There are few issues about which I feel more strongly than HIV/AIDS awareness and I take my advocacy/activism quite seriously, for a variety of reasons both globally-effective and intimately personal. I've found Twitter to be a fantastic resource for me in finding individuals, charity organizations, and hospitals/research centers to educate myself, lend support, and a million other uses when it comes to the disease. I cannot recommend it enough in this regard.

But...there's a downside, of course. For all of the people out there trying to educate, inform, and enrich life for everyone, there are just as many ignorant, corrupt, and hateful folks.

So -- one of the people I follow on Twitter (whose tweets are normally hilarious) posted a joke, a joke about HIV. Now, I firmly believe none of us should ever take ourselves so seriously that we can't find something to laugh at ourselves about, even if that laughter is in response to something as dire as illness, death, or catastrophe of some kind. I'm not saying I'm gonna do a 10-minute set of my best blond jokes at your funeral, but I have experienced the cathartic release of laughing at something truly devastating as a means of coping.

The tweet made me curious though; just how far would I be willing to go for a healing laugh? Are there certain subjects that are strictly verboten in any and every setting, or just around me personally?

With that in mind, I started digging around in the Twitterverse searching through thousands of tweets, and links, and blog posts for HIV/AIDS jokes. Believe me, there are A LOT and some of them are so repugnant I wouldn't even dream of sharing them here. Take my word for it, OK?

But the jokes are just that -- jokes. In bad taste? Of course! Not suitable for sharing in mixed company? Most definitely! But there is still an underlying intent of humor that cannot be denied, it softens the blow and makes them less painful, at least to me. But there's a lot of other talk going on out there, besides jokes and the tweets for doing good when it comes to HIV/AIDS. I'd like to share a tweet that stopped me dead in my tracks and caused me deep pain to even read:

"I feel the same way about people with hiv/aids as the nazi's did about the jews."

Now, all I know about the person who wrote this is that he lives in Iowa, has a wife/girlfriend, and generally likes to go out hunting, fishing and drinking with his buddies. I have no idea if there's some context that I'm missing, or if there's some extenuating circumstance that's not easily seen nor any of my business. But that doesn't change how I feel about it, right? Nor should it, if it's posted in a public forum such as it is.

The fact of the matter is, this young man (at least, that's what he looked like in his avatar photo) put this kind of ignorant hatred out into the world. Whether he believes it or not, was joking or serious, regrets it or is proud of it...it's there to inflict pain on anyone who reads it. At least, I should say, anyone who has any respect for the persecution and injustice that Jews withstood and suffered at the hands of fascist Nazis, or the pain, illness, and fear that anyone who has HIV or AIDS deals with on a daily-basis.

There are so many instances -- too many -- that emphasize the extremity of the hatred and intolerance that seems to be prevalent throughout our country these days. I know that I might be a tad hyper-sensitive about the whole HIV/AIDS issue, but to glibly liken yourself to a Nazi and their deplorable attempted genocide of the Jewish people?

And in such a sweeping, generalized way? I mean, I'd almost have preferred him saying, "...fags with HIV...", than to so callously throw all people battling this virus into his vile statement! Again...I'm utterly astounded and generally frightened to my core by this.

But that's what drives activism most assuredly, no? To be so affected by something that you feel compelled to action? I genuinely believe that all of us are capable of creating great change in any number of ways, but most definitely by simply sharing our experiences with the people we care about. So, I share this with all of you in hopes that it stirs you to action of some kind in making our world better for us all.

Where does that leave me and my (usually) inappropriate sense of humor then? I could get angry; ranting and raving at every offensive reference to HIV/AIDS, or find another approach. Is it possible to keep my sense of humor while trying to educate and raise awareness?

Let me share the line that started this whole voyage: "I wonder if people with HIV say 'I've got the Magic (Johnson) in me!'?" I think what offended me the most was...it's just not that funny. So, I replied to this tweet with my own: "No, we don't. We'll sometimes say, 'Let's go spread a little Magic!' though. (HIV Stigma isn't very funny, is it?)"

