There’s a new approach that’s taking place in HIV prevention and support programs, particularly those focused on gay men, that’s based on supporting us in maintaining good health, particularly good sexual health, by emphasizing our strengths and resilience rather than focusing on risk behaviours and pathologizing our weaknesses and vulnerabilities.

Here on PositiveLite.Com, we’ve featured several programs that utilize this new approach: It’s Hottest at the Start; The Sex You Want;  GPS (Gay Poz Sex); Spunk;  and Totally Outright. 

So I thought it was timely to learn more about the thinking behind this new approach and to understand more about the concepts of risk and resilience that underly it. To help me, I recently sat down with Duncan MacLachlan, the manager of community health programs at the AIDS Committee of Toronto (ACT). 

John McCullagh: Welcome back, Duncan, to PositiveLite.Com. I’d like to start by asking you to describe risk for me. When I think of risk, I usually think of things that could be dangerous, like smoking, for example, or drinking and driving. But it’s more complicated than that, isn’t it?

Duncan MacLachlan: Risk is complicated, John, because it always exists in a context.  It’s often oversimplified. Risk for gay men has, for the most part, been narrowly defined in terms of vulnerabilities. Things like HIV and other STI acquisition, or mental health, issues like depression and anxiety, or substance use. These vulnerabilities are real, of course. They exist because of things like stigmas, trauma and poverty, but they aren’t the whole story. Gay men know this. In the arena of sexual expression, we’re motivated by things like desire, pleasure, intimacy, connection and love not merely the fact that we may be challenged by anxiety or loneliness.

John: I hear you saying that risks don’t exist in a vacuum, they always have a context. That means, I guess, that we should be cautious when judging our own or someone else’s risk behaviours. And yet, that’s not the way, until recently, that we’ve done HIV prevention work. Instead, we’ve said, “This is what you should be doing” - like “Use a condom every time” - which was based on the theory that we’d all make rational choices when faced with risk.

Duncan: Exactly. We all know that our behaviour isn’t always rational. So this idea that we’re free to chose in every situation and that if we’re armed with information we’ll always make “good” decisions is false. Yet, while those of us doing prevention and education work with gay men have moved beyond this simplistic notion a long time ago, it still persists in society at large. It exists in our community as well; the demonizing of bareback sex is an example.

John: Duncan, how would you say we can best overcome the odds and challenges of the risks we face in our lives?

Duncan: Wow, John. That’s a big one! Here’s part of the answer. My studies of psychology teach me that it’s positive reinforcement rather than punishment that motivates us. Again, we all know this intuitively because we’ve experienced them both.  I’m a big believer in love and compassion, both at an individual level and a community level!

John: So tell me a bit about gay men’s resilience. It’s more than just coping isn’t it? 

Duncan: It is. As part of ACT’s current gay men’s resilience campaign, we asked guys what resilience meant to them. What they told us was that it meant bouncing back from a challenge and gaining some aspect of strength from the experience. I think sometimes resilience is coping, but, as you say, it’s often more then that. What’s really interesting is the notion of protective factors - characteristics that counter some of the challenges gay men face, like homophobia. Protective factors can be enhanced. An example Amy Herrick and others have identified in research is shamelessness or sexual creativity.  ACT’s Pig Sex Project (for gay guys who identify as “sex pigs” and who like to have raunchy sex. - Ed.) nurtures these protective factors by providing an environment where guys are affirmed and valued – our slogan is “It’s your choice” - rather than judged for their sexual expression. It’s also an environment where the guys share their strategies for risk reduction with each other because they feel safe to do so.

John: Can you give me some other examples of how we can build resilience.

Duncan: One of the most useful ways of considering the development of resilience programming, or evaluating existing programs and supports for their resilience effectiveness, is a model called the 7 C’s of resilience. These 7 C’s of resilience are: confidence, competence, character, contribution, coping, control, and connection.  People have better health outcomes and a higher quality of life when these things are nurtured and this can be easily measured. At ACT, we are using the 7 C’s of resilience to enhance our capacity to assess the effectiveness of our programming in building resilience.

John: So, Duncan, if I’ve understood you correctly, you’re talking about an asset-based approach to health, focusing on our strengths instead of our weaknesses, on our resilience instead of our deficiencies. That’s very different than talking about condoms, than talking about disease, isn’t it?

