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.

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!

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.

Our Canadian friend Shawn Syms asks, "What are the implications?":

What are the implications of exposure-without-disclosure charges expanding from the realm of HIV to other STIs such as herpes? In the case of HIV, the problematic nature of these cases is obvious. HIV is comparatively difficult to transmit, and it's completely possible and in fact commonplace for people with HIV to responsibly engage in protected/negligible-risk sex without having to tell anyone their personal medical information. Sex with a person with HIV is not intrinsically dangerous, but because of the vast amount of misinformation, discrimination and stigma surrounding HIV, people who disclose their status may be exposed to serious personal risk. And there is an increasing medical consensus that many HIV-positive people on successful medical treatment may not even be capable of transmitting HIV even in instances of unprotected sex.

But herpes is different. First, it's far more common than HIV -- which means many more people could potentially face charges. There were roughly 65,000 people with HIV across Canada in 2008, according to the Public Health Agency of Canada (PHAC). There are no official Canadian statistics on the number of people with herpes, because unlike other STIs such as gonorrhea, hepatitis C and syphilis, it isn't even considered a reportable condition by public-health authorities. But the World Health Organization estimates that herpes affects over 500 million people around the world. Some US figures say the numbers there may be as many as 1 in 4 women and 1 in 5 men.

And herpes is much easier to transmit. As the College of Family Physicians of Canada notes on their website, "Genital herpes is spread easily. The virus from an infected person can enter your body by passing through a break in your skin or through the tender skin of your mouth, penis or vagina, urinary tract opening, cervix, or anus. Herpes is most easily spread when blisters or sores can be seen. But it can be spread at anytime, even when there aren't any symptoms."

Outrageous.

"Risk" as a conceptual approach for much of the research on health has come under attack from many sides. Risk is everywhere and nowhere, it seems. When it comes to gay men's health, gay men's sexual risk practices have particularly been scrutinized by researchers who wish to stop gay men from doing such naughty things as having sex without condoms. Many have suggested that rethinking "risk" (traditionally conceived of through the lens of an isolated rational actor making complex cost-benefit analyses aimed at maximizing returns and minimizing harm for him/herself) as a concept is a necessary step towards creating a more effective / ethical / social public health.

As I was reading for my class today on the Sociology of Law, I came across this very interesting distinction between "risk" and "uncertainty" that gets made in the literature on organizational behavior:

"On the whole, then, high-technology start-up financing poses challenges not only of risk but also of uncertainty. Although lay parlance often employs these terms interchangeably, the organizational decision-making literature uses them to describe two distinct conditions. Under conditions of "risk," decision-makers may not be able to predict the future deterministically, but at least they can describe it probabilistically: with a little effort, individuals can identify the full range of options and outcomes, and they can determine roughly how likely it is that any given option will produce any particular outcome. Consequently, despite the presence of risk, decision-makers can still make rational choices based on expected-value calculations, and markets can still produce efficient coordination based on contingent-claims contracts.

Uncertainty, on the other hand, arises when decision-makers cannot determine either (1) the full menu of alterative behavioral options or (2) the relative probability of alternative possible outcomes. Unlike risk, uncertainty is deeply incompatible with the neoclassical model of fully rational decision-making. Instead of producing a careful expected-utility analysis of all lines of action, conditions of uncertainty tend to produce "boundedly rational" decision strategies, involving "good enough" choices, gut feelings, and rules of thumb. At a more macroscopic level, uncertainty elevates transaction costs and exacerbates intra-organization strains and power struggles. Consequently, unresolved uncertainty poses a fundamental cognitive and organizational obstacle to the formation and maintenance of stable markets for high-technology start-up capital."

-- Suchman, M. & Cahill, M. (1996) "The Hired Gun as Facilitator: Lawyers and the Suppression of Business Disputes in Silicon Valley." Law & Social Inquiry, 21(3): 679-712.

So my questions of the day: What would it mean to reconceptualize men's safer sex practices as enacted in an environment of uncertainty -- rather than in an environment of risk? Is "risk" really the appropriate concept for understanding these complicated, negotiated practices?

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.

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 ;)

Erósfera es un proyecto de educación para las sexualidades (sí, en plural por aquello de que cada sexualidad es un mundote) dirigido principalmente a jóvenes de todas las edades, orientaciones sexuales e identidades, en una lógica de no discriminación, noviolencia y en un marco de derechos sexuales y reproductivos, el rollo está muy laico, muy plural y muy incluyente.

