Sunday, October 25, 2015

HIV Risk, High Rates of HIV Infection, and Optimal Testing Frequency: Interview with Stephen Fallon, September 18, 2015

By Sean McShee

As part of my investigation into messaging about and perception of the best schedule for HIV testing for gay and bi men in Broward County, on September 18, 2015, this reporter interviewed Stephen Fallon, Ph.D.  He currently is Executive Director of Latinos Salud. He has consulted with the Centers for Disease Control (CDC), National Minority AIDS Coalition (MAC), Health Resources, and Services Administration (HRSA), U.S. Office of Minority Health Resource Center, the AIDS Institute, and many other agencies. The following has been edited for clarity. 

SM:     Could you define prevalence?

SF:      People sometimes define prevalence as the presence of a disease, or condition in a given group. Sometimes prevalence is defined as a one in X chance of encountering someone with that condition.

SM:     How would this affect your risk of infection?

SF:      Your chances of choosing a sex partner in South Florida who happened to be infected with HIV would be low, in the 1 in 100,000 range. If, however, you narrowed the hypothetical sexual partners down to the gay male community in South Florida your chances would greatly increase. In certain zip codes or subcultures, the chances could increase to a 1 in 3 chance that your partner tonight could be HIV positive.

SF:      There are a lot of bus placards telling gay and bi men that we’re in the eye of the storm. I don’t think gay or bi men necessarily do the math, but they do know in an intuitive sense, that hooking up in South Florida is riskier than hooking up in Kentucky.

SM:     Can you describe how high levels of back ground prevalence in any group could result in less room for “error”?

SF:      When we’re talking about background HIV prevalence, we’re talking about probability. If you have a slip up tonight with a sexual partner, what is the probability that your partner might be HIV positive. This type of information is useful for public health planning. It tells us how urgent the need is to educate a community in a given area.

SF:      But, if I’m HIV-negative, and I have sex without a condom or the condom breaks, and  I become HIV infected, it wouldn’t matter what the background HIV prevalence was in my neighborhood, because to me personally my risk was 100% in that encounter.

SF:      But prevalence is predictive. I don’t think everyone realizes just how dire the epidemic is down here in Miami-Dade and Broward County. 

SM:     Some groups, for example, hetero Whites, have low prevalence. They seem to be able to avoid the need for protection, while other groups, such as gay and bi men in general, and Black gay and bi men in particular, have high prevalence and can’t avoid the need for protection. Are these groups more at risk for infection than others are? Could you explain?

SF:      The eye of the storm has zeroed in on the Black gay male community. Some interesting research came out a few years ago. Two articles just came out recently. The one a couple of years ago found that, in general, members of the gay community are more open to dating outside the norms of heterosexual America, except when it came to dating African Americans. Gay white men were more likely to date Latinos, or Asians, to date outside of their age range, and to date outside of their socio-economic class than was the norm for heterosexuals in America. I think the research was done in San Francisco. But if Black gay men wanted to choose sexual partners from outside their race had far fewer options.

SF:      For whatever reason, the legacy of prejudice or personal erotic preference, many White, Asian, and Latino gay men do not date Black gay men. As a result, if a Black gay man becomes infected in a particular geographical area, other sexually active Black gay men in that same area are far more likely to be exposed to that recently infected Black gay man.

SF:      There is a mistaken belief in pop culture that the high rates of HIV infection in Black gay men proves that they’re taking more risks. That is definitely not true. Two recent articles were recently published. One of them pointed out, that people who have the least sex are more likely to place trust in a new partner and have condomless sex with this partner.

SF:      A study just came out, similar to some other studies from a few years back. These studies found that, on average, Black gay men have fewer sexual partners, and fewer condomless sexual acts than other racial groups. Yet, HIV infection rates among Black gay men in most urban areas are 2 to 5 times higher than those for White gay men, and 2 to 3 times higher than those of Latino gay men.

SM:     Some people have suggested a closed network of Black on Black gay and bi male sexual contact. Could this be related to the frequency of preferences for non-Black partners stated in Internet Profiles? Personal preferences can have social consequences. Any ideas on how to deal with this issue?

SF:      From a public health standpoint, the dating preference could be a legacy of racist assumptions that somehow certain people aren’t worthy. I can’t really relate to this, as my own first partner was African American, as was another long-term partner. 

SF:      From a public health standpoint, though in the cruel game of just epidemiology and counting numbers, if cross-racial dating increased, it wouldn’t mean fewer infections. It would just mean that new infections would be diluted over more populations.

SM:     How does high HIV prevalence influence the risk of Latino gay and bi men, and gay and bi male immigrants?

