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Canada must decriminalize HIV non-disclosure

Photo courtesy Pixabay

Safe sex should be lawful, says the Canadian HIV/AIDS Legal Network’s executive director

By Richard Elliott

Right now, people living with HIV in Canada can face years in prison and a lifetime “sex offender” designation if they don’t disclose their status to a sexual partner — even when there is little to no risk of transmission.

This cruel and unusual punishment is based largely on a 1998 Supreme Court of Canada decision saying that if there is a “significant risk” of transmission, someone who knows they have HIV must disclose that fact — and if they don’t, their sexual partner’s consent has been obtained by “fraud.” This, in turn, means they can be charged with aggravated sexual assault.

Too often, prosecutors and courts have interpreted this standard very broadly, prosecuting and convicting people living with HIV even in circumstances where there was not only no transmission of the virus, but negligible or even zero risk of transmission in the first place. A single consensual sexual act posing little or no risk of transmission is treated the same as rape in Canada’s courtrooms, and our rate of prosecution for this charge is among the highest in the world.

This is an infringement upon the human rights of people living with HIV, and over the past few decades, we’ve seen plenty of unjust prosecutions. In one particularly egregious case, a woman, herself a survivor of sexual violence, was prosecuted and registered as a sex offender because when she left her abusive partner and had him charged with assault, he retaliated by having her charged for HIV non-disclosure.

This criminal approach to HIV non-disclosure is rooted in stigma and misperceptions, in particular an inflated perception about the actual risk of transmitting the virus. HIV is difficult to transmit, yet people have an exaggerated sense of its risk, which has fuelled a fear of people living with HIV.

The result is punitive laws that are contrary to the science of HIV. In 2018, dozens of the world’s leading scientists and the leading scientific organizations in the field of HIV research published a peer-reviewed, international Expert Consensus Statement about HIV transmission risks in various circumstances, based on a thorough review of all the available literature.

Among other things, the science confirms that when a condom is correctly used – meaning it is worn throughout the sex act and doesn’t break – it is 100 percent effective in preventing HIV transmission. The science is also clear that someone who has a “suppressed viral load” – say, from effective HIV treatment — cannot transmit HIV sexually. Yet it has only been recently that people with suppressed viral loads have been spared prosecution. And people who use condoms are still being prosecuted and convicted for not revealing their HIV status.

In addition to being unjust and unscientific, HIV criminalization undermines public health. The laws deter some people from getting tested because it’s legally safer not to know their status. And criminalization deepens the stigma surrounding HIV, which of course makes it all the riskier and more difficult to disclose.

HIV is difficult to transmit, yet people have an exaggerated sense of its risk, which has fuelled a fear of people living with HIV.

We should not be criminalizing people who practice safe sex. Instead, we need to limit any use of the criminal law to the (extraordinarily rare) cases of actual, intentional transmission of HIV.

Thankfully, as a result of significant community advocacy, things are finally changing.

In June 2019, the House of Commons Standing Committee on Justice and Human Rights made several important recommendations to limit the use of the criminal law against people living with HIV, including changing the Criminal Code to stop the use of sexual assault charges to deal with cases of alleged HIV non-disclosure.

During the recent federal election, all the major political parties told us they recognized the need to limit the over-criminalization of HIV non-disclosure.

Today, we urge the newly elected government to follow through and reform the Criminal Code, in consultation with HIV community members and experts, to end HIV criminalization. It’s past time to end this ongoing injustice.

CORRECTION: A previous version of this piece stated that the Expert Consensus Statement was issued in 2019, when it was actually issued in 2018. This version has been corrected.

This column first appeared in Broadview’s March 2020 issue with the title “Safe sex should be lawful.”

Broadview is an award-winning progressive Christian magazine, featuring stories about spirituality, justice and ethical living. For more of our content, subscribe to the magazine today.

How to Develop a Curriculum Around HIV

large classroom from back of room
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Vitamin E effective, safe for fatty liver in HIV patients

Vitamin E effective, safe for fatty liver in HIV patients
Credit: McGill University

A type of fatty liver disease that commonly affects patients with HIV can be safely treated with vitamin E, a McGill-led study has found.

Nonalcoholic steatohepatitis (NASH) is a severe form of nonalcoholic fatty  disease (NAFLD) and is characterized by  and cell damage. It is a potentially dangerous condition that can progress to cirrhosis or .

“Vitamin E has been shown to improve fatty liver in the general population,” says the study’s lead author Dr. Giada Sebastiani, Associate Professor in the Department of Medicine, McGill University and scientist at the Research Institute of the McGill University Health Centre. “Here we provide evidence for its beneficial effect and safety in people living with HIV, who have a higher prevalence of fatty liver disease.”