En este centro encuentras una condonería para apoyar económicamente al proyecto, un centro de información documental de acceso gratuito donde puedes consultar desde "Papá, mamá, soy gay" hasta manuales y guías para encabezar, crear y medir tus propios proyectos sobre salud sexual y derechos sexuales, hay un área de trabajo con grupos donde se llevan a cabo los talleres, capacitaciones y ciclos de cine-debate sobre los temas que se manejan como empoderamiento de mujeres, no discriminación, diversidad sexual, prevención de VIH/Sida, etc. Además se cuenta con el servicio de consejería y asesoría psicológica, todo esto a cargo de personas sensibilizadas y capacitadas en el ramo, un colectivo de jóvenes que ha chambeado en un lugar tan difícil como Puebla por un promedio de 5 años (hay banda que está en estas cosas desde hace 8 o que recién se integraron el año pasado) un colectivo de jóvenes de diversas ONGs que sólo buscan que la información llegue.

Erósfera celebrará su cumpleaños número 2 con un ciclo especial de cine-debate gratuito donde se proyectarán pelis como "shortbus" de John Cameron Mitchell o "the Raspberry Reich" de Bruce LaBruce, asi como círculos de conversación y talleres en diversas preparatorias de la Ciudad. ¿Te interesa que Erósfera vaya a tu escuela? Contácta en www.erosferaweb.org o busca el perfil o el grupo de Erósfera en facebook. Si vives en Puebla ve a Juan de Palafoz y Mendoza 412, depto 9ª en el mero centro histórico de la ciudad.

Felicidades a tod@s y síganle dando a la chamba en Puebla, donde la educación sexual formal casi no existe y la que existe casi nunca es laica.

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.

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.

I was having drinks with a friend of mine -- we'll call him Patrick here -- this weekend when the subject of having sex with HIV-positive men came up. "Oh, I would never have sex with an HIV-positive guy," he casually remarked -- as if such a thing were already obvious. I was shocked not just by Patrick's statement, but also by the categorical bravado in his delivery. To have sex with HIV-positive men, as he went on to explain, was to expose himself to unnecessary risk of infection. I've been replaying this conversation again and again in my head. How could he be so outrageously calculating in his cooIly expressed exclusionary strategy? Today I want to spend a few moments reflecting on these kinds of statements, because I think many people would uncritically read them as legitimate prevention strategies. I will argue here, however, that in reality that these kinds of strategies that are totally bankrupt in terms of actual risk reduction. Moreover, what I think this kind of statement actually tends to do is not actually promote any real reduction in risk, but rather to reinforce and reproduce harmful stigma against HIV-positive people.

Before we get into a discussion of the ethics of "serosorting" -- the practice of choosing to engage in sex with only sero-concordant men -- I think we should bracket my friend's comments as existing only at the very periphery of this term's broad meaning. While taken at face value, it does indeed seem that my friend is practicing serosorting. But correct me if I'm wrong here, but it seems to me that serosorting was more intended to describe men who were seeking to minimize risk of transmission while engaging in sex without condoms. For my friend, this wasn't the goal of his strategy -- condom use was still part of his risk reduction strategy with other HIV-negative men. This is a very important distinction. What I'm going to be talking about here is men who report consistent condom use, but who continue to latch onto serosorting discourses that discourage serodiscordant sexual practices.

Because of these important differences, I want to suggest that Patrick's comments cannot possibly be said to be purely a method of risk reduction. To explain why I think this is so, we need to evaluate whether or not there is actually any risk worth avoiding by excluding HIV-positive men from your pool of eligible partners. Thus, to help illustrate this, let's attempt to assess the risk of transmission between a known HIV-positive partner and an HIV-negative partner when condoms are used. There is no data to suggest that many HIV infections occur in these contexts, absent condom failure -- rates of which are outrageously low (between 0.4% and 2.3%, depending on who you ask). If we take a generous account, let's presume that rate is 2%. In a single incidence, then, the risk of potential exposure is 1:50.

