Note: This post appeared over at Elizabeth Pisani’s new blog, “Portrait Indonesia”. “Wisdom of Whores” is still on hiatus as she travels Indonesia in preparation for her new book, but we thought that WOW readers might appreciate this particular post. If you’ve not done so already, please do go over to Portrait Indonesia and have a look around. You can get the RSS / Atom feed here.

AIDS prevention poster in Southeastern Maluku, 2011

I have a collection of daft AIDS posters going back years, but I’m glad to say they are getting harder to find. This one, in Saumlaki, the main town in the remote Tanimbar islands, was thus a great find. The headline reads: AIDS: there’s not yet any cure! On the right is this helpful information:

AIDS!!!
You can’t avoid it by:

• Choosing your sex partners on the basis of their appearance
• Drinking/injecting antibiotics, alcohol, or herbal medicine before and after having sex
• Washing your sex organs after having sex

Some, including the South African president Thabo Mbeki and uber-philanthropist Bill Gates would take issue with the last point. I, of course, would take partial issue with the second — you can avoid AIDS by taking medicine, you just can’t avoid HIV that way. But the most egregious part of this ad is the illustration.The population of Tanimbar is largely Melanesian. Overwhelmingly the highest HIV risk for them is the sex they might have on their frequent money-spinning travels to neighbouring Papua. Indonesian Papau, rich in minerals, forests and much else, is swimming in cash. It is also swimming in HIV; it’s epidemic looks more like East Africa 15 years ago than it does like any other part of Indonesia today. And it is populated not by pointy-nosed tourists with straight blonde hair but with flat-nosed Papuans with crinkly black hair.

Most AIDS posters are pretty useless, in my opinion. But this poster associates HIV with Western tourists slow-dancing under the palm trees — an “other” that most people here will never come across, while saying nothing about commercial sex in high risk areas (Papua, but also with the local transgender (or waria) population). Those are very real risks that many certainly do face, at least if Astuti, one of the latter, is to be believed. She excused herself early from a grilled fish dinner because her phone rang. Not her Blackberry, that’s for friends and family, but her “HP selinkungan” (cheating phone). In Tanimbar from neighbouring Kei for around a year, she hasn’t had a day without clients. And though she has helped distribute condoms and promote testing in other cities around Indonesia (in some of which one transgender sex worker in three is infected with HIV), she’s seen no sign of an HIV prevention programme in Tanimbar. By maintaining the fiction that something is being done about HIV prevention in Tanimbar, this poster is a lot worse than useless. It is actively dangerous.

Last night, I was sitting in a Brooklyn restaurant chatting with a Famous Artist and his life-partner, the Respected Historian. In just about third bottle territory, a huge cheer went up from the table next to us, crowded with 20-something year-old straight hipsters. The cause of their excitement was an incoming Tweet: gay New Yorkers can now get married.

I was thrilled. I was also thrilled that these young New Yorkers were so thrilled, and so engaged. I thought it vaguely interesting that the Famous Artist and the Respected Historian were shruggy about the whole thing. I guess when you’ve lived in a same-sex partnership in New York for a couple of decades, you’ve outlived the marriages of many of your straight friends and you’ve fought to bring partner-rights into the workplace for fellow faculty members, it doesn’t seem so life-changing. But New York is an important voice in an important nation. It is high time that it raised that voice in recognition of the fact that no-body should, just because of who they choose to sleep with, be denied the right to agonise over prenuptual agreements, to spend an irrational amount of money on a symbolic ritual ahead of which one stresses about the guest list, the menu, the wardrobe, to argue about whether to file taxes jointly or separately, to wonder whether to get divorced before or after the kids graduate.

