There are scant few thinkers out there publishing critically productive work in the field of HIV prevention and public health more broadly. I have long been a fan and avid consumer of Australian Kane Race's scholarship. His analyses of HIV prevention, drug policies, and public health more broadly are beautifully incisive and incredibly helpful for anyone invested in thinking critically about these complicated issues. He is a master of explicating the taken-for-granted, and making you see what before was obscured. In his latest book, Pleasure Consuming Medicine, he continues to advance his concept of "counterpublic health" -- a concept built on the work of feminist and queer scholars invested in understanding oppositional public spheres. I had the pleasure of interviewing Kane recently for this blog, and I'm thrilled to share his thoughts here. We talk about public health, HIV prevention, and his challenging concept that aims to shake up our conventional understandings of these complex phenomenon.


Question: In both published essays and your recent book, Pleasure Consuming Medicine, you've advanced a concept you term "counterpublic health" - a concept that of course borrows from Michael Warner and other scholars' work on the concept of "counterpublics." Can you talk a bit about that original "counterpublics" concept, and how you came up with the idea to adapt it to your critical work on health?

A counterpublic has a critical or oppositional relation to the public. It's a term that queer and feminist scholars are using to refer to collective contexts of discussion, debate and performance in which we forge oppositional interpretations of our identities, interests and desires. The term is useful because it references the venues, media and forms of circulation which help constitute a sense of collective political agency. It also points to the exclusions and ideological dimensions of the public sphere proper - and hence the necessity of developing alternative spaces in which critical understandings and strategies can emerge.

"To refer to these fields of public health as counterpublic health is, first of all, to register the disastrous impact of these mainstream ideological investments on the health and life chances of the groups thus stigmatized - queers, sex workers, drug users. It is to critique moralized notions of 'the public,' and think about how they affect our work."

For me the term is immediately useful for thinking about those areas of public health where mainstream investment in a moral ideology compromises the ability to respond effectively to public health needs. HIV prevention is an obvious example. Drug education and policy is another. In both of these fields we have a situation where political investment in a particular idea of public membership (e.g. family values, a drug-free nation, etc.) thwarts rational responses to public health. Ideological investment in these figures consistently obstructs efforts to conduct education (for example queer-friendly, sex-positive HIV prevention education) and institute services (such as needle and syringe exchange provision) which are known to be effective in improving the life chances of affected groups. To refer to these fields of public health as counterpublic health is, first of all, to register the disastrous impact of these mainstream ideological investments on the health and life chances of the groups thus stigmatized - queers, sex workers, drug users. It is to critique moralized notions of "the public", and think about how they affect our work.

The concept of counterpublics is also useful because it pushes us to think about the collective contexts and modalities through which alternative strategies develop. So much health work and health education today advocates individual solutions to public health problems. But if we think about the early response to HIV/AIDS, it is quite clear that much of its success depended upon creating a shared horizon of concern about the threat, as well as specific contexts of collective self-activity. Nancy Fraser talks about the journals, bookstores, conferences, conventions, festivals, lectures, educational programs, and events which make up what she calls a feminist counterpublic. I began to picture the multiple public contexts that people have activated and engaged in order to undertake HIV education and prevention - the media, working groups, drag shows, conferences, blogs, sex venues, erotic performances, public forums, dance parties, research centres, internet sites, phone-lines, bars and service organizations. These spaces of collective activity have been crucial for the undertaking of HIV prevention. They've enabled us to transform our bodies, practices, and pleasures without denying or eliminating them. In order to develop reflexive contexts around stigmatized practices like gay sex and illicit drug use, it has been necessary to create public or semi-public forums for the acknowledgment, discussion and remodeling of these practices. In his work on counterpublics, Michael Warner also draws attention to the discourse pragmatics of different spheres of public address and performance, and this opens up an important set of questions for people engaged in HIV education and prevention. Questions like, how does this particular format/venue/event engage bodies, and what possibilities does this open up for collective reflexivity about certain risks and/or practices?

Question: How is this concept of "counterpublic health" useful in your own work, and how do you hope others will take it up?

I think it helps define a broad field of public health practice and understand the conditions in which certain public health initiatives operate. This field is characterized by a tension between public morality and what I like to call practical ethics of public health. One of the first lessons of health promotion, for example, is that education works best when it is couched in terms of the values, vernacular and practices of the group in question. But when it comes to HIV prevention or drug harm reduction, this necessarily involves an acknowledgement of practices that are difficult to acknowledge (without scandal at least) in the conventional public sphere - practices like gay sex or substance use. Paradoxically, public morality makes those initiatives which are most likely to connect with the relevant groups in effective ways most at risk of political intervention.

"The concept could be used to describe any public health work that discovers that it is necessary, as part of its project, to challenge hegemonic ideas of average personhood and create new collective contexts for the airing of otherwise stigmatized practices."

The scenario is familiar. An educational campaign or service which is explicit about drug use or gay sex gets picked up by a tabloid newspaper. Moral outrage ensues and the story dominates talkback radio for a couple of hours. The minister's office panics and condemns the organization that produced the resource. It's a constant possibility. And it is very damaging because it compromises the ability of health promotion practitioners to engage people at the level of their concrete embodied practices.
Counterpublic theory is useful here because it understands this dynamic as a product, in part, of the mass media's mode of address: the presumption of the reader as a member of an imaginary national family unit that is white, heterosexual and drug-free. This is the ideal with which we are encouraged to identify our deepest interests at the hands of this form of address. But it's a fiction, in the sense that it is based on untested presumptions about the average reader or listener or voter. So while many readers may not actually organize their lives in this way, this image of the public takes on a forceful reality which counterpublic health practitioners must contend with all the time. Counterpublic theory provides a useful handle on these dynamics and encourages us to think about the constraints and possibilities inherent in different scenes of circulation and modes of address - and develop new ones. The concept could be used to describe any public health work that discovers that it is necessary, as part of its project, to challenge hegemonic ideas of average personhood and create new collective contexts for the airing of otherwise stigmatized practices.

Question: I met you back in 2006 for the first time at the "Against Health" conference here at Michigan. Should we be against health? Does the concept of "counterpublic health" help answer that question?

One of the things that conference did well was highlight the use and abuse of the term health. Health is tricky like that: it's just as likely to evoke moral criteria as practical criteria around wellbeing. But "morality" does not always amount to healthiness, and frequently moralism has distinctly unhealthy effects. I think it's unfortunate that, because the term is so frequently abused, many of us find ourselves in a situation where we start believing that we are, indeed, "against health". To be sure, health is only one concern among many, and it is not always the most pressing one. But I agree with the conference organisers that our efforts to live longer, happier, more pleasurable lives would be greatly enhanced by bringing some critical force to bear on the ways in which the term 'health' is exploited to pursue other agendas. Counterpublic health may be a useful concept here, because it describes the situation of doing public health work in a context where hegemonic ideals of sexuality, personhood and citizenship are loaded against you. I don't think we are or should be against health, but frequently queers are constituted in precisely that way.

Question: There is a long history of both collaboration and tension between public health practitioners and HIV activists. They've been the best of friends and the worst of enemies at times. I wonder how you see that relationship evolving today, both in Australia where you work and more globally?