But exposure does not equal transmission. You can be exposed to the virus and not actually seroconvert. Thus, we need to add into this equation the risk of transmission per sexual encounter in the absence of condoms,which vary depending on a number of factors: whether the poz guy is insertive or receptive, his viral load, genital ulcerations, etc. Let's say the poz guy is doing the fucking, for example's sake. The generic risk in this scenario for a receptive HIV-negative man is 1:122 -- that is, statistically speaking, there is a 1 in 122 risk of seroconversion after getting fucked once without a condom by an HIV-positive man (see here for a summary of this data). If we multiply these two risks together, we get something like a 1 in 6000 probability -- give or take. According to risks of death statistics, this puts a person's risk of seroconversion in this abstract, theoretical scenario somewhere between their risk of death by electrocution (1:5000) and their risk of death by drowning (1:8942). Obviously, this is a gross use of statistics -- but I think it helps illustrate the point: the risk of transmission between serodiscordant couples in one sexual encounter when using condoms is EXTREMELY low. Just about negligible. And this example likely grossly overestimates the risk, due to the fact that condom failure is not the same as sex without condoms. Many people will quickly realize the condom has broken, leading to a much smaller window of possibility for exposure. Thus, the 2% exposure rate included in this example is likely much, much smaller in practice.

Obviously, if we extend this risk over time, then we run into increased risk of transmission for a variety of reasons -- namely condom fatigue reported within serodiscordant couples. But if you use condoms, your risk of becoming infected from hooking up with a HIV-positive guy is probabilistically very low. Thus, excluding them from your dating pool cannot and should not be considered a risk reduction strategy -- unless you are having unprotected sex.

Now that we've established that there is no real prevention rationale for categorically excluding HIV-positive men from your pool of eligible partners, we need to seriously consider the ways in which doing so actually works to reinforce stigma against HIV-positive men. If you ask any HIV-positive man what kinds of difficulties come with seroconversion, many will immediately respond that stigma and the resulting fear of disclosure are today some of their most pressing concerns. New medications have alleviated what used to be a very immediate sense of death, and their adverse side-effects have been dramatically reduced with even more recent advances in treatment protocols. Rather than "purely" medical, the problems that men describe today with living with HIV are very much in the realm of the social.

Take for example a scenario another friend (we'll call him Matt here) described to me recently at a gay bar in Detroit. Matt was dancing with a cute young man, who curiously told him that "You should stay away from me. I'm dangerous." Matt asked him why, and he ambiguously answered that he was contaminated. Matt then asked him directly if he was HIV-positive, at which point the guy stiffened and gave a sheepish affirmative reply before running away. In this scenario, the young man had so internalized this harmful discourse of transmission that paints HIV-positive people as dirty and dangerous, that he himself did the running away. Matt has slept with HIV-positive men before -- this is not a problem for him. But he didn't even have to not reject him -- the HIV-positive man did the rejecting for him!

While this seems like a very contextual and bracketed example, I think it serves to illustrate the kind of emotional damage that stigmatizing discourses may be having on HIV-positive people's lives. I contend that Public Health -- in its ambiguous and contradictory uses of the term "serosorting" (a topic for another essay) -- is part of the problem here. By refusing to explain what this term means, and by remaining quiet in the way it gets practiced, Public Health is serving to reinforce stigma against HIV-positive people by allowing many men to use it as a rationale for their exclusionary practices. This essay is just a gloss on these issues -- it admittedly raises more questions than it answers -- but I desperately think we need to think critically about the way we (I mean both we as gay men, and we as people invested in promoting Public Health) allow stigma to continue operating in our communities through the lens of "health" and "risk reduction." Backed by medical logic, stigma seems rational, logical, and unproblematic. But we need to expose the ways in which these allegedly science-based logics are actually totally bunk in terms of their validity -- and are actually just forms of stigma veiled by scientific authority.

Author's Note: After publishing, I corrected the 1:122 risk of transmission per incidence for HIV-negative people engaging in unprotected receptive anal intercourse with HIV-positive men from the originally cited 1:132. I also added a link to Poz Magazine's summation of this theoretical risk data. Many people have emailed their frustrations with my gross misuse of statistics. I don't dispute this. Indeed, the kind of very sketchy analysis I engage in is problematic if you are interested in the actual, "real" statistical risk. I'm not really so interested in the precise number, and I don't think it matters much in making this argument. To my knowledge, even if we look at the outcomes here -- seroconversions reported when using condoms with HIV-positive partners -- we just don't see large numbers of transmissions. But I certainly welcome and encourage further research that is invested in precisely quantifying these risks -- and the variety of factors that are bound to contextualize them.