In a similar vein to the "Fighting Fire With Fire" approach, I've decided to combat this type of ignorance with better punch lines, sharper wit, and somewhat sardonic levity. Activism through comedy, if you will. Will I offend some people? Certainly. Will I make some people think about an issue differently? Maybe? I hope so. As they say..."See you in the funny pages!" LOL!

This post originally appeared on The Bilerico Project 

Jim Swimm is a forty-year-old Texan transplant in New York City: Gay, HIV+ and simply trying to make the world a better place... “ ‘cause I’m a superhero like that”. You can follow him on Twitter @Jims_Whim

I recently attended a screening of scenes from How to Survive a Plague, a documentary about the people on the front lines in the fight against AIDS in the early years of the epidemic, namely the members/founders of ACT UP. Along with the film's screening, there was a panel discussion of not only the film but the subject matter -- the state of HIV/AIDS activism, both then and now. There were people on the panel and in the audience who are featured in the film. It was an exceptionally interesting and emotional evening for everyone there, I'd imagine. It certainly was for me.

According to the film's director (who was on the panel and an ACT UP activist himself), this film is in no small part an effort to reclaim a piece of history for those people who were truly fighting for their lives in most instances. Peter Staley, a member of ACT UP who went on to found AIDSmeds.com, also commented about his hope that maybe the younger generation of LGBT people will gain a better sense of their own place in history by seeing the movie. These are wonderful aspirations and I certainly hope this film accomplishes both of them.

But...

During the panel discussion, something of a theme developed from a comment that was repeated more than once -- "We all just stopped talking about it" -- in reference to AIDS activism and the disease itself.  I left that night fairly pissed off about it all, to be frank. Not about the film clips or the subject matter of the film, but more by the comments that were being made by the panel. Phill Wilson, founder of the Black AIDS Institute http://www.blackaids.org/ and a prominent figure in the world of HIV/AIDS activism, seemed to be fairly irritated by it all as well, even saying at one point: “No, WE didn't all stop talking about.  Y'all did and just left the rest of us behind”. And I think it's that comment with which I identify so strongly. It certainly sums up why I felt so angered by people discussing how the movement just faded away. I mean...the film is called How to Survive a Plague, and all I could think -- as an HIV+, gay man is: "I'm sorry, but...who has?"  I seemed to have missed that memo, along with about 30 million people on the planet.

Now, don't get me wrong: I have great respect for the efforts of those people that were fighting against such tremendous odds back in the days when an AIDS diagnosis really was a death sentence. I don't mean to disparage anyone, most especially those people who are the subject of this film.  There has already been enough infighting and division within the LGBT community in regards to HIV/AIDS. I don't mean to add to the hard feelings. I can appreciate the courage it takes to voice your dissent in any setting, most especially if what you're fighting for is that major drug companies should produce the drugs they know will save your life. And the drugs those activists were out there demonstrating, yelling, and getting arrested to obtain are predecessors to the ones that keep me healthy. Let's face it: I owe my life to those people. But it did upset me to hear these "survivors" of that incredibly difficult period of time bemoaning their lack of historical recognition while pondering what made them all "just stop talking about it", you know? I question whether those folks realize that, though it's changed from those times the spent on the front lines, the struggle to beat HIV/AIDS has continued.

I wonder, what was it these people expected when they walked away from the fight against HIV/AIDS? Did they just assume the next, younger generation (in which I'm included, I suppose) would take up their picket signs and bullhorns without anyone to really guide them? Isn't there a mentoring process when it comes to any sort of civil rights activism? Where were the parents, teachers, and family members that usually pass along their passionate beliefs in these sorts of instances?

Oh, yeah...they're all dead.

Not all of them, of course. No, there are people, like those in the room that night, who made it through that awful time; people who were now sitting there casually pondering why things didn't magically continue to get better when they "all just stopped talking about it". Maybe I'm just too close to the issue, but it did not sit well with me.