SF:      A study found extremely high rates of HIV infection after immigration among Latino men coming from Central or South America to Florida, or to the East Coast, urban areas. Something like 25 percent of them who came here, HIV uninfected became HIV infected within five years of hitting our shores. I need to look that citation up because I found it shocking. In that case, it comes down to those other variables besides high rates of HIV infection here. People are coming in from another county, and, maybe, it’s the first time they can express their gay identity, and it’s the kid in a candy store. Or maybe that “trusted friend” who is teaching them a little English or letting them crash on their couch. There’s a certain warmth there that feels like love, and maybe you sort of pay them back with sex. Or there’s the pressure to conform with drug use, which might not have been common in their homes, and they’re not as familiar with how it clouds their decision-making. There’s just all sorts of complexities in human relationships that can influence risk for HIV.

SF:      There are a number of cultural norms among Latinos. But they differ among Latino communities by country of origin, social class, etc. One norm involves putting someone else’s needs above your own. The most important thing is to establish a simpatico relationship, a feeling of comfort with somebody and not to assert your own needs.

SF:      This norm becomes dangerous for someone living with HIV, because they may not be asserting themselves in the physician’s office, or asking the physician to clarify what they didn’t understand. Or maybe they’re not taking care of themselves properly because they’re taking care of their abuela (grandmother) or their hijo (son). Family matters first among Latinos.

SF:      For someone not infected with HIV, if cultural norms say build rapport first and then worry about your needs, it would probably be easier for someone to take advantage of them. They may not assert their desire for condoms, mutual HIV testing, PrEP, or some other means of protection.

SM:     Would high levels of background prevalence make “promiscuity” less of an issue than low levels, as it is much easier to encounter someone capable of infection in a high prevalence zone than a low prevalence zone?

SF:      In a saturation zone, where almost everyone is positive, even if you only have one partner, you have the same chance as if you had 100 partners. Chances are they all HIV-positive.

SF:      Statistically that’s true, but the risk depends on what am I doing with that partner. Am I protecting myself in some way, such as condoms, PrEP, or Treatment as Prevention? 

SF:      “Promiscuity” directly intersects with background prevalence, because if I’m a heterosexual non-intravenous drug using male living in Montana, I can be the biggest slut in the state. I can have sex with 15 women a week and I am probably not going to catch HIV because there’s no HIV for me to catch. I would not be able to get away with slip-ups like that in South Florida.

SF:      That’s also the reason we don’t promote an awareness of background HIV prevalence as the sole method of your safety. If we’re in a saturation zone (an area with extremely high rates of HIV infection), many people are becoming exposed to HIV and are in that window period for uncertainty. That’s the time after infection when you’d get a false HIV-negative test result because your immune system hasn’t had time yet to grow antibodies. During that window, the HIV test will not return an accurate result. People in that window are legitimately telling you that they are uninfected with HIV, but they’re not. 

SF:      If prevalence was low, then infections would be rare, and since I’m not going from partner to partner, if I am not promiscuous. I'm not likely to be in the window, when we have sex.

SM:     The Kaiser Family Foundation (KFF) estimated a national prevalence of 12-13% for gay and bi men. Would you agree with that estimate?

SF:      Yes, I do. When they said national they probably meant the gay urban areas.

SM:     They were using a nationally representative internet sample.

SF:      That would work out to a 1 in 8 or 1 in 9. When we did the studies here in Florida, back about 7 or 8 years ago, we were already finding a prevalence of 1 in 5 among African American gay men in South Florida, 1 in 11 among Latino gay men and 1 in 16 among white gay men.

SM:     The KFF and others have estimated an HIV prevalence rate for gay and bi men in major cities of a 20% or more  Can you estimate the background prevalence in South Florida generally and Broward in particular among gay and bi men?

SF:      I haven’t crunched the numbers for Broward County, but probably 20 percent higher than when we did those studies or about 1 in 4 among Black gay men, about  1 in 8 among Latino among gay men, and about 1 in 13 among white gay men.

SF:      Miami-Dade County is number one in the nation for new HIV diagnoses, and Broward County is number two. That’s out of about 3,000 counties that make up our country, so this is not a small distinction.

SF:      We used to have to coax people to come in for testing. When the CDC turned their model to prioritized testing, with behavioral HIV prevention seen as the follow up rather than the lead effort, frankly, I was a little skeptical. I have to admit they were pretty much right, though. As a community of HIV prevention service providers nationwide, we have largely normalized testing HIV testing in the gay community. We’re not just testing the “worried well” anymore. 

SF:      This may be specific to my agency, since we’re always out with the vans. Maybe It’s the self-actualized, health seeking type of clients who walk into the vans. We have found a large increase in the number of people willing to take an HIV test on their way into or out of a club. We are getting a lot of first time HIV-positive results. It’s almost frightening, but good also. 

SF:      It’s good because we can link them to care and people aware of their status reduce their risk for transmitting HIV. Our linkage to care program differs from some of the other linkage services. Some of them have to limit their care by mandate to a relatively few services.