New York is has also finally passed a bill that ensures that no-one helping a drug user survive an overdose can be prosecuted for possession of drugs or works. Since overdose is one of the most important causes of “accidental” death in New York, and thinking you might wind up in jail is an important disincentive to call an ambulance for a struggling mate, that’s an important step. Now all we need is for the New York State Assembly to pass a bill that prohibits the use of condoms as evidence for prostitution. Apparently the New York Police Department are unhappy with the bill. Other police forces that have proven more enlightened on this issue include those nice cuddly boys in the Police Force of the Union of Myanmar (Burma, to the stubborn). Surely if they can swallow it, so can NYPD.

I’d write more about this but today happens to be New York Pride. I’m suspecting it will be a good party.

The song was banned by the Canadian Broadcast Standards Council after a solitary Eljibiti radio listener whined that it bruised their fragile soul.

Every reader my age knows the “MTV” song virtually by heart — boneheaded delivery men being grumpy about the absurd amounts of money made by boneheaded musicians with more mullets than talent. The offending lyrics include the following:

“See the little faggot with the earring and the makeup
Yeah buddy that’s his own hair
That little faggot got his own jet airplane
That little faggot he’s a millionaire”

Our Sensitive Soul found this “extremely offensive” and labeled it “discriminatory”. Since the complainant says they are a member of the Eljibiti Community, I’m assuming they consider it to be offensive to gays rather than to rock stars. But that confuses me. A pop classic which won the Grammy for record of the year in 1986 portrays homophobia as a sentiment expressed by bigoted and resentful boneheads. One person in Newfoundland, who apparently has not mastered the skill of switching off the radio, considers the association of homophobia with stupidity to be offensive. And six adults of sound mind meeting on behalf of the Canadian Broadcast Standards Council spent I’m not sure how much time coming up with a 5000+ word decision that boils down to this: “The song contained a word that referred to sexual orientation in a derogatory way.”

Give me strength.

The decision makes for amusing reading, dredging as it does through the history of similar complaints. It seems that even more sensitive souls have in the past been upset by songs and skits about cigarettes (fags, to a good British sometime smoker such as myself). Of course the way Canada is going, it’s not impossible that cigarettes will soon be outlawed, with all evidence of their existence digitally excised from old Humphrey Bogart films.

In fairness, I should note that the overwhelming majority of Canadians of all sexual hues commenting on the Globe and Mail’s report of the ban think it is just plain silly. But I think I’ll try be more careful about my “hookers, fags and junkies” shorthand when I next visit Canada, just in case. I wonder if any radio listeners in Newfoundland are offended by any of these words: Big. Girl’s. Blouse.

Predictably, most of the comments on the YouTube site are of the “This stigmatises gay men, especially those with HIV” ilk. More nuanced views over at Towleroad, one of the most consistently rational and informative gay blogs.

One woman, who tends as many in the audience towards the well-preserved Russian hooker look, asked me afterwards whether it was true that HIV could pass through a condom. I get that a lot, so I just explained how daft the idea was. “Ah! I’m a Doctor of Psychology and I didn’t know that,” she said. That slightly floored me, but it was nothing compared with what followed: “You said there was not much good news around HIV. But my colleagues tell me there is, that nowadays homosexuality is 80% reversible.”

This in a country whose capital already allows gay marriage. Apparently there is still a long way to go…

Para los Hispanofonos, aqui la presentacion. Tampoco uno de mi mejores, pero se hace lo que pueda.

Apparently, I’m not the only gay man trapped in a straight woman’s body.

Thanks to RH for the tip.

Salaam kepada pembaca di tannah air kita. Kalau seandenya ada di Jakarta hari Minggu ini (Tanggal 3 Oktober), ayo ikut skrining khusus film baru Madame X, di Senayan XXI, Jam 9.30 (blerch!). Di minta 250,000 rupiah; dana akan digunakan untuk mendamping kawan2 waria yang perlu di rawat HIV. Satu di antara setiap tiga waria penjajah seks di Jakarta sudah perlu bantuan; untungnya ada kelompok waria seperti Yayasan Sirkandi Sejati yang kerja secara rajin untuk membantu komunitas tersendiri. They need your help, so please support them. Apalagi, dari trailer, kelihatannya Madame X adalah film yang norak habiiiiiiiiiiiiis, berarti tentu saja lucu dan berhasil. It should be fun!

