Last opportunity to challenge poppers ban!

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The TGA has published an interim decision on moving nitrite inhalants, also known as amyl or poppers, onto Schedule 9 of the Poisons Standard — a move which would make the sale, possession, use or administration of poppers a criminal offence under controlled substances legislation in Australian states and territories.

These laws are different in each state and territory, making the full exposure to criminal liability a bit difficult to predict. Under the relevant law in the Australian Capital Territory, for example, a person who purchased a poppers product from overseas, held it in their possession, used it themselves and offered it to a sexual partner could be guilty of four separate offences. (See Vic | NSW | ACT laws.)

The interim decision on nitrite inhalants can be viewed here.

Submissions open!

You can make submissions on the interim decision by e-mail until 11 October 2018.

See the instructions on how to respond and my own draft response below

There’s work underway on a public document with key messages and evidence that you can draw on to write your own submissions.

Update 18 Sept – 

 

My own (draft) response

To whom it may concern,

Re: Including a group entry for nitrite inhalants in Schedule 9 of the Poisons Standard

I am a gay man – a member of the community most affected by the proposed changes. I have worked as an educator in HIV prevention since 2004 and as a researcher in the same field since 2013. In addition to undergraduate qualifications in Law and Arts, I hold a Graduate Diploma in Public Health and I am currently a PhD candidate at the ANU School of Regulation and Global Governance.

I have used inhaled nitrites, popularly known as ‘poppers’, on occasion since 2009. The effects of poppers use are extremely short-acting. They play an important role for many gay men in making sexual intercourse less painful, due to their principal effect of relaxing smooth muscle. Indeed, a topical nitrite product, glyceryl trinitrate, is available for the same purpose as a pharmacist-only medication.

In the United Kingdom, the Conservative Party MP Crispin Blunt spoke publicly about the benefits that nitrite inhalants offer gay men, during debate over legislation to ban legal highs. A Home Affairs Select Committee report found the use of poppers was ‘not seen to be capable of having harmful effects sufficient to constitute a societal problem.’[i]

Poppers have been used by gay men for sexual purposes since the 1970s. The medical literature shows a smattering of case reports documenting injuries attributed to poppers use. Only recently have there been reports of retinal injuries subsequent to poppers use. This trend needs to be understood in a regulatory context.

In the EU in 2007 and in Canada in 2013, regulatory action was taken to ban the sale of the chemical formulations commonly included in poppers products. This in turn caused some manufacturers to include different formulations in poppers products. Users have reported the reformulated products often cause an intense headache, ‘blue lips’ and a characteristic chesty cough in the days after use. The Lancet attributes ‘poppers maculopathy’ to the reformulated product.[ii]

This highlights the risk of product substitution posed by any ban. Following the EU and Canadian regulatory action, alternative products have been brought to market. These are packaged in aerosol cans. These are not nitrite inhalants and their mechanism is effectively the same as paint-sniffing. These products would not be captured by the proposed ban, and indeed the proposed ban is highly likely to increase the market for such products.

Poppers have been in use for nearly five decades with very few reports of serious harm, and recent case reports describe a previously undocumented form of harm. This suggests the harm is the result of the reformulated products, which were only adopted due to regulatory action. Banning nitrite inhalants as a class will have a significant impact on the capability of many gay men to achieve sexual pleasure and intimacy without pain and discomfort. In addition, it will expose a historically marginalised, stigmatised and criminalised community to a new vulnerability to criminal prosecution.

A more targeted ban, leaving long-standing formulations legal, would reduce the risks of rare but serious clinical harms, and prevent the import and widespread uptake of copycat products whose risks are substantially unknown.

Yours sincerely,

Daniel Reeders BA LLB (Melb) Grad Dip Pub Hlth (Flin)

[i] Home Affairs Committee, Psychoactive Substances (report), London: Stationery Office, 23 Oct 2015, p. 14 https://publications.parliament.uk/pa/cm201516/cmselect/cmhaff/361/361.pdf

[ii] Gruener, Anna M., Megan A. R. Jeffries, Zine El Housseini, and Laurence Whitefield. “Poppers Maculopathy.” The Lancet 384, no. 9954 (November 1, 2014): 1606. https://doi.org/10.1016/S0140-6736(14)60887-4.

