Search as a journey

Project Info Literacy:
Why is search so difficult for college students, especially the first few steps of search?

Peter Morville:
This finding is emblematic of the intimate relationship between search, learning, and decision making, and it brings to mind the paradox of choice. After all, the search box offers unrivaled selection. You can ask it any question. Or at least it often feels that way. For a student, this freedom can be simultaneously exhilarating and totally paralyzing.

Also, most students lack a useful mental model of search. They don’t know how search works or what’s being searched, which may be fine for casual Googling but not for navigating dozens of research databases.

Finally, selecting a topic is inherently difficult. It’s like buying a house or finding a spouse. The process is fuzzy and uncomfortable because we’re not sure what we want. So, all too often, we procrastinate. We wait until the last minute to begin, which is a shame because getting started is half the battle.

The key is to recognize that search can be an iterative, interactive journey of discovery that not only helps us find what we need but also lets us learn what we want to find. When we embrace this more playful model of exploratory search, it’s not so hard to get started.  (source)

Reflecting on medical socialisation

My dad is a sociology lecturer.  When I was a kid, he used to bring me and my brother to work quite often.  So I’ve never had any illusions about how unglamorous an academic’s working life can be.  But there’s one part of it that appeals to me, deeply — teaching.

A few years ago, when Dad started tutoring in a health sociology subject for first-year med students, he began inviting me along, once a year, to run a scenario or hypothetical for his classes.

Total nepotism, but not too dodgy, since I don’t get paid, apart from the enjoyment I get from doing ‘bring your kid to work day’ at 30 years of age.

This week, I presented a scenario on hep B, which is almost non-existent in Anglo-Australians but prevalent around 10-12% in South-East Asian migrants.

I gave students background information on hep B in Australia and asked students to imagine themselves as GPs from clinics with many culturally diverse patients, invited to present their perspective at a consultation forum intended to plan a collaborative multi-disciplinary response to the hep B epidemic in Victoria.

The scenario is pretty true to life — right now, there are working groups and committed practitioners in different disciplines, working to ‘agenda set’ hep B as a priority, or in other words, construct it as a problem in sector discourse.

Note for the positivists: in cultural analysis, ‘constructed’ does not mean ‘not real’; we argue all real things are constructed symbolically, since (to drop into biological essentialism for a moment) everything we know is only available to us through perceptual processes that are highly shaped by mental frameworks and past experience, including socialisation in ideologies like positivism.

One of the challenges in building that multi-disciplinary response is the fact that we speak in different professional languages.

And there’s another layer of our communication, i.e. affect, that seems (in some undefined way) to be really essential to the formation of consensus between players who are all on the same team with regard to getting shit done about hep B.

The idea that you might customise your argument and speak in the same language as the people you are trying to persuade is, to a counsellor or health promotion worker, kind of ‘well, der’.

But it’s less comfortable for some other professions, who see themselves as talking in the neutral, objective language of Science.

Recently I had a disagreement with a doctor — a hero of mine, someone who has done more than anybody else to build evidence and raise awareness around hep B — and it ended with him implying I wanted to ‘ignore people unnecessarily dying’.

Ouch.

People sometimes struggle to customise their arguments because they have an implicit expectation of emotional matching, i.e. that the language and imagery will express the intensity of how they feel about the subject matter.

You see this every time public health practitioners launch a hideously stigmatising fear campaign, despite all the evidence showing that fear campaigns backfire, and then seem all surprised and wounded when the community doesn’t appreciate their sincerity.

In my scenario with the med students, I asked five questions:

  1. What ONE key message would you want to communicate?  (Picking an issue or angle from the scenario text.)
  2. What is our role as doctors participating in a multi-disciplinary consultation?
  3. Which disciplines will be easy to convince, and which harder?
  4. How can we customise our argument to persuade participants from other disciplines?
  5. Which of the readings offered the best framework for identifying barriers to access and possible solutions?

First-year med students are not representative of doctors, because the bulk and most intensive parts of their professional socialization are yet to come.

But it was striking how easily the students accepted the idea that hep B had been pretty much ignored just because it mainly affected an ethnic minority population.

For me, that realisation marked the point when I converted from being professionally interested in hep B to being personally outraged about it.

(The affective dimension, once again.)

But for the med students, it seemed the idea that minority status led to poor health outcomes had been thoroughly naturalised, and there was no outrage.

Maybe that’s an unintended consequence of teaching health sociology to first years?  (Discuss.)