I think that today most HIV activists work within the frameworks and institutions of public health, and they do some very good and very important work there. Certainly this is the case in Australia. But I wonder how well the discourses and paradigms of public health are able register the importance of critical sex education, which has been a crucial component of the community response to HIV/AIDS. I think we need more than the professional frameworks of public health are able to offer if we are to sustain effective forms of HIV prevention. We need to promote literacy and reflexivity around sexual practice, and this is not necessarily something that public health specialists are particularly well trained to do, or that is easy to register within the professional frameworks of the field. Sexual practice is infinitely more complex than is recognized in public discourse, and the risks it gives rise to are often disguised or distorted by our desire to identify with normative forms. There's a critical literacy around sex, health and stigma that has developed within communities responding to HIV/AIDS that is worth sharing with people who are new to gay life. I don't know how you argue for a critical focus on heteronormativity as part of HIV education within official institutions of public health, but I think that's an important dimension of our work.

"How do we equip people to think flexibly and creatively and astutely about their sexual practice and intimate lives? What forms of pedagogy can be developed to this effect?"

In some ways, the concept of counterpublic health is my response to this situation. It is designed to conjure a critical "outside" to given institutions of public health while recognizing that most of our HIV activist talent is now fully immersed within these institutions. I want the concept to signal the practice of connecting with subcultural knowledge and queer critique, and to convey the importance of keeping that connection alive. How do we equip people to think flexibly and creatively and astutely about their sexual practice and intimate lives? What forms of pedagogy can be developed to this effect? I think these are crucial questions.

Question: In one of your forthcoming articles, you talk about the "risk of HIV prevention." Can you talk a bit about what you mean by that?

I use that phrase in my paper "Engaging in a Culture of Barebacking: Gay Men and the Risk of HIV Prevention", which first came out in 2007 and is being reprinted this year in HIV Treatment and Prevention Technologies in International Perspective, edited by Mark Davis and Corinne Squire. The article is concerned with the way risk is measured in the prevention sciences, and the effects of the mismatch between gay men's HIV prevention practices "on the ground" and what's identified as risk within the science. Barebacking is the case in point. I was amazed to discover that most of the initial articulations of barebacking in the US media from 1995 were made by HIV positive men, speaking about unprotected sex with other HIV positive men. There's no risk of newly infecting an HIV-negative individual with HIV in these circumstances. And in fact this strategy is even promoted today in some US contexts as serosorting. But these men were denounced as deliberate risk-takers at the time because they were talking about breaching the condom code. In the moral panic that ensued, the concerns around HIV prevention that were actually informing the practice got lost. I'm interested in the extent to which mainstream behavioural science was complicit in this process.

"In failing to attend to the cultural categories and practices according to which gay men are organising their sex lives, behavioural science misses innovative HIV prevention practices and mislabels them as risk."

The risk of HIV prevention which the title refers to is the risk that, in failing to attend to the cultural categories and practices according to which gay men are organising their sex lives, behavioural science misses innovative HIV prevention practices and mislabels them as risk. This promotes an image of gay men as intentional risk takers, irrespective of the precautions and conditions that actually animate their sexual practice. I think this is what has happened in the case of barebacking, and the effect has been to produce unprotected sex without condoms as a thrilling transgression of public health norms. When in fact it needn't be, and in some contexts it is actually quite safe.

More broadly, I think there is a related risk that current practices of HIV prevention, including social scientific practices, can't quite grasp the relationality of liminal practices like sex and drugs, and end up reifying the idea of the rational choice-making individual as the subject of these practices. Sometimes we overemphasize the intentionality of sexual actors, when it seems to me that part of the appeal of sex and drug practices, at least on some occasions, is a certain losing sight of the self. I think there's something important about the focus on relationality and liminality in these approaches that needs further elaboration. We need to develop better ways of accounting for sex and risk which take this dimension of erotic experience into account, without pathologizing it. I'm hoping that grappling with this problem may produce some new and better ways of doing practice-focused sexuality research. But this is an ongoing project.

Question: What do you think needs to change about the way public health approaches HIV prevention?

Well, that's a difficult question to answer, because public health approaches HIV prevention differently in different contexts. But I think this would be one area. We need knowledge practices that are better attuned to the cultural categories according to which people are organising their sex lives and which are better able to account for the relationality and variability of sexual practice. Sexual practices, drug practices and prevention practices change - in the context of new technologies, new environments, and new circumstances. I think HIV prevention needs to keep in touch with these changes if it wants to remain relevant and responsive to those groups that are most at risk. There is a lot of emphasis in the international field today on determining the predictability of interventions. I think this emphasis is misguided, given what we know about historical and cultural change. Instead we need research methods and pedagogies that promote both individual and public responsiveness to the unpredictable situations that inevitably emerge.

"I think sex education needs to be a central part of HIV prevention education, and it needs to go beyond biological descriptions of anatomy and risk to provide opportunities for reflection on the dynamics of specific sexual contexts and relations if it wants to equip people to protect themselves and each other effectively."

I've talked about the need for critical sex education as a feature of HIV prevention programs. There is a great deal of resistance to this internationally. Indeed, one of the drivers of official enthusiasm for very expensive trials of Pre-Exposure Prophylaxis around the world at the moment seems to be the promise PREP holds out of avoiding difficult public discussions around sexual practice, drug use, and gendered relations. I think sex education needs to be a central part of HIV prevention education, and it needs to go beyond biological descriptions of anatomy and risk to provide opportunities for reflection on the dynamics of specific sexual contexts and relations if it wants to equip people to protect themselves and each other effectively. The same could be said for drug education. We need a less moralizing approach to drug education and service delivery that de-pathologizes people's desire for pleasure and proceeds pragmatically from that point.

I also believe that public health needs to resist current trends towards criminalizing HIV transmission. Sex is a relational practice. It takes place between two or more people. In criminalizing HIV transmission and non-disclosure of status, the criminal law produces a sense of HIV-positive individuals as exclusively responsible for HIV infection, and this in turn promotes a false sense of security and protection for HIV-negative individuals. So while one may well find willful or reckless transmission ethically troubling, there is a technical and practical question here about whether criminalization is an effective way to promote public health (not to mention a shared response to HIV). There is already a wealth of knowledge in the field about the negative public health effects of punitive strategies. Punitive strategies constitute individuals as stigmatized subjects; make them less likely to access services; promote evasiveness and disavowal; and reduce people's capacity to care for themselves. They also promote a climate of distrust, suspicion, hostility and fear - the very opposite of an enabling environment for public health. I believe public health needs to continue to insist on HIV prevention as part of its ambit, and not a matter for the criminal code.

Question: Many scholars today have trouble with the notion of social change, in part because both the foundation for advocating for that change and the notions of "progress" and "justice" have been so thoroughly challenged and at the very least made slippery. And yet, of course, many of us got involved in academia with some hope of our scholarship actually making some kind of impact on the world around us. How do you approach this problem?

Hmm. I think social change is already happening - sometimes very rapidly, sometimes quite slowly, always with complex implications - and the challenge is to work out how it is happening, and intervene in ways that you think will be productive. We have a habit in the HIV field of separating the concept of "science" from "intervention", but as someone who has been involved in the HIV field in various ways for almost 15 years now, I am utterly convinced that knowledge practices matter: they are performative - which is to say they are intimately involved in the production of certain realities over others. I've seen this happen. Science is intervention, whether we like it or not. So for me your question is a qualitative question. That is to say, if scholarship is already having an impact on the world around us, then what sort of impact is it having and how could things be improved?

