"Recently infected individuals: A priority for HIV prevention" by James Wilton first appeared in Prevention in Focus, Fall Issue 2011, a publication of CATIE. A French language version is available here. 

People living with HIV can potentially transmit HIV to others through unprotected sex at any time during their life. However, emerging research suggests that a disproportionate number of HIV transmissions—perhaps more than half—may originate from people during the first few months after they become infected with HIV. In this article, we explore why recently infected individuals are more likely to transmit HIV to others and how we can help prevent these transmissions from occurring.

 What’s happening in the body after HIV infection?

To understand why recently infected people are more likely to transmit HIV to others, we need to look at what’s going on in the body after HIV infection occurs.

After someone becomes infected with HIV, the virus begins to replicate very quickly and the amount of virus in the body and bodily fluids (such as the blood, semen, vaginal fluid and rectal fluid) rises rapidly. In some individuals, this takes its toll on the body and can cause fever, fatigue, night sweats, headache, diarrhea, sore throat and/or a rash. These symptoms generally appear about two weeks after infection occurs. Other individuals who become infected notice no symptoms at all during this period.

A few weeks after infection, the body’s immune system begins to fight back against the virus. An important part of this immune response includes the production of anti-HIV antibodies—small proteins made by certain immune cells, which can destroy HIV and prevent HIV from multiplying. Once antibodies to HIV have been produced, HIV replication begins to slow down and the amount of virus in the body (also known as the viral load) gradually decreases. Unfortunately, antibodies cannot fully control HIV infection.

Antibodies are not produced immediately after infection. The amount of time it takes for the body’s immune system to produce them varies from person to person. In most people, it is possible to detect HIV antibodies in their blood within approximately 34 days of infection, although this can take up to three months in some individuals. The presence of antibodies in the blood marks the end of the first stage of HIV infection—known as acute HIV infection—and the beginning of the next stage, chronic HIV infection.

The amount of virus in the bodily fluids is highest during the acute HIV infection stage. After antibodies are produced, the viral load slowly decreases but does not stabilize at a lower level until up to six months after infection.

Why do people with recent HIV infection account for a disproportionate number of transmissions? 

Higher infectiousness

The elevated viral load of someone recently infected with HIV is the main biological reason that they are more likely to transmit HIV to others at this time. The higher the viral load, the greater the risk is of transmitting HIV to others through unprotected sex. Researchers estimate that the risk of transmitting HIV to another person from one act of unprotected sex is 26 times higher during the first three months after infection than during the months and years that follow.

More high-risk behaviour

A high viral load alone is not enough to transmit HIV to another person; a recently infected individual also needs to be engaging in activities that can lead to the transmission of HIV, such as unprotected sex. Unfortunately, a person who has recently been infected with HIV is more likely to be engaging in high-risk behaviours than a person who has been infected for a longer period of time. There are two possible explanations for this. First, a recently infected individual is more likely to be engaging in high-risk behaviours because this is what led to their HIV infection. Second, many recently infected individuals are unaware of their HIV status and therefore may not realize the importance of having safer sex.

Reducing the number of transmissions from recently infected individuals: Challenges and solutions

Because recently infected individuals account for a large number of HIV transmissions, identifying these individuals and helping them reduce their risk of passing HIV to others is critical to HIV prevention. Research shows that when people become aware of their HIV infection and are provided with access to prevention and care services, most take measures to reduce their risk of transmitting HIV to others.

There are two major challenges to identifying recently infected individuals:

 1. the low levels of HIV testing in Canada; and

 2. the limitations of certain HIV tests.

As a consequence, many people who have recently become infected are unaware of their infection, as are their partners. Those who are recently infected may therefore continue to engage in high-risk behaviours until they are diagnosed with HIV.

Your organization may be able to play a role in overcoming these challenges, identifying these individuals, and reducing their risk of transmitting HIV to others.