Out of ten small groups, one group (in the first class) did identify ‘frustration’ as part of their key message for the consultation (and I nearly cheered).

Others saw their role as representing the experiences and needs of marginalised communities, contributing practical wisdom from their clinical experience, and acting as intermediaries between public health and everyday people.  (All sophisticated answers.)

In our whole-group discussion, they clearly understood the ethical and empirical difficulties inherent in ‘representing the other’.

As I expected, when it came to customising the message, personality had a strong influence on the communication approaches they preferred.

A couple of extremely bright analytical thinkers, two guys who had wanted all sorts of extra information about hep B before making up their minds, recommended we use statistics to persuade the rational-minded health workers.  One suggested we persuade the higher-up decision-makers, ‘because then everyone else will have to follow’.

By contrast, another couple suggested figuring out what our hypothetical consultation participants’ underlying objectives were, and customising our arguments to those, as well as the policy level on which they worked.

The second class had quite a different group culture, dominated by the cool kids on the middle table, and despite their rebellious stylings, their answers were a lot more formulaic.

Message: community awareness. Our role: medical experts.  Yawn.

Six weeks into first year, some were already beginning to feel aggrieved about ‘doctor-bashing’, and while they could easily imagine perverse incentives for drug companies (“there’s more profit in not finding a cure!”) they had a harder time imagining the same motives influencing medical specialists.

They nonetheless understood that different forms of knowledge are more or less persuasive for different professions and personalities, such as cost-benefit analyses for public health, real life stories for frontline workers, and emotional matching for change agents.

And they quickly understood how getting comfortable in a certain level of discursive power could prevent someone from acknowledging their ‘unknown unknowns’, along with the role of sociological analysis in helping them understand how medical socialization produces tacit  but influential ‘unknown knowns’.

Then we briefly discussed the usefulness of different readings on access, equity and health needs for the hep B consultation.

My argument about sociology was fairly pragmatic.  Being able to analyse your own and others’ disciplinary frameworks can make it easier to diagnose the sticking points in your communication attempts.

Choice of theory is heavily influenced by your personality, and as long as it works (and you check if it does) there is no need to get uptight or religious about it.

This is all very preliminary — more thoughts to follow as they organise themselves in my head! — but I’m really curious whether final year med students would have the same kind of responses to the scenario.

Building the evidence

On Friday, I presented at an interstate talkfest on HIV in culturally diverse communities.

The pre-reading for the meeting was heavy with public health strategies focused very tightly on disease reduction, and a mammoth epi report, analysing results from surveillance of HIV notifications, behavioural surveys, and mathematical modelling.

Despite having a massive committee and a very prescriptive action plan, it seemed that, aside from one very capable and energetic agency, actual action had almost come to a standstill.  The workshop was intended to revitalise it, but its title and main objective was “building the evidence”.

Does lack of evidence cause inaction?

I had only eight minutes to describe findings from our consultation report, and answer three questions posed by the organisers — not a lot of time, and not enough for reflection on the knowledge practices involved.  But I managed to squeeze in a provocative suggestion, and I was delighted when it was picked up in question time.

I suggested that health promotion planning is not especially sensitive to variations in the epidemiology.

In other words, whether epi reports there are 10 or 20 new infections in a particular cultural group — double the amount, 100% difference in statistical terms — I’m still going to propose broadly the same plan of action in response.

We’ll hire a project worker, identify partners, convene a reference group, review the literature, undertake community consultation, do some rapid assessment of the causes and most useful activities/messages/channels to use, do the work and then report back on how it went.

Knowing the number of new infections is much less important than knowing the size of the group, and developing a close understanding of what resources exist in that group in our state for undertaking health promotion work.

  • There’s no use planning a social marketing campaign if the target group is really spread out geographically and have no common media channels (like newspapers and radio programs) and habits (like reading and listening to them) and related skills (like print, media and health literacies for reading and learning from social marketing campaigns).
  • There’s no use proposing a key opinion leaders approach if the community is so new or disorganised that it has no institutions and structures for leadership and communication.

That kind of knowledge makes a HUGE difference in health promotion planning; stats on numbers of new infections, not so much.

I pointed this out in my presentation, and sure enough, in question time, there came the obvious objection, from an epidemiologist who does a lot of interesting work in mathematical modelling.

We have to ‘live in the real world’, he said, ‘we can’t ignore the epidemiology’.

Not really what I called for.