The study appears in the February 1, 2020 issue of the journal AIDS.

Dr. Sebastiani notes that NAFLD currently affects up to 48% of Canadians living with HIV and 25% of the , while NASH affects about one third of patients with NAFLD. There are several theories to explain the high prevalence of fatty liver among HIV-positive patients, explains Dr. Sebastiani: “It is possibly due to HIV-related inflammation, the antiretroviral drugs that they have to take lifelong, and to very frequent metabolic problems, such as diabetes and high lipids. Unfortunately, there is no approved therapy for fatty liver in people living with HIV.”

In the study, 27 patients with HIV and NASH were given vitamin E in an easily-tolerated dose of two pills per day. “We found that vitamin E improved both liver transaminases (the main blood tests for liver function) and liver fat measured by a non-invasive ultrasonographic test,” says Dr. Sebastiani. “These improvements were even more marked than those reported in the HIV-uninfected population.” Although she suspected vitamin E would reduce inflammation and fat in the HIV-positive group, Dr. Sebastiani was pleasantly surprised by the size of the effect.

Dr. Sebastiani notes that because the study did not have the benefit of a control group, and the study group was small and had a short follow-up (24 weeks), it’s considered a pilot project. “We would be interested in conducting a larger randomized controlled trial, with a longer follow-up,” she says.

Dr. Sebastiani came to McGill seven years ago from Italy with the goal of establishing a world-class research program focused on fatty liver and non-invasive diagnostic tools for liver disease. In the intervening years, cases of  disease, which was previously associated only with alcohol abuse, have exploded, particularly among obese Canadians. Dr. Sebastiani predicts that NAFLD will become the leading cause of liver transplants in the next 10 years.

“Vitamin E is an  for non-alcoholic steatohepatitis in HIV mono-infected patients,” by G. Sebastiani, P. Ghali, M. Klein, et al, was published February 1, 2020 in the journal AIDS.


How Universal Health Care Fails Queer Communities

A lack of data from LGBTQ Canadians creates holes in our medical system

EARLY one October, Nick North arrived at a Calgary hospital feeling a mix of fear and excitement. He had long felt that his body did not match who he was inside: he had been assigned female at birth but did not identify as a woman, and the day had finally come for his gender-affirming top surgery, a procedure to masculinize his chest. But, he recalls, when he handed his paperwork to staff, he had to repeatedly request they call him Nick, not the name on his birth certificate. “If I already know you can’t figure out my pronouns and call me the right name, then how do I trust you with my unconscious body?” North says. “How do I go into that not terrified?”

North remembers hospital staff telling him not to take it personally, but “you always take it personally,” he says. It had felt just as personal when his psychiatrist told him to wear a swim top to feel more comfortable at the pool with his kids, leaving North to educate him on why having a body he feels comfortable in—not a swim top—would help his dysphoria.

North believes a federal survey on transgender identity could improve services for men like him. “There are so many more of us than you know, and we’re not getting the proper health care.” Research has suggested that gender and sexual minorities experience worse health outcomes than the rest of the population. Until recently, agencies like Statistics Canada have faced challenges in trying to collect health data on LGBTQ individuals in a manner that is both precise and culturally sensitive. Increasing the amount of publicly available data on the national level could allow health care practitioners to make more-informed decisions about patients. “If you can’t be counted,” says Lori Ross, a professor of public health at the University of Toronto, “then you don’t count in terms of policy.”

LAST JUNE, the federal standing committee on health, a small group of MPs with a key role in crafting legislation, produced a landmark report on LGBTQ health in Canada. Tasked with examining the numerous health inequalities for gender and sexual minorities, the committee collected evidence of disparities: bisexual women and lesbians are at greater risk of chronic illnesses such as arthritis, for instance, and LGBTQ individuals in general have disproportionate rates of mental illness. The report emphasized that discrimination and the stress of being a minority affect these health outcomes. In other words, the health care system marginalizes LGBTQ people because it isn’t designed to acknowledge them. Experts like Ross say that simply counting sexual and gender minorities in population-based data would help the health system respond better.

The report made several recommendations relating to data collection. It suggested Statistics Canada change its practices to increase the number of LGBTQ respondents, improve its questions on sexual orientation, and include sexual-orientation and gender-identity questions on all surveys.

As a queer nonbinary person, Brent Saccucci’s sexual and gender identities are integral to understanding their health needs (Saccucci uses he and their pronouns). A PhD student and instructor at the University of Alberta, Saccucci researches queer mental health and social justice. They trace their experiences with mental illness to widespread social stigma around queerness, “which makes me nervous of sex with men.” They are also anxious about getting HIV and have to take pre-exposure prophylaxis, or PrEP, a preventative drug. “It’s all intertwined: the sex, the sexual health, the mental health—all are deeply affected by being queer and trans.”