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.

The AIDS Vaccine Advocacy Coalition has published a report with information regarding the forthcoming results from a controversial Thai HIV Vaccine trial. The trial is a Phase III trial which means it tests effectiveness and safety (for more info on this go here), and the largest of its kind ever. The hugely expensive trial triggered divisive debate in the scientific community, because it involved two vaccine candidates that had minimal / no results in previous trials. Here's the basic 411 on the report's info:

In September 2009 results will be released from an AIDS vaccine phase III trial in Thailand. This test-of-concept trial is the largest AIDS vaccine trial ever conducted. The study, known as RV 144, began in 2003 and enrolled more than 16,000 HIV-negative Thai men and women between the ages of 18 and 30.

[snip]

In late September, the first announcement of data will focus on the general findings: whether there was any evidence of vaccine impact on HIV infection and/or viral load. More detailed information on the findings will be released at the annual AIDS Vaccine Conference in Paris (October 19-22). Regardless of the content of these two announcements, in-depth analysis of the findings will continue well beyond October.

As the report notes, there may be several outcomes here:

Any clinical trial may show no effect, but if there is a positive result, it will be one or both of the following:

1) The vaccine strategy reduces risk of HIV infection;
2) The vaccine strategy reduces viral load in participants who receive the experimental vaccine regimen and go on to become infected.

Even a modest indication of either of these benefits will be exciting news for the field. It would be the first time that an AIDS vaccine shows an impact on either risk of infection or viral load.

The report is available in English (PDF) and Thai (PDF).

I finally placed my order for the highly anticipated first book from Australian cultural studies extraordinaire, Kane Race. If you have any investment in Public Health, HIV/AIDS, drug use, and conceptions of biomedical power, you must read this book. Very interesting use of the notion of counterpublics here, with Kane's "counterpublic health." Here's the book's description:

On a summer night in 2007, the Azure Party, part of Sydney's annual gay and lesbian Mardi Gras, is underway. Alongside the outfits, drugs, lights, and DJs is a volunteer care team trained to deal with the drug-related emergencies that occasionally occur. But when police appear at the gates with drug-detecting dogs, mild panic ensues. Some patrons down all their drugs, heightening their risk of overdose. Others try their luck at the gates. After 26 attendees are arrested with small quantities of illicit substances, the party is shut down and the remaining partygoers dispersed into the city streets. For Kane Race, the Azure Party drug search is emblematic of a broader technology of power that converges on embodiment, consumption, and pleasure in the name of health. In Pleasure Consuming Medicine, he illuminates the symbolic role that the illicit drug user fulfils for the neoliberal state. As he demonstrates, the state's performance of moral sovereignty around substances designated "illicit" bears little relation to the actual dangers of drug consumption; in fact, it exacerbates those dangers.Race does not suggest that the use of drugs is risk-free, good, or bad, but rather that the regulation of drugs has become a site where ideological lessons about the propriety of consumption are propounded. He argues that official discourses about drug-use conjure a space where the neoliberal state can be seen to be policing the "excesses" of the amoral market. He explores this normative investment in drug regimes and some "counterpublic" health measures that have emerged in response. These measures, which Race finds in certain pragmatic gay men's health and HIV prevention practices, are not cloaked in moralistic language, and they do not cast health as antithetical to pleasure.

Kane's prose is sometimes a bit dense, but it's often truly revelatory. Here's what my professor and mentor David Halperin has to say:

"Kane Race's Pleasure Consuming Medicine supplies what we have missed for so long: a radical but responsible exploration of both the ethics and the politics of pleasure. Exhilarating in its daring and its intelligence, startling in its originality yet completely sensible in its interpretations, the book unerringly describes the paradoxical world where we now live out the cruelties and ecstasies of human embodiment."--David M. Halperin, author of Saint Foucault and What Do Gay Men Want?

In short, what are you waiting for? Order a copy!

The UNAIDS has just released a report (story | report) saying that "between five and fifteen men will need to be circumcised to prevent one HIV infection in the ten following years, at a cost of between $150 and $900 per infection prevented." Their conclusion: circumcision is a "cost-effective" intervention strategy for HIV prevention. In this report, there is no consideration for whether this procedure is ethical. Nor is there any consideration of what kinds of cultural meanings might be attached to the foreskin in communities they're ready to scalpel -- or how a mass program to remove their foreskins might be interpreted and expressed culturally.