It’s taken two whole years, but US CDC has finally published data from the 2008 round of HIV and behavioural surveillance in gay men in 21 cities. Nearly one in five gay men is infected; in some cities (notably Baltimore) it is twice as high, at 38%.

Reacting to the report, CDC’s HIV prevention director Kevin Fenton said:

For gay community leaders, it is critical that together we engage and make HIV education, prevention, and testing of the highest priority. We must ensure that HIV is not a rite of passage for young MSM. We can rekindle a sense of urgency and action in the gay community to again embrace the work needed to drive down new infections. Now is the time to act.

But no-where in his lengthy blog post about the results does Dr Fenton say WHY HIV prevention is urgent, WHY young people should interrupt their sexual enjoyment by scrabbling for a piece of latex. He, like me, is part of a dinosaur generation that just assumes that everyone knows that HIV is a Bad Thing. Can the same be said of a generation that became sexually active after ARVs transformed HIV from a death sentence to an expensive annoyance, at least in the eyes of people who are not yet living with the boring round of blood tests, drug failures, to-tell-or-not-to-tell seductions that HIV infection brings? And we’re certainly seeing lots of infection in those groups: among teenagers not old enough to drink in most US states (18 and 19 year-olds) seven percent are already positive and because drugs are now keeping people alive, rates rise almost steadily with age.

Sadly, in the two years since the data were collected, CDC hasn’t yet managed to publish any results from the behavioural part of the survey, except to tell us a bit about testing. It’s not pretty. In Seattle and San Francisco, fewer than one in five gay men who tested positive for HIV in the 2008 survey said he didn’t know he was infected — the lowest proportion in the country. In Baltimore, close to three out of four who were actually positive said they thought they were negative or didn’t know their status (73%). That was UP from 62 percent three years earlier; the rate was 70% or more in another three cities.

For uninfected guys who think serosorting is a good way to stay uninfected, that should give pause for thought. You’re uninfected. You’re only going to bareback with someone else who is uninfected. You’re responsible enough to actually ASK about your partner’s status. Of those who tell you they’re negative and really believe it (because they’ve tested negative), one in 11 (9%) is infected with HIV. That might make you a bit more responsible. Now ask when his last negative test was. If he tells you it was less than a year ago, you should be OK, right? Not really. Among those who say they last tested negative within the last year, 7% (one in 14) was infected with HIV. People infected in the last year are more likely to have a lot of virus in their blood and semen than people infected longer ago. So in fact, that 7% may be among the most dangerous people to be having unprotected sex with (though of course people who were tested longer ago may also have been infected just recently).

Gay men who are also black, like Dr. Fenton, are especially likely to be infected (28% prevalence, vs 16% in white men), and especially likely not to know that they are (59% of black guys living with HIV didn’t know it, versus 26% of white guys). [I should note that these data come from men approached at gay venues such as bars, saunas, gyms etc. -- places where people go to cruise. They therefore are likely to represent the higher end of the risk spectrum, though they may exclude some high-risk people who confine their cruising to the web.]

I don’t think that simply encouraging more testing will be enough to stop new infections. As we’ve seen, plenty of people who have recently tested negative go on doing risky things (otherwise they wouldn’t now be positive). And certainly not all of those new infections are the product of sex with people who believe they themselves are negative, although it is probably a disproportionately high percentage.