Duncan: Yes, although an asset based approach that is rooted in resilience doesn’t mean we don’t talk about condoms or disease. Using condoms might be an important part of many gay men’s resilience.

John: So give me an example of how focusing on our assets, on our strengths, correlates with reducing risk behaviours?

Duncan: Sure. Let’s talk about sex, sexual creativity for example, which is another of the protective factors identified in Amy Herrick’s research. More and more guys are talking about viral load with each other. We now know that having an undetectable viral load reduces risk of transmission. We’re not sure by how much, but it makes a difference. Our willingness to push the boundaries of sexual pleasure enables us to explore the utility of a great variety of cock and ball “accessories” that enhance our ability to stay hard, facilitating condom use.

John: Duncan, you’ve really helped me understand why building on our successes is ten-times more compelling than trying to build on our failures. Because we all want to be successful and healthy. Thank you so much.

Duncan: You’re welcome, John.

Reference: Herrick, A. et al. Resilience as an untapped resource in behavioral intervention design for gay men. AIDS Behav (2011) 15-S25-S29

This is the second of three articles by PositiveLite.com writers on “what undetectable means to me.” Read Bob Leahy’s earlier take on this topic here.  Wayne Bristow will follow later this week.

Three months after I started anti-retroviral therapy (ART), I got a call from my doctor. Even though my next appointment with him was still a week away, he phoned me because he wanted to give me the good news right away. My lab results had just come back showing that my HIV viral load had reached an undetectable level.

He was excited for me and I was excited myself. Why? Because the goal of HIV treatment is to reduce the amount of virus in the blood to a level so low that it cannot be detected by the standard tests. Being “undetectable” confirmed that ART was working for me. HIV had been stopped in its tracks; it’d been defeated in its attempts to damage my immune system. It was a milestone that I celebrated that day and continue to celebrate because my periodic viral load tests still come back undetectable. 

Reaching this status was a personal demonstration in my own life of what everyone had been saying in recent years. That, thanks to ART, HIV is different now. It’s no longer the death sentence it once was but is, instead, a chronic, communicable disease that can be controlled by medication.

This is a big deal as far as I’m concerned. I’m of the generation that was most affected by the AIDS epidemic of the 1980s and early 1990s. The majority of my peers, gay guys  in the prime of their lives, were either dead or dying. At that time, there was no treatment that could have saved them. I was one of the lucky ones in that I didn’t become infected at that time, but to this day I still grieve the loss of those men - my friends, colleagues, loved ones, drinking buddies and sex partners.

Many years later, as the result of some decisions I made that I now regret, I became HIV-positive myself. But, because of the anti-HIV drugs that are now available, I’m not going to die of AIDS like my friends did 15 or 25 years ago. Rather I’m going to live the kind of active, healthy life that they could only have dreamed of. Achieving an undetectable viral load is a marker of that expectation.  

I’m fortunate in that I was diagnosed early, have access to ART and am the patient of a knowledgeable and caring physician. It was he who advised me to go on ART immediately after my diagnosis because he believes that long term outcomes are better if treatment is started early. Everything I’ve subsequently read and learned confirms that belief. On top of that, I tolerate my drugs so well that I could go from one day to another not thinking about HIV at all (except that my role as assistant editor of PositiveLite.com won’t allow me to do that!).

For many others, however, having a chronic illness such as HIV can be exhausting, unpredictable and isolating. Finding good care and treatment may be hard. And having HIV can, all too commonly, be fraught with stigma and discrimination. Meanwhile, other HIVers of my generation are long-term survivors who often suffer significant side effects and damage to their bodies caused by the toxicity of an earlier generation of anti-HIV drugs. So celebrating my own good fortune is tempered by this knowledge.  

That having been said though, having an undetectable viral load provides me with a positive sense of being in good health with good long-term health outcomes. Baring a cure, I anticipate dying with HIV, not of it.

The status of being “undetectable” also gives me a sense of positive self-esteem and emotional well-being. I’m not diseased. What I have is a well-managed, chronic illness. It’s unfortunate, but it’s nothing to be ashamed of. It’s part of the human condition.