Challenge: Low levels of HIV testing

It is estimated that 26% of people who are HIV-positive in Canada do not know that they are infected and many do not learn of their HIV status until they have been infected for several years.The low levels of HIV testing in Canada means that most recently infected people probably pass through the brief stage of HIV infection when their viral load is elevated without getting tested for HIV.

People who have recently become infected may be unlikely to get tested for several reasons. Firstly, many may believe that they are not at risk for HIV infection despite participating in behaviours that put them at risk. Secondly, there are no definitive signs that someone has become infected with HIV. Only some people who have recently become infected will experience symptoms and those symptoms are not specific to HIV infection. Therefore, many people who experience symptoms may confuse them with those of another illness and not get tested. Furthermore, for people who do believe that they are at risk of infection, there are several barriers that may prevent them from getting an HIV test, including stigma and discrimination, fear of criminalization, and barriers to accessing testing and other health services.

Solutions

 • Outreach and educational campaigns are needed to improve people’s awareness of their risk of infection and of the symptoms associated with recent HIV infection. People need to be encouraged to get tested if they are engaging in behaviours that put them at risk for HIV infection or have developed symptoms (such as fever, fatigue, night sweats, headache, diarrhea, sore throat and/or a rash) after a high-risk exposure.

 • Frontline service providers need to increase awareness of the need for, and benefits of, HIV testing among people who are at risk of infection. It is important that HIV-positive people learn about their HIV status as soon as possible after infection, regardless of whether or not their viral load is still high, so that they can access treatment and support services for people living with HIV and counselling on ways to prevent transmitting HIV.

 • Access to HIV testing, particularly for marginalized populations who are at risk of HIV infection, needs to be improved. Frontline organizations may be able to play a role advocating for improved access.

Challenge: Limitations of HIV tests

The limitations of tests used to detect HIV infection is another major barrier to identifying recently infected individuals.

Several types of HIV tests are available but for each type of test there is a brief period of time after infection during which they are unable to detect infection in a person who is HIV-positive. The time period from when a person becomes infected with HIV to when an HIV test can detect their infection, is known as the “window period.” During the “window period,” an HIV test may find a recently infected person to be HIV-negative. The length of the “window period” is different for each type of test and varies from person to person.

The HIV tests most commonly used in Canada look for antibodies to HIV in the blood. These tests cannot detect HIV infection in someone who has acute HIV infection because the body has not yet produced antibodies. The “window period” for antibody tests varies because some people produce antibodies faster than others. For most people (up to 95%), the window period of the antibody test is approximately one month, but for some individuals it may be as long as three months.

This means that for people at high risk of HIV, testing can be done as early as one month after exposure using standard antibody assays and rapid point-of-care tests. People who test positive will know for certain they are HIV-positive. Of those who test negative, 95% are indeed negative. Up to 5% of people who test negative at one month could later test positive at three months. It is important to ensure that people who test negative at one month are advised to return for repeat testing once the three-month window period is over.

Other HIV tests have been developed which detect the virus itself—such as the HIV RNA or the p24 antigen tests. These have shorter window periods (from seven to 14 days) than antibody tests and so can potentially detect HIV infection during the acute phase.20 Unfortunately, access to these new testing technologies varies across Canada.

Another limitation of HIV tests is the time it takes for many of them to produce results. Most HIV tests do not produce results immediately and require people to wait one to two weeks before getting the results. During this time, people may continue to engage in high-risk behaviours and some people may never return to get their test results.

Tests known as rapid or point-of-care (POC) tests can provide results on the same day that a test is performed. Most rapid/POC tests can provide results within minutes. This ensures that a person receives their results. Rapid tests that detect antibodies are available in some parts of Canada but rapid tests that can detect HIV RNA or the p24 antigen do not yet exist.

Solutions

 • Frontline service organizations need to increase people’s awareness of the different “window periods” for each type of HIV test, and emphasize that a negative result does not necessarily mean that a person is HIV-negative. Messaging should emphasize that a person who has recently tested HIV-negative may be in the “window period” and may be highly infectious. Knowledge of the “window period” and the increased risk of transmission during this time is particularly important for people who base their decisions of whether or not to have unprotected sex on knowledge of their HIV status or their partner’s.