Saccucci has struggled to find affirming, queer-competent health professionals. “I remember one time I was at the doctor and asked, ‘What else can I do to mitigate the risk of getting HIV?’ The doctor was like, ‘I guess you could have fewer sexual partners.’” This didn’t sit right, and instead it was Saccucci’s therapist who calmed their fears.

Jody Jollimore, the executive director of the Community Based Research Centre, a nonprofit that promotes the health of gay men, says that the federal government must prioritize LGBTQ health, which could include gathering more public-health data. Federal surveys can help set health priorities: census data is used to make recommendations on long-term care for seniors, for example. According to Jollimore, “there’s a real gap between what’s getting funded and where the actual issues are” for queer and trans Canadians. For instance, access to PrEP still varies by province; Saccucci could not get it in Ontario but can in Alberta. More data on the experiences of those like Saccucci would make it easier to develop health standards across the country.

Alex Abramovich, a scientist with the Institute for Mental Health Policy Research at the Centre for Addiction and Mental Health in Toronto, spent over a decade sharing with city council the concerns he heard from homeless LGBTQ youth, who often experience discrimination in the shelter system. In 2013, Abramovich was put in charge of a working group that advised the city to add questions about gender identity and sexual orientation to that year’s Street Needs Assessment.

According to that assessment, at least 20 percent of youth in the shelter system are LGBTQ—and that was a conservative estimate. Without this kind of data, says Abramovich, government and decision makers can “say there isn’t a problem or that we don’t really have an issue of LGBTQ people being overrepresented in, for example, homelessness.” Evidence from those new questions helped create Canada’s first transitional housing program for LGBTQ youth. Similar data sets at the federal level could have equally profound implications for services and funding.

Over the past two decades, Statistics Canada has begun addressing the data gaps on sexual minorities. In 2001, the census began collecting data on same-sex common-law relationships. In 2003, the annual Canadian Community Health Survey (CCHS) began asking respondents about sexual orientation, with the General Social Survey (GSS) following suit the next year.

These measures, however, still fall a few colours short of a full rainbow. Travis Salway, a professor of health sciences at Simon Fraser University, counts around nine publicly available federal data sets from the US on sexual and/or gender minorities that are useful to researchers: these government-run national surveys include a drug-use survey and a questionnaire on aging. To Salway, the only comparable resource in Canada is the CCHS. Researchers, he adds, depend on these data sets to conduct their work. And any increased data sets must be matched by funding for research and services; data alone can’t fix the problem.

Salway’s research shows that sexual minority adults are four times more likely to attempt suicide than their heterosexual counterparts; to identify whether these kinds of disparities are getting better or worse (and for whom), accurate and nuanced federal-survey data is crucial, he says. The Canadian census counts only sexual minorities who are married or living together. Additionally, the GSS and the CCHS are done by phone. “You can imagine, being asked over the phone by a government interviewer about sexual orientation, that it would be sensitive,” says Lori Ross. This discomfort could affect the survey’s ability to provide accurate population estimates.

Statistics Canada is working to address the problem of insufficient data on trans people as well. It has created two new questions that could be used in various surveys: one asks for sex assigned at birth, and another asks about current gender identity. The latter question allows for write-in answers that let respondents identify beyond the male-female binary. It has been launched on social surveys such as the GSS and CCHS, and Canadians may even see it on the 2021 national census.

Meanwhile, many in the LGBTQ community are finding their own ways to bend the health care system toward equity and healing. Trans Pulse Canada, for instance, is a national, community-based survey with the tagline, “In this census, trans and non-binary people count!”

Nick North has created a community of other trans people and allies that offers support, advice, and commiseration. North experienced complications in his top surgery, so he needs a revision, which recent changes at Alberta Health and a system under pressure have delayed for months. At times, he says, he felt like the surgery would never come, but it has now been scheduled for this spring.

For Brent Saccucci, creating a supportive health team has involved enduring many uncomfortable appointments with uneducated or insensitive service providers. Saccucci worries about whether Alberta’s United Conservative Party government will remove universal coverage of PrEP, which would make it inaccessible to them and those without private insurance. Ultimately, however, in spite of a health system they describe as “exhausting at times,” Saccucci has created their own path to wellness. They’ve even found a therapist with whom “my queer identity seems to fit.”


How Universal Health Care Fails Queer Communities

Frailty is a Predictor for Mortality in Adults With and Without HIV

Independent from other risk factors, frailty can be a strong predictor for both mortality and incident comorbidity among adults of middle age, according to a new report from The Journal of Infectious Diseases. This was true for people with and without HIV, the study authors said.