Where those stats make a big difference is in public health.  Government funding is the ultimate zero sum game, and epi helps decision-makers objectively assign priority to competing worthy causes.  It is a hugely important tool in rational government. Around the world, where governments have ignored the epi and funded politically convenient work, HIV epidemics have exploded.

And while I’ve said that epi isn’t always terribly relevant for health promotion planning, I still read every paper and every report, cover to cover, and squeeze every last drop of meaning and use out of it. The key thing is where I use it — in my funding submissions and advocacy to government.

I want to draw a strong distinction between (1) health promotion and (2) public health.  They are not the same thing, and shouldn’t be conflated.  They have different vocabularies, pointing to different underlying concepts and philosophies, and they focus on different levels.

Obviously they are connected – since public health people fund health promotion workers.  In spaces where they overlap, however, like the talkfest I was at, you can pretty quickly see communication problems arising between the two different languages.

It’s a problem of articulation – in two senses: how we find the terms to express ourselves, and how our discourses (the languages of our disciplines) can join together and mesh at their points of connection to transmit power.

Power in this case means funding for work, but it can also mean domination, where one can override the other, and alternatively it can mean trust, where two groups who use different language and knowledge practices can still work together effectively.

Epi and behavioural surveillance are vital for the public health functions of commissioning, monitoring and evaluating health promotion activities and outcomes.  As I’ve argued here, health promotion people should know about them, but the inputs into our planning need to be broader.

Culturally diverse communities are mostly migrants, whether temporary (international students, casual workers and visitors) or permanent (skilled migration, family reunion, and humanitarian entrants), and migration patterns change all the time.

Health promotion in this area requires a process of continuous rapid assessment, and instead of dismissing this because it doesn’t look like formal epidemiology, we need to borrow principles for assessing and improving its rigour and validity from qualitative methodologies.

We also need better recognition of the difference in languages, concepts and inputs used by public health and health promotion, and the need for careful and respectful engagement at points where they interface with each other.

Without it, decision-makers and researchers will be left to hold talkfest events, to scratch their heads and wonder why their ‘evidence’ never makes it into practice.

A core theme for stigma work

This is a two-part post. Click to read the first part, Strategies to tackle stigma.

Part 1 sets up the challenges for anti-stigma project work:

  • for attitudes to change you have to make people think
  • getting from a message to a movement
  • finding a theme that’s relevant to very diverse groups

This post is about finding that cross-cutting theme. I have one in mind, but since this is a blog about prevention strategy, I don’t want to present it like some grand auteurish insight; I want to show how it fits together with findings from the various disciplines a good educational practitioner works across.

There’s an anti-stigma campaign targeting gay men in the federal pipeline, and it’s based on unusually thorough market research into the experience and practice of HIV stigma among gay men – pos and neg, young and old, in different cities around Australia.

But the prospects of research and campaign work addressing HIV stigma in all the other communities and groups affected by it are pretty slim, unless the issue is taken up at a state level.  That’s not unreasonable, either — the smaller groups are so diverse it’s essential to craft interventions with local knowledge, rather than picking up strategies defined elsewhere.

Research with migrant communities in Victoria has shown HIV stigma is both prevalent and highly influential.  It often takes the form of ‘extra knowledge’, layered on top of otherwise accurate knowledge of HIV transmission routes, associating HIV infection with immoral behaviour (Lemoh, 2006).

In African, Middle Eastern and South-East Asian communities, people have used stigma to avoid feeling personally vulnerable to infection (McNally & Dutertre, 2006).  In other words, they ‘other’ infection risk, and perceive low personal relevance in HIV prevention materials.

At the same time, on becoming aware that someone in their community is HIV-positive, they may ‘play up’ fears of contamination through casual contact such as sharing food, hugging and kissing.  In focus groups I have conducted, participants — riled up by learning that immigration health screening doesn’t exclude all HIV-positive applicants — called for public identification and/or quarantine of  PLHIV for their protection.

So stigma is practiced in both gay white men and culturally diverse heterosexuals.  Shouldn’t be too much of a problem to frame a message that discourages stigma in both groups, right?

When writers, advocates and activists talk about ‘stigma’, they often don’t give a definition of it, assuming instead there’s a single phenomenon called stigma and we all understand what they are referring to.

This is a big problem, because it turns ‘stigma’ into a buzzword — a concept loaded with political force but lacking in analytical power.  When you use it that way, you express an evaluation or judgment, but it doesn’t convey anything specific or detailed about the situation.