Nobody's perfect -- I know that. And no one has a rule book for these situations.  There are so many factors involved here, not the least of which is the grief with which all of these folks were/are dealing. I know that watching so many of their friends, family, partners, and fellow activists get sick and die must have taken a toll on them.  I think what I most wanted to tell those people that night was: there are plenty of us out here that are "still talking about" HIV/AIDS. While we're not chaining ourselves to the doors of drug companies or spreading the ashes of our loved ones on the White House lawn, there are those of us trying to raise awareness of a disease that is plaguing all of our lives. Not only would we love for you to rejoin the fight, we could really use your new perspective. There is so much to learn from your experiences, your insight, and your fearlessness.

This article first appeared on The Bilerico Project.

 Jim Swimm is a forty-year-old Texan transplant in New York City: Gay, HIV+ and simply trying to make the world a better place...”cause I’m a superhero like that”. You can follow him on Twitter @Jims_Whim

 

 

Youth in the Caribbean and the Caribbean Diaspora in Canada face many similar issues with respect to the risk of contracting HIV. An international project that linked youth from Jamaica and Ontario to address these issues resulted in a powerful 20-minute video documentary that takes you into the hearts, experiences and struggles of those living with and affected by HIV.

You can see the video here.

You can also read more about the issues facing these youth on the website of the Interagency Coalition on AIDS and Development that, along with partners in Canada and Jamaica, produced the video. But to summarize:

In both the Caribbean itself and in the Caribbean Diaspora in Canada there are challenges in capturing the full picture of HIV among these young people. In the Caribbean there are inconsistencies in data collection and methodology while neither Ontario nor Québec, where 94% of the people of Caribbean descent in Canada live, report ethnicity information with their HIV statistics. However, some broad facts are clear:

• Half of new HIV infections worldwide are among young people. More than half the Caribbean population is under the age of 24.
• HIV prevalence in the Caribbean is higher than in any other world region outside sub-Saharan Africa.
• In Canada, there are a disproportionate number of African, Caribbean and black (ACB) people living with HIV. Since reporting began, youth have accounted for 27% of all positive HIV test results in Canada.
• The Caribbean is the only region, aside from sub-Saharan Africa, where the proportion of women and female youth living with HIV (53%) is higher than that of men and male youth.
• In both the Caribbean and the Caribbean Diaspora in Canada, heterosexual sex is the main mode of transmission, with steadily rising rates of HIV infection among women and female youth.
• In both Canada and the Caribbean, the highest prevalence of HIV infection is found among gay men and other men who have sex with men. In Jamaica, 32% of these men are living with HIV. In Canada, in 2009, 44% of new HIV infections were among this population.

There are a number of social factors - or determinants of health - that shape HIV risk at an individual level. These factors influence how people’s lives unfold as well as the choices available to them and, in turn, their health outcomes. Key factors for youth in the Caribbean and the Caribbean Diaspora include the following:

1.  Gender norms. Norms of masculinity and femininity in Caribbean societies play an important role in shaping HIV risk. Young men’s masculinity emphasizes multiple partners, aggression and the need to affirm heterosexuality through these behaviours. These norms of masculinity pose challenges for women and female youth in negotiating safer sex, increasing their vulnerability to HIV. These same norms, as well as the pervasive homophobia in Caribbean culture, also lead gay men to hide their sexuality which increases their own risk and that of their partners.

2.  Popular culture can also play a role in influencing gender roles and sexual expression - and also HIV risk among youth. In the Caribbean and the Caribbean culture, music, for instance, can be an important part of the lives of many young people. Some researchers have linked genres including dancehall in the Caribbean and hip-hop in North America - both of which project unapologetic sexuality and hyper-masculinity - with increased sexual risk taking and multiple partners among youth.