I like to use the example that reader Thomas Kraemer provided a few weeks back in the comments: We could cure breast cancer tomorrow if we could just institutionalize double mastectomies for young girls. Or as my professor cynically joked the other day, "Why stop at the tip of the penis? If we could remove the whole shebang we could rid society of any number of not just medical, but social ills as well!" Oh, sure, some folks out there will resent the comparisons. "The breast is more important than the foreskin!" To this response, I have just one question: "Says who?"

I think we desperately need to be mobilizing against this movement towards circumcision. It's wrong-headed, poorly thought-through, and is really aimed at circumscribing any need for creative prevention approaches by creating a biomedical intervention. The crisis is clear: Prevention specialists -- trained in the too-often culturally incompetent fields of health and biomedicine -- are just downright flummoxed by the inability of their interventions to stem the rise in new infections. If you've ever worked in the field, you've undoubtedly seen their red-faced angst before: "Why won't these people just use condoms, goddammit?" Nevermind the structural constraints of poverty and gender. Nevermind the meanings implicitly and inadvertently attached to condoms by Western medicine (e.g. distrust, fear, etc.).

Thus, in an era when classical prevention strategies are failing globally, old-school prevention types have opted to search for a biomedical intervention that would avoid any need for dealing with the messy realm of the social. "If we can just chop something off, then we won't have to deal with compliance!" Ta-dah! The magical solution! Obviously, this logic is outrageously problematic. It presumes that circumcision will not be rife with cultural meanings and dilemmas, and it also presumes a hostile population that is "non-compliant." It never allows for the consideration that perhaps it is prevention that is the problem -- not the communities it seeks to change.

I am amazed by the number of studies in epidemiology -- the sheer mass of publications -- that continue to rely on behavioral survey instruments that unreflexively presume a set of concerns worth asking about that stem from an understanding of the epidemic in which it is people's behaviors that fuels the HIV/AIDS epidemic. This is downright shameful given the massive amounts of data that demonstrate how obviously correlated new infections are with social-structural factors like race, class, gender, and sexuality. It's like trying to telling people in Detroit to eat better when there is no grocery store -- not a single one -- within city limits.

It's past the point of naivety -- since the amount of data demonstrating the epidemic's social-structural roots is so compelling. It amounts to a kind of willful ignorance to continue trying what you know will likely fail because it is easily funded and requires little critical thought. It's easy. It's lazy. It would all be a bit humorous if it wasn't resulting in a body of prevention literature that does very little to actually work towards meaningful prevention. People are dying. Scientists are laughing their way to the CDC-NIH bank.

Removing foreskin in the name of health promotion is unconscionable. It amounts to a kind of cultural imperialism that will undoubtedly stir up backlash against Western Public Health. The idea is not seen as radical because we in the US already practice it so commonly. But believe me: If circumcision was virtually unknown in the United States as it is in other areas around the Globe, we would not be having this debate. But because it is such an institution here, the idea of promoting it elsewhere seems totally sensible. It's the worst kind of ethnocentrism, and it needs to stop.

Via AIDSMap -- just confirming what was already widely suspected:

The two sexually transmitted infections most strongly associated with HIV acquisition in gay and bisexual men are anal warts and anal gonorrhea, Australian researchers report in the online edition of the Journal of Acquired Immune Deficiency Syndromes.

Herpes infections did not emerge as significant in this study, but men with warts were three times more likely to acquire HIV, and men with gonorrhea were seven times as likely. The authors suggest that more frequent screening for anal sexually transmitted infections in gay men should be investigated as a means of HIV prevention.

Interesting that herpes was not correlated. If you're unaware, STIs like gonorrhea can increase risk for transmission for a number of reasons. In cases where STIs cause lesions (like syphilis or HPV), these sites become more vulnerable for transmission. Also, in general, it seems that co-infection with STIs can dramatically increase your HIV viral load, thus making it easier to transmit the virus. In this study, it seems that these infections are also highly correlated with unprotected anal intercourse -- thus there's a reason men with these infections were more likely to acquire HIV.