 • People who test HIV-negative within the “window period” should be encouraged to refrain from high-risk behaviours and return for another HIV test at an appropriate time. A second test is important to rule out the “window period” as the reason for the test being negative. In Canada, we encourage people who test HIV-negative on an antibody test to test again at the end of the three-month “window period,” or sooner if appropriate.

 • Organizations should learn if, and where, rapid antibody testing or RNA/p24 testing is available in their area. A person who is suspected of being in the acute stage of HIV infection (for example, if they have recently had a high-risk exposure or they have experienced flu-like symptoms after the exposure) should be referred to a site where RNA or p24 testing is available. Service providers may need to advocate for improved access to rapid antibody testing and RNA/p24 tests in their area.

Conclusion

The goal of HIV prevention is to reduce the number of HIV infections in the communities we serve. A large number of HIV transmissions in your communities may be occurring from recently infected individuals, and therefore represent an important priority for HIV prevention efforts. Although several challenges exist in identifying these individuals and engaging them in prevention services, frontline organizations can play a key role in overcoming these challenges and reducing HIV transmissions.

James Wilton is the Project Coordinator of the Biomedical Science of HIV Prevention Project at CATIE. James has an undergraduate degree in Microbiology and Immunology from the University of British Columbia.

Check out Hottest at the Start  – a campaign by the Health initiative for Men (HiM) in BC to raise awareness on acute infection and transmission and to encourage gay men who have had a recent potential exposure to HIV to get an ‘early’ HIV test.

See PositiveLite.com’s John McCullagh interview HiM’s Jody Jollimore about this campaign here. 

For CATIE's full list of references, with links, to today's article, please go to the original article here. 

Check out CATIE's own blog on PositiveLite.com here.

(left to right Keith Reynolds, Daniel McGraw, Darren Ho)

Earlier this year on PositiveLite.com, we profiled Totally Outright, a program for young gay men who show promise as future community leaders. Today, in a special series of articles by three graduates of the program, we hope to show how, by investing in these and similar young men, we’re able to ensure that the future of Canada’s gay community will be in good hands.

The uplifting stories of Daniel McGraw, Keith Reynolds and Darren Ho illustrate how, with a minimum of resources but with lots of creativity, it’s possible to create the gay leaders of tomorrow. But the program not only forms future leaders. It also provides participants with the chance to build communication skills, practice outreach techniques and strategize solutions for the numerous challenges faced by gay men.

All three of the young men who tell their stories on PositiveLite.com today have found a place in the gay community beyond the bars and clubs. Both Daniel and Keith now work in gay men’s health while Darren, a university student, has started a project to address the lack of visible presence of LGBTQ people among ethnic communities.

Totally Outright has been running in Vancouver for several years and graduates 20-25 young men annually. Created and evaluated by the Community Based Research Centre (CBRC), it’s delivered by Health Initiative for  Men (HiM), a community organization dedicated to strengthening the health and well-being of gay men through a sex-positive, integrated approach to health. The program has been so successful that a Toronto version was launched this spring by the AIDS Committee of Toronto (ACT). 

Read what Daniel, Keith and Darren have to say and be inspired!

If you are interested in starting a version of Totally Outright in your own community, or just want to understand this program in depth, Health Initiative for Men has provided full background information in CATIE’s Programming Connection.

New research suggests that a disproportionate number of HIV transmissions - perhaps more than half - may originate from people during the acute stage of HIV, which is the first few months after someone is infected. Why? Because HIV replicates very quickly immediately after infection so a person is much more likely to pass on the infection at this stage if they’re having unprotected sex. And they’re more likely to think they’re negative.

Health Initiative for Men (HiM), a gay men’s health organization in Vancouver, has developed an innovative and sexy harm-reduction campaign - Hottest at the Start - to raise awareness about the acute stage of HIV infection among young gay guys - and maybe those who are not so young - who are are having anal sex without condoms.