Investigators from Amsterdam studied more than 1000 middle-aged adult patients in order to understand the impact of frailty among the aging population with HIV. The investigators compared 598 middle aged to older adults living with HIV and 550 adults who did not have HIV that were all over the age of 45 years.

Now that people with HIV are living longer due to antiretroviral therapy non-AIDS-related comorbidities are increasing. The study investigators wanted to identify people with HIV who were at an increased risk for poor outcomes as they age to pinpoint what research should be prioritized moving forward. Then, in turn, it would help in figuring out what implications these findings hold for the patients’ health care management.

The investigators said defined frailty as weight loss, low physical activity, exhaustion, decreased grip strength, and slow gait speed. If a person met 3 or more of these characteristics, they were considered frail; if they met 1-2, they were “prefrailty.”

At baseline, 7.5% of the patients met the definition for frailty. Then, the patients were tracked for follow-up for 6 years to measure incident all-cause mortality and 4 years to measure comorbidity. The investigators took hip and waist circumference measurements at each study visit. Additionally, waist-to-hip ratio, height, and weight were measured and blood samples were obtained. The participants also completed a questionnaire on smoking behavior, alcohol use, medication use, recreational drug use, and depressive symptoms.

A majority of these patients who were living with HIV were men who have sex with men. During the follow-up period, the investigators reported that 7.9% of the HIV-positive and 5.4% of the HIV-negative participants became frail. The investigators also observed that during the follow-up period, 56.9% of the participants with HIV and 49.3% of the HIV-negative participants became prefrail.

The frail participants more often were HIV-positive, a current smoker, and had more pre-existing comorbidities, the study authors said, while noting this group reported less alcohol use.

During the mortality follow-up for both groups, the study authors discovered that 38 patients died (31 from the HIV-positive group). Of the deceased participants, 11 were frail at baseline, 20 were prefrail and 7 were not. None of the deaths were AIDS-related, the study authors said.

Being frail was independently associated with an increased risk for mortality after adjustments for age, HIV status, smoking status, and alcohol use, the investigators reported.

There was no effect of HIV status on frailty or mortality, they added.

The measurements collected at the follow-up visits were not associated with mortality, the study authors said; they did not impact the link between frailty and mortality, either.

Some of the incident comorbidities included hypertension, COPD, decreased kidney function, and osteoporosis. These combined to make up almost three-quarters of the incident comorbidities, of which there were 320 total across both participant groups.

“Clinicians should be aware that frailty is predictive for future adverse health outcomes and may want to consciously screen their patients—even those who have not yet reached ‘geriatric’ age and do not yet have significant comorbidity for frailty in order to proactively identify those at greater risk of adverse health outcomes,” study author Eveline Verheij, a PhD candidate, told Contagion®. “Based on studies from the geriatric field in the general population, elderly patients living with HIV may be confident that lifestyle interventions such as increased physical activity may help prevent and maybe even reverse frailty, although this needs to be further investigated in the setting of HIV.”


Bridging the research gap on the sexual health of men in the LGBTQ+ community

Findings could inform health policy, but professor warns against jumping to conclusions


Bridging the research gap on the sexual  health of men in the LGBTQ+ community

Health-policy makers often make decisions that drastically impact people all across the country, but before they can do that, they need to understand what the population truly needs. That can be difficult, though, when policies affect specific groups with even more specific health needs — such as men who have sex with men.

Gay, bisexual, and other men who have sex with men (gbMSM) can be uniquely affected by sexual health-related policies, but it’s historically been very difficult to get information that truly represents their needs as a diverse population.

A survey to bridge the gap

A major initiative to gather information has been the European Men-Who-Have-Sex-With-Men Internet Survey (EMIS), which asks questions about the mental and sexual health practices of gbMSM all over Europe — and, in the 2017 version, also those of men in Canada. “This is really meant to be kind of a public health report,” said Dr. David Brennan, a professor and assistant dean, research at U of T’s Faculty of Social Work, who was instrumental in implementing the survey in Canada.

This was the first study in a long time to gather health information about the sexual health of gbMSM on a national scale. It contains results from both transgender and cisgender respondents from a variety of backgrounds all across the country. The survey’s questions were informed by health experts from across Canada, and cover topics like safe sex practices, drug use, depression, anxiety, and homophobia.

Some of these trends have been investigated by more specific studies in the past, and the new study is consistent with past results. For example, rates of anxiety and depression in gbMSM were higher than rates in the general population, according to Brennan. There’s still, however, a wealth of new information to be found from the study, as it measured some things that have, frankly, not been measured before.

Reducing the risks associated with sex between men

Today, gbMSM in Canada can find plenty of information online about safe sexual practices. In fact, Brennan recounted that his research lab, CRUISElab, discovered that most gbMSM turn to Google for sexual education.