And the specific detail matters enormously because stigma comes in many different shapes and forms.

Let me give an example.  A research study in Tanzania used interviews to investigate the experience and practice of HIV stigma around the time that ART was being rolled out.

As PLHIV got access to lifesaving medication, the story of stigma changed, from shame (e.g. ‘slowly dying PLHIV are a burden on their families’) to blame (e.g. ‘PLHIV are a threat to our safety and should be quarantined’).

This shows that stigma is not a homogeneous practice, and knowing the specific details of how stigma works in a particular community or setting is essential for effectively reducing it.

A generic appeal (e.g. ‘be nice to PLHIV’) might have been effective in reducing shame stigma, but it would fail against blame stigma, and apart from simply restating the problem, the common formulation ‘HIV doesn’t discriminate, people do’ might have increased the fear of infection that underpinned the blame story of stigma.

This narrative shift, from a dying/victim/shame story to a surviving/threat/blame story, in my view explains the resurgent interest in punitive strategies for regulating HIV-positive sexuality that we’ve seen around the world since 2000.  These strategies have included criminal prosecution and the moral panic against barebacking and its mythical variants in gay community and the mainstream media.

So I have another challenge:

  • define stigma (and identify the local ‘stories of stigma’)

Here’s my definition:

Stigma involves (1) selection and labelling of a difference, (2) stereotyping people who are different in that way, (3) us-and-them thinking, (4) status loss and discrimination, enabled by (5) power relations (Link & Phelan, 2001). Stigma reproduces the social structure that marginalises minority groups (Parker & Aggleton, 2004).

Link & Phelan (2001) set out to provide an exclusive definition, so if some social practice doesn’t embody all five components, it’s probably not stigma.

  • Poz men serosorting so they can bareback safely?  Not stigma, because it’s based on prevention objectives rather than nasty stereotypes of neg men.
  • A neg man rejecting a poz guy because he’s afraid of HIV infection?  Not necessarily stigma, either, if he takes responsibility for his fears and he’s not basing his decision on stereotypes of poz men.
  • Prosecuting someone who deliberately sets out to pass on HIV?  Not an expression of stigma if it intends to give redress to someone who was deliberately or deceptively injured, but it will almost certainly contribute to the stereotyping component of stigma.

This definition is not perfect — there will be times when we want a more inclusive and broad-ranging definition, such as the one offered by Parker & Aggleton (2004) that I normally include as a supplement.

And Link & Phelan are trained as social psychologists, a discipline that tends to assume its concepts are universally valid across cultures.  (Dun dun DUN!)

It also assumes that ‘what can’t be measured doesn’t exist’.  As a statement of materialism, that’s unobjectionable, but in the social sciences it sometimes turns into ‘what we don’t yet know how to measure doesn’t exist’.  And when people assume their concepts are universally valid, it becomes ‘differences we haven’t even bothered to look for don’t exist’.  And that’s kind of the case with social psychological research into HIV stigma; it generally hasn’t considered whether and how it might be cross-culturally variable.

Research into moral reasoning has shown empirically that it is cross-culturally variable (Haidt, Koller & Dias, 1993).  Across cultures, however, it tends to combine — in different proportions — the same five foundational intuitions:

  • Harm/Care
  • Fairness/Reciprocity
  • Ingroup/Loyalty
  • Authority/Respect
  • Purity/Sanctity (Haidt & Joseph, 2004).

The nice thing about this research is that it’s not a philosophical argument about how people should reason morally; it describes how they do.  I’ve never seen it applied to stigma before;  morality is one of those topics that social psychologists have dismissed as unmeasurable, and some bleeding hearts have argued that judgment in general is problematic and stigmatising.

Recasting Link & Phelan’s stigma definition in terms of Haidt’s moral theory, it seems that:

  1. Purity norms trigger Ingroup norms: stereotyping PLHIV as unclean leads to othering (us-and-them thinking);
  2. Harm prevention is offered as a socially-acceptable ‘cover story’;
  3. Disease is Fair consequence for not following Authority (social norms).

For me as a practitioner, this reframing gets me a lot closer to understanding what’s actually happening when CALD communities practice disease stigma:

If someone was a carrier of such disease it would mean: be careful when you come near me as I am an outlaw. Therefore no one would want to be in such situation and deprived of all protection and rights. (Vietnamese married man, quoted in McNally & Dutertre, 2006, p158).