"To me, to articulate and teach critical theories of sexuality is to develop one counterpublic space among others."

And for me this raises methodological questions. I'm attracted to fields like cultural studies because they provide models of embodied scholarship and a context for reflecting on practices of embodied scholarship which I find more promising, politically and ethically, than research methods which require you to cloak your subjectivity at the door as a condition of entry. I find it bizarre for example that we have so many people working in the HIV field (and also the drugs field) who are participants in affected communities but who are blocked if not actively discouraged by the professional or scientific frames within which they work from reflecting, as part of their work, on their experience in any structured or sustained or critically informed way. We need to be producing spaces and contexts for this to happen! In the mainstream field, it now seems as though "research" and "community" are conceived as entirely distinct domains, the first completely disembodied, the second increasingly tokenistic. We should refuse this binary. We need participants of affected communities to be engaged in critical reflection and research about the conditions and details of their experience, and for the knowledge they produce through this process to be taken seriously as part of policy debate. For the past couple of years I have been putting most of my energies into developing a large undergraduate course in sexualities here at the University of Sydney. There is nothing more exciting than seeing a student begin to pick up the tools of queer studies and cultural theory and start to use them to understand their world and their experience of it. I think the new generation of sexuality researchers will be critically astute, engaged with social policy, and produce work that is both conceptually innovative and empirically informed, and grounded in their experience of the world. Certainly, these are attributes I hope to foster in my teaching.

To me, to articulate and teach critical theories of sexuality is to develop one counterpublic space among others. And many need to be developed. Like other cultural researchers, I try to work at various interfaces and engage with multiple publics - some academic, some pedagogical, some policy-related, some popular, some subcultural - where the aim is to participate in debate and develop new ways of understanding, and therefore acting upon, experience. It's true that academic work has a quite specific field of circulation, but it connects to many others. One would hope that by identifying and giving weight to certain under-articulated or hidden forms of experience, new spaces for thought and practice - and new possibilities of responsiveness - open up.

"SEX IN AN EPIDEMIC"
Director: Jean Carlomusto
Trevor's Rating: 2.5 / 5 Stars

This documentary is a strange mix of things -- an attempt to throw everything about AIDS from the start to the present into one confused film. Archival footage is rarely identified, creating confusion over whether the interview you're watching was conducted by the filmmaker or was just rescued from the annals of history. It became clear watching interviews of people I knew were dead that the filmmaker had done little of her own work. In fact, she basically stole the entire concept of the film Sex Positive, chopped it down to 20 minutes, and inserted it into the film without credit -- the kind of thing that if done on a written work would be called plagiarism.

Indeed, this is one of those films that is well intentioned but poorly executed. There is plenty of interested archival footage, but it is sloppily stitched together without a strong narrative structure. Unlike We Were Here, this film lacks the kind of clear focus and narrow scope that made that film so powerful. It pretends to be telling a national HIV story, but it's really about New York City. What happened there did not happen in San Francisco, and those differences go unspoken in the film but were clear. ACT UP happened in New York for a reason, but we don't hear about that because the film has no concept of its geographic specificity.

This film will be a resource for those looking for archival footage, and a random array of interesting but vaguely related facts. Here's a trailer:

"WE WERE HERE: VOICES FROM THE AIDS YEARS IN SAN FRANCSICO"
Director: David Weissman and Bill Weber
Trevor's Rating: 5 / 5 Stars

I can recall sobbing uncontrollably exactly three times in my adult life. Last night was one of those times. I ventured out to the Castro theatre for the "sneak peek" screening of "We Were Here: Voices from the AIDS Years in San Francisco." I knew I was in for a tear-fest, but I had no idea just how incredibly moving and utterly devastating the film would be. Before the screening, both the filmmakers admitted not wanting to make this film -- how can you possible represent the horror of those years without doing some injustice, without leaving some story untold? The idea is daunting.

No documentary to my knowledge exists that chronicles these years so intently, most likely because these stories are so incredible painful to tell -- and just as painful to listen to and absorb. I can only imagine that this film's road to the screen is paved in rivers of tears. As someone who did not experience those years, these representations are my only access to the memory of an era that shaped my gay world. It's why I have the kind of sex I do. It's why I have so few gay mentors from that generation. It's why bathhouses closed and disco died. And it's probably why gay marriage is the 21st century gay raison d'être.

As such, I listen to these stories intently whenever I can, mostly in the form of movies -- Longtime Companion, It's My Party, Angels in America, Sadness, and the like. With the exception of William Yang's incredible Sadness, these representations are rarely retrospective. They are told from the battleground itself rather than the hill overlooking the cemetery years later. This kind of war analogy is invoked several times in the film: as one interviewee explains, AIDS was what World War II was to many Americans. But of course as a comparison it is somewhat limited in its utility. War involves a coordinated opponent that you can see or at least pinpoint on a map. AIDS turned gay men's own bodies against them, crippling the young and muscular as quickly as it did the old and infirm. And during the first years of the epidemic, they had absolutely no idea how it was transmitted or who might already be infected.

Five individuals -- four gay men and one woman -- narrate the film, each with a unique experience that adds a new facet to the incredibly rich and devastatingly moving story. A flower vendor remembers giving away flowers to neighbors who wanted to bury their friends with dignity but had no money to give. An artist chokes back tears as he relives his lover dying as he frantically drove him to the hospital -- and in a heartbreaking turn, losing a second lover to the disease a few years later. A volunteer at the AIDS ward in San Francisco's General Hospital remembers finding a way to be a part of a gay community in comforting those who were dying. Their stories are heart wrenching.

The film was screened to a sold out crowd at the Castro Theater. Many in the room had lived through those awful years -- some in San Francisco, others elsewhere. Sitting in that room full of so many sobbing, hurt, and mournful gay men was one of the most challenging experiences of my life. At one point early in the film, a series of self-portraits by the photographer John Davis flashed across the screen. The series, titled "FIERCE," shows the artist emaciated, his body decimated by his illness. His naked, pale figure is contorted, stretched into alarming positions. An IV line is implanted in his chest. The crowd was silent except for the wailing howl of one man towards the back who could no longer hold back his tears. Even now as I write this, I cannot help but bury my face in my hands and cry. I will never forget the sound of that man's anguish. It will haunt me for the rest of my life. (And I'm not the only one to have this experience at the premier, it seems.)

Davis' self-portraits are both grotesque and stunningly beautiful at the same time. After the film, the director noted that these photos documented the duality of the epidemic so beautifully that they helped him to conceive of the film. On the one hand, you have thousands of men dying -- leaving behind friends, lovers, tricks, clients, parents, children, and admirers. On the other, you have an outpouring of support from both gay men and those outside the community, helping to take care of those who were dying and to fight for the support HIV-positive people needed to survive. AIDS could have destroyed gay community. But it didn't. Gay men's resilience in the face of death itself is nothing short of awe-inspiring.

The moment the film ended and the credits began to roll, the floodgate of my emotions let loose. I bent over in my chair, put my head in my hands, and gasped for air in between sobs. The crowd rose to its feet for a standing ovation, but I could not get out of my chair. I stayed in my seat, bawling. Crying for all those men I never knew, who I wish desperately were here today. For all their sass, for all their sex, and for all their creativity that was snuffed out far before it's time. But they're not here. And that is one of the hardest parts about being a post-AIDS gay man for me. Missing what I did not know. Longing for what I cannot have.