However, over the last few years, there have been a few very important developments for HIV-related sexual health, and it’s unclear how far this information has travelled. One of the goals of this survey was to measure the prevalence of knowledge and usage of pre-exposure prophylaxis (PrEP), a drug that can be used to prevent infection in HIV-negative people who are at risk of contracting HIV.

PrEP’s a fairly recent development that has only become widespread since the last EMIS in 2010, and it is not covered by provincial health insurance in most parts of Canada, including Ontario.

This may pose a significant barrier to men interested in using the drug, as evidenced by the numbers in the study — while only about 8.4 per cent of Canadian respondents had ever used PrEP, over 50 per cent said they’d be likely to use it if it were both available and affordable. More respondents had used PrEP in Québec and in British Columbia — where the drug is covered by the province — than in Ontario.

Another important area the study illuminated is ‘party-and-play’ sex, or ‘chemsex,’ in which participants use drugs to enhance their sexual experience. When injectable drugs are introduced in sexual situations, there can be a much higher risk of participants contracting certain sexually transmitted infections.

Conclusions do not indicate a lack of concern with safe practices

That being said, Brennan recommended that readers be wary about assuming chemsex participants are automatically less concerned with sexual safety. Some researchers have found that in gatherings where participation incurs a greater risk of sexually-transmitted infections, participants build up a community of sorts to take care of each other’s sexual health.

Not only should the general public avoid leaping to conclusions, but researchers should as well. It’s easy to draw conclusions that might be unconsciously influenced by our prior biases, especially when reading research on gbMSM. In Canada, the survey reached out to a lot of participants through dating apps, which could affect the study’s results, as these participants may be more likely to have more or more frequent sexual partners.

This doesn’t, however, mean that they’re necessarily being less safe than the general population.

“I’ve had many calls from reporters wanting me to tell them that people using these apps are actually having more unsafe sex. And, no, there’s really not much evidence to show that,” said Brennan. “It’s less about the venue or the location and more about… preferred behaviour.”

The survey is, of course, limited in its sampling methods — it can only collect data from participants who were willing to reach out in response to ads on dating apps, or at sexual health centres that the study has paired with across the country.

But that doesn’t mean the data is any less useful. This data could be instrumental in drafting a health policy that accounts for the realities of being a Canadian man in the LGBTQ+ community.


Bridging the research gap on the sexual health of men in the LGBTQ+ community

Australian researchers present two possible ‘PrEP cascades’ that could be used to measure uptake

The most recent of a series of national gay men’s surveys in Australia shows that over one in seven (14.7%) of all the non-HIV-positive respondents in the 2018 survey is taking PrEP. A smaller survey conducted in 2017, which focused on gay men’s opinions of biomedical prevention alone, found that one in five (20.5%) were taking PrEP. It also found that about one in seven (15.1%) reported that they were taking PrEP and experiencing reduced anxiety and more confidence about sex.

This high proportion of gay men on PrEP has enabled Australian researchers to construct two sample ‘PrEP cascades’, which could be used in other countries and locations to gauge the uptake of PrEP among their key populations at risk of HIV — and some of its impact.

About cascades

One of the most powerful advocacy tools for measuring progress towards full HIV treatment coverage has been the ‘treatment cascade’, exemplified by UNAIDS’ 90-90-90 campaign. This measures progress against a standard in which 90% of people with HIV have been diagnosed, 90% of them are on sustained antiretroviral therapy, and 90% of those have undetectable viral loads. Achieving, as a result, 71.9% of a country’s entire HIV-positive population should result not only in far fewer cases of AIDS and deaths, but also, as the more person-centred U=U campaign reminds us, mean that far fewer people are infectious.

Globally, however, we also now have biomedical prevention in the shape of PrEP. It is a prevention measure for HIV-negative people which, unlike, say, the distribution and social marketing of condoms, depends mainly on provision via formal healthcare systems. Given that the scale-up of PrEP could make its own substantial and cost-effective contribution to ending the global HIV epidemic, as this recent Dutch modelling study shows, it is important to measure this contribution and devise a ‘PrEP cascade’ to measure its distribution and effectiveness.

Professor Martin Holt of the University of New South Wales and colleagues have now devised two PrEP cascades based on the data provided by two different surveys that could be applied to other countries.

The first cascade has only three steps that measure eligibility, awareness and use. The figures in it have been derived from a multi-year survey that has enabled the researchers to chart how PrEP use has increased over time.

The second cascade is from a smaller study and only, so far, makes use of one year’s worth of figures. However, it contains seven steps. These add willingness to use PrEP, discussing PrEP with a doctor, regular HIV and STI testing and whether PrEP has resulted in decreased anxiety about HIV and greater sexual pleasure. Holt says this step was added because 90-90-90 has been criticised for not including quality of life and mental health in its metric, and indeed this is sometimes added as a fourth 90.