This, in turn, has enabled me to feel good about being out of the closet, as it were, with respect to my HIV status. Proudly labelling myself, as I do, an HIV-positive gay man is a profoundly liberating experience. People can see that I’m healthy, enjoying life and contributing to the community through volunteer work (if I hadn’t reached the age of retirement, I’d still be working) and that’s allowed me to become a role model of sorts.

One of the most important outcomes for me of having an undetectable viral load is that it’s lessened the burden of worrying about infecting others when I have sex. A number of recent research studies have demonstrated that, with certain caveats, a person taking HIV treatment with an undetectable viral load in their blood should not be considered sexually infectious. Indeed, Julio Montaner, one of Canada’s and the world’s most respected HIV scientists, has publicly gone so far, in an exclusive interview with PositiveLite.com, to state that he’s “very comfortable that [ART] is at least as protective - or more - than condoms”.  

From this knowledge comes my desire to focus my energies on fighting against the criminalization of HIV non-disclosure. Because those of us who do what we have always been taught to do and wear a condom when we should or if we have an undetectable viral load - or both - don’t pose, in the words of the current law, a “significant risk” of infecting our sexual partners. What we do have, however, is a responsibility to protect our own health while not harming the health of others. That applies whether we’re HIV-positive or HIV-negative or don’t know our status. 

So, to summarize. I realize I’m privileged and don’t represent every HIVer out there, but I rejoice in my “undetectable” status. It allows me to live an active, healthy life with the expectation that, when the time comes, it’ll be old age not HIV that I’ll die of. It gives me a sense of emotional well-being that enables me to be proudly poz and to give back to the communities to which I belong. And it lessens the worry of infecting those with whom I have sex. For all these reasons, I feel blessed to have an undetectable viral load. As I said at the beginning, it’s a status that I celebrate every day.

Putting on a two-act play with just a couple of actors on stage is always a bit of a challenge. To be successful, the script has to be compelling and the actors skilled. Luckily for Toronto audiences, the new production of Jeff Baron’s much-produced 1996 play Visiting Mr Green, that opened last night, is a winner.

How could it not be with acting legend Theodore Bikel in the title role? He’s now 87-years-old and made his film debut in 1951 in the African Queen. Born in Austria and classically trained at Britain’s RADA, he’s been a multiple award-winning star of American stage, screen and television for almost 60 years. He’s ably supported by up-and-coming local actor Aidan deSalaiz, already a veteran of the Stratford Shakespeare Festival and a graduate of Stratford’s Birmingham Conservatory for Classical Theatre Training. And how refreshing it is to be able to enjoy a play where a gay character is played by an openly gay actor.

Yes, Visiting Mr Green is a gay-themed play. It’s also a Jewish one, produced here by Toronto’s Harold Green Jewish Theatre Company. The plot is simple. Ross Gardiner, a secular Jew, works on Wall Street where to succeed in his chosen career and climb the corporate ladder - not to mention maintain the love and respect of his casually homophobic father -  he must hide his sexuality. Or so he thinks. His world begins to change however, when, driving too fast in his car, he almost kills an elderly man as he’s crossing the street. Ross is charged with reckless driving and sentenced to do community service in the form of visiting the victim, the lonely and recently widowed Mr Green. At first, neither man wants anything to do with the other but they put up with it since it’s court-ordered.

These men come from two totally different worlds, despite living in cosmopolitan New York. The older man’s life is focused on family and his traditional, deeply-held Jewish values. The younger guy, meantime, is a worldly man-about-town struggling with the heterosexism of his dad and of his chosen profession along with his own internalized homophobia, a struggle immediately recognizable to those of us who’ve been in the same position. Seemingly these guys have nothing in common apart from their Jewish heritage, but, even there, there are differences as one is observant and the other not. Yet, through the course of the play, they come to realize how much they do in fact share and have in common (and no, Mr Green doesn’t turn out to be gay). Their recognition of this at the end of the play touched me deeply.

This is a serious play but also a very funny one. And its theme and Yiddish-based humour make it a very Jewish one too. It’s also a play that’ll resonate with a gay audience. Bikel is perfect as the elderly Jewish guy that we all know, either in real life or through the movies and television while deSalaiz’s Ross is the embodiment of the young, self-confident gay man, despite struggling with being out at work.