SF:      Our model is whatever it takes. For some people, you can just give them some of the information. They can handle getting into care on their own. When we can call them up, they will tell us they’re in care. But many of our clients come from different backgrounds, linguistic and socio-economic. They certainly come from different countries and cultures. They benefit from the extra effort that our linkage staff gives them. I tell my staff, “Your job description is whatever it takes. Give somebody what they need, and get them into care”.

SF:      Now we know how much better current treatments are. The prevention and care community had thought we were doing so well in the early and mid-90s with the medications available then. But now, when we look backwards, we’re finding that we were only buying people an extra 3.2 months of life expectancy.

SF:      Now with today’s regimens, if someone is newly infected or treatment na├»ve, their life expectancy can almost approach that of someone uninfected with HIV, if, and this is a big if, they follow the steps properly, staying on their meds and seeing their doctor regularly. It’s very exciting.

SM:     I have not found any regularly published reports of HIV prevalence among gay and bi men in Broward. Do you know of any?

SF:      No. We do have regular updates to the HIV testing data, and that does stratify by demographic or behavioral group. But it doesn’t also calculate the prevalence within each population.

SM:     Every few years in San Francisco, Health Department Planners, Epidemiologists, and Providers estimated the prevalence of HIV in San Francisco. Would be useful here? Would it be helpful for HIV planning?

SF:      It would definitely useful for planning. I’m not sure how useful it would be for the layperson on the street or for a provider. Even if an agency had the numbers and found out the epidemic has changed incrementally from year before, the agency is probably not going to change its focus radically. Broward has many fine agencies. Each of them serves everyone, but they also each have their specialty populations Here at Latinos Salud, we serve Latino gay men, as well as, anyone who identifies as transgender, and anyone living with HIV whether Latino or not.

SF:      We can’t make certain statements about whole groups of people, but we do find some general skill sets allow us to help some people more effectively: the building of rapport, the familiarity of a face that looks like yours, or an accent that sounds like yours. None of that would change if they told me that in 2013 HIV prevalence was 1 in 16 among Hispanic gay men and in 2014, it rose to 1 in 14 Hispanic gay men. That wouldn’t change how we do our work. There’s still plenty of need either way.

SM:     For years, there have been reports that people were more infectious just after HIV -conversion before anti-bodies have developed than throughout the course of HIV infection. Could this lead to a sort of spiral effect, with each new infection leading to even more infections that are new?

SF:      We all know that if I become HIV infected and I run to the clinic tomorrow or even next week and I test. I am going to get a false re-assurance. I am going to get HIV-negative test result even though I’m infected. Many people don’t really know why that is. They haven’t learned the reasons why. Our immune system is like a castle with all the cannons aiming out. It doesn’t know to look inside itself where HIV is growing. It’s inside the castle. So, for a few weeks to a few months, the virus has a free reign and the population of the virus can become enormous, up to 2 million viral particles of HIV per milliliter of blood.

SF:      At some time after the initial infection, the immune system figures out that HIV is there. Then you start getting sick with HIV conversion-flu. That’s actually a wonderful thing. The immune system is dragging that population of HIV down. Now you’re in a tug of war. We do know that without medication you will lose that tug of war eventually. But, thank god, the immune system was there to take it to a tug of war rather than a rout. 
SF:      We know that if somebody has been recently infected, they honestly don’t know, and can’t know, that not only are they HIV-infected but they are highly infectious.  

SF:      If you were to have a slip up with somebody in the first two months after their infection, they are 12 to 20 times more contagious than they will be for the rest of their life. You would actually be safer going to a hospital where someone was horribly ill with opportunistic infections related to AIDS and having unprotected sex with them That would be safer than having unprotected sex with someone newly infected. I don’t think many people appreciate or know that. 

SF:      While the decade of your life does not predict the time of your diagnosis of infection with HIV, “older guys” are more likely to know their status or to have been infected at an earlier age. Many younger gay men think that all the HIV is in the population of older men. As a result they believe that as long as they don’t hook up with “an older guy”, they will be safe, but “older” gay men are the just the population who know they have HIV infection.

SF:      Now, younger people are naturally sexually active. It’s that age when you are experimenting and figuring out what you like. Unfortunately, this also makes their peers who believe that they are HIV uninfected, their greatest threat of HIV infection, as they are most likely to be recently infected.

SM:     Is that type of spiral effect occurring in Broward right now?

SF:      In discussing background prevalence, the term we use is core groups,  If there’s a lot of HIV infection in a one group (XYZ group), it may not be in another group of peers who are somehow slightly different (ABC  group). Suppose you’re in ABC group. Maybe you are all in your twenties and living in South Florida, but maybe XYZ group has much more HIV infection in it. If you’re picking your sexual partners from group XYZ rather than ABC group that will have an effect. If there’s no HIV to catch, you can do whatever you want, but of course, there might be other STDs. There’s no such thing as a truly free pass.