The surveys

The first survey is the Gay Community Periodic Survey (GCPS), which has been conducted in Adelaide, Canberra, Melbourne, Perth, Queensland (Brisbane, Cairns and the Gold Coast) and Sydney since 1996. Tasmania was added in 2014, which was also when it started to collect figures on PrEP. Participants are recruited at gay venues and festivals and increasingly online. It recruits annually in Sydney, Melbourne and Queensland and biennially elsewhere. The latest figures are from 2018.

The second survey is from the PrEPARE Project, a biennial online-only survey specifically assessing gay men’s attitudes to biomedical prevention. It has been conducted in 2011, 2013, 2015 and 2017, but only the figures from 2017 were used in the cascade.

The first step in both cascades is eligibility for PrEP, although this is defined slightly differently in the two surveys. Eligibility criteria were:

  • methamphetamine (crystal meth) use in the last six months,
  • any STI diagnosis (other than HIV) in the last year,
  • condomless anal sex in the last six months with a non-virally suppressed HIV-positive regular partner, and
  • condomless anal sex with a casual partner in the last six months.

However, for the last criterion the GCPS restricted this to receptive condomless anal sex, while the PrEPARE Project included receptive or insertive sex. These criteria are also slightly different from the national PrEP guidelines, which specify condomless sex in the last three, not six, months and only syphilis, rectal gonorrhoea or rectal chlamydia in the last three months as STIs.

Briefly, in terms of participant characteristics, there were 39,670 cumulative non-HIV-positive participants in the GCPS from 2014 (many will have participated in several different years), with 8638 in 2017 and 7878 in 2018. Across the years, their average age was 35, with 70% born in Australia, 51% university educated, and 64% in full-time employment.

In 2017 in the PrEPARE Project there were 1038 non-HIV-positive participants. Their average age was 36, more were born in Australia (80%) than in GCPS, slightly fewer had a university degree (45%) and the same proportion as in GCPS were employed. They reported more condomless sex, sexual partners and HIV testing than the men in the other survey.

Cascade results

The Gay Community Periodic Survey’s three-step cascade for 2018 was as follows:

  1. Eligible for PrEP: 37%
  2. Aware of PrEP: 32%
  3. Using PrEP: 15%

Eligibility increased from 28% of participants in 2014 to 36% in 2017 and 37% in 2018, reflecting more gay men fitting into the condomless sex and the STI criteria.

Awareness increased rapidly from 30% of those eligible (8% of all respondents) in 2014 to 80% of those eligible in 2017 and 87% in 2018 (32% of all respondents).

The proportion actually using PrEP in 2014 was very low – only 3.7% of those eligible, or 0.3% of all respondents. This rose rapidly to 37% of those eligible (11% of all respondents) in 2017, and 45% of those eligible (15% of all respondents) in 2018.

The PrEPARE Project’s seven-step cascade for 2017 was as follows:

  1. Eligible for PrEP: 54%
  2. Aware of PrEP: 53%
  3. Willing to use PrEP: 36%
  4. Discussed PrEP with a doctor: 26%
  5. Using PrEP: 21%
  6. Tested for HIV and STIs in the last three months: 20%
  7. Reduced HIV concern and increased pleasure because of PrEP: 15%

Comparing the two surveys’ figures for 2017 is interesting. In the PrEPARE Project, 54% were eligible versus 36% in GCPS (maybe reflecting the slightly wider criteria in PrEPARE and the participants’ different risk profiles); nearly everyone who was eligible was aware; and more were using PrEP.

Cascades can identify ‘break points’ where the proportion of people staying in the cascade declines most abruptly, and the PrEPARE Project isolates that at a point not included in the GCPS – willingness to use PrEP. Although 97% of those eligible had heard of PrEP, only 68% of those were willing to use it – a relative decline of one-third from those eligible, and almost as great a decline as from those who were aware. There was also a further 14% decline from willingness to having a discussion with a doctor, meaning that less than half of eligible respondents had discussed PrEP with their doctor. Seventy-eight per cent of those who had discussed it with their doctor actually started PrEP – or 35% of those eligible.

Virtually everyone who started PrEP (97%) tested regularly for HIV and STIs. Of those, 76% reported reduced HIV concern and more pleasure. That’s 29% of those eligible – or 15% of all respondents, which coincidentally is the same figure as the ‘end point’ (using PrEP) of the 2018 GCPS survey.

