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”

Communicating health risk in a context of uncertainty

In my writing about criminalisation and HIV stigma I have been strongly critical of the rational-individual ‘model’ (assumption) that underpins the health psychology and economics upon which so much of public health practice is based. I’ve argued we can learn a lot instead from behavioural economics and bounded rationality.

One of the biggest bounds (limits) on human rationality is the finite nature of what we know, especially with respect to what’s likely to happen in the future or about some newly-emerged and previously unknown problem or technology.

Nobel prize-winning research by Kahneman and Tversky (1979) developed ‘prospect theory’, which shows that in economic decisions, rather a lot depends upon how a prospect is framed — in particular in terms of whether it involves possible loss or gain.

There have been some rather clunky attempts to incorporate this insight into health promotion, such as by framing condom use in terms of what someone has to lose. It’s an important insight but it involves translating health behaviour into economic terms, which as Dan Ariely points out has a suppressive effect on social norms like altruism — not ideal!

Today and tomorrow, I’m attending the NCHSR Social Research Conference at the University of New South Wales. At this morning’s opening plenary, Alan Peterson from Monash University is presenting on communicating health risk in a context of uncertainty. He argues early framing of risks is influential upon subsequent responses: think about the panic about the high death rate in the early days of H1N1 flu in Mexico.

Continue reading “Communicating health risk in a context of uncertainty”

Tender, loving financial incentives

This week, an American public health practitioner posted on the US national AIDS blog about a new program starting up in the States. The program is called TLC-Plus, short for “Enhanced Testing, Linking into Care, Plus Treatment” for PLHIV. Here’s how the author, Carl Dieffenbach PhD, explained the need for that middle component, “linking into care” —

“Unfortunately, many people don’t make it to their follow-up medical visits for a variety of reasons. Yet these individuals can continue to spread the virus in their communities until we entice them to step through the door, whether it’s giving them a pat on the back or offering financial incentives.”

Continue reading “Tender, loving financial incentives”

Shining a light on campaign strategy

Who knew it could be so controversial calling for HIV prevention campaigns tailored for gay men under thirty?

I’m saying gay men under thirty have different prevention information needs, and good campaign strategy shouldn’t wait until infection rates begin rising before investing in campaigns tailored to meet those needs.

That’s just common sense, and not a very exciting news story, until the AIDS Council disagrees — and then there’s a fight and quick, everybody, gather round! Place your bets and let’s get ready to rumble… In yesterday’s edition of MCV, by Rachel Cook, I read:

‘”Anyone who understands anything about health promotion wouldn’t attempt to blame the ads,” Kennedy said. “We do not agree with Daniel’s analysis and his claim that VAC does nothing for young, gay men is just demonstrably false.”‘

I don’t blame the ads for rising infection rates, and I don’t claim VAC does nothing for young gay men. Putting words in my mouth doesn’t help Mike’s credibility in responding to my concerns.

The hostile response does illustrate why I don’t place much weight on the feedback VAC quotes in support of the porn image campaign’s relevance to men under thirty. When they react with such hostility to criticism, it’s little wonder they don’t hear it much.

In my case, it’s a massive overreaction, since I am broadly supportive of that campaign: infection rates have steadied in the age brackets it was designed for. I’m concerned about a lack of campaigns targeted for men under thirty, and the porn image campaign doesn’t cover them.

Apparently, when they’re not in the country, Mike Kennedy, Colin Batrouney (health promotion manager) and Jason Asselin (health educator) are happy to agree with me. For example:

Kennedy M, Batrouney C, Asselin J (2008) “Shining a light on gay anal sex: community reactions to an explicit campaign promoting condom use for anal sex with casual partnersAIDS 2008 XVII International AIDS Conference (Abstract THPE0387).

They describe holding “focus groups with the campaign’s target population, men in their 30s and 40s” and later conclude “prevention campaigns will need precise targeting and generalised campaigns will be less effective”.

In their own words, the campaign was not developed for (or focus tested with) men under thirty, campaigns need precise targeting, and you can’t rely on a single campaign to fit everybody.

Again, quoting Mike’s own words, the porn image campaign achieved only 40% recognition among men under thirty at Midsumma Carnival. (Okay, the “only” part is mine.)

Coming back to how VAC receives critical feedback: the abstract states “Community responses were generally very positive but an interesting subset of negative responses was demonstrably tapping into internalised homophobia triggered by images of gay sex in public media.”

This makes it clear the authors interpret positive feedback as the general rule and critical feedback as the exception. It concerns me that the Executive Director of an organisation that provides counselling feels it’s okay to diagnose internalised homophobia in men he’s never met, simply because they don’t identify with images/themes in a campaign, and to dismiss their responses on that basis.

Some audience members do experience internalised homophobia; in fact, it’s something we all struggle to overcome. Research by the American psychologists Michael Ross, Simon Rosser and colleagues (2008) in AIDS Education & Prevention has shown a strong connection between internalised homonegativity and increased rates of unsafe sex.

Kennedy, Batrouney & Asselin’s abstract admits the porn image campaign does not meet the needs of those men.

