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There was a delicious troll comment directed at me the other day, as follows, that actually got me to do some thinking; a difficult thing to do at the best of times, I've been told.

Your doctor... (0+ / 8-)
...just wants you to keep your diseased dick in your pants. Advice that you--someone who for years insisted on engaging in unsafe sex with multiple partners, while refusing to get checked for HIV--would be well-advised to follow. How many others did you infect as a result of your irresponsible pursuit of sexual gratification? How many gay men are now sick or dead due to your selfishness?

Jeez, I know me and my buddies have been munching on your brain for quite a few years now, but surely you must have at least a little bit of common sense left. Try to use it for once in your fucking life.

by HIV Virus on Wed Jul 13, 2011 at 12:49:25 AM EDT

Well, good morning to you too, asshole, I thought.

But is there more to this than the residual bile presumably left over from the infamous, and now defunct, Peederian hate site Political Flesh Feast?

There are quite a few Kossacks who are HIV+, and I am one of them. I came out as poz on this site last year on World AIDS Day; that diary spent most of the following twenty-four hours at the top of the wreck list and went viral, no pun intended, across the internet. Pretty high profile, in short, for what was essentially a very private story that not many of us - that is, those of us who are HIV+ - ever share, and certainly not in the very public way that I chose.

The question that arose for me out of that comment I linked above is this: what level of responsibility do I, as someone with a communicable, ultimately deadly and presently incurable disease, have towards the men I get intimate with, and more broadly to the people I love? I'm already, coincidentally, fully responsible for my own status; I own that, and do not pretend otherwise.

The answer is simple, and I think basic common sense: a very high level. That's probably generally true, in that you take steps to protect your partner, and yourself, regardless of your HIV status. There are other unpleasantries out there you'd prefer not to have, after all, and condoms - I call them 'dick sweaters' - don't protect against all of them.

So it's important to understand the risk landscape, and make informed choices based on it. Every sexual act carries with it, unfortunately for something that's really quite fun if done well, a certain risk. So let's take a look at that.

Anecdotal and other evidence show a spike in infections in the younger gay cohorts; HIV incidence, that is, the number of new infections per annum, is over 50,000 in the United States for the most recent data period. Here in New York City, in the gay neighborhoods of our gleaming metropolis, the infection rate is one in four. My theory is that this is due to the astonishing efficacy of current HIV therapy, to the fact that a large percentage of the infected are asymptomatic and thus unaware of their status, to HIV stigma, and to the simple fact that the most awful days of the pandemic are receding in time. Simply put, the deterrent effect of seeing our community visibly devastated is no longer what it once was. At the same time, researchers are discovering that existing AIDS drugs offer some measure of protection to the uninfected:

Until a few years ago, condoms and abstinence were alone in that [HIV prevention] tool kit. Recent studies have added circumcision, vaginal microbicides, a daily pill for the uninfected (known as pre-exposure prophylaxis, or PrEP) and early treatment for the infected (known as “treatment as prevention”).

One study released Wednesday, known as Partners PrEP and conducted in Kenya and Uganda by researchers from the University of Washington, showed that participants who took a daily Truvada pill — a mix of tenofovir and emtricitabine — had a 73 percent lower chance of getting infected. The study was done in 4,758 “discordant couples,” those in which one partner was infected and the other was not. Partners who took a Viread pill — which contains only tenofovir — had a 62 percent lower chance.

Another aspect to consider is the question of how infectious someone with HIV actually is, because there are varying levels. A proxy for measuring infectiousness is the amount of virus copies in the blood stream, a metric known as the viral load. Simply put, lower is better; you get into the danger zone when it is >1,000 copies/ml. Most people on antiretroviral therapy, like myself, have a viral load that is undetectable with current technology, which in layman's terms means under 45 copies per milliliter of blood, the most sensitive level of testing available. The way you get there is by adhering to your damned treatment, which, to be blunt, isn't too difficult.