The surveys also showed that participant characteristics had some influence on the cascades. In the GCPS, PrEP users were less likely to come from Canberra or Perth and more likely to be of Anglo-Australian ethnicity, have a degree and be employed. They were unsurprisingly more likely to have behavioural characteristics that made them eligible, apart from using crystal meth – which, interestingly and possibly worryingly, was higher among non-PrEP users. In the PrEPARE project, men over 40 were less willing to use PrEP, whereas men born in Australia and those who knew someone who already used it were more willing.


What the GCPS figures show that awareness of PrEP does not translate straightforwardly into taking it, and while their cascade is easier to compile, it misses out two crucial steps – one cognitive (being willing to take PrEP) and one action-based (going to a doctor to discuss it). The authors comment that adding willingness to take PrEP to the Gay Community Periodic Surveys would be useful.

They comment that, in future, it would be useful to standardise PrEP cascades so that studies use the same sequence of steps. The GCPS three-step cascade is easier to calculate as its steps – eligibility, awareness, and use – are already enumerated in a fair number of studies. However, as the PrEPARE Project shows, cascades with more steps may be needed to identify the ‘break points’ which are the reason why high eligibility may end up with low usage.

In this case, the significant drop-off was in the proportion of men willing to take PrEP. This indicates a need for research into reasons for this – whether due to perception of low risk, fear of side effects, social stigma or some other reason – so that interventions to address these reasons can be devised.

The authors recognise that developing these cascades was possible because of both the large numbers of PrEP users in Australia and because of the regular behavioural surveillance of gay men there. However, they do comment that a shorter cascade like the GCPS one could be constructed in other locations.



HIV-positive airmen are fighting the government to stay in the Air Force in a landmark case


HIV Air Force

Two HIV-positive US Air Force members have filed a lawsuit after they were discharged following their diagnoses in 2017.

The lawsuit, which was filed by Lambda Legal in December 2018, identified the men using pseudonyms of Richard Roe and Victor Voe, ABC News reports.

The men are arguing that they were unfairly dismissed following their diagnoses despite the fact that there is no protocol in the Air Force for such measures. The lawsuit also argues that their dismissal is unconstitutional and is based on outdated science that fails to consider the existence of HIV-medication.

Dismissal of HIV-positive men is out of step with science, lawsuit argues.

While there is currently a policy in place that prohibits HIV-positive people from signing up to the military or armed forces, there is no such policy for service members who are diagnosed while serving. In fact, the Air Force has a policy that prohibits the dismissal of service members solely on the basis of their HIV status.

The two men claimed their first victory in January when a federal appeals court upheld an injunction which will allow the case to proceed. The injunction means that the military will be banned from discharging the men while the lawsuit is pending.

In a unanimous decision, a three-judge panel said the Air Force had failed to consider “current HIV treatments and transmission risks” when it decided to discharge the men.

This is a major victory, but there is more fight ahead.

Bizarrely, the military has argued against the lawsuit by claiming that the men could pose a risk to other service members on the battlefield if they came into contact with the men’s blood. The argument fails to take into consideration the fact that antiretroviral medication makes the HIV virus undetectable and untransmittable.

“Members of the US Armed Forces embody the best of the American spirit,” the lawsuit read.

“They serve and defend us for love of country and community. Our military treats service members’ wounds and illnesses, and, when able, they continue to serve.


“Service members with HIV, however, do not enjoy the same treatment. Asymptomatic HIV has been diagnosed in a significant number of active-duty service members.”

The Air Force has argued that there are ‘potential complications’ of allowing the men to serve.

The Air Force said that there were potential medical complications to allowing the men to serve, and said they would be “unable to reasonably perform” their duties, according to court papers.

They said that their HIV status would prevent them from being deployed to the US Central Command area of responsibility.

“This is a major victory, but there is more fight ahead,” said Scott Schoettes, counsel and HIV project director at Lambda Legal.

“Our adversary in this case is the military itself and its current leadership, which seems not to be willing to actually accept or grapple with what these changes in the medicine mean for people living with HIV and their ability to serve.”



Gay men living with HIV have a misconception about their viral load, study finds



Photo by Stanley Dai on Unsplash

A new study has found that more than a quarter of HIV-positive gay and bisexual men have misconceptions about their viral load.

The study, which was published in the Journal of Acquired Immune Deficiency Syndromes, found that 20 percent of men wrongly thought their viral load was undetectable. Meanwhile, a further 7.5 percent had successfully repressed viral loads but believed otherwise, AidsMap reports.

A person’s viral load refers to the quantity of the virus that exists in their blood. People who are diagnosed with HIV today are usually prescribed antiretroviral drugs which can make their viral load undetectable.

48 percent of HIV-positive men who participated in the study had less than perfect adherence to treatment.

157 HIV-positive men participated in the study, with recruitment taking place in Atlanta, Boston and Chicago. Notably, researchers discovered that 48 percent had less than perfect adherence to antiretroviral drugs.

