Much has been going on in the world of HIV, sex and drugs in the last month or so; the US marines recruiting at gay community centers, more mysteriously disappointing study outcomes for PrEP, encouraging news about the effect of microbicide gels against herpes, a new super-easy condom with a brand name that will put off anyone who cares about staying power.

I’ve ignored it all. That’s in part because I’ve discovered a site that really says everything that needs to be said about HIV prevention. Particularly insightful, in this post entitled “usefulness connected realizing hiv indicators”, is this gem:

“For that faculty your body gets very suasible to numerous germ infections and so the indicators are sure not e’er the HIV symptoms. The true unique method to aver that a soul is with HIV is the HIV checking.”

I don’t think I can add to that. Which is my polite way of saying that I’m taking a sabbatical from HIV and epidemiology. I plan to spend the next year or so travelling around Indonesia, eventually writing a book about this wonderful and mad land. Which has it’s own fair share of Bad English, as you can see over at my new blog, Portrait Indonesia.

I’ll be spending a lot of time out of range of wi-fi etc., but will try and post at least weekly. If you’d like to follow my progress, you can sign up here.

For now, on the subject of sex and drugs, it’s over and out. Thanks for taking an interest over the last four years.

What is therefore needed is an analysis of Bailey’s data. Why are persons in homosexual relations prone to be in illegal lottery scams? Is it because they are faced with discrimination at the workplace and cannot get or retain a legitimate job? Or are they suffering disproportionately because of the economic hardships? Is it that their lifestyle requires big bucks?

Additionally, some persons who appear to be sporting a homosexual lifestyle have been noticed to shop in groups. Is it that they are proud of the lifestyle and want to flaunt it, or are they afraid of violence and feel safe in a group? It seems to me that there needs to be more research done on persons within this community.

Not surprisingly, Jamaica’s lonely gay rights group, J-FLAG, was concerened that this would give homophobes one more reason to beat the shit out of gay men. Much more surprisingly, Jamaica’s top cop was also upset by the statement; although Bailey refused to retract it, his boss apologised on behalf of the Jamaican police.

It happens that J-FLAG has roped Miss Jamaica and her gay brother into a new campaign that aims to start chipping away at homophobia:

I’m in two minds about it. On the downside, the phrase “unconditional love” implies loving someone despite some hideous deformity in their character. I love my brother even though he’s… (sharp intake of breath, try not to hold your nose)…gay. On the more positive side, it does make sense to try and start from where the target audience is, and it’s clear that most of the target audience in Jamaica are very far from being ok with gay brothers. So far, indeed, that the national TV station has refused to carry the ad.

I’m interested that Rev Dick felt the need to point out that Jamaican political satirist Owen Blakka Ellis, who has had the gall to say that being gay isn’t so bad, was a “returnee from Canada”. Obviously he’d be pro-gay, then, Canada being a paradise for over-entitled whiny gays, seems to be the implication. It’s true that Canada’s at the other end of the gay stigma spectrum from Jamaica.

I have been accused (with some justitification) of being impatient with people who pull the stigma card when they have things so relatively easy. But this beautifully written, nuanced essay about young gay men in Canada from Michael Harris reminded me that “relatively easy” does not mean “easy”. The tornado that was AIDS has been more or less dissipated by treatment in Canada, but the wreckage it left has indeed shaped the landscape for another generation. Read it, please (pdf here).

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 screen shot above shows a small corner of Filth Fair, a new, quite clever word game app commissioned by the somewhat staid scientists at The Wellcome Trust to go with their new Dirt season. On the left, the app before the Apple censors rejected it. On the right, the revised version. Even then, it has a 17 age rating; though the censors don’t have to give reasons for their decisions it appears that they remain upset about the use, hidden within the painting/puzzle of the words sex and pornography.

I remind you that these censors sit in a country which allows pregnant girls to marry at 14 in some states. To see a fig leaf on your phone, though, you have to be 17.

The Apple censors didn’t apparently, think there should be any age restrictions on homophobia. A recent app from Exodus International that seeks to cure people from the affliction of being gay was released with no age restrictions. Needless to say, there was quite a bit of protest. I’m glad to say that sense beat the censors, and the anti-gay app has been removed.

If you’re in London, I’d urge you to visit the Dirt exhibition. Perhaps because of my own dirty mind, I got roped in to writing a chapter for the book of Dirt, that goes with the exhibition. There’s quite a lot of fun stuff in it, quite apart from the sex and drugs bits.