3.  Poverty. An important factor that significantly influences the context of people’s lives, and, in turn, their HIV risk, is income and social status. In both the Caribbean and within Canada’s ACB population, poverty and unemployment rates are significant challenges. In the Caribbean, youth living in poverty may have less control over their sexual rights and less access to education, therefore increasing their HIV risk. Young women may engage in transactional sex with older men to pay for school fees, food and money.

4.  Migration and acculturation. Caribbean people commonly migrate within and away from the region to improve opportunities for employment and education. Sometimes children are left behind and can as a result face increased risks of physical and sexual abuse and may suffer from psychosocial problems. Immigrants from the Caribbean to Canada also face challenges that may increase their risk of HIV. They may have to cope with racism, difficulties with the immigration process and problems in finding and maintaining housing and employment. Fitting in with the dominant culture can also cause problems. This is especially true for lesbian, gay, bisexual and trans youth who may experience rejection from their families and multiple forms of oppression, including racism and heterosexism within white society, racism and sexualization within the white gay community, and heterosexism and homophobia within the ACB community.

5.  HIV stigma and discrimination. In Caribbean societies, gay men, sex workers and sexually active youth are stigmatized and marginalized. As a result, in the Caribbean itself, these groups are often excluded from targeted HIV-related programming and from school sexual health curricula. This results in limited access to essential HIV prevention information. There are also conservative attitudes towards gender roles and sexuality within the Caribbean Diaspora in Canada that contribute to HIV stigmatization and prevention messaging.

PositiveLite.com’s own Scott Foley has experienced many of these issues first hand and he is currently writing about them in his own series of articles which you can read here. Scott has this to say about the One Blood: Youth Linked in Action video:

“It really touches on some of the issues I myself have faced. The stigma of going to a public health care facility is very real. If my trip to New York City to get an HIV test hadn’t happened, I probably would never have gotten tested in my own country. Even if I’d strongly suspected I had HIV, I still wouldn’t have gone.

“The music is another thing. Dancehall and reggae promote way too much violence towards gays and promiscuity. I got caught up in dancehall music at a very young age and that’s where I learned about sex from a Caribbean perspective. I surprise myself that to this day I still listen to dancehall music even though I should know better. It’s so powerful in my culture.”

Clearly, many factors influencing HIV risk are rooted in cultural and social contexts. To stem the rise of HIV in Caribbean and Caribbean Diaspora communities in Canada, collaboration and targeted education and care are required. The youth who made and participated in the One Blood: Youth Linked in Action video documentary that we are highlighting here are taking a lead in this effort.

The year 2011, just ended, marked the thirtieth anniversary of the HIV/AIDS pandemic. Much has been achieved in those three decades, most notably advances in treatment that have changed the face of HIV for those who have access to antiretroviral (ARV) medication from a terminal illness to a chronic yet manageable disease.

But of late there’s been other good news to celebrate. Just last month, for example, researchers from the University of Western Ontario announced that clinical trials are about to begin on a new HIV vaccine they’ve developed. And it does seem that, increasingly, more and more experts are becoming convinced that appropriately treated HIVers with an undetectable viral load are much less likely to pass on the virus than people not on treatment. However, as PositiveLite editor Bob Leahy recently pointed out by how much and in what circumstances is still subject to debate.

The latest people to take the view that HIVers on treatment with undetectable viral loads are unlikely to infect their sexual partners are the two organizations that write the HIV treatment guidelines for the UK, the British Association for Sexual Health and HIV  and the British HIV Association. They’ve done this via their newly revised guidelines for the use of post-exposure prophylaxis (PEP).

PEP is an emergency measure aimed at preventing HIV infection after the possible exposure of an HIV negative person to the virus. The new UK guidelines are notable for no longer recommending that PEP be provided in a number of situations where the “source partner” is known to be HIV+ and to have an undetectable viral load. These situations include unprotected vaginal intercourse, unprotected insertive anal intercourse and oral sex. But PEP is still recommended following unprotected receptive anal intercourse.