Keep up with the movie's progress on its website or its Facebook group.

So first the French gay rags TETU and PREF, and now the very respectable The Times! My mission to take over Europe is in full swing! I was of course honored to be interviewed for this piece on HIV across the pond. The author is interested in the idea of gay generational gaps in approaching / experiencing HIV, and I tried to add a bit of complexity to the standard-issue story. Indeed, rather than make young gay men the target of our ire, I try to turn it around to say that fear-based HIV prevention and abstinence-only education are part of the story here. Check it out!

This is worth applause today -- and is undoubtedly the result of pressure from advocates (including the ACLU but also a myriad of HIV-positive advocacy organizations):

In a written opinion dismissing a charge of bio-terrorism against a 45-year-old HIV-positive man, Macomb County Circuit Court Judge Peter Maceroni ruled that the mere fact a person is HIV-positive is not enough to accuse him or her of unlawfully possessing a harmful biological substance.

The eight page ruling, released Thursday morning, concludes that HIV is not transmitted by saliva without there being blood present. Prosecutors and preliminary hearing testimony did not indicate Daniel Allen was bleeding at the time he allegedly bit the victim, Winfred Fernandis, Jr.

Hallelujah!

Here are a few things from around the web that I've been meaning to blog about:

1. Larry Kramer slams Obama in a speech at an ACT UP / Healthgap demonstration in New York. A choice quote:

President after President have treated us so badly. Ronald Reagan. George Bush the first. Bill Clinton. George Bush the second. Barack Obama. They have all treated us like... shit. Like little pieces of shit that they can step on with their heels and grind into the ground. Obama is treating us just like that. Like little pieces of shit he can grind into the dirt with his heel to make us go away. I wish you could see that. I wish you could see what he is doing to us for for what it is. He is manipulating us into invisibility. He HAS manipulated us into invisibility. Our people in Washington live in a never-never cloud cuckoo-land, thinking that this man likes us, not responding as, little by little, he take bits and pieces of us away. That is how they control us. Can't you see that? Why can't our people in Washington see that? They give them a dinner as they take away another right.

2. DC-based Fuk!t has signed up our favorite twink Brent Corrigan for a safe-sex PSA. This would be all well and good, but the asshole director (an MD - no surprise there!) gave perhaps the most condescending interview with The Advocate I've ever read RE: Corrigan's previous bareback porn movies. Just listen to this pathologizing, fucked up response to whether the doc believes Corrigan was "taken advantage of" when doing bareback porn when he was 17:

"Oh, I would say that he was taken advantage of pretty clearly. No 17-year-old knows what they're doing (laughs). He knew what he was doing as well as any 17-year-old brain knows what it's doing. He definitely was taken advantage of, I don't have any question about that... which is why he's grown considerably. He's an amazingly mature individual for someone who's been through what he's been through."

And that, my friends, is why Terry Gerace, MD, is my asshole of the day! Typical doctor bullshit.

3. Canada's highest court has ruled that an HIV-negative man is not placed at "significant risk of serious bodily harm" if they fuck a HIV-positive bottom. The court ruled in 1998 in R. v. Cuerrier that HIV-positive people must disclose their status before engaging in sex that carries a "significant risk" of transmission. Topping can't be used to prosecute that anymore. It's a step, but far from enough.

4. In other news, the Michigan judge hearing a case against an HIV-positive man being charged with bioterrorism for biting his neighbor during an incident he describes as a hate crime has refused to drop the outrageous bioterrorism charge.

AIDSmap has a story up about a study just published about gay men, with the title "Having older sexual partners increases HIV risk for younger gay men." If you didn't read closely, you might think that the researchers had actually done a study that might buy them the cache to make such a claim. I thought I would take a moment here to dissect what the study actually found, and what we can(not) safely conclude based on those findings.

First, the study wasn't just about "gay men." Though many of the men involved did identify as such (74%), they recruited "men who have sex with men" - which includes a variety of other kinds of guys. Second, and more importantly in my book, they study involved a small sample of 74 men in North Carolina. That's right, 74 people are the basis for that rather startling headline. The meat of their claim is this statement here:

Men with PHI had partners on average 6 years older than themselves, whereas uninfected men's partners were 4 months their junior (P , 0.001). After adjusting for race, sex while intoxicated, and having a serodiscordant/serostatus unknown partner, a participant had twice the odds of PHI if his sex partner was 5 years his senior (odds ratio 2.0, 95% confidence interval: 1.2 to 3.3)

Let me try to translate that into slightly more clear English:

On average, the men that recently HIV-positive participants reported having sex with before they seroconverted were 6 years older than them. By comparison, HIV-negative men's recent partners were 4 months younger than them. When we take into account these guys' race, whether they reported being intoxicated while having sex, and whether they had sex with poz guys or guys whose HIV-status they didn't know, a participant was twice as likely to be in the HIV-positive group if he reported having partners five years older than him.

I hope that was somewhat more readable. In any case, what they're trying to say here is that because there is an association between having sex with older guys and being HIV-positive yourself, there may be causal relationship between those two things. But of course their data doesn't actually show this. Indeed, what there data merely says is that - of the 74 guys they interviewed - the ones who were poz were more likely to report having sex with older men before they were infected. The data they are relying on here is a survey asking men about their three previous partners before infection if poz or their three previous partners before their enrollment if neg.

But of course we can infer other possible theories here, and not just the causal link that they're alleging here. Or at least it could be missing pieces of the story. Now, importantly they did control for race, substance use, and sex with poz and unknown status guys. These are all important factors that should indeed be taken into account, so we don't mistake the difference in age between partenrs for the causal factor when it's actually other factors.

However, in a strange move that they don't explain, they actually don't include in their associative model condom use with their previous serodiscordant or serounknown partners, which actually varies considerably between the two groups (click to embiggen):

Just to clarify: This data isn't about condom use with any last partner, but only the previous partner who was either HIV-positive or for whom you did not know their status. That's a pretty important piece of data, and the different shown above is striking. But there's a bit of a statistical trick going on in their write-up. While the difference above is stark, non-condom use with a previous poz or HIV-unknown partner is not actually what they include in their model. Rather, for their odds ratio calculation, they include whether or not the participant reported having sex with a serodiscordant or serounknown partner at all. But this of course is the less meaningful datapoint -- what actually matters for risk is whether you used a condom with that last positive or unknown partner!

I don't like being duped, and seems to me to be what's going on here. They are using statistical trickery to manipulate our interpretation of their findings. What other conclusion can we reach? They have more meaningful data, and yet they willfully leave it out of the model and never address that exclusion. There is just no way that this was an accident -- they obviously ran the model with the condom use data and it was likely weaker than the one they decided on. Thus, I'm suspicious.

But beyond the statistical manipulation, this is a study of 74 men in North Carolina. Let's not get ahead of ourselves and start making any big claims about "gay men" universally or even across the United States.