SF:      The more HIV there is in a group, the less likely you are to luck out, if you fail to have some type of protection. The more HIV infection there is in a group, the more necessary; it is to have some type of protection such as condoms, prep, etc.

SF:      The more newly infected people in the group, the more highly contagious that group is.

SF:      Latinos Salud is doing the fourth generation HIV test. That means we’re testing for antigens rather than just anti-bodies. In general, the antigens present 15 and half days earlier than anti-bodies do. If someone comes in, and they’re in the window of uncertainty, even a little ways into it, we’re likely to catch their infection and help them to know their status. 

SF:      When most people become aware of their HIV-positive status, they significantly reduce their risk taking with partners who are either HIV-negative or unknown status. Most gay men, like all humans, are moral creatures. We all slip up sometimes, but most people try to protect their communities. When people know their status, most reduce their risk behavior. That’s why the fourth generation testing is exciting. We don’t have to wait for the anti-bodies.

SM:     What do you think is the optimal HIV testing frequency for gay and bi men in Broward?

SF:      The CDC came out with their recommendations a few years ago and they said once a year or every 3 months or 6 months if at higher risk. This is a universal recommendation, and that’s what the CDC has to do, because they can’t tap everyone on the shoulders and give them an individualized message. 

SF:      I wrote a column that we will be playing up for national gay men’s HIV awareness day, “The Safer Selfie” ( http://southfloridagaynews.com/Health/there-are-options-on-protecting-one-s-self-from-hiv.html). The Selfie is all about “look at what I’m doing right now. Look at what interests me. Look at my hobbies. Look at my travels.” We all get our own music play lists through our smartphone. We all get to stream whatever we want. Everything is personalized today. 

SF:      The ways to stay safe should be personalized as well. For instance, I personally practice negotiated safety. What that involves is getting an HIV test with your partner to rule out a prior infection that you may not have known about. You and your partner then have to have a serious discussion about what each of you wants and whether that’s going to be sexual exclusivity (monogamy), or not. If both of you are committed to sexual exclusivity, you then have to have one more HIV test to rule out the window of uncertainty. Then you can have condomless sex without being unprotected, at least as far as HIV is concerned. 

SF:      You can’t do negotiated safety unless you’re willing to get into awkward conversations. Negotiated safety was never really discussed here in the US, because just as it was becoming studied, Highly Active Anti-Retroviral Therapy (the medical breakthrough of the mid-90s) came out. People thought these meds would just stop the virus in its tracks, and we wouldn’t need to do prevention. People who truly understand negotiated safety understand one of its key precepts. You have to agree with your partner that if he comes back and tells you “I did slip up. I did have unprotected anal sex with somebody else “. You have to promise in advance that you will not leave him, at least not immediately. Otherwise, the fear of losing you is going to keep him from admitting what he did.

SF:      For some people that won’t work. Some people will say PrEP is the thing, for me, “I don’t want to depend on the other guy, I want to know that I’m controlling my risk of acquiring HIV by taking the meds”. Other people will say, “I grew up on condoms, I know how to use them. They work fine for me.” So we don’t have one answer for everybody.

SF:      There have been a lot of studies that claimed that negotiated safety doesn’t work. One study found that 1 in 3 couples had broken their exclusivity pledges within 3 months, but this study was amongst very young gay men. I’m not sure that’s a fair comparison. The ability to handle all the “awkward conversations” involved demands emotional maturity. Not that all “older” guys are that emotionally mature either, but you’re less likely to find it in younger guys. 

SF:      At Latinos Salud, we talk to each client to find where they’re at, what they’re comfortable with, and together choose the path that reduces their risk the most we can.

SM:     What do you think about public health messages concerning the frequency of HIV testing for gay and bi men?

SF:      A recommendation should be a guideline and not a rule.

SF:      It is a good idea to have a regular schedule for HIV testing, but it has to be one that works for you and your partner(s). If you negotiate safety, it shouldn’t be “we tested once but haven’t tested again for 30 years”. Knowing that there is some schedule, whatever you and your partner decide, whether it’s twice a year or once every three years. Just knowing that the test will be coming is more likely to make you honest if you have a slip up. You should set a frequency, once a year is not bad, I guess, for a couple. But each couple has to have the right to schedule differently. The truth is we often do sense when we’re floating away; we know when we are drifting in the relationship. In which case maybe, we want to test more often than once a year,

SF:      In our lifetime, we might pick different methods for different phases, maybe condoms for now. It might be PrEP later. It might be negotiated safety at another time. Our choice might be based on our maturity, our partner selection, or our personal tolerance of risk. Public health has one goal: No new infections and education to support that. It’s up to individuals to match that knowledge with their life.   