 

Making trouble within the discursive ecology of HIV

Last night ACON held its second ‘State of Play’ forum at the Colombian, which offers the gay community in Sydney an update every six months on the changing epidemiology and emerging issues around HIV and STIs.

In my last post I highlighted an emerging inequity around HIV prevention, where new infections have dropped 43% in Australian-born MSM but risen 13% in overseas-born MSM. There’s evidence this is due to inequities in PrEP awareness, access and uptake.

chuttersnap on unsplash

Something I missed in my last post is that overseas-born MSM now exceed Australian-born MSM in raw numbers of diagnoses.

Continue reading “Making trouble within the discursive ecology of HIV”

We are creating new inequities around PrEP

When the debate about public funding for PrEP started up, I was concerned that it would go down the same path as PEP — with a set pool of funding, left to state/territory governments to administer, with de facto rationing based on sexual risk, and only available from a set number of locations. So my own position on PrEP was that it needed to be funded via the Pharmaceutical Benefits Scheme (PBS) and not rationed.

In the meantime, gay and bisexual men had two choices: importing generic medication from overseas or joining a PrEP trial like EPIC-NSW. (Full disclosure: I’ve done both. I’ve also worked on projects funded by Gilead. See my disclosures.)

A huge win in the fight against HIV/AIDS?

Australian PrEP distributor Dynamix International recently sponsored the magnificent ‘In bed with U=U’ campaign by TIM, featuring my gorgeous friends Mark, Davey and Ed, as well as an associated speaking tour with superstar advocate Bruce Richman from the Prevention Access Campaign.

At the Sydney leg of the tour, Dynamix founder Phil Joffe announced he’d been able to negotiate the cheapest price to import generic PrEP in Australia — $27/mo. This has provoked PAN to seek a better offer from its own recommended supplier.

Market forces, woo. 🙃

So I was bemused this week to see community orgs trumpeting a ‘huge victory’ in securing PBS listing for PrEP from 1st April. The mandatory PBS copayment is $39.50, or $6.40 if you receive a Centrelink payment and have a healthcare card (HCC).

We don’t know exactly what deal the government struck with the pharmaceutical companies, but the PBS advisory committed recommended a ceiling price of $240 per month. So consumers can pay more than the price to import generic medication from overseas, and it’s possible the government pays more on top of that. This problem isn’t specific to PrEP — this is a problem with the PBS copayment and the terrible deals Australia strikes with pharma companies. (Thanks Jonathan Nolan for that reference.)

This isn’t universal healthcare: it’s residualism — making public-funded PrEP available to people on a Centrelink payment and letting the free market sort out affordable access for everyone else. You can’t even get a rebate from private health insurance, because they only reimburse amounts above the PBS non-concessional copayment.

The response of some PrEP advocates on this issue has been disappointing. ‘It’s only $40 and if you care about your health you’ll pay it.’

As a PhD student I’m not eligible for Centrelink benefits, thanks to the Howard government. I get a stipend of $27K, which is a grand every fortnight — double what someone on Newstart gets. I’m living in Sydney while I do fieldwork, and for a while there I was paying 50% of my income on rent. I’ve written about living with major depression and complex trauma, and the marriage plebiscite did not help with that at all.

I have scripts for three medications — an anti-depressant, sleeping tablets, and a proton pump inhibitor. I routinely don’t get the second two scripts filled, and I put off appointments with medical specialists, because I can’t afford them. Caring for my health doesn’t change my bank balance.

There will be many people in the same situation — people on incomes too high to qualify for a healthcare card, but below a liveable wage. I’m only able to access PrEP because the EPIC-NSW trial exists.