“These relatively high levels of inaccurate reporting of viral suppression exist in a sample that reported almost universal engagement in HIV care and ART medication, although approximately half reported sub-optimal ART adherence,” the study’s authors wrote.

“The results do not necessarily represent an intentional misrepresentation of viral suppression; rather men might be reporting their viral status based on misconceptions or information that was out of date.”

The study comes just months after research suggested that there is zero risk of a people with the virus passing the virus on to a sexual partner while on effective antiretroviral treatment.

The results do not necessarily represent an intentional misrepresentation of viral suppression; rather men might be reporting their viral status based on misconceptions or information that was out of date.


The study, published in The Lancet and called PARTNER2, investigated almost 1,000 gay male couples who did not use condoms across Europe over more than eight years where one partner had the virus.

Over the course of eight years, just 15 of the HIV-negative men involved contracted the virus—however, researchers were able to confirm through genetic testing that none of those men contracted the virus from their partner.

Another study from 2017 found that the vast majority (96 percent) of HIV-positive men in the UK accurately reported having an undetectable viral load.

People who contract the virus now live ‘normal and healthy lives’ thanks to treatment options.

Debbie Laycock, head of policy at UK HIV charity the Terrence Higgins Trust, told PinkNews that the vast majority of people with HIV now live “normal and healthy lives” thanks to treatment options.

“We want to see an end to new HIV transmissions by 2030 and this is something the government has committed to achieving.

She continued: “Through regular testing, condoms, Pre-Exposure Prophylaxis and effective treatment which means people living with HIV can’t pass on the virus – we now have a once-in-a-generation opportunity to end the HIV epidemic. It’s vital we seize this.”



The Rage to Live: film and lecture series takes historical look at artists, AIDS, and activism

The Rage to Live: Queer Film Legacies and the Work of David Wojnarowicz and Marlon Riggs
  • The Rage to Live: Queer Film Legacies and the Work of David Wojnarowicz and Marlon RiggsTHE CINEMATHEQUE

A historical look at artists active amid the onset of the AIDS crisis in the U.S. is underway this weekend, with an in-depth exploration of issues such as racism, sexuality, representation, and more.

The Cinematheque, in partnership with the Morris and Helen Belkin Art Gallery and Griffin Art Projects, are presenting a film and lecture series from today (January 31) to Sunday (February 2) entitled The Rage to Live: Queer Film Legacies and the Work of David Wojnarowicz and Marlon Riggs.

The series is being presented in tandem with two current art exhibitions.

At the Morris and Helen Belkin Art Gallery until April 5, the exhibition David Wojnarowicz: Photography and Film 1978-1992 focuses on the artist’s photographic and filmic work, including over 100 photographs, silkscreens, 16mm and Super 8 films, test prints, and collaborative videos.

Wojnarowicz (1954-1992) rose to prominence in New York’s art world in the 1980s for his work that was both political and personal, and he had garnered national recognition by the time he was diagnosed as HIV–positive in 1988.

The Sodomite Invasion: Experimentation, Politics, and Sexuality in the work of Jimmy DeSana and Marlon T. Riggs, at North Vancouver’s Griffin Art Projects until April 25, presents the work of two U.S. artists: New York City–based photographer Jimmy DeSana (1949-1990) and experimental filmmaker and documentarian Marlon Riggs (1957-1994), who was also an HIV/AIDS activist.

Both artists died of AIDS–related illnesses.

The series kicked off tonight (January 31) with an opening keynote talk by New York City–based artist and New York University associate professor Lyle Ashton Harris.

At 1 p.m. tomorrow (February 1), the panel discussion Queer Perspectives: Intersectionality and the AIDS Crisis will feature interdisciplinary artist Adrian Stimson of the Siksika (Blackfoot) Nation in conversation with I Yerevan Biennial artistic director and curator Lorenzo Fusi and Harvard University professor Robert F. Reid-Pharr.

Both Stimson and Reid-Pharr will be keynote speakers as well on Saturday and Sunday (February 1 and 2).

Film screenings will include Riggs’ “Ethnic Notions” (1987) and “Affirmations” (1990); and Color Adjustment (1991), a documentary examining racial stereotyping on U.S. television; and his final film Black Is… Black Ain’t (1995).

Also scheduled are Marion Scemama’s Self-Portrait in 23 Rounds: A Chapter in David Wojnarowicz’s Life, 1989-1991; David France’s 2012 How to Survive a Plague, a U.S. documentary about the early years of the AIDS crisis; Robin Campillo’s 2017 French drama BPM: Beats Per Minute, about the Paris chapter of Act Up during the 1990s.

Full details are available at the Cinematheque website.

by Craig Takeuchi