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.

It´s official. Taking antiretroviral drugs when you don´t have HIV cuts the risk that you´ll get infected. It´s exciting news, if not unexpected. But it´s going to be a major headache for politicians.

The results of the iPrEx trial, were published today in the New England Journal of Medicine (with pdf but not the supplementary bits here). The trial was among 2470 gay men and 29 transgendered women in six countries. Everyone took a pill a day; half were randomly assigned to take a combination of tenofovir and emtricitabine (sold by a now very happy Gilead under the brand name Truvada), the other half got a placebo. Neither participants nor researchers knew which was which.

The published headline: people who took Truvada were 44% less likely to contract HIV than people who took the dummy pill — an encouraging result, if not stunning. The real headline: people who actually took Truvada nearly all the time were 73% less likely to get HIV: a huge victory. It´s a smaller protective effect than using a condom all the time, of course. The thing is, we know that people aren´t good at using condoms all the time. And what these study results show us is that people aren´t very good at taking a pill every day, either, though they are keen to tell researchers that they do. One of the most striking things about the results was the mismatch between self-reported pill taking and measured levels of active drugs in people´s bodies.

The researchers cleverly did a study within a study to try and figure out how important it was that people dilligently took their pills. Among people who actually got Truvada, they compared intracellular and plasma drug levels in those who got HIV with a random sample of those on Truvada who didn´t get infected. They found that only 9% of those who got infected had measurable levels of the active drugs in their bodies, compared with 51% of those who didn´t get infected. To put it very bluntly, pre-exposure prophylaxis dosn´t work it you don´t take your pills.

Let´s remember that this was a group of men who were poked, prodded, bled and counselled by study staff every FOUR WEEKS, and they still weren´t taking their pills every day. It´s not all that clear why, though men who got the real drug were more likely than those on the fake pills to report nausea. It´s possible that people were less motivated to take their pills if they weren´t sure that they were actually getting real drugs, or even that if they were, the drugs would actually work as prevention. That may also be why guys in the study didn´t report any rise in risk behaviour (though it´s hard to imagine that they could; 80% of them reported at the start of the study that they´d had unprotected anal sex with someone who might be HIV infected). But it´s a worry; if PrEP goes mainstream for gay men, we´ll need a lot more work on how to get people to take their drugs more diligently.

Another major worry: 10 people who tested negative at the start of the study were actually in the very early stages of HIV infection. Both of the 2 who happened to be assigned to the Truvada group developed resistant forms of the virus, suggesting that giving these drugs in the early stages of infection when the virus is replicating very rapidly may fertilise resistant strains. More shocking to me (though less worrying) was that half of the men who had acute early HIV infection at the start of the study had symptoms of the infection, but none were picked up by the study physicians. This is a pet peeve of mine; bad enough in routine health services but nothing short of a disgrace in a study designed specifically to look at HIV infection in high risk men.

Worries about resistance aside, the news seems pretty good. So why do I say it´s a political nightmare? Because antiretroviral drugs are expensive; a lot of people who need them to prolong their lives can´t get them. Now we´re talking about giving them to gay guys so that they can go out and screw around as much as they like without having to think about using the cheaper and potentially more effective (but generally more bothersome) option of condoms. I´ve been a bit sniffy about this myself in the past, though I did spend about 15 years taking a pill every day so that I could have as much sex as I liked without contracting that long-term, life-changing sexually transmitted condition called pregnancy. But in many countries it is still very hard to give out condoms because it is seen to promote promiscuity. If we could figure out a way to improve adherance, putting ARVs on the public tab will probably save money overall. It´s certainly something we should be trying out in all sorts of different ways. That includes the possibility of “disco dosing” — taking pills only on the days when one has a pretty good idea that one´s going to end up barebacking. But as condoms have taught us, the fact that things work technically doesn´t necessarily mean they work in real life, let alone in politics. Even if we can find a better way to deliver pre exposure prophylaxis (implants? it´s what I do instead of pills these days against that other STD, and I love it) I think it is going to be a hard sell in many countries.

For more, see Roger Tatoud´s reflections on the wisdom of taking a pill every day to avoid taking a pill every day.

Still, for now the news is good. Click on the image at the top of this post, add your own positive Truvada story, and get 5 free mp3 downloads. I think it´s worth celebrating a bit while we can.

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.

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.]