Eliminating HIV depends on widespread access to free PrEP

Free access to PrEP via the EPIC-NSW trial has led to a 41% decrease in new HIV diagnoses among people who had good access to information about PrEP (i.e. not Aboriginal people or people born overseas). A similar drop occurred in London, although Public Health England immediately claimed this reflected early testing and early treatment for people living with HIV.

Why do I attribute that drop to PrEP? Because we saw years without any change in rates of diagnosis under a New South Wales (NSW) HIV strategy that emphasised early testing and treatment. This is confirmed by an epidemiological study presented at CROI.

Clearly, the priority for prevention strategy is making PrEP widely available for free.

In case it sounds like I’m bashing NSW, I’m not. The only reason we’re able to monitor the effectiveness of different strategies for HIV prevention in NSW is because the NSW state government committed to an ambitious and accountable prevention strategy known as Ending HIV. Targets for reduction were built into the KPIs for senior health department decision-makers, creating incentives to act. As the saying goes, ‘what gets measured gets managed’, and NSW is releasing and acting on timely data.

By contrast, the Victorian Department of Health and Human Services hasn’t made an annual BBV/STI monitoring report available on its website since 2013.

If we are serious about community ‘ownership’ of the HIV response, how is this possible when measures of prevention performance are kept secret?

We are seeing new inequities emerging around PrEP

Simply put, inequities are differences in health outcomes between groups that are preventable and therefore unfair (Whitehead 2001, cited in Braveman 2011).

When I write about preventing inequities in the gay community, people don’t get it. They feel hurt that I’m focusing on the gaps rather than acknowledging the great work they’re doing. They call me a hater.

Here’s the thing: inequities emerge because we do great work that is more easily accessible by some groups than others.

The fundamental causes of disease model suggests that inequities in health arise because some groups have more access to ‘flexible’ resources like money, literacy, education and prestige, so they can take up new opportunities for health quicker than others who have less of those resources (Link & Phelan, 1995).

This dynamic shows up again and again. It’s particularly obvious with the cancer screening programs introduced in the 1990s. And the NSW data on HIV infections shows it happening with PrEP.

In particular, overseas-born gay and bisexual men saw a 13% increase in HIV diagnoses in NSW in 2017 compared to the six-year average for this group. The 2017 data report concludes ‘PrEP uptake continues to expand, but work is needed to increase access for overseas born MSM.’

We saw this coming

I conducted community-based research on the sexual health needs of culturally diverse men who have sex with men in 2010 and the sexual and reproductive health needs of international students in 2012. I wasn’t the first to write about it — I was following in the footsteps of Maria Pallotta-Chiarolli in 1998 and Limin Mao with the Asian Gay Community Periodic Survey in 1999 and 2002. (That study restarted again recently.)

One of my own findings keeps needling my conscience. International students have much lower rates of HIV testing. Only 1/3 of international students apply for Australian permanent residence. Based on diagnoses in students applying for permanent residence Australia, I estimated that every year my home state of Victoria sends up to 18 students home with undiagnosed HIV.

It’s not a matter of translating some resources and putting them on a website or in clinic waiting rooms. It requires dedicated funding for campaigns and proactive community engagement and outreach.

(You know, the kind the marriage equality campaign didn’t do, with the result that ethnic and migrant communities got tagged, yet again, as inherently homophobic — when no attempt was made to change their hearts and minds.)

I am beyond frustrated with our failure to anticipate these inequities, to take them seriously until they show up in ‘the numbers’. And these are just the groups we count: activist movements like PASH.tm are still fighting for the right of trans MSM to be counted, accurately or in some cases at all.

There is every sign that ACON in New South Wales is already responding to the changing insights available from the epidemiology. Victoria should take note. And our next national HIV strategy better bloody emphasise widespread access to free PrEP.

Anyhow, let me end on an optimistic, inspiring and frankly emotional note with this gorgeous message from Mexican-American and Australian writer Ed Moreno.