SM:     How often do you think single guys should be tested?

SF:      If you follow the CDC, the assumption would be that a single gay man means that you’re also having some recreational sex. Their recommendation would be test twice a year or four times a year, if you’re very sexually active. If you’re single and not hooking up at all, however, you don’t need to test. 
IH

SM:     Is there anything that you would like to say to the readers of SFGN about background prevalence and frequency of HIV testing?

SF:      Like in the rest of life, we assume that everybody has the same level of knowledge and the same interpretation of the facts that we do. Anytime that we’re going to be entering a potentially risky situation, we should first define our terms and make sure we’re on the same page with our partner. If I say I “love you,” have I just pledged monogamy? Or did I just mean I feel close to you at this specific moment? We owe it to ourselves to make sure we heard what our partner truly meant.

SM:     You wear many hats, how would you like to be identified for this interview?   
           
SF:      As a great guy. 

Stephen Fallon, Ph.D., Executive Director, Latinos Salud (latinossalud.org/) , and Skills4 (skills4.org).

Previous consultant to the Centers for Disease Control (CDC), National Minority AIDS Coalition (MAC), Health Resources, and Services Administration (HRSA) , U.S. Office of Minority Health Resource Center, the AIDS Institute.


Monday, August 31, 2015

Community or Population: Gay and Bisexual Men differ from Men who Have Sex with Men

By Sean McShee

In the last ten years new, HIV infections have only increased in gay and bisexual men, among all groups at risk for HIV infection. Part of the problem may be an incoherent approach to cultural competence for gay and bisexual men.

People use two phrases, “gay and bisexual men” and ”men who have sex with men (MSM)” to describe the group on which HIV has had the most impact. Some people use these phrases interchangeably, assuming they refer to the same entity. Others use the phrase ”men who have sex with men (MSM)” believing it to be the more inclusive phrase. Neither of these usages suggests any awareness of cultural differences.

The updated National HIV/AIDS Strategy of 2015, however, uses the phrase “gay and bisexual men” much more often (50 times) than the phrase or its acronym “men who have sex with men (MSM)” (7 times). It also calls for cultural competency for gay and bisexual men in HIV service delivery. These two phrases refer to different things. While the phrase ”men who have sex with men (MSM)” refers to a population, the phrase “gay and bisexual men” refers to a community.

How do populations and communities differ?

Professionals define a population to serve their professional ends. As a result, a population has very clear boundaries. A population lacks any subjective awareness of its “group-hood”, as well as its shared norms, values, customs, and meanings. Without shared norms, values and customs, no need exists to socialize new members.  As these comprise some of a culture’s defining features, cultural competence has no relevance for a population.

People in a community, however, have a subjective self-awareness of their “group-hood”.  They share norms, values, customs, and meanings. A community transmits these norms, values, customs, and meanings to its new members when it socializes them into the community. These factors define a culture and require cultural competence.

Like other social processes, a community grows organically and has “fuzzy” boundaries. Unlike a population’s strict definitions and rigid boundaries, a community includes “others” within its “fuzzy” boundaries. For example, the gay and bisexual male community includes “fag hags” (straight women who like to hang out with gay men). People may vary in their integration into a community. Some gay-for-pay hustlers, porn stars, and strippers may be more integrated into the gay and bisexual male community than their exclusively gay, but closeted, “Johns” are integrated.

Epidemiologists defined the phrase “men who have sex with men (MSM)” to describe men at risk for HIV through anatomical male on male sexual activity. They defined “MSM” to ignore self and community identification and to have physiological and epidemiological validity.  Once we move into HIV program design, delivery, and evaluation, however, social processes occur. When those social processes occur, culture becomes paramount. This raises two critical questions:  1) Do effective HIV delivery programs require cultural competence for gay and bisexual men? and 2) How can we tell if a program has succeeded in reaching non-gay or bisexually identified MSM?
Question 1:
Do effective HIV delivery programs require cultural competence for gay and bisexual men?

Cultural groups parallel to gay and bisexual male culture

Given its binary focus on gender, transgender people become invisible in HIV data. When transgender women become visible, they have very high rates of HIV infection.  Non-op transgender women have the same anatomical sexual options (oral or anal sex) as gay and bisexual men have. Generally, they are counted among MSM. This may be the most glaring example of cultural incompetence since the Northern European “flesh” colored crayon.  At least that crayon had the excuse that it pre-dated the concept of cultural competence.

The phrase ”men who have sex with men (MSM)” includes several cultures based in ethnic groups: same gender loving (African American), two-spirit people (Native American), and Mahu (Polynesian), etc. Others no doubt exist.  These cultures exist parallel to gay and bisexual male culture and require cultural competence. No one can be globally culturally competent. People may be globally culturally sensitive, but cultural competence always refers to a specific culture.