Toronto is having a strong theatre season and Visiting Mr Green has a lot of competition for the attention of theatregoers. But this one deserves your entertainment dollar. Go see it! 

Visiting Mr Green plays now through February 18, 2012at Jane Mallett Theatre, St Lawrence Centre for the Arts, 27 Front Street East, Toronto 

For tickets, visit the box office, call 416 366 7723 (toll-free 1 800 708 6754)or book online at www.stlc.com

 Photo credit: Racheal McCaig

Totally Outright is a thought-provoking, leadership and community-building program for young gay men. It’s designed to introduce them to community leaders, mentors and experts in gay men’s health. It’s about building a community of well informed, sexually-savvy young men who can communicate with a wide range of people to enhance gay community health.

The program was created by the Community Based Research Centre (CBRC) in British Columbia and then further developed and delivered by Health Initiative for Men (HIM), a gay men’s health organization in Vancouver. It’s been running in that city since 2005; now a version is being offered in Toronto - more of that later.

I recently had the opportunity to chat about Totally Outright with Jody Jollimore, the program manager at HiM. Here’s our conversation.

John McCullagh: Jody, what’s Totally Outright?

Jody: In a sentence, John, Totally Outright is a leadership program for young gay guys. And we use a very broad definition of gay, so we include other guys who have sex with guys, and trans men who identify as gay.

Around twenty guys get together over two full weekends for a series of workshops teaching them how to be, as we put it, healthy, sex-savvy trendsetters. These workshops cover all sorts of important topics. We start with a backgrounder on a history of gay health activism in Canada and BC, and build from there, with presenters speaking about gay sex, policy making, assertiveness training, harm reduction, coming out, and a lot more. Really, a lot of the skills that young gay guys could use navigating the community. It’s no wonder that a lot of them liken it to “gay high school”, where they pick up some important and fundamental skills and information.

John: So it’s not so much a support program as a skills-building course. Tell me more about the the skills the program aims to build among these young men.

 Jody: They’re quite diverse but some are built more directly than others. For instance, the mental health presentation may be more useful for some guys at that time than others, but it gives them the tools to find help should they need it and to understand how being a gay man might affect their mental health. Then there’s a workshop on assertiveness training, to directly teach the guys how to be more assertive in their lives with what’s important to them. That could translate to negotiating condom use and peer pressure or asking a guy on a date or their boss for a raise.

A great strength of Totally Outright is the peer education aspect. For example, a participant may not himself find the drug-related harm reduction workshop especially useful because he doesn’t use drugs, but he’s now a resource among his friends. After the program, the guys themselves become ambassadors, the trendsetters as we call them, for the skills and information they’ve picked up.

John: Why was the program developed?

Jody: It was conceived as an evidence based HIV prevention intervention for young gay guys, encompassing an approach to address the social determinants of health in that population. The model has continued to develop into a capacity-building program that not only increases the leadership skills in the participants, but also provides guys with an option to continue to pursue a career in gay men’s health or to take a role as a community leader.

John: What kind of guys, Jody, do you look for to participate in the program?

Jody: While Totally Outright is open to all young gay men, we’re looking for participants who’ll benefit themselves and their community. We look to see how they’re involved in other groups and organizations, working or volunteering, or how they have demonstrated ambition and dedication through the experiences they describe to us. We’re looking for guys who’ll remain active in the community or their group of friends after the program, to really put what they’ve learned to use.

John: How does Totally Outright work?

Jody: It gives great health promotion information in a ready-to-use format. It engages the guys and the presenters – who are all volunteers – with the community. And it begins relationships among the guys, other organizations including those who provide the presenters, and the larger health care community. We hear from participants that one of the most important things that guys take away is the experience of getting together with other gay guys, in a non-sexualized way, to have a chance to talk about the realities of their lives in a safe and empathetic atmosphere. It’s a powerful experience!

John: What are the components of the training, which I understand takes place over two full weekends?

Jody: There are three different components: the presentations, outreach, and a group project. Most of the time will be spent participating in the presentations, which we always work on making as interactive and engaging as possible. At the beginning of the program, the guys are separated into groups of four or five, and are tasked with developing an idea for a program or service that would improve the health of the community. The scope is very broad, and we’ve had groups come up with fantastic ideas: a dedicated community centre, a shelter for runaway youth, and an outreach program to visible minorities, for example. They’re given time during the two weekends to work on it, as well as some time during the weekend in-between, and then at the end of their program they present their ideas to everyone, including the other participants and many presenters.

