TheSexYouWant.ca - go see it - is a resource created by the AIDS Committee of Toronto (ACT) with whom I go back aeons, in partnership with GMSH (Gay Mens Sexual Health Alliance) with whom I’ve also had more than casual contact. I was part of the HIVStigma.com campaign that GMSH facilitated, and I’m also a member of their poz prevention working group since its inception.
ACT and GMSH worked on TheSexYouWant.ca initiative in consultation with an Advisory Committee of HIV educators from across Ontario. More than a few of them are HIV-positive, like myself.
So I will try and remain unbiased. In fact, I’ll try and put them on the spot!
Here’s the background: The goal of this project is to create resources for informing gay and bisexual men on emerging issues in HIV prevention and transmission. So I asked Duncan MacLachlan, Manager of Community Health Programs at ACT to tell me more.
Bob Leahy: Hi Duncan. A big thank you for talking to PositiveLite.com. Tell me first of all what goes in to developing a resource like this? I’m thinking how do you define what the need is and decide on what approach you want to take?
Duncan MacLachlan: The GMSH primarily serves front line workers across the province of Ontario working in the area of gay men’s sexual health. Those workers told GMSH they needed resources to address new knowledge about HIV and the intersection of sexual health and other issues faced by gay men. They told us that they wanted to be able to provide those resources in different formats – online for sure, but also in condom lube packs, pocket cards, booklets, and posters – and in multiple languages. By working together, representatives – as you mentioned – from across the province, informed decisions about content, tone, and look. ACT was contracted to coordinate production and produce the resources in collaboration with GMSH so that everyone could have access to them.
BL: To what extent does research inform gay men’s health initiatives like this?
DM : New research about HIV – for example the discovery that anal fluids represent a fifth category of body fluids that can transmit HIV – is a key motivator in the need to update resources. In addition to basic science, community based research and evidence from our collective work with gay men across the province informs all of our work.
BL: Do you want to talk about what I’ll call the evolution of HIV prevention – what we have tried in the past - from condoms to scare tactics to - well, everything, to the kind of thing we see happening now?
DM: Evolution is a good way to describe the paradigm shift underway. Resources like this are significant examples of a shift in HIV prevention for gay men, and gay men’s health generally, to focus on strength’s and resiliencies, instead of weaknesses and vulnerabilities. Research tells us that positive reinforcement is more successful than fear messaging.
BL: Some would suggest that it hasn’t worked, that infection rates aren’t nearly where they should be and that we aren’t seeing a reduction in risk behaviours, despite all our efforts. What would you say to that?
DM: Two things. First, we need to have realistic expectations about what anyone, including gay men, can be reasonably expected to achieve. We would argue that perfection is unrealistic. No one I know maintains perfect adherence to diet and exercise for example, so why are gay men expected to use condoms every time? Second, if we stopped talking to guys in outreach, providing information and hooking them with testing and other referrals, and removed all the condoms and lube that are distributed by ASOs across the province, rates of sexually transmitted infections would go up.
BL: I want to talk specifically about TheSexYouWant.ca website. Tell me how you arrived at the title.
DM: It was important to the advisory committee that the title of the resources embraced sex positivity and personal choice. The title captures both elements very well.
BL: It’s a resource rather than a full-fledged outreach-type campaign, right?
DM: It’s a series of resources as described, in nine languages. The lines here between a campaign and resources here are blurred. It looks like a campaign to many who encounter it and that is fine.
BL: I’m liking the way the site goes beyond what I’ll call HIV 101, it goes one step further, like HIV 102 or even 103. I’m guessing you’re trying to mirror the kind of conversations gay men are having amongst themselves – which I suppose are mostly not at the HIV 101 level at all, right? Or are they?
DM: Conversations, where they happen, happen at all levels. We do community development work best when we learn from the populations we serve. Gay men have been telling us for some time that there are a variety of ways – having sex with guys of the same serostatus, getting tested for sexually transmitted infections more frequently, or enquiring about viral load, for example - in which they negotiate risk when it comes to sex. We have captured these strategies and expanded upon them.
BL: Do you encompass – I think you do - an approach that reflects a slightly different way of looking at risk? I’m thinking there seems to be a trend to acknowledging that we all take risks, and not just in sex either, and that we need to come to prevention with a realistic approach to processing that fact, no?
DM: Definitely. Building upon what I said earlier, we take a very pragmatic approach. We are interested in what works. The notion that there is this idealised “good gay guy” that uses a condom all the time has been detrimental to prevention efforts.
BL: Inevitably you talk about contentious issues, right? Care to share what’s the most difficult one you encountered to give advice on?
DM: In developing these resources, we are committed to serving the needs of the members of GMSH. The best way to do that is respectful consensus building. The process we developed and remained committed to allow all voices to be heard. It takes longer, but consensus produces better results that more people can use in their communities.
BL: Some high profile people in our community who have huge experiential knowledge of HIV – I’m thinking of Sean Stub right now have been saying HIV prevention isn’t being as forthright as it could be on the viral load issue. That the risk of transmission with undetectable viral load is less than we are comfortable acknowledging right now. Others are saying getting people to undetectable represents the future of HIV – that it is indeed THE way to end the epidemic. Defence lawyers too have been talking about the relatively low risk of undetectable. So there is a real danger of gay men being confused, no?
DM: We have to be careful we are not creating confusion where there is none. The science continues to evolve, and so must the dialogue. We are now at a place where we can say that undetectable viral load reduces risk of transmission. What we can’t say with certainty is by how much. Again, gay men may use this strategy to reduce risk, but there is no evidence that it affords the same protection as a condom.
BL: Let’s put you on the spot. Here’s a Sean Strub-type question for you. He posed it in discussion with Mark S King (see above). It’s based on two commonplace situations. Which act reflects the highest degree of risk? A negative guy having sex with a condom with a person of unknown status (which we recommend)? Or a negative guy having condomless sex with a person with HIV with a stable and undetectable viral load who has been consistently taking their meds (which we don’t).
DM: Actually, “we” recommend guys make their own choices. We have a responsibility to provide good information, not tell people what to do. If you want the truth, the answer is “it depends.” In each of these scenarios there are variables we don’t know about given the limited information provided.
BL: My take is that this is really tricky stuff. What would you recommend if people still have questions?
DM: : Sex has always been about pleasure and risks. New strategies and information create more options. This is something we have been striving for and dreaming of! We encourage guys to talk about risk with each other, in outreach opportunities, and in other places where they feel affirmed and validated.
BL: I can’t resist asking you a question about social media? What do you guys think about its future, and how might you integrate it in to your future work?
DM: Social media has a robust future. More and more ASOs are using it for event promotion, outreach, research recruitment and fundraising.
BL: Anything else you want to say about The Sex You Want.ca?
DM: Check it out. We’re interested in your feedback!