The guidelines are also notable for not recommending PEP in any situation in which the source partner is thought not to belong to a social group in which HIV prevalence is high, such as gay men or people from high-prevalence countries (such as those in sub-Saharan Africa). The guidelines also clarify that, due to the very low risk of infection, PEP is unnecessary following human bites or contact with a discarded needle.

 (Unlike the UK and many other countries in the developed world, Canada has no national guidelines for the use of PEP for non-workplace exposure - such as unprotected sex, a condom breaking during sex, needle sharing or sexual assault -  although some provincial guidelines exist. As a result, PEP for non-workplace exposure is rarely promoted in Canada. On the other hand, PEP after workplace exposures - for example a health care worker who accidentally suffers a needle-stick injury - remains the “standard of care” and is widely used in this country.)

Yet, despite the growing body of evidence that having an undetectable viral load significantly reduces the likelihood of an infected person passing on the virus to an uninfected sexual partner, Canada has witnessed an escalation in the number of people prosecuted for allegedly exposing partners to HIV even if they had an undetectable viral load and/or were using protection such as condoms or engaging in a low risk activity such as oral sex. Ontario is home to the majority of HIV-related prosecutions in Canada and is also one of the leading jurisdictions in the world when it comes to such prosecutions.

Part of the problem is that the law around HIV disclosure has never been legally defined. Rather, it comes from a 1998 decision of the Supreme Court that HIV+ people have a legal duty to tell a sex partner that they have HIV before they have sex if there’s a “significant risk” that they’ll pass on the virus to that person. This lack of clarity on what constitutes significant risk has meant that the police, Crown attorneys and lower courts have been inconsistent in how they interpret what sex acts, and under what circumstances, pose a significant risk of HIV transmission.

In last month’s Canadian Medical Association Journal, Julio Montaner, one of Canada’s and the world’s leading HIV medical doctors, along with colleagues from the British Columbia Centre for Excellence in HIV/AIDS called for the end of prosecutions for allegedly exposing sexual partners to the virus. “To put the burden on the person infected with HIV that they have to disclose when they may be on treatment or using a condom, or doing both, is really not appropriate,” Montaner told The Vancouver Sun. “Let me be clear, I think that people who behave irresponsibly, they need to be judged accordingly and there are laws to address those issues...but to have a policy that selectively targets HIV is discriminatory and discourages people from seeking out testing and treatment.”

All this will be coming under intense scrutiny next month, when the Supreme Court of Canada is to hear two appeals involving HIV non-disclosure. In both cases, one from Manitoba, the other from Québec, the accused are HIV+ and had consentual sex with their partners without disclosing their HIV status although they used condoms or were on ARV medication that kept the risk of transmission very low. In each case, the accused were acquitted by the provincial Courts of Appeal. However, prosecutors in both cases applied for an appeal before the Supreme Court.

So it was of particular concern that in September 2011, Ontario’s Attorney General indicated his government’s intention to file an application to intervene in the Supreme Court hearing. The government’s intent was to call on the Court to rule that people living with HIV must disclose their status before any sexual activity whatsoever - even in the case where there’s a negligible, effectively zero, risk of HIV transmission - and that not disclosing should be prosecuted as an aggravated sexual assault, which is one of the most serious offences in the Criminal Code.

It was especially troubling that the Ontario Attorney General's office took this position at the same time that it was engaged in ongoing discussions regarding the development of prosecutorial guidelines for allegations of HIV non-disclosure.

So it was good news to learn that, just before Christmas 2011, Ontario quietly withdrew its application to intervene before the Supreme Court. The government hasn’t released its reasons for this about-face, although it must be said that the governing Liberal party has just recently been returned to power following a provincial election where they gained a plurality of seats in the provincial parliament. The premier also appointed a new Attorney General who may have been instrumental in deciding against his predecessor’s decision to intervene.