We featured Hottest at the Start and it’s sexy prevention messaging - including its steamy promotional video - on PositiveLite.com in October 2011. So when Jody Jollimore, program manager at HiM, was in Toronto at the recent Gay Men’s Sexual Health Summit, I caught up with him to learn more about the messaging behind the campaign and why HiM took the approach it did to reach gay guys who are having unprotected sex. You can see this interview in the video clip at the bottom of this post.

Check out the Know Your Risk Calculator  that Jody refers to.

You can find out more about the acute stage of HIV infection on CATIE’s website. 

Video services courtesy of Guy McLoughlin. Images courtesy of Health Initiative for Men.

Sometimes we worry here on PositiveLite.com that we are a bit gay-centric.  Our founder, publisher and editor are all gay men, and while we have three active women writers, we have far more male ones. But that’s not to say that, first, we don’t have a huge curiosity about women and HIV and secondly we aren’t committed to writing about women’s issues.  So when Publisher John McCullagh and myself travelled to Oshawa  recently to attend the 2012 Durham Regional HIV/AIDS Conference we decided to take the opportunity to focus on women’s issues that were a prominent part of the program.

According to OCHART – View From The Front  Lines 2011  (which takes the pulse of HIV work in Ontario each year) there were 1,018 new HIV diagnoses in 2010 in our province. Of those, more than 50% were in gay men and other men who have sex with men, 20% were in members of the African, Caribbean and Black communities, and 6% were in people who reported using injection drugs. Women account for about 1 in 5 new diagnoses although the number of new diagnoses in women has declined by over one-third since its high in 2006.

The mean age of women who are newly infected is 35, not too different from the mean age for males.

Community-based HIV/AIDS programs appear to be reaching at-risk women: agencies estimate that between 25 and 28% of clients using education, outreach and support services are heterosexual women, which reflects the epidemiology.

That's what the data says. The same report is instructive about where new infections are occurring and clearly all the action isn't in the big cities. Says OCHART  “Although Toronto still has the largest number of new diagnoses each year, that number has been dropping steadily for the past five years – while the number of new diagnoses per year has been increasing in other parts of the province. In the last year alone, there was an increase in new diagnoses in South West (10%), Central East (10%), and Ottawa and Eastern (24%). Each of those parts of the province had its largest number of diagnoses in a single year in 2010.”

So Durham is at the epicentre of this trend of increasing new infections away from the larger urban centres.  It’s regional agency, the very progressive AIDS Committee of Durham  Region, is located in downtown Oshawa, somewhat of a bedroom community to Toronto, although home to a major GM factory important to local employment.   Oshawa has a sprawling population of about 152,000; it’s about 60 kilometers east of Toronto. 

Areas such as Durham have their own contributing factors to new infection rates. The proximity of a sexual playground like Toronto is one, of course.  But so are things like the lack of a centralized LGBTQ community and related establishments, homophobia, fewer resources for the at risk and infected and the phenomenon of the married MSM (men who have sex with men.) Women are even more isolated here than they are in large urban centres, seldom considered at risk, with HIV testing not on many health care professionals' radar.

Armed with this background, publisher John McCullagh talked to Claudia Medina (whom I have known since she was a baby, LOL). Claudia is the Women's Prison Program Co-ordinator, Prisoners with HIV/AIDS Support Program (PASAN).  Claudia talks about the particular problems that women with HIV face who are incarcerated in the Canadian correctional system.

Two years ago today, I was diagnosed with HIV. Having managed to remain negative throughout the first 28 years of the epidemic, here was I, in my sixties, suddenly finding myself HIV-positive. The diagnosis itself was not unexpected - I had made some decisions to have unprotected sex - but the shame of having to admit that I had seroconverted was difficult for me to reconcile with the self image I had of myself. And with the image others had of me. After all, here I was - an educated, aware gay guy who’d lived through the early years of AIDS, a social worker who’d worked within the gay community for over thirty  years - now having to deal with the shame that I’d allowed myself to become poz.