An epidemic of bullshit – new in Overland

Two or three times a year, there’ll be a major conference on sexual health, or a report released on how many new sexually transmitted infections – STI for short – were diagnosed in the previous year. Usually there’s an up-tick in something and media coverage follows like, well, clockwork. Just as predictable are the narratives invoked to contextualise the findings.

recent article by Aisha Dow is a case in point: along with online dating and hookup apps, the article suggests that ‘complacency as a result of improvements to HIV treatment, decreased condom use and more young people travelling overseas could also play a part.’

For a long time I assumed the clinicians and epidemiologists offering these explanations were playing out a cunning media strategy. Now, I’ve come to believe they just don’t read any social research. They offer journalists the same explanations they themselves have read in the newspapers – contributing to an unchecked epidemic of bullshit.

Continue reading at Overland

L0059461 'The easy girlfriend', poster, England, 1943-1944Image credit: Reginald Mount, ‘The easy girlfriend’ (poster), Norwich: Her Majesty’s Stationery Office, 1943-44. This file comes from Wellcome Images, a website operated by Wellcome Trust, a global charitable foundation based in the United Kingdom. Refer to Wellcome blog post (archive).

Small bites (Jan ’18)

Highlights from my week on the interwebs

Victoria’s model of community visitors should be retained (The Age, 30 Dec 17)

John Chesterman, a long-time community visitor and Acting Public Advocate, offers a compelling argument for retaining the Victorian approach to a scheme that exists in a range of different models in different states and territories.

The proposed safeguards prioritise consumer protections such as complaint mechanisms, which are fine if you have the ability and confidence to voice your concerns.

These protections will certainly be important, but they are not enough. Nothing beats being able to say: “Well, we were at that house last week and Louise’s plan may well say she is supposed to go bowling, but she didn’t go bowling. She was at the house.”

This is a really nice example of The Age doing what it does best.

Does the ‘African youth crime’ panic sound familiar to you? It should.

The LNP opposition, the Labor government, the Herald-Sun and The Age have been falling over themselves to condemn ‘African youth crime’ in Victoria.

As Calla Wahlquist points out, the reality is more complicated (The Guardian, 3 Jan 18).  But trying to counter panic with facts is like bringing a banana to a knife fight.

Stopping a panic depends on telling a more compelling story. Here’s John Birmingham, writing in 2000 about the ‘Asian gangs’ panic of the 1990s:

When the first stories of (Vietnamese gang) the 5T were being laid out at the (DailyTelegraph and the (Sydney MorningHerald, the gangs were little more than groups of unemployed Vietnamese teens who had slipped through the net of the secondary school system and often had no close family to rely on. Coming from refugee camps in Hong Kong where 2000 children were kept under armed guard for months without seeing daylight, they may never have been in school. Some had seen their families killed. They arrived in Sydney, were given a few months English training if they were very lucky, then set loose to fend for themselves. April Pham, a youth worker in Cabramatta, told me that they didn’t think of themselves as having ‘low self-esteem’. They just thought of their lives as shit. They could not even cope with welfare. In March 1991, during a deep recession, the Bankstown, Cabramatta, Fairfield, Marrickville and Campsie social security officers combined had only two Indochinese aged between sixteen and eighteen receiving job search allowance. ‘Half the kids don’t have any income,’ said April. ‘The dole is a huge hassle. We virtually have to drag them in there. They live off and with their friends, a dozen in a one-bedroom flat. They share expenses. If one has fifty dollars, everyone gets it.’

This was the 5T in its earliest days. But even bullshit has a critical mass and past that point it becomes self-generating. Cut off from any other source of identity, the loudest message those young Vietnamese had beamed at them was ‘street gangs’. If they ever sat on the floor of their dismal unfurnished flats and wondered what this strange new country expected of them, they need only attend to their media image. Unfortunately that particular fantasy was powered by an alternating current. Just as the symbol of a powerful underground teen-mafia explained the suburban catastrophe of drug-fuelled crime — and offered salvation through the symbol of an unshackled police force waging their War on Drugs with a nuclear armoury of supercharged drug laws — so too did it provide a reassuring myth for their notional enemy (the 5T). Cast adrift in an alien world which obviously distrusted and feared them, the rootless beta-version outlaws were presented with an expertly crafted narrative of their own power and significance. They weren’t sloughed off failures. They weren’t pathetic. They weren’t doomed. They were the 5T. And though they might walk in the valley of the shadow of death they would fear no evil because they were the baddest motherfuckers in the valley. I mean, really, what did everyone expect them to do? Get a haircut and a job flipping patties at McDonalds?

