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.”

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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.”

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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.

More bad advice from the Manhunt “Cruise Director” Michael Alvear

You have to be a Manhunt member to read the Cruise Director posts, so I’m including it here – apologies for the long excerpt!

How Do I Overcome My Fear Of Having Sex?
By transferring your irrational fear of safe sex into a rational fear of unsafe sex.

Yo, Mike!
I had my first HIV test about two-and-a-half years ago. I’m sorry to say that I had it done because I was a bit “irresponsible” in my teen years. Glad to say my test came back NEGATIVE and ever since, promised myself I’d never have unprotected sex again. Unfortunately, that has not been 100% the case. I’ve had two more HIV tests since, both of which were a requirement at the companies I’ve worked at. I am once again thankful to say they were both negative.

However, the whole HIV-test process has taken a real emotional toll on me, since I have become terrified of having sex. Every time I meet I guy I’m scared to go near his dick, for fear I might catch something. The fact that condoms are not 100% safe makes me terribly uneasy and incapable of having a good, nice fuck.

Continue reading “More bad advice from the Manhunt “Cruise Director” Michael Alvear”

Prop 8 and Gay vs Black voters

The sting in the tail of last week’s Obama election happiness was the news that California had passed Proposition 8, a special ballot to amend the state constitution to abolish same sex marriage.  Almost immediately, social news sites like Reddit and blogging communities like Daily Kos focused their attention on CNN exit polling showing that 70% of black voters surveyed had voted to deny same sex couples the right to marry.

Apart from some thoughtful coverage this news unleashed a torrent of racist recrimination, mostly from gay men, some of it seriously ugly.  In response, DKos diarist Shannika [via Trevor] has offered a laundry list of demographic reasons why black voters couldn’t have carried Prop 8 to victory.  However, I feel this doesn’t really contradict the underlying misconception — that blacks somehow held the balance of power in the first place.

Now, my hero Rachel Maddow has bought into the debate in her own irreducibly intelligent style, inviting Princeton political scientist Melissa Harris-Lacewell on the program to discuss the issue.  (From 3:30 in the video.)  Harris-Lacewell makes the important point that anti-Prop 8 campaigners failed to reach out to communities of colour, where they could have argued the similarity between Prop 8 and the legislative ban on inter-racial marriage (which was only overturned by a court case in 1967).  She suggests it was an opportunity left begging: “African[-American]s understand the language of ‘separate but equal'”, and says one of the nice things about Obama’s resoundingly-effective grassroots strategy is that no demographic can henceforth be safely neglected.

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There’s one question that isn’t being asked much:  should we be fighting for marriage rights in the first place?  My heart goes out to queer Californians whose marriages have been left in legal limbo, and I sympathise with gay men and women who believe marriage is the last bastion of legal inequality.  Except that it isn’t.  I agree with Michael Warner’s analysis in The Trouble With Normal (1999) where he argues marriage is the tentpole for a social hierarchy that regulates everybody from the top (white middle-class married couples with children) down to the bottom (gay men and sex workers).

There’s something deeply unseemly about climbing on the heads of those sex workers to scrabble up to win access to the marriage club.  There’s something similar going on when 27% of GLBTI voters go for McCain, as if by endorsing a conservative they can put some distance between themselves and the bottom of that pile.  And there’s something really sad about some poor 19-year old kid who’s ashamed of sex and his sexuality thinking it will all just evaporate if he could  promise forever to someone equally-deluded with the State nodding its legal blessing.

Rattling bones

Two great moments took place in 1996. One was the famous Protease Moment, when scientists electrified the Vancouver AIDS Conference with the announcement of the first truly-effective HIV treatment protocol, using a combination of 3+ meds including a protease inhibitor. The other was an Australian social researcher, Gary Dowsett, standing up at the same conference saying the young men in his research study were post-AIDS. They had grown up and come out and learned how to have sex with HIV always in the background; it was nothing new, not a crisis, and didn’t form the centre of their gay existence.

One man in the audience was the gay writer Eric Rofes, and he got the significance of both moments immediately. Within two years Rofes had written and published one of the great classics, Dry Bones Breathe (Haworth, 1998). He castigates “AIDS Inc” for its insistent reliance upon a crisis mentality, and the failure of the “brain trust” to respond to those two great moments. At an AIDS org in SF, he sees all the classics* sitting on a bookshelf, but a staffer tells him nobody there has any time to read them. That sounds familiar, I thought, having worked for the AIDS council in my home state at a time when HIV infection rates were rising.

I had coffee on Friday with a colleague from a PLWHA org in another state who’s working on a project about what sector shorthand calls ‘interesting times’ – a constellation of trends including the normalisation of gay, the declining relevance of community, increasing UAI and serosorting, criminalisation, public health, the Internet, and so forth. It calls for an open mind about how all of these things interact in the current moment, but crisis thinking admits no subtlety and takes no prisoners; at some point in the past 11 years of the culture wars, advocacy became a blood sport.

By “crisis thinking” I don’t mean we’re all still running around waving our hands in the air, although I have seen that happen. I mean the strategic deployment of outrage in response to anyone who questions the norms underpinning the community-based response to HIV. The ever-percipient Rofes called the institutional actors on the conservative moral underpinnings of their insistence on the need for gay men to take personal responsibility for the epidemic, pointing to its continuity with a contemporary moral panic about sex.

That panic was still going strong eight years later, when I made it the focus of a 2006 conference paper on “Barebacking and Bugchasing: Images in a Jurisprudence of Desire”. Without question it underlies much of the argument for gay marriage and the criminalisation of HIV transmission. The problem for the HIV sector in Australia (and elsewhere) is that a full decade later most of our key decision-makers are still no closer to understanding the points Rofes made in 1998 and Dowsett made even earlier.