But I was well-connected in the community and had the support of a wonderful life partner and some great friends. They, along with the excellent care I was receiving from my GP, who is also an HIV primary care physician, enabled me to handle my emotional turmoil. And because I have a natural curiosity, and because I wanted to learn as much as possible about HIV and what it meant to live with it, I began to read voraciously about every aspect of it. I found a great deal of help and useful information at a number of websites, particularly Canada’s CATIE,  Vancouver’s Health Initiative for Men  and the UK’s aidsmap.com. 

Then I found PositiveLite.com. This website was a revelation - a Canadian online HIV magazine by and for people who are either HIV-positive or who are our friends and supporters. Here were women and men, both from Canada and elsewhere, who were writing openly about their lives as poz people. And they were writing not just about living with HIV but about all aspects of their lives, which were as rich and as varied as those who were not living with this chronic illness.

But there was more. They were also writing, from their own lived experience as HIVers, about issues of importance to us all - the best approach to take in the 21st century in preventing the spread of HIV, developments in treatment, about stigma and discrimination, about how to manage disclosure and deal with the increasing criminalization of non-disclosure, about aging with HIV and about how, paradoxically, HIV had changed their lives for the better.

I was so impressed with what I read on PositiveLite.com that last summer I wrote to publisher Brian Finch to tell him so. He was very gracious in his response and asked if I would be interested in providing more specific feedback about the website, which was about to undergo a major redesign. I said I would. Before I knew it, I had an email from PositiveLite.com editor Bob Leahy inviting me to write for the magazine the story of my seroconversion.  I agreed to do so, anonymously. I was not quite ready, at that stage, to have my name, face and the intimate details of my life plastered all over the internet for all to see.

I guess Brian and Bob must have liked what I wrote, because they arranged for my story to be picked up by aidsmap.com. So it was not long before Bob started using his considerable charm in encouraging me to become a regular contributor and to write more about what I was learning. I took some time to say yes, because I’d just retired from my long-time job and was looking for volunteer opportunities that would provide me with the chance to to work with people face-to-face and to make new friends - writing, after all, is a somewhat solitary pursuit. But, in the face of Bob’s persistence, I overcame my hesitance.

So before I knew it, I was actually starting to enjoy sharing my experiences as an HIVer and my increasing knowledge of HIV with PositiveLite.com’s community of readers. Through doing so, I quickly decided that I no longer wanted to remain anonymous. I was ready to stand tall and proud as an openly HIV-positive gay man. For this I have to thank Brian and Bob and the opportunities they provided me to share my thoughts and experiences with others. After all, coming out as a gay guy when I was in my early twenties had been a liberating experience and I reckoned that coming out as poz should be equally as liberating. And so it has proven to be. I now feel a great sense of freedom and liberation living as an openly poz guy.

It was not long before I began to attend HIV community events and do interviews for PositiveLite.com with other people who who had interesting things to say. Then, at the beginning of this year, Bob offered me the position of assistant editor. And now, just three months later, I find myself as publisher. Never in my wildest dreams did I think, on March 15, 2010, the day I received my HIV diagnosis, how having HIV would change my life in a such a positive (pun intended!) way within two short years. 

As he wrote here yesterday, Brian has come to the decision that it’s time for him to pursue some new opportunities and that he’d fulfilled his job of creating PositiveLite.com. Last week, he asked me if I’d consider taking over the position of publisher. How could I say no? I’m in awe of Brian and what he’s created here. He’s a guy who’s lived proudly and openly with HIV for over half his life. He’s a true survivor with a passion for enabling HIVers who may not otherwise feel they have a voice to have the opportunity to be involved in a discussion about what it really means to be HIV-positive today - the rationale behind PositiveLite.com.

