Four years ago, we wrote the first community-based article about exciting possibilities for PrEP to bring us an era when new HIV infections might be brought to a halt. Two years later, we wrote an article dispelling the myths about PrEP perpetrated by the misleading folks at AIDS Healthcare Foundation and their supporters, and we discussed why psychotherapy/counseling was important for many people's lives for whom PrEP would be a great risk-reduction solution.
Now, we want to tackle the inevitable situation of a rise in less dangerous sexually transmitted infections, almost back to the worst levels of the 1980s (but not yet the staggering levels of the late 1960s and 1970s). The easy fix �" and some have wanted us to go back to this �" would be to try to scare everybody about antibiotic resistance and to terrorize people back into using condoms. Except, we know from experience that won't work. Moreover, condoms are helpful at blocking some STIs, but not all of them, and only have about a 70 percent success rate for most people anyway.
We admitted we had become powerless in seeking the easy fix �" that our efforts to date had become unmanageable. To begin, we had to acknowledge the reality on the ground. The way social health educators have, in the past, handled our messages �" especially to communities on the margins �" had stopped working. In public/social health, we sometimes look at ourselves wondering how we keep winding up seeing a possible recipe for disaster, especially among gay and bi cisgender men and trans men.
Too often, our approach for prevention had been to spew moralism from on high about the intimate realities of a person's life. Join that with a kind of passive-aggressive behaviorist agenda-setting. Then join that with moralizing peer-pressure in health messages. Top it off with a reliance on devices that have been deeply loathed by men for five centuries and thrown away at every opportunity even at great personal cost. Now is it any wonder we eventually wind up with resentment, revolt, and reproach? No. Until we realize there is no more power to drive our health messages with fear, we remain sunk.
Condom code
This is what happened with the condom code by 1995. What had once been a modestly successful, fear-based behavioral change campaign, dissolved in reaction and disregard �" 64 percent of men who have sex with men had abandoned full compliance, a number that remains only slightly higher today (and higher among heterosexual men). Biomedicine saved us from an explosion of HIV infections. The suppression of the virus in our " lang=NL>herd" through the widespread use of highly active antiretroviral therapy kept new transmissions almost to zero among those who were medication-adherent and who were not simultaneously using hyperstimulants (which could throw off adherence and/or spark mutations and breakthroughs in viral load).
So, we came to believe that this power greater than ourselves could restore us to sanity. This process of seeing what had failed was how we discovered TasP (treatment as prevention). It is also how we discovered that high viral loads in patients who usually don't know their status were the main sources of our new infections. We learned that men were coming up with risk lowering strategies by getting educated and employing knowledge on their own. We realized that if we vaccinated people against hepatitis A and hepatitis B, we could dramatically bring down infections. Some of us, unaided by many physicians and insurance companies, have strongly advocated that all queer men get vaccinated for HPV, even if they've had a wart from a strain, because there is likely protection for other strains and from cancer. Many of us have advocated strongly for annual flu shots and for the vaccine against meningococcus, and for the same reason �" in close quarters like meetings and conferences, these are easily spread and can be deadly. We could use more help from doctors and insurers about these, too. We learned from all of this that we really needed a testing campaign for HIV.
We made a decision to entrust ourselves to the care of that process. At community suggestion, we have tried many ways to make that testing widely accessible, acceptable, and free of stigma. Yet, we still regularly hear reports of gay/bi/queer men shaming other gay/bi/queer men about getting tested. Yet, clearly, plenty of us �" the shamers and the shamed �" are still having a whole lot of sex.
So, we took a fearless and searching "asset and liability" inventory of ourselves. We all have to ask ourselves: Why the shaming? Have we internalized the hatred of ourselves so much that we would rather scorn and shame each other into lonely lives of hermitage, or into unwanted bourgeois affectations, or into preventable infections with dangerous pathogens? It seems that way. What can we as queer men do about that?
We know we do have to get bluntly honest with the whole process, with ourselves, and with each other, about the exact nature of the problem. It has been a long issue with the Centers for Disease Control and Prevention that we don't have a national, open and frank, multi-racial/ethnic gay, bi, polysexual, and pansexual men's and transguy's testing campaign, not only for HIV, but also for the hepatitis C virus and other STIs. Even the CDC's "Get tested for STD Awareness Month" campaign was only youth-specific. Its newer campaign is better, but it's still conservative organizations like the CDC and Food and Drug Administration that throw us roadblocks (CDC is still telling people a lie: that oral sex is a significant risk for HIV; and the FDA still won't let gay men who've had sex in the last year give blood �" all of which is a matter of outright homophobia, not of science). The campaigns have been highly sanitized, and have lacked any national social marketing campaign to go with them.
This is really the crux of the matter, to have a set of clear action items on which queer men can organize. We need more queer bodies in the streets and the suites to be fighting for bluntly sexually frank and scientifically honest test-and-treat campaigns, as well as national funding for the campaign, for social marketing, for paying for the medications for treatment, and paying for therapy/counseling with those at high risk.