We’ll know more if/when we see the analysis of the behavioural data. But for now it seems mightily as though we have failed to explain to young, gay men WHY they should make a huge effort to avoid HIV infection in a post-AIDS world. In public health terms there are lots of reasons, notably cost and the danger of resistance. But at the individual level it’s frankly harder to make a case, especially when we’re simultaneously rightly concerned with “normalising” HIV so as to avoid stigma for those who are infected. “HIV’s just another virus: Don’t get it!”, is a mixed message that is not working so well. Until we make individuals believe that “HIV Sucks; Don’t get it!” it will probably hover somewhere between rite of passage and status quo. And it may be time to acknowledge that unless you’re a public heath nerd, or pay taxes somewhere where the state pays for treatment, that may not be such a bad thing.

Note: in an earlier version of this post I had included an image which I had randomly taken off Google images. The people in the image were not named, and I didn’t seek their permission to use it. One of them has contacted me to request removal of the image. I apologise without reservation for having used it. [But I still want one of those T-shirts.]

The Canadian ruling is the more complex, because it has given us the right decision for the wrong reasons. A judge has said the nation’s blood transfusion service can refuse gifts of blood from men who have had sex with other men. The right reason for this decision is that it is a cost-effective way of reducing the likelihood that sexually transmitted viruses, in particular HIV, make it in to the blood supply. The reason given (which I think sets a bad precedent) is that the blood transfusion service is not bound by legislation intended to reduce discrimination against people who choose anything other than vanilla sex, because it is not a government agency.

Of course that’s nonsense. You shouldn’t be allowed to discriminate against people on the basis of who they choose to have sex with in the private sector, in NGOs, in schools or anywhere else, unless they are choosing to have sex with someone who doesn’t or can’t consent. But I don’t believe that asking gay men not to give blood is discriminatory. None of us has a right to put out body fluids into a pool from which the public will draw, and the judge, Catherine Aitken, agreed, saying: “Put simply, blood donation is a gift. A gift is freely offered, but also must be freely received, or freely declined….There is no requirement under the law for CBS, or any other blood provider, to accept the gift of blood from anyone.”

I do agree that the exclusion criteria are a little draconian. “A man who has had sex with another man even once since 1977 is not allowed to donate blood in Canada or the United States,” says the blood service. In terms of HIV, what we’re most worried about are brand new infections — people who have lots of virus in their blood but haven’t yet got enough antibodies to HIV to show up on the screening tests that blood banks use. Those are the ones more likely to lead to the “tainted blood scandals” (blerch) that got the voters so exercised about blood safety in the first place. Blood donated by people who’ve been infected for longer will get picked up in the normal screening process so it’s not quite such a drama if they give blood. In most countries, it make it more expensive for the taxpayers who foot the bill, because blood is pooled into batches for testing, and any reactive test, including false positives, mean the whole batch gets thrown out. (Canada tests individual units so that’s less of a problem).

Activists whine say that refusing to accept blood from gay men tars them with the brush of “AIDS victim” and reinforces stigma. “Not everyone who is gay has AIDS”, declared Kyle Freeman when he brought the case against the blood service that precipitated the ruling. Well of course not. Not everyone who is gay has HIV, either. But in Canada, a gay man is around 20 times more likely to be infected than a heterosexual (pdf) (51% of HIV infections are concentrated in the roughly 4% of sexually active adults who are gay men). If gay guys think that fact is stigmatising, they might want to reinvigorate HIV prevention efforts in their community. Screening men who have sex with men out of the pool of blood donors is not discrimination, it is common sense. (As an aside, I find it interesting that no-one seems to be whining complaining about the rights of drug injectors being violated because the blood service won’t accept their blood. Surely their rights are being violated in exactly the same way, even though they are actually less likely to be infected with HIV than gay men in some Canadian cities).

Meanwhile, across the border, American courts continue to chip away at the great edifice of true discrimination against people who choose their sex partners according to their own taste, rather than that of the Sex Police in groups like the Traditional Values Coalition. Hot on the heels of a ruling that repealed a ban on gay marriage in California, another California judge, Virginia Philips, has ruled that the “don’t ask, don’t tell” rule that makes it impossible for openly gay people to serve in the military is unconstitutional. This is very good news indeed; let’s hope the mid-term elections don’t scare the administration and the Senate into prolonging the agony for gay men and women who want to invest their lives waging war on behalf of the citizens of the US.