I’m both honoured and humbled that Brian has entrusted his creation to me. His are enormous footsteps to tread in, yet I fully intend to ensure that his trust in me is justified.   I can do that only because Brian will be remaining an integral part of PositiveLite.com as our founder and I will continue to benefit from his wisdom and wise counsel. I’m also supported by our knowledgeable and indefatigable editor, Bob Leahy, and by an amazing community of writers and contributors, who are at the heart of PositiveLite.com. Without them, the magazine would not exist.

I have a strong sense that this three-year-old, PositiveLite.com, is poised to continue its progress beyond its early years as it becomes an increasingly important and respected part of Canada’s HIV community. And while we are indeed Canadian, and will continue to reflect the Canadian experience, we remain open to the world - indeed half our readers and many of our writers now come from outside our nation’s borders. We welcome that diversity of experience. Yet we are equally committed to reflect the increasingly diverse face of HIV, both in Canada and elsewhere.

At present, most - but by no means all - of our writers are gay men who write about HIV and their lives from that perspective. This reflects the historical nature of HIV in countries like ours. Gay men still account for the majority of HIVers in Canada, and their experience of HIV will continue to be portrayed in our pages. But the face of HIV is changing, a reality that all of us here at PositiveLite.com are committed to reflecting. Thus, we’re actively engaged in increasing our coverage of HIV as it affects women, First Nations, transpeople, those from countries where HIV is endemic, injection drug users and others. By the same token, by the middle years of this decade it’s estimated that 50% of all HIVers in North America will be aged 50 or older. This reflects the reality that, thanks to anti-viral medications, HIVers are living longer than anyone ever expected only 15 years ago. There are also an increasing number of people who, like me, are seroconverting in later life. These realities will continue to be reflected in our pages even as we continue to tell the stories of younger people infected with and affected by HIV.

We will always remain faithful to our mandate, to be a place for HIVers and our allies to talk about the reality of our lives. Sometimes we will be funny, sometimes angry, sometimes controversial, but always honest.

As I said earlier, you, our readers and writers, are at the heart of what we are all about here at PositiveLite.com. I hope you continue to enjoy, be inspired by and encouraged by what you read here. And if you think you have something to say yourself, then why not consider writing about it here on PositiveLite.com. It may be that you just want to comment on something you’ve read here, in which case I invite you to share it in the comments section at the end of each article (currently an underutilized resource). Or it may be that you want to contribute your own thoughts through submitting a post of your own. In that case, I invite you to contact us through our facebook page, via email to our editor Bob Leahy at This email address is being protected from spambots. You need JavaScript enabled to view it. or by sending me a tweet @John_McCullagh. 

Thank you all for your support. And Happy Reading!

There’s a new approach that’s taking place in HIV prevention and support programs, particularly those focused on gay men, that’s based on supporting us in maintaining good health, particularly good sexual health, by emphasizing our strengths and resilience rather than focusing on risk behaviours and pathologizing our weaknesses and vulnerabilities.

Here on PositiveLite.Com, we’ve featured several programs that utilize this new approach: It’s Hottest at the Start; The Sex You Want;  GPS (Gay Poz Sex); Spunk;  and Totally Outright. 

So I thought it was timely to learn more about the thinking behind this new approach and to understand more about the concepts of risk and resilience that underly it. To help me, I recently sat down with Duncan MacLachlan, the manager of community health programs at the AIDS Committee of Toronto (ACT). 

John McCullagh: Welcome back, Duncan, to PositiveLite.Com. I’d like to start by asking you to describe risk for me. When I think of risk, I usually think of things that could be dangerous, like smoking, for example, or drinking and driving. But it’s more complicated than that, isn’t it?

Duncan MacLachlan: Risk is complicated, John, because it always exists in a context.  It’s often oversimplified. Risk for gay men has, for the most part, been narrowly defined in terms of vulnerabilities. Things like HIV and other STI acquisition, or mental health, issues like depression and anxiety, or substance use. These vulnerabilities are real, of course. They exist because of things like stigmas, trauma and poverty, but they aren’t the whole story. Gay men know this. In the arena of sexual expression, we’re motivated by things like desire, pleasure, intimacy, connection and love not merely the fact that we may be challenged by anxiety or loneliness.