John Birmingham (@JohnBirmingham), Leviathan Sydney: Vintage, 2000, p427-8.

I’ve written before on this blog about the role narratives and feature journalism can play in showing the linkages between the micro (incidents of crime) with the meso (lack of meaning and life opportunities) and macro (structural racism) perspectives.

These narratives are almost exclusively found in The Age — the Herald-Sun‘s tabloid format and style mitigate strongly against them. But lately Fairfax seems to have been chasing the Herald-Sun’s right-wing readership. This is a doomed effort: nobody can compete with News Corp on sensationalism, and it will hasten the exodus of its historically progressive readership over to the ABC and The Guardian.

Call Me By Your Name — a hot take

This film could have been an hour shorter, and all the better for it, if it had cut out all the butt shots (i.e. the whole first half). There’s no chemistry between the two leads, Timothée Chalamet and Armie Hammer, and for a teenage romance that’s inexcusable. The counter-narrative of straight sex and seduction highlights the timidity and sterility of the queer encounter at the heart of the film. Go and (re-)watch Moonlight instead.

Listening: Asgeir ‘In Silence’ album

I came late to this and it’s romance at its best. The English version is great — musician John Grant reportedly helped out — but the Icelandic originals are otherworldly.

Small Bites

Highlights from my week on the interwebs

People who score lower on a measure of social class tend to score higher on a measure of ‘wise reasoning’ in situations of conflict (Science, 20 Dec 17)

“people who grow up in a working-class environment have to rely on shared, communal resources more than people in the middle class, and therefore hone social techniques that smooth out conflicts with their peers. Those in the middle class, in contrast, tend to focus on education, which improves their IQ scores, but they don’t put nearly as much effort into conflict resolution skills…”

These are provocative findings and I’m not 100% sold on the explanation offered for them — but I do wonder if they can be generalised to wise reasoning in policy-making!

There is no such thing as Western civilisation (The Guardian, 9 Nov 16)

Kwame Anthony Appiah’s second BBC Reith lecture confronts the ‘clash of civilisations’ narrative. (Hat tip Chris Lemoh for this.)

In the centuries that Petrarch called the Dark Ages, when Christian Europe made little contribution to the study of Greek classical philosophy, and many of the texts were lost, these works were preserved by Muslim scholars. Much of our modern understanding of classical philosophy among the ancient Greeks we have only because those texts were recovered by European scholars in the Renaissance from the Arabs. […] So the classical traditions that are meant to distinguish western civilisation from the inheritors of the caliphates are actually a point of kinship with them.

This is a nice piece in which empiricism confounds essentialising claims to continuity:

What was England like in the days of Chaucer, father of English literature, who died more than 600 years ago? Take whatever you think was distinctive of it, whatever combination of customs, ideas, and material things that made England characteristically English then. Whatever you choose to distinguish Englishness now, it isn’t going to be that.

Many different causes for and pathways through bipolar disorder 

Remember in the 1990s we used to talk about finding ‘the gene’ for _________? Autism, homosexuality, overweight, criminality, you name it. But hunting for single causes in a complex world is a fruitless game.

A review of findings from a large cohort study of people with bipolar disorders took a ‘causal pluralist’ approach, finding that no single gene predicts onset, causal pathways interweave genetics and lived experience, and the trajectory of the disorder is not bipolar but multidimensional. See: press release; published article [open access]

Listening to: Zola Blood, ‘Infinite Games’ album (2017)