However, the appeal before the Supreme Court will still be going ahead - it starts on February 8, 2012 - at which time the Court will be asked to define “significant risk”. Hopefully, in reaching a decision on the two cases before it, the bench will take into account current medical and scientific research about the risk of transmission and make a decision that’s compatible with scientific, medical, public health and community efforts to prevent the spread of HIV and to provide care, treatment and support for people living with HIV.

You can listen to an excellent debate about the current law - and recommended changes to it - in a podcast of the CBC Radio current affairs program The Current that was broadcast on December 21, 2011. In it Anna Maria Tremonti talks with Tim McCaskell, a long-time AIDS activist and person living with HIV, and Carissima Mathen, an associate professor of law at the University of Ottawa.

Sources:

Peabody, R.: PEP guidelines for the UK revised to take account of undetectable viral load. London: NAMaidsmap (December 2011): http://www.aidsmap.com/PEP-guidelines-for-the-UK-revised-to-take-account-of-undetectable-viral-load/page/2186929/ Accessed December 29, 2011

Wilton J.: Post-exposure prophylaxis fact sheet. Toronto: CATIE (2011) http://www.catie.ca/fact-sheets/prevention/post-exposure-prophylaxis-pep Accessed December 29, 2011

Wilton, J.: Enhancing the potential benefit of PEP. Toronto: CATIE (June 2011) http://www.catie.ca/en/catienews/2011-06-23/enhancing-potential-benefit-pep Accessed December 29, 2011

HALCO News Fall 2011. Toronto: HIV & AIDS Legal Clinic Ontario http://www.halco.org/wp-content/uploads/2011/11/HALCO_Newsletter_Fall_2011.pdf Accessed December 29, 2011

Salerno, R.: Ontario withdraws intervention in HIV criminalization cases. Toronto: Xtra! (December 2011) http://www.xtra.ca/public/National/Ontario_withdraws_intervention_in_HIV_criminalization_cases-11273.aspx Accessed December 29, 2011

PositiveLite.com’s editor Bob Leahy recently talked with Duncan MacLaughlin, the manager of community health programs at the AIDS Committee of Toronto (ACT), about the evolution in promoting gay men’s health that’s moving away from focusing on our weaknesses and vulnerabilities and more towards emphasizing our resilience and strengths. This interview, which you can read here, was specifically about a new ACT initiative TheSexYouWant.ca, which goes beyond the basics to tackle more advanced questions that gay and bi guys have about sex, pleasure and risks.

ACT is now taking this one step further by starting a discussion-based support group called SPUNK! for gay and bisexual men who use drugs. Drugs and alcohol have long been blamed for higher rates of bareback/condom-less anal sex and higher rates of HIV and other STI transmission among gay and bi guys. Research studies suggest that there’s a connection between drug use and HIV/STIs but these links are more complicated than is commonly understood.

The fact is, many gay guys who are HIV-positive or HIV-negative or who don’t know their status use drugs and alcohol and have sex. Lots of guys manage their partying. For some guys, though, it can be a struggle. There’s a lot of misinformation about drugs, and there’s so much shame and stigma in both the gay community and in the broader culture that open, honest and practical conversations about drugs don’t often take place.

SPUNK! is a response to that. The word “spunk” was chosen for the group because it’s a synonym for both resilience and semen. Resilience is about finding our strength and meeting life’s challenges with this strength. Semen is something that gay men need to talk more about; it has significant meaning for us.

SPUNK! is a group where gay and bi guys who party with drugs and alcohol can meet in a safe, non-judgmental space to talk about drugs and sex - one that isn’t 12-step, or a clinical withdrawal and detox management service. Rather, it aims to be a space where men can connect with each other and engage in an open and meaningful dialogue in a confidential, sex-positive and drug user-positive way. It’s a place where guys can talk about making a positive change towards feeling good about their relationship with substance use and the sex they have.