In this way of practicing stigma, the stakes are a lot higher.  It goes right to your moral status as a person, and it’s permanent.

The Vietnamese IDU interviewed in that study didn’t seem to care about their health, and that sounded to me like they felt their own moral worth was forfeit now they could no longer hide their use of illicit drugs.

By contrast, in the West, it is often assumed and argued that coming out is both the central strategy and key objective of our community politics and stigma reduction work.

That just isn’t going to fly for a single, African man living with HIV and TB, who’s afraid to leave his council housing flat to see a doctor or go to the supermarket in case somebody figures out he’s ill.  He thinks his life is over, and he’s afraid (to the point of paranoia) of social contact, which is what we need to make us feel human.  Stigma for him means solitary confinement.

We can do two things here.  One is trying to reduce the practice of stigma.  The other is supporting the people who experience stigma to deal with it.

For both things, I think the place to start is step (1) above — challenging the invocation of Purity norms against people living with blood-borne viruses.

‘Unclean’ is a cross-culturally relevant metaphor for stigma. Off the top of my head, here’s a not very systematic list of examples:

  • PLHIV talk about how a positive diagnosis made them feel dirty
  • Gay men ask ‘are you clean?’
  • Erving Goffman talked about stigma as ‘spoiled’ identity
  • IDU and BBV educators alike talk about ‘clean’ needles
  • Hand-washing supposedly gives you a ‘clean(er) conscience‘ and it seems to have worked for Pontius Pilate
  • Someone who is corrupt is called ‘dirty’, while someone with no criminal record is called a ‘cleanskin’
  • In Islam and Judaism, food prohibitions is based on symbolic cleanliness, and cleaning is an essential ritual in most religions
  • In the Indian caste system, contact with the untouchable casts contaminates the holier castes and must be cleansed
  • Even in gay culture, sex onsite venues are frequently set up as bath-houses, enabling immediate cleanup after sex.

So that’s my thinking.  If you want a core theme for multi-issue/multi-group stigma work, critiquing the categorisation of people as clean/unclean  — however you tackle it — is the place to start.

Strategies to tackle stigma

Recently, I’ve been thinking about how you might tackle HIV stigma across a whole range of different groups, such as gay/bisexual men and heterosexuals, men and women, from White and diverse cultures, sex workers and injecting drug users and white picket fencers.

There have been some generic approaches, often making very broad appeals (“motherhood statements”) for dignity/respect.  I’m not fond of this approach, because it’s easy to agree without thinking to a general sentiment, and changing attitudes takes mental effort.

In other words, if you want social change, you need to get people thinking.  But you need to provoke a particular kind of thoughtful, attentive, seeing-both-sides mental state.

If you get people riled up emotionally, at some point they will shut down, dig in, get tunnel vision, and defend their positions. Tabloid and talkback journalism counts on that reaction. In fact, exposing misinformed people to factual corrections can sometimes make the initial beliefs even stronger.

The literature on stigma reduction is really clear that it’s not about ‘correcting myths’ with accurate information.  You really need people who practice stigma to rethink the social and emotional purposes that underpin their belief in the stereotypes.

Discussion groups are brilliant for this purpose, but you can’t put the entire population through six-week groups, 12 people at a time!

There have been social marketing campaigns against stigma, but I am skeptical about whether this approach can work;  reducing complex issues down to single-minded propositions tends to result in broad appeals (wishy-washy) or shock tactics (which backfire).

Where community-level interventions have worked, they have been multi-strategic and multi-level, using a social marketing campaign headlined by name-and-face personal narratives, backed up by community diffusion activities through opinion leaders and more localised opportunities for debate and discussion, and giving audience members some concrete action they can take to demonstrate their commitment.

All of that calls for time, effort, and resources, and if you take diffusion seriously, your intervention looks less like an ad campaign and more like a social change movement.  Does this sound familiar?  In Australia, think of thisisoz, and worldwide, Dan Savage’s It Gets Better project or the Obama campaign or the recent Egyptian revolution.

But don’t get carried away thinking the technology does the work.  What matters is whether your message makes people think.  You might create the greatest Facebook page in the world, but that’s not much use if people Like-and-forget it.

In Pt 2, I’ll talk about the message content, and a theme I think might work across all those different social groups I listed above.

New paradigms

I’m in Sydney, sampling a day of the Australian sexual health and HIV medicine conferences.  Most of the really exciting social research is presented these days at biomedical conferences, because they are prestigious.