12 steps
We have to become entirely ready to use the process to remove our liabilities and enhance our assets. We still face the primary concern of infection with HIV, a national lack of sufficient care and medications to keep the infected healthy and virally-suppressed, and lack of sufficient care and medications to get PEP (post-exposure prophylaxis) and PrEP into the hands of every sexually-active MSM in this country (and in the world). If you don't want to take your daily pill to keep from getting a deadly virus, you might imagine how women on contraceptives feel every day, and how advantaged you are to have this option.
Next, we face infection with HCV, and the insurance provider and Big Pharma games about paying for the new very effective treatments. Hence, we face a lack of adequate treatment to get the HCV-infected cured so they can't pass it on. There is a lack of money directed toward standard sexual health testing for HCV. There is a lack of knowledge among MSM that HCV can be passed by blood-to-blood contact during rough sex (jewelry and fisting in the presence of high viral concentration anybody?) and can live on toys and in lube for weeks.
Finally, we do face rising infections of gonorrhea, chlamydia, syphilis, and even NGU (non-gonococcal urethritis), along with the lower-cooking infections of herpes and chancre (more than half of MSM carry HSV2, and suppressing the virus with medication and avoiding sex during budding is the best way to avoid infection). We have seen some antibiotic resistance in the bacteria that causes gonorrhea, Neisseria gonococcus, and we remain two antibiotics away from standard treatment failure. Local physicians and public health bigwigs still have not done the work needed to figure out how we will give intravenous infusions of bioactive silver to every gonorrhea case when the antibiotics are gone, but that's what we face. It would be better if they figured that out sooner, rather than in a crisis.
We also have to remember that if you get a notice that you've had a direct exposure to syphilis, you need to not only get tested, but also to get epidemiologically treated right then. Syphilis can hide for 12 weeks, so epi-treatment is non-negotiable. It's a must.
We have to become workers among workers, and get the people with the money and power to help keep us from falling short. It is insanity that we are the only major nation in the world that doesn't guarantee health care as a human right; and even the current Democratic Party platform could do a better job of moving us more quickly toward universal health care for all. It's insanity that the Republican Congress wants to cut funding for Ryan White monies, rather than increase funding for PrEP, the AIDS Drug Assistance Program, and Housing Opportunities for People with AIDS. It's insanity that we don't have federally funded STI clinics in every city. So, we all have to get more involved in political and health advocacy.
We need to make a list of all persons we have to reach, and become willing to build coalitions and alliances with all. Because we need help, and we need personal changes, too. It's incumbent on us to learn new risk reduction methods about toys, lubes, jewelry, and hand care regarding the blood-to-blood spread of HCV. And that gives us one more thing to talk about without stigma before we have sex. And we do need to talk before we have sex.
No, you can't trust everything that somebody tells you. But we can make it a standard operating procedure to put our testing and risk reduction strategy in our online profiles, just as we do with TasP and PrEP, and to talk about them in bars and coffeehouses and wherever else we actually meet in real life. We can make it a habit to be adult about disclosures of anything we have and what we do to treat it, instead of playing victim. We can all be knowledgeable about real risk and real risk reductions. We can call-in the people who shame others, and tell them that is not acceptable. If they won't listen, we can call them out. We cannot accept shaming and the projection of stigma about what we have to do to stay sexually healthy. The guys standing in line outside of Strut, or who call you when you've had an exposure, are the HEROES, not the pariahs, among queer men.
To stand up for our own sexual health, we have to be knowledgeable, go to the doctor or the clinic openly, get our shots, take our meds, reduce or eliminate the harm from all the drugs, test and treat, and openly talk about what's going on. Finger-wagging about either barebacking or condom-coding, or the structure of our relationships (polyamorous, open, monogamous), or the frequency of our sex, or how we like to play, cannot be tolerated among queer men, unless we want to consign each other to sickness and death. Stop the madness of shaming about sex.
We need to make direct coalitions and alliances with our people wherever possible, and to avoid actions that would injure them or others. Those of us who are white MSM also have to get over our own racism, our classism, our misogyny, and our biases against anybody who expresses gender in a way some of us might not like. If you're a queer white man and you're not working to rectify the prejudices that come from your "-isms" every day, you're doing active harm to people's health and lives. Adopt your first clue, because your own ass may literally be at stake. Seriously, no one can be left behind when it comes to our health: we are a herd. Your "no fats, no femmes, no blacks, no Asians" offenses on Grindr do not change the fact that we are a petri dish. We are all in this together. The AIDS crisis has taught us that we rise united or we fall apart. The disparities around HIV are glaring, and they need fixing now; STIs are in the same bucket.
So, as the 12 steps go, there are the final three which are called "maintenance steps" for the whole process, adapted to fit here. They are: We continue to take personal inventory and, when we are wrong, we try something better. We seek, through dialogue and listening carefully, to improve our conscious contact with each other and all queer men through this process. Having "got woke" to our own shortfalls and built up our own assets, we try to carry the work to others, and to practice these principles in all our affairs. We are offering this essay to begin to make that happen.
Luke Adams is a certified sexual health specialist with the American College of Sexologists and a lifetime member of the Association for Transpersonal Psychology. Race Bannon is an author and community activist who writes the Leather column for the Bay Area Reporter.