Moreover, what is most troubling for me about this data is what they clearly want us to do about it: Prevent younger men from having sex with older guys. This to me is the next logical step in Public Health logic, and it's the one that had a bunch of us gay men's health activist up in arms a year or two ago when Michael Scarce reported on the Ning that STOP AIDS was working on an intervention research project that would attempt to do just that. It's important to know the ways in which HIV gets transmitted, and to be able to implement culturally tailored prevention efforts that come out of that knowledge. But dissociative mixing is not the answer.

Citation:

Hurt CB et al. Sex with older partners is associated with primary HIV infection among men who have sex with men in North Carolina. J Acquir Immune Defic Syndr, online advance publication, 2010.

Under the new policy, those who test positive will begin ARV treatment immediately -- which is a radical shift from the decade-long strategy of waiting until the patient's CD4 count drops before a certain level. The policy is defended in two ways: First, that studies increasingly evidence that there can be significant damage done by the virus to HIV-positive people who do not begin treatment immediately. Second, that reducing viral loads in HIV-positive people will reduce rates of transmission:

A growing body of evidence indicates that HIV causes detrimental effects throughout the body long before the CD4 count falls into the "danger zone" for opportunistic infections (OIs).

The large SMART treatment interruption trial found that patients who stopped therapy when their CD4 count rose above 350 cells/mm3 -- and therefore had periods of unchecked viral replication -- not only had a higher rate of OIs and AIDS-related death, but also of non-AIDS conditions including cardiovascular, liver, and kidney disease.

Early treatment has been linked to decreased risk of morbidity and mortality even at CD4 counts above 500 cells/mm3. Many experts are convinced that chronic inflammation due to ongoing HIV replication contributes to non-AIDS conditions and what appears to be accelerated aging in people with HIV.

Another benefit of early ART is that it lowers the risk of HIV transmission, since treated HIV positive people have lower viral loads than untreated individuals, regardless of CD4 cell count. In 2008, Julio Montaner and colleagues from British Columbia presented a mathematical model showing that treating all people with HIV according to ART guidelines (which then had a CD4 count threshold of 350 cells/mm3) could dramatically reduce the rate of new infections.

At least two things worth mentioning:

1. This policy would put people on meds who may not need them until there are better, less toxic drugs available. For instance, someone diagnosed today may not have gone on them under previous guidelines for another two years. In two years, its possible that there will be ARVs available with fewer side effects.

2. Obviously, if implemented, this would eliminate the possibility of long-term non-progressors (a rare group of positive people who can live healthfully for many years before ARV therapeutic intervention is necessary). A friend of mine in SF who was infected in the mid-80s just went on ARVs for the first time. A very rare situation, indeed. But still worth mentioning.

Thoughts?

I love when people pretend to have something new or powerful to say about HIV/AIDS. 99% of the time, they are more likely to recycle tropes that we've been telling ourselves for the past decade or two. The latest example of this is David Mixner's post at DCAgenda, "What happened to silence = death?", in which he makes the tragically pseudoradical claim that we just need to talk about HIV more to end the epidemic. You know, silence=death, y'all!

Now let's put aside the fact that he seems to misunderstand the silence=death mantra of ACT UP -- it wasn't really just about mentioning HIV or getting tested, but about coming out into the streets and demanding action from homophobic institutions that were helping to fuel the silence and the epidemic, like the Roman Catholic Church and the CDC. But this gross misunderstanding aside, I still have a few words to say in rebuttal:

David,

While I appreciate your commitment to HIV Prevention, your editorial doesn't shed any new light on the issue. You make no mention of the fact that Public Health's stigmatizing and demonizing efforts to smear gay men and their sexual practices may be part of the reason why gay men checked out of prevention and of thinking about HIV/AIDS more generally. You tell people they're a piece of shit for long enough, eventually they stop tuning in to hear more.

My problem with Public Health is that there is no accountability for the racist, sexist, rabidly sex-negative, and often antigay messages that are trumpeted from the mountaintop under the guise of HIV prevention. "Oh, that campaign was racist? Well at least it started dialogue." You hear it time and time again, from the local to state to national level. In their minds, reducing HIV infections is the only end worth measuring - and if it reinforces or reproduces racism or antigay sentiment along the way, so be it.

And don't make the mistake of thinking more funding = better prevention. Most of the CDC dollars allocated to prevention fund tired, useless, and ineffective interventions that have no relation to the complexities of gay men's lives. Just take a look at the available "DEBIs" that ASOs have to put up with. Many people on the ground tell me that they have to pretend to be engaged in these pathetic excuses for interventions while secretly radically changing the curriculum on the ground. The CDC's efforts force ASOs into positions of dishonesty and secrecy. Where's the critique of the CDC's infrastructure in your analysis? Of the damning and devastating impact of abstinence-only education? Of Congress' forcing states to pass HIV disclosure criminalization laws, even though they are harmful to Public Health, if they accept Ryan White dollars?

So forgive me if I'm not sympathetic to your critique. But I think you've missed the point. It's not gay men who need to shape up. It's the CDC, local, state, and federal governments, and the larger institution of Public Health that needs to get its priorities straight.

Trevor

Phew. And that's how Sue sees it.

I hadn't heard about PEP411.com before this video, but it's quite wonderful. This video is aimed at young Black men, detailing how you can get your hands on post-exposure prophylaxis within 36 hours after a potential exposure to HIV. The sooner the better, theoretically, though the science behind the timing is somewhat murky. What we do know for sure, however, is that when begun soon after exposure, it can dramatically reduce your odds of serconversion. The drugs are essentially a cocktail of anti-retrovirals, just like those prescribed to HIV-positive people. Taken immediately after exposure, it is thought that the drugs are able to inhibit the virus from taking hold of your immune system.

Here's the video:

Although I will note that the video states that "limiting your number of sexual partners" reduces your HIV risk. I resent and disagree with this widespread assertion, and believe it is this prevention message that has led some men to the idea that boyfriends are "safety zones" from infection. A recent modeling study estimated that the majority of new infections in major metro areas among MSM today are the result of sex with primary partners.

I was overwhelmed by the turnout last Friday night for the forum in Chicago, "What is justice for the black gay man?" I'm not particularly good at estimating crowd size, but the room was very spacious and it was standing room only. In attendance was a regular who's-who of Black gay men and their allies in Chicago, including a few local politicians and government officials. In this regard, I want to applaud the organizers of the event for bringing together a fabulous group of Black gay men and their allies for a discussion devoted to some rather difficult topics.

I was excited to hear the panelists, of course -- particularly E Patrick Johnson and Keith Boykin, both of which have done some pretty groundbreaking work in their respective fields for advocating for LGBT issues broadly and for Black gay men specifically. Johnson's performance work, "Pouring Tea," I particularly love for the way it brings to life an extremely diverse set of experiences of Black gay (or otherwise same-gender-loving) men living and thriving in the South. Keith's critical work on the down low was also I think an incredibly important invervention into the stigmatizing discourses around this issue that became hyperbolic when writers like J. L. King (who went on Oprah to spread his pathologizing understanding of the phenomena) and Benoit Denizet-Lewis, who wrote a grossly distorted piece for the New York Times. Denizet-Lewis has actually made something of a career of pathologizing gay men, which probably explains mainstream media's love for his alleged "exposes."