Working in the community health sector, a day is all my PD budget can afford, unless I approach a pharmaceutical company to sponsor my attendance. It’s a big problem if community workers can’t afford to take part, because we need that knowledge too.

Graham Hart from University College London just gave an incredibly lucid presentation on the change in paradigm he’s seeing in HIV prevention.

Where research used to focus heavily on individual behaviour, and how it interacted with the biology of STI, now we’re looking at the behaviour (and structure) of people in groups, and the overall ecology of STI, plus time,  because epidemics change as they ‘mature’.

In the past decade, we’ve seen a very mild upward trend in the number of men who have unprotected sex with casual partners.  Hart puts up UK data showing about 20% of gay/bi men had this kind of sex in the previous year.

He puts up another slide showing the number of men who report ‘serosorting’ (deliberately choosing a partner who reports the same HIV status for unprotected sex) has increased from about 7 to about 18% in the past decade.

This he attributes to the impact of the Internet, although I’m told serosorting showed up in Australian data from the 1980’s — almost as soon as the HIV antibody test became available.  My guess is that serosorting is not, actually, a new development; having a name for the phenomenon is what’s new.

This is why we need a sociology of HIV prevention research and practice, since there are trends and patterns in how long-existing practices ‘in the real world’ get named and tagged as the ‘next big thing’ in HIV prevention.

In fact, Hart touches on this issue.  He talks us through a range of new approaches, including biomedical and ‘social structural’ interventions.

Biomedical techniques include circumcision, lubricating gels with anti-HIV ingredients, and pre-exposure prophylaxis (PrEP) which is basically taking PEP before you fuck unsafely.

Hart points out that even circumcision, the most effective biomedical intervention found to date, is less effective than consistent condom use.

He tells the audience, “don’t give up on condoms just yet.”

I couldn’t agree more.  With Ford Hickson, I’m very, very skeptical of the claim that “condoms are failing”.  Ford points out that people who say prevention is failing want it to fail so they can take the money and do it themselves.

(And not because they’re bad people.  That’s just a consequence of how funding processes put us in competition, not collaboration, with each other.)

Instead, our benchmark should be about 70-80% of gay/bisexual men practicing consistent condom use during casual sex… or maybe even most of the time. That’s about the best any country ever been achieved.

Setting that benchmark lets us ask how we divide up and target the rest.  Only 1-2% of them are the “barebackers” that 99-100% of media coverage and community debate has focused on.  The rest are just guys who occasionally have unprotected sex.

That includes me, by the way.  Once, ever.  With a guy in a sauna.  It was his first time being fucked.  We knew and liked each other.  I knew he was a consistent condom user with his other partners.

With these ‘occasional’ guys, as Michael Hurley says, the infrequency of the occasions is a marker of their general commitment to safe sex.

When it is infrequent, although there are fewer occasions of risk, the intensity of risk might actually increase, because those men have less practice in risk reduction techniques that can help prevent HIV transmission during unprotected sex.

And if it occurs without planning, they may not be prepared to ask questions about their partner’s history of occasional unprotected sex and sexual health testing.

There have been resources in Australia that talk about those ‘risk reduction’ techniques, such as HIV-Positive Gay Sex (AFAO), but nothing I know about that has talked honestly to gay men about occasional unprotected sex.

We really need to start doing that, and I’m hoping tomorrow’s policy forum on “HIV from Epidemic to Endemic” will help start that conversation.

In closing, I want to ask a provocative question.  It picks up on Hart’s message “don’t give up on condoms just yet.”  He wasn’t talking to gay men.  He was talking to an audience of people working in sexual health medicine: doctors, nurses, researchers, and policy people.

Here’s my question:  is it possible we might be pushing for biomedical interventions that are less effective than condoms just because professional audiences are bored by hearing about condoms?

Reply privileges

In my early twenties, that guy was me.  These days, I pick my battles.

At any given time, I have a lot on my mind or in my notebook, and not enough time/energy to write it up.  What I love about Facebook and blogging is that I get to talk to amazingly smart people, all around the world, about stuff we care about.

When someone misrepresents me, or tries to drag me off topic, they’re trying to waste my time on correcting them or fighting on multiple fronts.

In my head, people who do that lose their ‘reply privileges’.  Not their right to reply — which is endless — but their claim on my attention, time and energy.