The intent of the group is to raise awareness among its participants about the reasons they may enjoy using drugs and alcohol and about why they may struggle with substance use. It’ll offer them encouragement, alternatives, tools and inspiration for making a positive change. This isn’t necessarily about stopping the use of substances, because you can be a substance user and be healthy at the same time. It’s more about making positive changes so that you can have the sex you want while caring about your own well-being and that of the guys you play with.

The first group, starting in January 2012, will be for men 30-years-of-age and older. A group in the spring of 2012 will be for guys younger than 30. Both groups will be led by facilitators trained in running groups like this and who’ve had years of lived experience in LGBTQ communities and substance-using and party scenes.

More information is available on the ACT website, on Facebook, by email at This email address is being protected from spambots. You need JavaScript enabled to view it. or by calling 416 340 8484, ext. 235.

 

The Canadian population is aging. It’s estimated that the percentage of seniors will almost double within the next 25 years, when one quarter of the population will be aged 65 or older. Canadians living with HIV are also aging. However, HIV and seniors aren’t something that we often talk about in the same sentence. But, given the facts, we should.

It’s estimated that today 12% of the close to 70,000 Canadians who have an HIV diagnosis are aged 50 and older and that this is expected to increase over the next decade by 20%. In the U.S., the numbers are even more dramatic, where it’s estimated that by the middle of this decade most individuals with HIV will be over 50 years old.

The reason for these increasing numbers is that, because of improved treatment options, HIV+ people are living longer. It’s also because, both in Canada and the U.S., adults over the age of 50 account for between 15% and 17% of new HIV diagnoses every year.

When discussing HIV and aging, it’s important to keep in mind that, while most HIVers in Canada are gay men and other men who have sex with men, a substantial percentage are women and heterosexual men and that aboriginal, African, Caribbean and black Canadians are heavily over-represented.

While older people are more likely than younger ones to present late for HIV testing and care and, for that reason, not uncommonly receive an AIDS diagnosis at the time they learn they’re HIV+, most older adults will have lived with HIV infection, and have been on antiretroviral (ARV) therapy for over 15 years. As these adults develop illnesses more commonly associated with aging than with HIV, they represent a unique challenge for their care providers. An HIV clinician, for example, may be very comfortable with the nuances of ARV therapy, but uncomfortable managing multiple age-related, but not necessarily HIV-related, illnesses. At the same time, these HIVers are typically too young to be seen by a geriatrician, who would be more comfortable with age-related illnesses but but less so with managing the complexities of HIV.

To address these issues, two organizations, one American, one Canadian, have recently published recommendations for treatment and management strategies in caring for older people living with HIV.

The American Academy of HIV Medicine (AAHIVM), which published its report in November 2011, provides best practice guidelines for HIV practitioners and other health care providers who treat, diagnose and refer older people with HIV. You can read the full report here, but as a non-medical man, two things stood out for me among the recommendations made.

The first was that primary care providers should perform routine, opt-out HIV screening in all adults, regardless of age or individual circumstances, because it’s very difficult to reliably estimate HIV risk in older people. This is already taking place in New York City and San Francisco, while the only jurisdiction in Canada that’s attempting something similar is Vancouver with its It’s Different Now project about which I wrote a couple of months ago here on PositiveLite.com.

The second thing that stood out for me in the American report was the recommendation to bypass the sometimes contentious federal treatment guidelines as to when to start ARV therapy. Those guidelines currently recommend that HIV+ people begin treatment when their CD4 cell count falls below the 500 cell mark. The AAHIVM is recommending, however, that ARV therapy should be considered for all HIV+ people over the age of 50, regardless of CD4 cell count. This is also the guideline currently used in British Columbia. (Canada has no national treatment guidelines of its own, although both Québec and B.C. have provincial ones, so many doctors in other Canadian provinces refer to the U.S. guidelines.)

The new Canadian report on HIV and aging is from the Canadian AIDS Society (CAS)  and was published in May 2011. It covers a lot of ground from prevention to diagnosis, treatment and care, and incorporates background information and physiological and psychosocial considerations, before making its recommendations. It’s available to download here. 