So needless to say, I was eager to hear these thinker's thoughts about how best to advocate for and understand the experiences of Black gay men. I expected to hear about social justice rooted in a denial of access to social benefits, racism, pathologizing discourses about Black MSM's sexualities and behaviors, an HIV epidemic that is crippling agencies working with these populations and disproportionately infecting Black men, and an interwoven network of stigmas that makes daily life for these communities trying at best, and unbearable at worst. Alongside these problems, I also wanted to hear about the ways in which many Black gay men are surviving and even thriving despite these obstacles.

I didn't really hear either of these things. Instead, I was shocked and nearly appalled when it became clear that justice for the speakers was primarily about "loving yourself" and "being true to who you are." Indeed, the problem that was posited as the most trying for Black gay men was their own internalized racism and homophobia, a kind of pathologizing and psychologizing approach to social injustice that I found utterly baffling. No, it wasn't pervasive systems of racism, homophobia, sissyphobia, and pozphobia that are systematically embedded in social institutions and cultures that should be the focus of social justice movements -- but rather the internal psyches and emotions of Black gay men themselves.

This is not far from the latest self-help craze for Oprah to latch onto, "The Secret," which proposes that to succeed in life we merely need to imagine ourselves as successful, wish for that to be true, and think positively. If we aren't rich, then it's our fault for not wanting to be rich. If we don't have health care, then it's our fault for not wanting to become insured. This isn't just offensive, it's downright manipulative for the way that it seduces people into believing that the onus of achieving loosely defined "success" in life falls entirely on individuals. Nevermind the vast libraries of scholarship that illustrate the ways in which various forms of social inequality make achieving these markers of success difficult if not impossible for many social groups -- particularly those born into poverty but also those marked by certain socially ascribed characteristics such as race, gender, and sexuality. Under this individualistic / rational framework, you are a free agent whose choices in life are the only factor that will influence whether or not you grow up to be a CEO or a garbage collector. As a sociologist, this is the kind of ignorant, distorted, and highly conservative perspective on the world that erases the foundations for a politics of social justice.

I'd call attention here to two comments from the audience after the short presentations by the panelists that I think help illustrate the underlying politics (or lack thereof) in their comments. First, there was a question from a self-identified "successful" Black gay men near the front of the room who noted that he loved himself, his life, and his partner just fine -- but his self-love, well-paying job, and house didn't translate into his ability to formally marry his partner of many years. Thus, I read him as trying to point out the ridiculousness of the panelists' claims about what justice should mean for Black gay men -- it cannot be framed just in the terms of psedo-scientific self-help jargon, but rather must first and foremost recognize the structural and social injustices that make that self-love difficult to achieve. The self-love is the OUTCOME of justice, not the root CAUSE.

Second, a man near me later stood up to ask why it was that the panelists were defining homophobia as a kind of psychological problem, rather than as a pervasive social system of power relations that is embedded in institutions and cultures. Heterosexism, he posited, would perhaps be a better way to situate the claims for justice that could foment a Black gay politics. "No, no" the panelists said (I'm paraphrasing), "I don't think that's how we understand homophobia." But it was clear that this was EXACTLY how they were positing homophobia and more broadly the social justice politics that should stem from that form of social inequality -- as I hope is made clear by my (distilled) description of their talks above.

Don't get me wrong, I hope that Black gay men are happy. That's a good thing. But you just don't build a social justice politics based on psychological concepts like internalized homophobia and depression. That's the building blocks for a public health intervention, which increasingly are supplanting actual social justice movements for gay men in general -- Black, white, or otherwise. It's perhaps not a coincidence that these efforts are funded by state agencies that perpetuate these very injustices. The disease or problem in this model becomes not the system and the dramatic injustices it enables, but the various medical problems experiences by minority groups like "self-destructive behaviors" and "low self-esteem." It is precisely though this pathologizing reconfiguration that political movements become neutered and inequality gets perpetuated, reproduced, and made more insidious because these injustices come backed by medical authorities with so-called "evidence."

Let's take care not to fall victim to these alluring models for social change. They may make us feel warm and cuddly, but that isn't going to mean a damn when said happy person gets denied health insurance because he's HIV-positive. Or when he gets fired from his job because a co-worker saw him kissing his boyfriend at a local nightclub. Let's see how happy they are after that.

Just thought I'd share this (definitely NSFW) video intended for a lesbian audience. It was posted on French lesbian and gay website www.yagg.com. For those of you who do not read French, you can find a translation of the very few subtitles on this website. I do not think that anyone will have the least difficulty getting the point anyway ;)

Well color me proud! Our very own Chris Bartlett is featured today in a New York Times story on social marketing for the dead. Chris has jumpstarted the Gay History Wiki, which is a project that attempts to gather the bits and pieces of Philadelphia's gay history 1960-present on one little site. Archiving those who died of AIDS is a key part of that project. From the Times piece:

Beginning in 2005, Mr. Bartlett began assembling the names of every gay male Philadelphian who died after being diagnosed with H.I.V. or AIDS, searching obituaries and the Names Project registry of people commemorated by the AIDS quilt, combing through records of social clubs and the rosters at St. Luke and the Epiphany, the Philadelphia church that took on the task at the epidemic's height of "burying the people no one else would," Mr. Bartlett said.

Inspired by Steven Spielberg's Shoah project, a Holocaust memorial, in 2007 Mr. Bartlett built a database on wikispaces.com, the free portal that invites editorial interventions, and by the end of last summer was ready to broadly promote his site. Unlike the AIDS quilt, an intensely elegiac but largely static artifact, the Gay History Wiki is a sprightly free space open to posts and tags, to biographical data added and amended by survivors for their vanished friends.

[snip]

Beyond the novelty of this approach is something equally important, Ms. Schulman of the Act Up Oral History Project suggested: the opportunity to fill in blanks in a haphazard narrative. "The AIDS story has been limited to depictions of doomed individuals," and not impassioned, ad hoc communities, she said.

A conviction that gay men and women and their friends came to one another's assistance during the crisis -- improvising buddy systems, treatment groups, food banks and other survival networks -- fueled Mr. Bartlett's pursuit, as he recreated a mesh of lives that unexpectedly turned out to have meaning for a cohort of young gay men.

"Everyone knows AIDS is a big issue, but for people 25 and under, it's not really a topic of discussion," said Evan Urbania, a 29-year-old marketer who regularly visits the Gay History Wiki. "I'm a social media guy, and the importance of involving the stories of people who have passed on, particularly as a gay man whose development was influenced by people who are 20 or 30 years older, is very powerful to me."

Oh, Chris! I'm tearing up a bit just reading this! Thanks for all you do, honey! xoxoxoxoxooxoxox

Hallelujah! Christmas has come a bit early for Prevention activists in the US. From Julie Childs over @ PreventionJustice.org:

This weekend, the Senate joined the House in approving the final 2010 appopriations bill that will lift the ban, without the deadly not-near-1000-feet-of-anything amendment that would have rendered it virtually meaningless.

Long overdue, and now happening in the context of economic crisis where prevention efforts are being defunded on a daily basis due to state cuts. CDC must act on their pledge to do all they can to help syringe exchange now that the ban is lifted. It's not going to be easy.

But the best way to bring any possible justice to this long-standing affront is to immediately work with all due haste to remove any possible barriers - funding, local misinformation or bias, bureaucratic social service practices that would alientate users, etc - and get the needles out where they are needed. As has been said so many times before, the point is the point.