John: I hear you saying that risks don’t exist in a vacuum, they always have a context. That means, I guess, that we should be cautious when judging our own or someone else’s risk behaviours. And yet, that’s not the way, until recently, that we’ve done HIV prevention work. Instead, we’ve said, “This is what you should be doing” - like “Use a condom every time” - which was based on the theory that we’d all make rational choices when faced with risk.

Duncan: Exactly. We all know that our behaviour isn’t always rational. So this idea that we’re free to chose in every situation and that if we’re armed with information we’ll always make “good” decisions is false. Yet, while those of us doing prevention and education work with gay men have moved beyond this simplistic notion a long time ago, it still persists in society at large. It exists in our community as well; the demonizing of bareback sex is an example.

John: Duncan, how would you say we can best overcome the odds and challenges of the risks we face in our lives?

Duncan: Wow, John. That’s a big one! Here’s part of the answer. My studies of psychology teach me that it’s positive reinforcement rather than punishment that motivates us. Again, we all know this intuitively because we’ve experienced them both.  I’m a big believer in love and compassion, both at an individual level and a community level!

John: So tell me a bit about gay men’s resilience. It’s more than just coping isn’t it? 

Duncan: It is. As part of ACT’s current gay men’s resilience campaign, we asked guys what resilience meant to them. What they told us was that it meant bouncing back from a challenge and gaining some aspect of strength from the experience. I think sometimes resilience is coping, but, as you say, it’s often more then that. What’s really interesting is the notion of protective factors - characteristics that counter some of the challenges gay men face, like homophobia. Protective factors can be enhanced. An example Amy Herrick and others have identified in research is shamelessness or sexual creativity.  ACT’s Pig Sex Project (for gay guys who identify as “sex pigs” and who like to have raunchy sex. - Ed.) nurtures these protective factors by providing an environment where guys are affirmed and valued – our slogan is “It’s your choice” - rather than judged for their sexual expression. It’s also an environment where the guys share their strategies for risk reduction with each other because they feel safe to do so.

John: Can you give me some other examples of how we can build resilience.

Duncan: One of the most useful ways of considering the development of resilience programming, or evaluating existing programs and supports for their resilience effectiveness, is a model called the 7 C’s of resilience. These 7 C’s of resilience are: confidence, competence, character, contribution, coping, control, and connection.  People have better health outcomes and a higher quality of life when these things are nurtured and this can be easily measured. At ACT, we are using the 7 C’s of resilience to enhance our capacity to assess the effectiveness of our programming in building resilience.

John: So, Duncan, if I’ve understood you correctly, you’re talking about an asset-based approach to health, focusing on our strengths instead of our weaknesses, on our resilience instead of our deficiencies. That’s very different than talking about condoms, than talking about disease, isn’t it?

Duncan: Yes, although an asset based approach that is rooted in resilience doesn’t mean we don’t talk about condoms or disease. Using condoms might be an important part of many gay men’s resilience.

John: So give me an example of how focusing on our assets, on our strengths, correlates with reducing risk behaviours?

Duncan: Sure. Let’s talk about sex, sexual creativity for example, which is another of the protective factors identified in Amy Herrick’s research. More and more guys are talking about viral load with each other. We now know that having an undetectable viral load reduces risk of transmission. We’re not sure by how much, but it makes a difference. Our willingness to push the boundaries of sexual pleasure enables us to explore the utility of a great variety of cock and ball “accessories” that enhance our ability to stay hard, facilitating condom use.

John: Duncan, you’ve really helped me understand why building on our successes is ten-times more compelling than trying to build on our failures. Because we all want to be successful and healthy. Thank you so much.

Duncan: You’re welcome, John.

Reference: Herrick, A. et al. Resilience as an untapped resource in behavioral intervention design for gay men. AIDS Behav (2011) 15-S25-S29