Continuing the theme of VAC not taking critical responses seriously, the abstract suggests “Campaign design should include draft responses to such negative criticism”. In other words, community debate is met with message management and canned public relations messages.

I’m going to conclude with a question: if Mike is right and there was no lack of campaigns targeting young men specifically, why did they just accept Department of Health funding to develop one?


Rising infections in gay men under 30

If current rates continue in 2009, new cases of HIV in gay men under 30 will be double their number in 2007. That goes against the overall trend for gay men in Victoria, which levelled off in 2008.

I have expressed concern in a couple of interviews about the lack of campaigns targeting gay men under thirty — I think the last one was in the nineties. That gets taken as an attack on the current Victorian AIDS Council campaign using porn images, but I actually think the plateau in overall infection rates shows the current mix of campaigns is doing good.

I also acknowledge the Victorian Government Department of Health for funding and coordinating a reinvigoration of our state’s HIV response.

While I think the explicit sexual imagery matches the sexual confidence and sophistication of men in their thirties and above, it doesn’t work as well with younger men, who are generally less confident, more conservative, and dealing with different issues, like coming out and the gay scene.

Not invariably, but generally.

That’s not just my opinion: it shows up in the social research. Garrett Prestage from the National Centre in HIV Clinical and Epidemiological Research has reported that while they have around the same total number of sexual partners as men in older age brackets, younger men tend to organise their sex lives differently, practicing “serial monogamy” (long strings of short, supposedly monogamous relationships).

Campaigns targeting young gay men need to include relationships and the scene as themes, and they need to address prevention issues relevant to guys in relationships.

Older men might remember the campaign advising men in relationships to close out the HIV test “window period” before they stopped using condoms with each other, but there hasn’t been a campaign about that since the nineties; how is a 23yo guy supposed to know that?

I feel quite uncomfortable raising the alarm about rising infection rates, because I don’t think infection rates should be the focus of campaign strategy in the first place.

The cultural processes that influence sexual behaviour are like a P&O cruise liner: they take a long time to stop. So by the time infection rates begin to rise, you’ve got a big job ahead of you, just trying to turn them around; and you are no longer doing prevention, only damage control.

In their report on The Contemporary Context of HIV Infection in Victoria, researchers Sean Slavin and Marian Pitts quote one young newly HIV-positive man saying:

Then I had my risk re-evaluation. I think a lot of people have it in
their early twenties. As a teenager I was really a safe sex fundamentalist. I redrew my risk profile a bit and started taking more mid-level risks, which were fine by themselves. They probably wouldn’t have caused me to convert. Then I started to top bareback. (p17)

Many of the attitudes our campaigns target in men aged 30 plus were formed in the intense sexual and social learning process men undergo in their twenties. It’s just good sense to invest in campaign work specifically targeting gay men under 30. I am only forced to make a fuss about the infection rate because that good sense has not yet been acknowledged.

Missing the point in Canada

To tell or not to tell

From Saturday’s Globe and Mail
April 11, 2009 at 12:57 AM EDT

Knowingly exposing others to HIV ought to be a serious crime.

Or should it?

That is the furious argument unleashed by the trial of Johnson Aziga, a man who was found guilty last week of first-degree murder. The murder weapon was unsafe sex. The thoroughly repugnant Mr. Aziga was found to have infected seven women with HIV, even though he knew he was infected, and even though he knew he had a legal obligation to inform his sex partners. Two of his victims died of AIDS-related cancers.

Peter Troyer, a 37-year-old Toronto man who is himself HIV-positive, has no doubt about where he stands. “It is absolutely reasonable to have a law,” he says. “He exposed people to a potentially dangerous virus without their consent. I wouldn’t want to live in a society that didn’t punish this behaviour at the highest level.”

Continue reading “Missing the point in Canada”

Bad science HIV-style

One of my favourite blogs is Ben Goldacre’s Bad Science, where he bangs on a bit about the pseudoscience of homeopathy. There’s no shortage of bullshit about HIV, either. Thousands of people died in South Africa when it was governed by AIDS denialist President Thabo Mbeki and a Health Minister who recommended beetroot, garlic and lemon juice instead of toxic Western antiretrovirals. Now the author of the Raw Top Blog has posted an anonymous AAP report about an eminent zoologist speculating that HIV may evolve to become less deadly to its human hosts, just as SIV seemingly has in monkeys. The zoologist, Roger Short, is the same guy who wrongly claimed a good squeeze of lemon juice in the vagina would kill HIV and – as an added bonus – work as a contraceptive, too. In the community sector one of our key roles is translating medical and scientific knowledge of HIV into everyday language and circulating the outputs through cultures and communities. This is a good example of the same process taking place independently – and erroneously. If you live in a country where you can access affordable anti-HIV medication, then HIV diagnosis is no longer an immediate medium-term death sentence. That’s completely different from the argument that HIV is evolving to become less deadly. In fact, HIV might evolve to become more infectious, or develop resistance quicker, as treatments apply selection pressure. Linked on the same page Raw Top mentioned: oh, look.