Needle exchange is one of those tried and true tools in our prevention toolkit. We know it works, but dag nabbit if the government hasn't stymied efforts to put it into practice by criminalizing its practice. This is one important step forward, but as Julie notes there are more barriers in place at the level of bureaucratic policy, funding guidelines, and state and local legislation regarding the practice.

On this World AIDS Day, I think this still remains one of the most hilarious and yet deeply insightful commentaries on the virus. Thanks, Southpark!

If you haven't seen this episode, watch it ASAP. You'll thank me later.

Sorry for the long citation, but I think in this case the details are so maddening and violently upsetting that it's worth knowing the details. Michigan is charging an HIV-positive man under terrorism charges ("use of a harmful device") for biting another man during an argument between neighbors:

An HIV-positive Macomb County man is facing charges created under Michigan's 2004 terrorism laws for biting another man in a neighborhood scuffle. That, HIV advocates, state lawmakers and legal experts say is "cowardly" and "nonsense" and increases ignorance and stigma surrounding the virus.

[snip]

The case arose out of an Oct. 18 fight between 44-year-old Daniel Allen and his neighbor Winfred Fernandis Jr. What happened that day is disputed.

According to a report from Clinton Township Police Department, Fernandis said Allen jumped him without provocation when he went to retrieve a football neighborhood kids accidentally threw onto Allen's yard. Fernandis, according to the police report, said Allen "hugged up" to him and began to bite him. Fernandis suffered a bite wound on the lip so severe, police say, it went all the way through the lip. Fernandis sought medical treatment and the wound was sewn shut.

The story, a man severely biting another man, drew the attention of the Detroit-area media, and Fox 2 News soon had Allen on video admitting he was HIV-positive.

That admission lead Smith, a Democrat, to say he would seek additional charges. On Nov. 2, Smith's office amended its complaint to add a charge of possession or use of a harmful device. That law is a 25-year felony and was part of a 2004 package of terrorism laws created by the legislature in the wake of the Sept. 11, 2001, attacks.

The law makes it a crime to have a harmful device, which is defined as either biological, chemical, electronic or radioactive. Smith's office is arguing that Allen being infected with HIV was "a device designed or intended to release a harmful biological substance," and that his bite was thus an attempt to spread HIV.

Smith's office is relying on a Michigan Court of Appeals ruling in a case of an HIV-positive, and hepatitis B infected prisoner who spit at prison guards during an altercation in the prison. In that case, People v. Antoine Deshaw Odom, the three judge panel found:

We therefore conclude that HIV infected blood is a 'harmful biological substance,' as defined by Michigan statute, because it is a substance produced by a human organism that contains a virus that can spread or cause disease in humans.

The three judge panel was silent on whether the hepatitis infection weighed in as a factor as a harmful biological substance. As a result of this finding, the court upheld a stricter sentencing score for Odom. In 2008, the Michigan Supreme Court refused to hear an appeal on the matter, upholding the Appeals Court decision.

As someone said to me about this case, if this is upheld, it's open season against HIV-positive people in Michigan -- and elsewhere. Read the rest of the VERY upsetting story here.

A few days ago, I published a piece that managed to re-posted on numerous blogs (here, here, here, to name a few) that critiqued the use of "serosorting" as a rationale for refusing to have sex with Poz men when condoms are used. A flurry of interesting and highly productive conversations came out of this piece that center around a number of problematics: Rationality vs. Emotionality (as noted in Daniel's response piece); Responsibility vs. Recklessness; and Individual Rights vs. Collective Ethics, to name a few.

But alongside these productive conversations came what I see as a highly vitriolic and slanderous response that emerged in the responses on Qweerty -- a kind of mainstream gay blog that gets quite a bit of traffic. I see a big part of the issue here as resulting from the title the folks at Qweerty assigned the repost:

As you can see, they've suggested here that I called people who refused to sleep with Poz men "assholes." I didn't, and I don't think that -- just to be totally clear. I don't know much about Qweerty, but in the past I've certainly seen comments there that suggest a pretty conservative readership when it comes to sex. But I had no way of anticipating the anger and vitriol that has spilled out in the comments against me and my arguments. I certainly understand that these issues are highly emotional, but most readers did not engage the arguments -- they opted instead to call me names. Ouch.

But I'm a big boy. I can take a bit of name-calling. You work long enough in HIV prevention, and you realize that someone's going to smear your name if you say anything that differs from the party-line prevention soundbites. So in the interest of making something productive happen out of this violence, I wanted to take a moment to see if there were underlying logics in the nearly 100 comments that were enabling the anger -- logics that anyone interested in unpacking the politics of prevention should be interested in. Here we go.

1) "I take it this was written by someone Pos." & "hell no. he sounds like som sort of con man": A number of readers suspected that I must be HIV-positive for writing this. I think this is INCREDIBLY telling about the kind of divisive and polarizing kinds of conversations that are all too common in our communities. I'm not HIV-positive, but why does this matter so much? The subtle underhanded suggestion here is that I must be HIV-positive because I seem to be trying to coerce negative men into having sex with me.

2) "Trevor, you have no idea about the breadth of the stigma associated with HIV+ status; and only the few of us very long-term poz, and their friends and boyfriends, who witnessed and were subject to it do.": Let me try to translate: I've got the misery, keep your hands off. This is clear boundary-drawing, attempting to say that I have no right to discuss this issue because of my negative status. All too common when discussing issues of stigmatized minorities.

3) "What a nut. He seemed to also want to outright say -- but didn't -- that it was the duty of negative guys show their commitment to positive guys by fucking them.": Like the comments in #1, these readers presumed that I believed there was some kind of charitable commitment necessary for neg guys to be coerced into fucking poz guys. Again this is really not the point. The point is that there are prevention discourses circulating that making refusing sex with poz men seem entirely logical, and I'm challenging the logical bases by which that refusal becomes obvious or rational. Fuck whoever you want, but don't pretend like it's obviously just about self-preservation

4) "Hoppe is using the same tired rationalizations the community used in the eighties. I'm glan [sic] folks are seeing through this bulls-t. We have to stop aids in our community now. We've known the transmission method for years. And the available strategies have been obvious for years: positives only with positives, negatives only with negatives, honesty and caring for everyone, peer group pressure on thoughtless barebackers, condoms always for negatives except in a monogamous relationship when trust is rock solid. If anyone's feelings are hurt by this, tough s-it.": I think this comment speaks for itself. Here the claim is made that the only strategies for prevention transmission are 100% serosorting, shaming people who don't use condoms, and only allowing for unprotected sex within relationships. And I say: Tell that to the 68% of new infections that are estimated to be the result of condomless sex with people's primary partners. And obviously the pathologization of "thoughtless barebackers" is the kind of shaming that does nobody an ounce of good.

5) "I'm fed up with having to dance around the constantly shifting, ever increasing sexual minefield that horny, unconcerned poz men represent.": In this readers's mind -- and in many others -- the responsibility for transmission rests squarely on the backs of poz men. As if neg guys share none of that responsibility. As if the men leaving the backroom are akin to murderers. This is worse that stigmatization, it's criminal slandering -- and its the kind of hateful logic that Public Health scholars and institutions have too often served to promote and help disseminate in their efforts. I'm not saying poz guys are totally without any responsibility here, but c'mon.

and finally, my absolute favorite:

6) "Is it wrong to refuse to take a ride on a train you know has no brakes? Jesus, how can anyone write such a self serving, irresponsible idiotic article?": Wowzer! There's a lot going on here. First, it obviously equates having sex with Poz guys to getting on a train headed for certain death. I don't think I need to explain why that's the most disingenuous comparison I've heard in months.