Then, there is a co-factor in one of the gay male community's dirty little secrets, namely the crystal meth epidemic. Crystal - also known as tina, crank, glass or simply crack - is, as sex drugs go, probably the most potent, most widely available, and far and away the most addictive and destructive. Crystal works by flooding your brain with dopamine and serotonin, and along the way wipes out whatever inhibitions an individual might have. On the plus side in terms of sexual health, crystal meth causes something known colloquially as 'crystal dick', which is shorthand for its debilitating effect on a male erection.

That, however, is where factor three comes into play: Viagra and its derivatives. Originally targeted at older men with diabetes and heart disease, Viagra and its various clones are a key part of the sex drug cocktail. This not entirely by chance; the drug makers quickly realized that marketing these pills to a broader, younger audience equates to quite a bit of steady revenue, to the tune of a billion dollars a year. And if you show me the man, gay, straight, whatever, who doesn't at least occasionally want to be a raging stallion, I'll show you a talented liar.

Another factor that isn't really a subject of conversation is, simply put, safer sex fatigue [.pdf]. The gay male community especially has been carpet-bombed with safer-sex messages for over two decades now, to limited effect and more importantly, decreasing relevance. It is not an easy thing, when your sexuality is stigmatized to begin with, to maintain 100% adherence to the limits set on you by, in some cases, the very institutions responsible for that stigma in the first place.

"It's something that we're seeing, particularly in the gay and bisexual community, with having all these messages for the past 20 years about using condoms and reducing risk, I think people get tired of that at times. It's a hard behavior to sustain," said Dr. Rita Shahin, acting director of communicable diseases for Toronto Public Health.

Last year, Toronto's board of health reported 279 people infected with syphilis, the highest number of cases in more than 12 years. In 2002, that number was 195 and in 2001, only 31 people were diagnosed with syphilis.

The main reason, though, why some or even many gay men engage in self-destructive behavior is in our relationships with ourselves and the larger society.

"Few talk about how external and internalised homophobia, with its 'stigma-shame-acting out' nexus, might be the catalyst to crystal addiction and to risk-taking behaviors leading to HIV infection."
~ Jean Malpass [The Body]

This discussion, about the effects of shame, anger and self-loathing, is one our community is starting to have, prodded inter alia by wider social acceptance - cf. the DADT repeal and majorities in favor of marriage equality - and by our thought leaders themselves. I'm referring specifically to Alan Downs' The Velvet Rage: Overcoming the pain of growing up gay in a straight man's world, a trenchant analysis of the staggering rates of depression and alienation in the gay male community and the very real price tag they carry.

Downs coined the phrase to refer to a very specific anger he encountered in his gay patients – whether it was manifested in drug abuse, promiscuity or alcoholism – and whose roots, the book argues, are found in childhood shame and parental rejection. "Velvet rage is the deep and abiding anger that results from growing up in an environment when I learn that who I am as a gay person is unacceptable, perhaps even unlovable," he explains. "This anger pushes me at times to overcompensate and try to earn love and acceptance by being more, better, beautiful, more sexy – in short, to become something I believe will make me more acceptable and loved."

And say what you will about sex, it is one of the most immediate proxies for the love and sense of belonging that so many gay men desperately search for. It's that old saying about him not being 'Mr. Right, but Mr. Right now'.

So these are some, not all, of the risk factors that influence, consciously or otherwise, the decision-making process prior to and during sex specifically for gay men. I happen to believe that we can't make informed decisions without knowing the psychological landscape in which they are made. I also believe that all of us, including yours truly, have a responsibility to ourselves, our families, and the community at large, to live the best, healthiest, and most authentic lives we can. I'm worth it, and so are you. And don't ever let anyone tell you otherwise. Especially not some anonymous pisser on the internet.

There's never been a better time to be queer in America; let's make the most of it.

Originally posted to LGBT Kos Community on Thu Jul 21, 2011 at 12:00 PM PDT.

Also republished by HIV AIDS Action.

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