduce the spread of HIV among gay men, the only time a specific prevention option is mentioned is in relation to the need to address the “barriers/problems” gay men face in using condoms. You’d think we were in 1994, not 2014.
I suspect this gap reflects in part the need to avoid specifics in such a document, and in part the lack of consensus among stakeholders about the appropriate role of biomedical advances in HIV prevention.
But back to measurable targets. It’s 2014. Time to take Leading Together, the Federal Initiative, and any other plans and frameworks we might have to next level. I mean really folks. Canada signed onto the 2001 Declaration of Commitment on HIV/AIDS, which means we were supposed to have time-bound national targets by 2003. Oops! And we signed onto the 2010 Political Declaration on HIV/AIDS. By now, we should we well on our way to reducing HIV transmission by 50% by 2015 and reducing illness and death related to HIV/AIDS. We’d better get busy! In addition, why not have measurable targets related to the most affected communities? To reducing the proportion of people living with HIV who are unaware of their status? To improving treatment access and retention in care? To bringing sexy back? (Just checking to see if you’re still reading!)
Feel free to add your own ideas to the list.
Happy New Year!