Phew. I think I need to take a few days off from blogging. This was quite an intense ride. In the end, I'm reminded of something my mentor Eric Rofes wrote before he died (see pp. 6-7 of THRIVING, PDF found here):

I recently published on a gay news website an editorial viewpoint that attempted to open up new ways of thinking about HIV prevention, crystal use, and gay men who occasionally have sex without condoms. I was attempting to offer new vision. I understood the risk of attempting to offer new thinking and introduce complex concepts in a brief article on a popular website, but I did my best to inject some fresh thinking about risk-taking and the hazards of social marketing into a discussion which has become predictable and, at times, trite. At the same time, despite my awareness of the challenge I was taking on, I had not expected the rage reflected in some of the letters of response from readers. A sampling follows:

Patrick Syring from Arlington, Virgina, wrote:

"Your advocacy for barebacking and party drugs is abhorrent and disgusting. Gaymen like you tarnish the rest of us who play safe and cherish life more than you do. I hope you die painlessly but quickly."

Anthony Altieri wrote:

"Your article is one of the stupidest things I have ever seen in print. You are obviously a fucking idiot...You cannot blame people's self-destructive behaviors on prevention campaigns. Have you ever heard of a little thing called "personal responsibility"? Probably not. There are plenty of reasons people make unwise decisions: addictive behavior, loneliness, desperation, isolation, lack of purpose in their lives, lack of education, but I am confident you will NEVER find a case of 'I have uprotected sex and use drugs because I saw a poster telling me to use a condom.' The aids [sic] epidemic has been ongoing since the early '80s. DEAL WITH IT. USE A CONDOM YOU FREAKING MORON. Please do us all a favor, unplug your computer and refrain from subjecting the world to any more of your bullshit. Go sit quietly in your bedroom with the lights off, avoiding the realities of life. You seem to be pretty good at that anyway."

Why do conversations among gay men about HIV, barebacking, crystal use, and bathhouses get so ugly and divisive? Why are they argued in such a vehement manner? Are they simply another example of internecine warfare driven by personality conflicts, ego battles, and bad manners? How can we make sense out of distinct visions that seem to underlie these debates: one which argues that the crisis moment of AIDS has passed for gay men and one which berates gay men for taking a single step beyond the bomb shelter we've inhabited since the early 1980s? Why is gay men's sex so frequently the target of such contentious debate and demonization? How did we reach a point where there are such deep divisions among gay men about sexual health and safety? And in what ways do vehement responses to new vision effectively serve to keep out of our movement fresh, innovative thinkers offering fresh analyses?

Amen.

The San Francisco AIDS Foundation has just released their latest episode of their podcast featuring AIDS experts discussing hot topics of the day, this time around concerning the Thai Vaccine Trial showing a 30% preventative effect. The episode features SFAF staffer Erik Ireland and Executive Director of the AIDS Vaccine Advocacy Coalition, Mitchell Warren.

You can see here that "behavior change" is an issue, and that they regard this vaccine as not implementable because of this problematic. As Daniel Reeders has just recently argued here, implementing a 30% preventative effect among men who have no safer sex behavior to change would have a sizable impact on new transmission. But obviously the "public health nannies" (as termed by Elizabeth Pisani) don't agree.

Just shameful - and proving that Byzantine notions of HIV transmission are still alive and well in the good old United States:

A policy that bars HIV-positive inmates in Michigan prisons from working in food service jobs does not violate state law, according to the Michigan Department of Civil Rights. But though the policy may be legal, one leader in the Michigan Department of Corrections says he wants to change it.

The policy came under scrutiny in April when Michigan Messenger reported Michigan Department of Corrections official Russ Marlan stating the policy was in place to prevent the spread of the infection.

"A prison holds about 1,000, 1,200 people and as those 1,000 prisoners go through for breakfast, lunch and dinner, prisoners are scooping that food onto their trays," Marlan, who serves as MDOC's assistant director, said at the time. "So if a prisoner was HIV-positive and sneezed onto a food item and then a prisoner ate that food item and that prisoner had a lesion in their mouth they could contract the disease."

Another MDOC official, spokesman John Cordell, gave another explanation at the time, saying that life in prison runs on very different rules and it would be possible that a prisoner might feel an HIV-positive prisoner who was preparing and serving food was intentionally attempting to infect him. That, Cordell said, could lead the uninfected prisoner to attack the HIV-positive prisoner in "the big yard on Tuesday."

[snip]

In fact, MDOC policy does allow people with Hepatitis B and C to work in food service but under certain conditions. They are allowed to work as long as they don't have open cuts or sores, a runny nose or other obvious problems. Both viral infections which attack the liver have had infections linked to close contact, such as food service, by the Centers for Disease Control and Prevention in Atlanta. HIV is only spread via exchange of bodily fluids.

Who, again, said we don't need better education about HIV?

And scientists are completely baffled:

A new AIDS vaccine tested on more than 16,000 volunteers in Thailand has protected a significant minority against infection, the first time any vaccine against the disease has even partly succeeded in a clinical trial.

Scientists said they were delighted but puzzled by the result. The vaccine -- a combination of two genetically engineered vaccines, neither of which had worked before in humans -- protected too few people to be declared an unqualified success. And the researchers do not know why it worked.

"I don't want to use a word like 'breakthrough,' but I don't think there's any doubt that this is a very important result," said Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, which is one of the trial's backers.

"For more than 20 years now, vaccine trials have essentially been failures," he went on. "Now it's like we were groping down an unlit path, and a door has been opened. We can start asking some very important questions."

[snip]

Col. Jerome H. Kim, a physician who is manager of the army's H.I.V. vaccine program, said half the 16,402 volunteers were given six doses of two vaccines in 2006 and half were given placebos. They then got regular tests for the AIDS virus for three years. Of those who got placebos, 74 became infected, while only 51 of those who got the vaccines did.

Although the difference was small, Dr. Kim said it was statistically significant and meant the vaccine was 31.2 percent effective.

So what we're looking at here is a 30% effectiveness rate. How bizarre. Adding confusion is the fact that those who did become infected with the vaccine did not have lower viral loads than those who became infected with the placebo, something that is generally expected with vaccine trials:

The most confusing aspect of the trial, Dr. Kim said, was that everyone who did become infected developed roughly the same amount of virus in their blood whether they got the vaccine or a placebo.

Normally, any vaccine that gives only partial protection -- a mismatched flu shot, for example -- at least lowers the viral load.

That suggests that RV 144 does not produce neutralizing antibodies, as most vaccines do, Dr. Fauci said. Antibodies are long Y-shaped proteins formed by the body that clump onto invading viruses, blocking the surface spikes with which they attach to cells and flagging them for destruction.

Instead, he theorized, it might produce "binding antibodies," which latch onto and empower effector cells, a type of white blood cell attacking the virus.

Obviously, this trial is not the Holy Grail. But it is indeed interesting and compelling new data that will have an obvious effect on future trials. Combining two failed vaccine candidates was a HIGHLY controversial idea, but it appears to have paid off -- at least in some small fashion.