Cultural competence for gay and bisexual men’s services

While cultural competence has become central to service delivery, it remains an elusive concept, difficult to define or measure. In practice, programs declare the problem “resolved”, when program staff matches program recipients on one demographic variable. While people can match on one demographic variable, they can differ in other key cultural/identity variables: race, class, ethnicity, gender, sexual orientation, etc. A perfect match on all variables of identification may not be possible. This simplistic understanding of cultural competence mystifies cultural competence as something that only people in that culture can possess. This understanding of cultural competence precludes the identification and transfer of cultural competence to people outside of that culture.

We should probably distinguish cultural competency from the marketing imperative of having a staff that matches the clients, and the justice/meritocratic imperative of hiring minorities.

It probably does help to have matching demographic profiles on the most visible of these key identifiers. People, however, should be able to identify, describe, and learn how to work with cultural differences. Some cultural differences, such as Sign Language, are more easily identified and learned than others are. Once identified, people from outside that culture can learn about them, increasing cultural competence in a pluralistic society.

How gay and bisexual male culture differs from mainstream cultures

Despite the difficulties in defining or measuring cultural competency, certain differences between gay and bisexual male culture and the dominant culture do stand out.

Chronological Age vs. Coming-Out Cohort.  HIV programs report data with chronological age ranges. Within gay and bisexual male culture, the coming out cohort (the time in which someone came out) could have as much importance as chronological age. For example, let’s assume the following coming-out cohorts:  1) Pre-Stonewall, (before 1969); 2), the Golden age of Promiscuity (1969-1980); 3) the frAIDS (1981-1987); 4) ACT UP/Queer Nation (1988-1996), and 5) Anti-Retroviral Treatment and Normalcy (1997-present)    Those people who came out in different cohorts came out into very different gay and bisexual male cultures.

Someone who became HIV infected in 2015 at age 65 could belong to anyone of these cohorts. If he belonged to the ARVs and Normalcy Cohort, he would have had a very different life experience that someone belonging to the Golden Age of Promiscuity Cohort.  He would lack memories of the worst of the epidemic and may never have encountered, as a gay or bisexual man, any HIV prevention messages specific to gay or bisexual men.

Narrow vs. Broad Definitions of Sex. In mainstream culture, sex means penis-vagina intercourse with the rest as foreplay, and maybe deviance. Many gay and bisexual men define sex much more broadly to include mutual masturbation, oral sex, anal sex, water sports, multiple fetishes, and leather. Each of which has a different risk level for transmitting HIV and other STDs. This makes answering questions about “how many sexual partners have you had in the last six months”, difficult to answer and meaningless to interpret. Yet, HIV test sites ask these questions, leaving it up to the respondent to define “sexual acts” and “sexual partners” as they wish.This violates a key requirement of survey question design.

Contact tracing vs. norms of frequent testing.  Contract tracing for STDs makes sense for cultures with a courtship/dating pattern. While the dominant culture has an ideological standard of monogamy (its practice is another matter entirely), gay male culture differs drastically. Gay and bisexual male culture accepts a plurality of relational styles:  anonymous, semi-anonymous (screen name or first name known only), short-term, open, and closed relationships. Long-term partners may no longer have sex with each other, but each partner may have sex outside the relationship. No one in a gay bar, gym, or sex club has a last name. While this probably originated as a protective factor during the time of bar raids, it has continued to this day. People who “hook-up” on line may only know each other’s screen name. For this community, contract tracing has minimal utility; norms of frequent regular testing schedules for STDs for all sexually active people have much more utility. 

Disclosure and hook-ups/anonymous sex.  Disclosure of HIV status also makes most sense in a courtship model of a relationship. Some gay and bisexual men have a rather “abbreviated” courtship period. For a hook-up to work, the parties involved have to create a mutually erotically charged atmosphere rather quickly, but few people find that discussions of HIV enhance an erotic atmosphere. For many, HIV is an erotic turn off. This type of situation encourages perfunctory assumptions and discussions about status.

Some gay men have a fetish for anonymous silent sex where verbal disclosure violates the norms for that situation. Culturally appropriate HIV prevention messages would recognize this fetish and problems with disclosure in these situations. These messages would emphasize that people should assume their partner’s HIV status differs from their own. 

If double-consciousness characterizes African American culture, as DuBois suggested, respectability/flaunting dichotomy may characterize gay and bisexual male culture, both at a collective and at an individual level. Some gay or bisexual men, heavy on the respectability side, have consistently used HIV to push for a standard of monogamy rather than monogamy as one fetish among many. 

Some gay and bisexual men will object to these last points, but internal conflicts define living cultures. In order to serve communities with internal cultural conflicts, a program cannot take sides, but has to be able to serve all sides. This emphasis on respectability further complicates culturally appropriate HIV messages. It defines cultural differences as problems to eradicate rather than an as opportunities for prevention.