Thanks to Sarah Chown for nudging me to write about this.

So gay guys go on having unprotected sex after they are diagnosed with HIV, a new descriptive study of gay poz guys at a clinic in Boston tells us. Nothing new there, although it’s sobering to be reminded that one in two of the men who know they have HIV choose to bareback with someone who may be negative.

The most important finding from the Boston study is that the more recently diagnosed a guy is, the more likely he is to be exposing other people. We can’t tell from the paper if that’s something new. It may be that there’s a blast of screwing around soon after diagnosis, possibly as a reaction to it, then a calming down. The post-diagnosis binge is one of the possible explanations given by NAM’s ever-sensible Gus Cairns, posting over at rectal microbicide site IRMA.

The thing that most determines whether a poz guy will pass on HIV during unprotected sex is his viral load. We know that’s likely to be highest for the few months after he first gets infected. So if we do get better at detecting HIV early and we don’t do anything about bringing viraemia down instantly, the “post-diagnosis sex binge”, if real, would be a worry we’d have to add to the known dangers of the “slutty phase” that affects undiagnosed men as well.

Gus gives us another potential explanation:

3. The historical explanation. It can’t be about young gay men not having experienced AIDS, because it was recent diagnosis that was the risk factor, not age. But it could be about prevention fatigue that affects all ages, and lack of relevant, effective and up to date messages. The result would be that the recently diagnosed have higher risk behaviours (and have caught HIV) because they haven’t internalised prevention messages in the way that the longer-term diagnosed seem to. Does risk behaviour decline over time in the longer-term diagnosed for one reason or another (more ease of disclosure, self-education, awareness of criminalisation, catching one too many STIs, etc) or will men diagnosed today continue to be higher-risk than men diagnosed years ago?

If it’s a binge thing, behaviour will get safer over time. If it’s an “I’ve zoned out HIV messages” thing, it won’t. But there might be something else going on: The “HIV isn’t so painless after all” thing.

One of the reasons that HIV prevention messages are failing is that much of the public health world still treats HIV as though it’s AIDS, as though it is self-evident why you would want to prevent it. But now that AIDS has virtually disappeared, what’s the big deal about HIV? Why bother to protect yourself, or to avoid passing it on?

Guys who were diagnosed longer ago are more likely to have realised that HIV (like diabetes and arthritis) is actually more than a one-pill-a-day shrug-off. The ups and downs of treatment — having to call off a date because you’ve blown up like a tomato, worried that your boss will see you popping pills, having to cancel a day’s skiing because you’ve got to go for your viral load monitoring, — it can be a real pain. A pain that, on reflection, you might go out of your way to avoid passing on. That may be one reason why people who were diagnosed longer ago are less likely to expose their partners to HIV.

But treatment is improving all the time; as prevalence goes on rising and the ick factor falls, HIV becomes less and less of a pain. It seems likely to me, then, that barebacking will continue to rise. That makes people in public health crazy, of course. We have to think about resistance, a reappearance of AIDS, costs to the health system. But frankly, the guys who think HIV is no big deal at the individual level are not entirely wrong these days, at least in rich, socially tolerant countries with good health systems.

Ken Mayer and his colleagues in Boston end their paper by saying that we need “Innovative programmes that facilitate education and skills building around safer sex when MSM are relatively recently diagnosed”. But frankly, we’re never going to figure out how we should prevent HIV in a post-AIDS world if we can’t make a convincing case to the individuals most at risk that we should prevent HIV.