The CAS recommendations are more broad-ranging than the AAHIVM ones and are addressed not only to health care providers, AIDS service organizations, policy makers and researchers but also to ourselves as people living with HIV.

The report has some interesting things to say about HIV prevention among older people. It points out that because older adults haven’t generally been considered a vulnerable population, HIV prevention programs haven’t usually been targeted at this age group. For the most part, this population received little sexual health education when they were young and, as a result, many older adults may not be aware of HIV prevention methods and behaviours that put them at risk of infection.

In addition, because of agism, health care professionals and educators may assume that these older adults are not sexually active, leading to missed opportunities for education and screening for HIV and other STIs. Further, talking about sex may be considered a social taboo. Like many younger people, older adults may also intentionally hide their sexual orientation, extramarital sexual activity, involvement with sex workers and substance use. For these reasons, CAS is recommending that HIV prevention programming should recognize that older Canadians may be at risk of acquiring HIV.

It’s also recommending engaging older people already living with HIV within a framework that has a positive impact on their physical, mental, emotional and sexual health. This, in turn, would create an enabling environment that’ll reduce the likelihood of HIV transmission. This is a revised concept of “poz prevention” that CAS refers to as Positive Health, Dignity and Prevention.

Like the AAHIVM study referenced earlier, the CAS document recognizes that for older people living with HIV, appropriate care must take into account not only HIV-specific physiological and psychosocial effects but also the effects of aging and the co-morbidities that are associated with it.

CAS is concerned that as HIV+ Canadians get older and seek services outside HIV-specific care, they may find that services are not tailored to their needs and that they may experience greater stigma. For example, health care services that have been traditionally offered to older people (such as home care, rehabilitation, specialists) may not be accustomed to dealing with people who are HIV+, gay or who have a history of drug use. It may be a challenge to meet the care needs of older HIVers in this context, particularly in smaller communities, with the existence and access to services likely to vary across the country.

The report goes on to talk about the inter-related physiological factors that affect the health of older HIVers, including the effects of HIV itself and of ARV therapy on the body over time, the aging process, other health conditions associated with aging and lifestyle issues such as diet, smoking, alcohol and drug use, exercise and nutrition. It also recognizes that a range of social determinants of health play a key role in how HIV and aging affect Canadians, including housing, income support, employment, food security, racism, sexism, homophobia and social exclusion.

It also talks about the psychosocial effects of HIV and aging, which, much like the physiological effects, are closely inter-related. They may include depression, cognitive changes and coping with loss and anxiety. Many of these issues were addressed in some depth by educator Patty Solomon whom I interviewed for PositiveLite.com following a presentation she made at the 2011 Ontario HIV Treatment Network conference.

The conclusion I draw from reading these two reports is that there’s still so much we don’t know about older people who are living with HIV. But what both the AAHIVM and CAS show conclusively is that ensuring an appropriate response to the challenges of HIV and aging requires a range of stakeholders, including HIVers ourselves, to take action in a number of areas. Their recommendations in this regard are bold efforts to begin to help us to understand the needs of older HIVers and the kind of strategies that need to be implemented to meet them. As I said at the beginning of this article, talking about HIV and seniors is something that we need to do.

Sources:

American Academy of HIV Medicine. HIV and aging (November 2011). www.aahivm.org/frmHomeDetails.aspx?nId=NDE= Accessed December 12, 2011

Canadian AIDS Society. HIV and aging (May 2011). www.cdnaids.ca/hiv-and-aging Accessed December 12, 2011.

CATIE. Treatment Update 176, January 2010. http://www.catie.ca/en/treatmentupdate/treatmentupdate-176 Acccessed December 12, 2011.

Public Health Agency of Canada. HIV/AIDS epi update (July 2010); HIV/AIDS among older Canadians. http://www.phac-aspc.gc.ca/aids-sida/publication/epi/2010/6-eng.php Accessed December 12, 2011