In December of '08 I joined San Francisco's HIV Prevention Planning Counsel (HPPC) as a youth service provider and as a member of the TMSM community. The HPPC is made up of service providers, researchers, community members and other interested persons, who advise the SF DPH on how to create real-world prevention strategies and how to prioritize CDC funding in SF.

In January '07 the HIV Prevention Section of the SF DPH prioritizd the creation of an action plan to adequately address the HIV prevention needs of Latino MSM. In early '08, Oscar Macias and Erik Dubon of the SF DPH convened a group of Latino MSM and allies to discuss a local Latino action plan for SF. The group enlised Rafael Diaz and Jorge Sanchez as consultants to assist in the creation of the Latino action plan.

This information is from their presentation to the HPPC on Sept. 10 '09. This will lay out an overview of their findings and their recommendations to the HPPC and SF DPH.

Final action plan N= approx. 239

Community Forum N= approx 45

Researcher Interviews N=6

Interviews w/ Latino MSM N=157

Dialouge w/ Providers N=31

Finding 1: San Francisco is a magnet for migration of young Latino men looking for sexual freedom and gender self-expression; they are treated as sexual objects and land in high risk contexts that put them at risk for substance abuse and HIV.

Recommendation 1: A guiding structure (perhaps a website online) that orients new waves of young Latino gay men who are newcomers to San Francisco; "landing pads" would be healthy and supportive contexts rather than situations of risk where Latino gay men are sexually objectified.

Finding 2: In San Francisco, it is very easy to find sex, but extremely difficult to find meaningful relationships. "Hot Sex" is the most valued commodity and men feel socially pressured to give up expectations of partnerships where they can integrate emotional and sexual satisfaction.

Recommendation 2: Programs that provide relevant and tailored education on the interconnection of sexuality, relationships, substances and HIV. Community building in context that emphasize a sense of familia.

Finding 3: Main reason for UAI (unprotected anal intercourse): perceived seroconcordance. Men are approaching HIV prevention by making assessments of HIV risk within particular sexual encounters - pursue risk reduction strategies other than condom use.

Recommendation 3: Programs that help men make sound and accurate assessments of HIV risk in different sexual contexts and situations, including knowledge of HIV status of self and sexual partners.

Finding 4: Stimulant use and participation in "Party and Play" (PNP) contexts are strong correlates of HIV risk. Sex under the influence is forced underground by stigmatizing attitudes and by health providers who do not address the issue.

Recommendation 4: Culturally relevant programs that address the functional use and impact of substances - emphasis on connection between stimulants and HIV. Need anti drug-stigma campaign and increased provider training.

Life Concerns and Priorities

Participants completed a brief survey listing 23 life concerns. They were asked to list and rank-order their 10 most important concerns:

Financial Well being 39%

Finding a good job 38%

Physical Health 34%

Depression/anxiety 24%

HIV/AIDS 21%

Having good friends 15%

Paying bills/debts 14%

Finding good housing 13%

Finishing school 13%

Emotional well-being 11%

Finding 5: Content of HIV prevention does not address the most pressing concerns of Latino gay men: Financial well being (#1) employment (#2) physical (#3) and mental (#4) health. Desire for improved physical and mental health is beyond issues related to HIV/AIDS (#5)

Recommendation 5: Programs need to address Latino gay men's concerns for job stability and financial well being; that is, connect HIV prevention with the existing with the strong motivation towards "Superacion" (improve one's situation - financial, educational, physical and emotional).

Finding 6: Latino English-speaking gay men have substantially lower rates of participation in Latino-identified HIV programs in the city - no HIV prevention programs specifically targeted to monolingual English-speaking Latino gay men.

Recommendation 6: Programs that welcome and target Latino English-speaking gay men need to be developed. However, this should not be done at the expense of existing programming designed for immigrant, Spanish-speaking men.

Finding 7: Riskiest group: older (over 35), English-speaking, unemployed, drug-using, HIV-positive, marginally housed, Latino gay men. Their risk is connected to poverty, social alienation, and social situation of vulnerability.

Recommendation 7: Create a program that targets the particular issues of older English-speaking Latino gay men of lower socioeconomic status who are marginally housed (mostly in SROs or shelters). The program should address issues of life stability, as well as access to culturally appropriate mental health and substance abuse services.