In addition to the internal conflict, these last points describe a major political conflict. Serious value conflicts exist between gay and bisexual male culture and the dominant culture about relational pluralism vs. ideological adherence to the standard of monogamy. 

Question 2:
How can we tell if a program has succeeded in reaching non-gay and bisexually identified MSM?
HIV reporting uses the phrase ”men who have sex with men (MSM)” which, counter-intuitively, obscures the program’s reach to non-gay and bisexually identified men. In order to tell if a program has reached non-gay and bisexually identified men, it has to collect data on that population. That program has to collect data on how clients identify at intake, at pre-determined intervals while they remain in the program, and at outcomes. This will show if the program has any disparities in reach, retention, or effectiveness between gay and bisexually identified men, same gender loving men, two-sprit men, non-op transgender women, and non-culturally identified MSM. When programs fail to record and report this data, and use the phrase ”men who have sex with men (MSM)” that phrase hides rather than includes non-gay and bisexually identified men.
Whether greater gay and bisexual male cultural competence might cause the high numbers of new HIV infections among gay and bisexual men to begin to decline is an open question. We should, however, ask that question.

Next month Intersectionality.


Monday, June 29, 2015

Political Coalition or Social Community

By Sean Little
Some LGBT rights activists have proposed adding more letters to the acronym, “LGBT”, to become more inclusive. Suggested additions include the following letters: “A” for Asexual, ”Q” for Queer, “A” for Allies, “Q” for Questioning, “I” for Intersex, and some others. At the same time, the importance of culture has increased in the fields of policy analysis, program planning, implementation, and evaluation. People in these fields should examine how these proposed additional letters effect cultural competence. This examination could refine LGBT cultural competence. It may also involve disentangling social communities from their associated political coalitions. This examination may be more important than the decision about adding initials.

Few discussions about LGBT politics can avoid the term “community”, but many people do manage to avoid defining that term. Some people use “community” to mean a political coalition. Others use it to describe a social entity (or entities). Still others use it to describe a population. 

Populations, Political Coalitions, and Communities

The concept of a population serves the interests of the outsiders who have defined it. Those people in a population may lack any subjective identification with others in that population or even with that label. MSM (men who have sex with men) exemplifies an externally defined population.  Epidemiologists developed that acronym to include non-gay/bi identified men who had sex with men. Few men identify as a man who has sex with men.

A political coalition functions instrumentally. It has goals, no matter how vaguely stated. By definition, it has a certain amount of political unity, but consists of discreet elements. People participating in a political coalition may not have much in common other than their goals and their need to work together. 

A community exists for itself. The members of a community subjectively identify with that community. If it has a purpose, it would be to adapt to the larger physical and social environment. A community may have interests but its members can disagree about those interests. It transmits its language/dialect/slang, values, beliefs, norms, customs, and roles from one generation to the next. Its shared culture unifies a community.

Culture belongs among the terms associated with community:  socialization, norms, values, customs, beliefs, and patterns of interaction. Culture determines the language or dialect of service delivery and the acceptability of slang. The values of a culture distinguish between acceptable and unacceptable behavior. When a cultural mismatch occurs between a program and its target, two types of failure can result. The intervention can fail to reach the target population. People may be so desperate for some services that they access those services, no matter how mismatched. They then may perceive those services as a part of a nexus of oppression. 

Community and social networks

It’s possible to think of a community as a set of interlocking and overlapping social networks. These networks socialize new members. All individuals belong to multiple social networks and exist at the intersection of multiple social networks.

A culture exists on many levels from the nano (smaller than micro) to the macro. Every group of friends forms a nano-culture. Larger, public social networks, such as the regulars at a leather bar, will have their own values, norms, and customs, forming a micro-culture. Each MCC church, a gay gym, or a lesbian softball team will have its own micro-culture. While the micro-culture of one leather bar will differ from other leather bars, all leather bars will share many cultural elements. If a leather bar failed to exhibit many cultural elements of mezzo-leather culture, people would be unable to identify it as a leather bar.

At the next level, the interlocking and overlapping set of social networks of all leather bars forms a community and a leather bar mezzo culture. The set of all MCC churches, gay gyms, and lesbian softball teams will each have their own mezzo culture. Lesbians, gay men, bisexuals, and transgender people each have mezzo cultures with large overlaps. LGBT culture forms a macro-culture.

At each higher level, the culture becomes more abstract. At the macro level, culture has reached such an ethereal degree of abstraction that cultural competence may lack utility. For cultural competence, the mezzo-culture may be a more appropriate level than the macro level. 