For more nerdy observations on the Mayer and co. paper, read more.
As far as I can tell, the paper looks at syphilis, gonorrhea and chlamydia in HIV-positive gay men who come to a gay-friendly clinic for health care. It seems that guys are deemed to have had an STI if they test positive in a baseline study screening or if their clinic records say they had any one of those infections in their urethra, rectum or throat in the year before the start of the study or. But the arse or mouth appear to come only from clinic records. If that’s correct, then pharyngeal and rectal infections may be substantially underestimated. Rectal STIs include infectiousness in Bottoms, which is worrisome for negative guys practicing “strategic positioning” — only ever being the Top when they’re barebacking with a guy who is poz and who’s status they don’t know.

The study does have some measures of viral load at baseline; guys with detectable viral load (>75 copies/ml) were 68% more likely than guys with undetectable viral load to have barebacked with someone who might be negative. Since viral load is THE key in transmission, that’s not good. The effect disappears, though, if you sling it in to a model with a lot of things that are related to viral load, including meds and years since diagnosis. But it would be hard to wave too many flags about that anyway — viral load is apparently measured only at baseline, while the unprotected sex we don’t want to see in conjunction with it can be up to six months previously, and STIs (which also lead to spikes in viral load) up to a year previously. As though that’s not enough confusion about time periods, drug use is measured up to three months previously.

Just to be clear, the thing that the Boston gay community (and/or the public health authorities) need to be most worried about in terms of ongoing spread of HIV among guys in care, are, in this order:

• Poz guys with detectable viral load being the top in bareback sex with guys they don’t know are poz

• Poz guys with urethral STIs being the top in bareback sex with guys they don’t know are poz

Drug use: ah yes. I was surprised by two things. The first is that “binge drinking” (defined as five or more drinks in one day any time over the last three months — oh dear, oh dear) is so low — at 19%. The other is that crystal meth use is so high — 23% worship at the shrine of Tina. If there is one mistress that makes you behave worse than most, it is surely Tina.
On the other type of drug, there’s a bit of a surprise too while 66.1% of the nearly 400 guys in this study are on ARVs, only 54.4% had an undetectable viral load. That means that over 11% of these men are on meds and don’t have an undetectable viral load in a single baseline measure. Pause for thought for those who’s prevention strategy relies on thinking “Oh well, if he’s poz he’s probably on meds so he’s not infectious”.

One more deeply curious finding. Men who had any unprotected anal sex with someone that they didn’t know was HIV-infected over the last six months were over four times more likely to have had an STI in the last 12 months (odds ratio 4.42, 95% CI 1.88 – 10.36). But when they looked separately at insertive and receptive anal sex, they found lower chances of infection for both. In receptive anal sex, which you might expect to be associated with greater risk of STIs generally, guys were under four times as likely to have had as STI as those who never took it up the butt without a condom, and despite the fact that it’s by definition a subset of the previous measure, the confidence interval is narrower (OR 3.86, 95% CI 1.78 to 8.28). In insertive anal sex, which you’d expect to be perhaps less likely to associated with STIs, it was lower still: guys were just over twice as likely OR 2.11, 95% CI 1.04 to 4.30). I’m on a flight right now without my trusty stats textbooks, but in my mind, those you can’t have smaller sub-sets of the same measure giving you tighter confidence intervals.

Maybe they are not sub-sets. The “risk behaviour” measure is unprotected anal sex with anyone who is not known to the poz guy to be infected with HIV. In the results section of the paper, the other two measures are described as “unprotected serodiscordant insertive anal sex” and “unprotected serodiscordant receptive anal sex”. In other words, it’s possible that it excludes the “don’t know his status” partners, although the truth of it is that the only status you every really know for any length of time is poz. As the paper says in its introduction, poz guys have higher rates of all these infections, especially syphilis, so if there were a way of restricting the analysis to those who only had truly negative partners, you’d perhaps get those lower rates. But you’d still likely have wider confidence intervals.
In my day job, I teach a course in scientific writing; it includes a fair bit of paper critique work. If I were to add this paper to the course, what else would you expect students to pick out?