Finding 8: HIV positive men are reporting higher rates of risky sexual activity than HIV negetive men (59% v. 44%). Meanwhile, high rates of HIV stigma discourage disclosure.

Recommendation 8: Culturally tailored Prevention for Positives that addresses sexual behavior, HIV disclosure, and assessments of risk for HIV transmission among positive Latino men in a way that is non-stigmatizing. Campaigns aimed at reducing HIV stigmatization in the Latino gay community.

Finding 9: Non-gay identified men found in the social context that Latino gay men participate in: all (100%) straight-identified men interviewed were classified at HIV risk: these individuals unlikely to visit agencies or attend groups.

Recommendation 9: Programs tailored to MSM who identify as heterosexual should be developed, with targeted individual assessment and counseling by culturally trained prevention workers.

Finding 10: Many HIV prevention providers - often themselves members of the Latino gay community - are accomplishing very hard work under difficult circumstances.

Recommendation 10: Programs that address high burnout rates of HIV service providers. Existing Latino programs should be funded to carry out activites that prevent burnout and sustain the long-term, enthusiastic work of their front-line staff.

Whew! I know that was long, but it's good stuff. After some discussion on budget (pretty tall order for a city that just got it's state HIV prevention funds cut from 2.9 million to $500,000!) the HPPC voted unanimously to support the LAP recommendations.

The LAP team will be presenting they're more thorough data in a few months.

[ Image redacted -- see here ]

Canadian activist and writer Shawn Syms has penned a very thoughtful and insightful essay for Xtra.ca on the horrific AIDS campaign out of Germany that compares AIDS to Nazi Germany. It's a very smart essay - and a must read. Here's a peak:

This campaign is a joke. There is nothing shocking or cutting edge about it. Its horny Hitler is hilarious. The fact that he, Hussein and Stalin are all deceased adds a certain necrophiliac irony to the whole cartoonish exercise. For a campaign with a digital component, they seem to have forgotten the lessons of Godwin's Law, which points out the absurdity of making online comparisons to Adolf Hitler. If anything is disturbing, it's the fact that the "logic" behind this campaign makes sense to anyone -- especially an AIDS-awareness group like Regenbogen, whose members include people with HIV.

"AIDS" is not a "mass murderer." It's a health condition caused by an untreated viral infection. HIV is the virus that can lead to AIDS, usually after many years and in the absence of medication. HIV is a significant medical condition, and there are countless reasons why anyone who doesn't have that virus should avoid getting it, and that anyone who does have it should avoid passing it on to anyone else.

But it doesn't help anyone to confuse HIV and AIDS with one another, or to exaggerate the impact of HIV by inextricably linking it to death. Dr Joseph McGowan of North Shore University Hospital recently counselled a parent about her 10-year-old son's HIV infection on the medical website TheBody.com: "If he is monitored carefully there is no reason your son ever has to progress to AIDS. He can expect to live a very long life." This is the current reality of HIV for most people in developed countries. The constant, hyper-emotional assertion that HIV equals guaranteed death ought to be calmly challenged every time it rears its insistent head. Neither is it "murder."

And since "AIDS" is not a person, let alone a "murderer," who are we really talking about here? Of course, we are talking about people who have HIV in their bodies. The Regenbogen campaign isn't actually about AIDS itself at all. It's about the risks of (presumably unprotected) sex with regard to HIV transmission, arguing that passing on HIV is akin to Nazism, and suggesting that the other person engaging in sex has no role other than that of victim. Notably, the mass murderers in the campaign are all men and their victims are all women. Meanwhile, the most recent high-profile HIV-criminalization case in Germany targeted a woman, Nadja Benaissa of the pop group No Angels.

Did the campaigners not think twice about wrongly comparing human sexual behaviour to the Holocaust, and inappropriately demonizing people with HIV in the process? The insistence on seeing HIV transmission as villainy obscures the most stubborn fact about the epidemic -- far from being the realm of malevolent or sociopathic people, HIV is transmitted through behaviours that are otherwise completely natural and normal, such as penetrative intercourse -- or behaviours that may often be hard to control rather than "intentional," such as needle sharing in the context of addiction. We already know that those most infectious with HIV usually don't know they have it, and that most people with diagnosed HIV take great pains to prevent further transmission.

If you haven't seen the disgusting video included in the campaign, you can see all the ads and the videos here.