As culture becomes more important to effective policies and programs, the distinction between political coalitions and social communities also increases in importance. Some people have proposed the letter “A” for allies among the additional acronymic letters. Allies, by definition, differ from those with which they are allied. Allies belong with the language of political coalitions, not with the language of culture. Of course, some allies participate in LGBT mezzo cultures and networks. For example, the straight son of two lesbian parents has become a marriage equality activist. He lives in at least two LGBT mezzo cultures:  the LGBT marriage equality mezzo culture, and the LGBT parenting mezzo culture. “Fag hags”, like the fictional Grace Adler and Karen Walker (Will and Grace), are allies and participate in the gay male mezzo-culture. Communities differ from populations in that communities may include people outside of the narrow and arbitrary definitions of populations.   

Asexuals share many political goals with the LGBT communities, but their relationship to social policies and programs may differ. A program directed towards asexuals would require a very different type of cultural competence than one directed towards gay men. For example, most programs directed at gay men involve, with good reason, HIV and STD awareness, but asexuals have very low risk for HIV or STDs. 

People, identifying as “Questioning”, probably do not develop coherent and long lasting cultures and communities of their own. The state of “Questioning” implies leaving that state when those issues being questioned are resolved. This state may be part of identify formation progress. Some people currently identifying as “questioning” may resolve their identify as heterosexual and cisgender. 

Political coalition with an agenda or social community with a culture

The acronym has much greater utility as a political coalition with an agenda, than as a social community with a culture. This argument does not claim or imply that political coalitions have no value. They obviously do. Distinguishing between these two constructs has great importance, however, for those of us concerned with how culture affects policy, program design, implementation, and evaluation,

Like living organisms, all communities and cultures have boundaries and exclude what lies outside those boundaries. Cultures can clash. Those cultures that clash will have problems mixing, for example, scientists and fundamentalists. This exclusion allows policy and program planners to design policies and programs for particular groups and not others. Political coalitions, however, should include as many discreet elements as possible to further the agenda.

Evaluation exists in the world of public policy, program planning, and delivery. In this world, culture plays a critical role. Despite its importance, the field of evaluation has not yet developed an adequate understanding of LGBT cultures. The proposed addition of more initials to the acronym can be an opportunity to further our individual and collective understanding of culture. We need to be clear whether we are talking about political coalitions with agendas or communities with cultures. Otherwise, we will never develop a coherent understanding of culture. 

Next post, that other acronym MSM


Thursday, June 11, 2015

Written for the Act Up San Francisco 25th Reunion




By Sean McShee

When I first began to get involved in HIV activism, I thought it could keep my friends alive. Neither my friends from before HIV, nor many of the new friends I made through HIV activism, however, lived long enough to benefit from anti-retrovirals.

I want to remember those people who help to build the pre-ACT-UP momentum in San Francisco. Bobbi Campbell, aka Sister Florence Nightmare, had the honor of being the first out person with AIDS in San Francisco. Dan Turner and Bobbi Campbell helped to write the Denver Principles. If you are not familiar with the Denver Principles, please look them up on Wikipedia.

In the middle 80s, LGBT anti-war activists, the more activist types from the Democratic Clubs, and other unaffiliated people began to talk about HIV activism. It may have helped that Hank Wilson and I had adjoining lockers at the Y. We had known each other since Bay Area Gay Liberation (BAGL) and our conversations naturally drifted to politics in between cases of “locker room eyes”. I was in an affinity group resisting Reagan’s Wars, and Hank was, well, Hank.

Ed Wyre, John Ashby, Kate Raphael, and I began to do civil disobedience trainings. Eileen Hansen became involved. Keith Griffith, Terry Beswick, John Belskus, Frank Rich, and others came to the trainings and promptly began civil disobedience. At some point, the people we had trained and others like Steve Russel, and Randy W. began the ARC/AIDS vigil as an act of civil disobedience, expecting the SFPD to arrest them. They kept that vigil going for years. We began to set up the AIDS Action Pledge, modeled on the anti-war Pledge of Resistance. Sometime in 1988, the AIDS Action Pledge changed its name in 1988 to ACT UP San Francisco.

I’m sure I’m forgetting some people, but, unfortunately, once you dry-out, you can no longer blame a faulty memory on an alcoholic black-out., just a bad memory for names, and a LGBT cultural preference for never using last names.

Right after the ACT UP split, I moved into Hank’s building. We began to help each other in that other deathwatch of the 80s and 90s – that of our aging parents. Each of us took care of the other’s apartment when he had to go and do long distance elder care.

When HIV first hit, I had both a family of choice and a family of origin. Now, I have neither. When HIV first hit, we had activism and hope, as well as fear. Now, I am not sure what we have. Maybe the death toll was just too high and the burnout too severe.
One of the reasons I left San Francisco was that I kept seeing ghosts. I can no longer do activism. Now I write for South Florida Gay News, mainly on HIV, and do consulting. Watching the news one night late last summer, I heard that people in Fergusson were doing die-ins. Life goes on, but it always changes. La lucha continua. (The struggle continues).