If I post another message in the same thread, it will be for the audience, because I truly believe they’re smart enough to figure out what’s happening and discount it accordingly.  In gay men’s health, there’s so much we need to talk about, there’s just no point getting bogged down fighting old battles with people whose opinions are never going to change.

Reckless Young Gay Barebackers

Forgive me, please, but I am pissed off to the point of despair.

Doug Pollard, the original ‘Rainbow Reporter’ and for a gay news addict, the voice of God, posted this Guardian article on Facebook.

Simon Papson, an amateur thespian and semi-pro writer of aggrieved letters to the editor, had the following little moment of “I told you so” for yours truly…

No argument from me. I tried to make this very same point right here last year, and was shouted down by a friend of yours as being wrong. “Young gay men only want monogamy and safe sex,” he said. Hmph.

And when I called him on putting words in my mouth…

You didn’t use THOSE EXACT WORDS, but you strongly argued with me when I said the opposite. Even pointed to studies which confirmed that young men were looking only for monogamy and safe sex, to make your point. Any time I mentioned a significant sub-culture of casual unsafe sex among young gay men, you disputed its existence.

The irony here is that I got my head kicked in MCV for weeks by VAC after I raised concerns about HIV infection rates among young men – in particular the fact VAC waited until infection rates began to rise before investing in a prevention campaign that targeted younger gay men specifically.

The problem with what Papson said, in both cases, is the word ‘only’.

As I wrote here, young men have different, age-specific concerns about HIV and sex, relevant to the challenges they’re facing at that point in their lives.  Such as finding partners, forming relationships, dealing with monogamy and infidelity, and figuring out how to have safe, unprotected sex in relationships.

“Not invariably, but generally” <– what I said.

And yes, I cited more than one paper to support that argument.  It’s quite bizarre that people like Papson want to dismiss as unreliable all the research I cite and rely entirely on articles in non-scientific outlets like the Guardian.

Sorry, what the fuck?  How is that more reliable?

Let’s look at that Guardian article.  The headline does all the damage:  “Young gay men fuelling HIV epidemic, study warns”.  Unfortunately, that headline is a close derivative of the headline on the press release issued by the journal that’s publishing the study. The study article itself is not an easy read, so I’m going to try and summarise it in plain English here.

The study analysed the similarity of genetic code taken from HIV in blood samples from 519 HIV-positive patients at a clinic in Belgium over seven years.  This technique is called phylogenetic analysis.  Phylo- means ‘tree’ in Greek, and scientists are basically computing a viral ‘family tree’ showing whose infections are related.

In this study, they found quite a large number of ‘clusters’, where people had viruses similar enough to say they were related. The study found that men in those clusters were younger than men outside of clusters.

Not “young”.  Younger. The median age of those “younger” gay men was 36 years old, compared to 38 years in the non-cluster group.  (PDF p25).

Now, let me get back to Papson.  Papson offers a version of the RYGB meme.  That stands for Reckless Young Gay Barebackers.

When HIV infection rates first started rising, a number of commentators, from Steve Dow to Adam Carr, leapt to the intuitive but wrong conclusion that the rises were being driven by barebacking among young men who never lived through the AIDS crisis and therefore suffered from complacency.

It took a long time for the AIDS Council to get the message across that infections were happening among men in their thirties and forties, and they got their heads kicked repeatedly in the gay press all the while.

As a result, they developed a defensive, kneejerk response to any mention of young gay men and HIV risk, even from their own staff members.

The RYGB meme actually made it harder to raise awareness of the issues facing young gay men.

Papson’s no doubt patting himself on the back for fighting the good fight against a “sub-culture of casual unsafe sex” amongst young gay men;  meanwhile I’m banging my head against a desk…

Treatment as prevention: sustainability not stigma

Treatment as Prevention is the idea of treating PLHIV early and en masse, based on the slowly emerging consensus among medical researchers that HIV treatment reduces infectiousness. That consensus is an interesting story in its own right, since there’s not yet any new evidence to support it.

Based on a wildly unrealistic mathematical model — set in South Africa of all places — public health practitioners have been planning experimental trials of the TAP concept, and a recent post on Peripheries blog takes aim against stigma, cited as a major objection against treatment as prevention.

Intriguingly, the post states a couple of times that it’s not about stigma. Over the past three years I’ve been doing a fair bit of training and writing about how we conceptualise stigma in HIV prevention work, so I contacted the author to find out what he thought it really was about.

Continue reading “Treatment as prevention: sustainability not stigma”