The outreach is on the second Saturday, which is the longest day of the program. Rather than ending at five as we do on the other days, we bring the guys back to the HIM office where we have some presentations on campaigns, media, and outreach. Then we break the guys into groups and spread them around Davie Street to actually apply some of what they’ve been learning, as well as letting them try their hand at doing outreach, one of the volunteer opportunities they will have after the program ends. The outreach component is often cited by the guys as one of the most fun parts of the program, and they really do seem to have a great time.

John: It does indeed sound fun. So what, Jody, have you learned over the years that you’ve been delivering Totally Outright?

Jody: John, if there’s one thing that I’ve learned, it’s that given the opportunity young guys in our community can be counted on to really help themselves and others. There’s a lot of talk about how disengaged youth are, but Totally Outright demonstrates year after year just how active and involved young guys can be.

John: Totally Outright looks like a great example of how we’re redefining the way we do sexual health promotion among gay men. Thank you, Jody, so much for talking about it to PositiveLite.com.

Jody: My pleasure!

The AIDS Committee of Toronto (ACT)  is now bringing Totally Outright to that city. Rui Pires is the Gay Men’s Community Education Coordinator at ACT. I recently talked with him about the Toronto version of Totally Outright.

John McCullagh: Rui, why did ACT decide to organize a Toronto version of this program?

Rui Pires: First and foremost, John, young gay men account for the majority of HIV infections among youth in our city (85% in 2009). And while Toronto has some wonderful programs for young gay men, there are not nearly enough services and supports that address sexual health and pre-existing problems such as social marginalization, stigma, internal and external homophobia and bullying. Totally Outright addresses HIV prevention within the context of these issues, while also acquainting youth with other services and resources that they can access. As the Vancouver model seems to be achieving these objectives, it makes sense to implement it in Toronto.

John: What are your hopes and expectations for Totally Outright?

Rui: Given the current community attention placed on bullying and teen suicides, I hope this program will help break the isolation of gay and bi male youth by bringing young gay and bi men together not only to talk about things like relationships, loneliness, negotiating safer sex, or be able to talk to their friends about HIV and sexual health related topics with some self assurance. But I also hope it’ll be a window through which they can see how older gay men are leaders in addressing HIV, how some men have lived with HIV with dignity, and see what needs to be done to address HIV and the stigma associated with it. I hope this will cause youth to see promise in the response to HIV that is particular to being a gay or a bi male.

I hope that the message they can take away from the challenge of AIDS is the value of volunteering, getting an education and looking at how they can give back to community.  When I talked with young men who took the Vancouver program, and are now in Toronto, I am impressed by how many have gone on to take up leadership positions in the sexual health field. Some are working on related university degrees while others have gone on to volunteer in the field. I hope we’ll be able to hear people talk about the Toronto program as being inspirational, as they already do about the Vancouver one. 

John: Good luck with the program, Rui. And thanks again for speaking to PositiveLite.com about it.

Rui: My pleasure, John. It’s very important for the community to know about the work we do so I appreciate the opportunity in speaking with you!

Totally Outright is a program for gay guys between the ages of 18 and 26.

The next Totally Outright program offered by HiM in Vancouver will take place on the weekends of March 10/11 and March 24/25, 2012.

In Toronto, the program will be offered on Saturdays in March and again in June.

Guys from outside Vancouver are invited to apply as arrangements can be made for transportation and accommodation. Toronto’s Totally Outright program is looking for participants primarily within the city and offers no accommodation.

You can apply and get more information as follows:

In Vancouver:

HiM, 310-1033 Davie Street, Vancouver, BC V6E 1M7

Telephone: 604 488 1001 Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

Facebook: www.facebook.com/totallyoutright

Web: www.totallyoutright.ca

In Toronto:

ACT, 399 Church Street, 4th floor, Toronto, Ontario M5B 2J6

Telephone Rui Pires: 416 340 8484 ext. 264

Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

Web: www.actoronto.org/to