Statements as Pretension (SASP)

So the big 'news' coming out of the IAS meeting in Rome has been all about Treatment as Prevention. I have some problems with this public health approach that I want to explore with you (or rant into the ether at any rate). I'm not going to pretend that I'm doing something scientific here, or even thorough — I'll leave that for work. I just want to articulate my own concerns.

The other thing I don't want anyone to come away thinking is that I am questioning in any way the effectiveness of anti-retroviral medications in reducing (even reversing, to some extent) the impact of HIV on people living with the infection or reducing their infectiousness with respect to their partners. I'm totally on board with that and wouldn't be on board with anything if it were not for these drugs and their predecessors. I would be dead.

The supposed 'failure' of prevention. This is the first thing that really gets my goat. Can we say that prevention has failed when within a generation the community of gay men has gone from zero condom usage (pre-HIV) to rather consistent 75% condom usage (check the various studies and then try to find one about condom usage among heterosexuals)? Imagine what might be possible if there were actually adequate investment in prevention with gay men and other men who have sex with men.

Can we say that prevention has failed when the infection rate among injection drug users has gone down or at least stabilized (projecting from statistics on new diagnoses)? Imagine what we would be able to do if we had the resources, policies and capacity to distribute a truly adequate number of syringes, including in prisons and in places that make injection less harmful than it is in a back alley?

And my last comment on this: are these people pronouncing the 'failure' of treatment when people die despite their HIV treatments (or because of their long-term side-effects)? Of course not. I would hate to think where we would be without the level of prevention (classic approach) that we have had, and dream of how much more we could do with adequate resources.

Treat me, remove all trace of your responsibility. Since when did it become my exclusive responsibility to protect you from HIV infection? What about the shared responsibility that our public health authorities have been talking about since HIV/AIDS first reared its head in the 1980s? I am perfectly willing to assume my responsibility to prevent the transmission of HIV, including protecting others from the virus within me. But this doesn't belong to me alone. How many times can I be expected to insist on condom-only penetration when, after disclosing my status to a partner, he attempts condomless sex several times? Where's his responsibility in this?

I take these treatments for my own health, not yours. If you get some secondary benefit from my adherence to effective treatment, then bonus for all of us. Just don't expect me to put your interests ahead of my own and embark on a lifetime of treatment before the treatment guidelines indicate its necessity for controlling the impacts of HIV on me. Don't go messing with those guidelines, either, by looking at anything other than my interests. This is a form of chemotherapy that is not without effects (if it were completely innocuous, it wouldn't be working on the HIV), so I won't be taking it for the purpose of relieving you of the burden of putting on a condom or adapting your sexual practices to protect yourself.

The new drugs have minimized the side effects. Where (or when) have I heard that before? Late 1990s, 'Hit Hard, Hit Early'? Have we learned anything from that time? Have the public health authorities done anything to repair the damage that approach did to many through lipodystrophy? No. So now you expect us all to endorse putting people on treatments that are relatively new for the rest of their lives (since research shows there can be negative health impacts of stopping treatment, even when you started it earlier than the guidelines would recommend)? Will you promise to investigate and repair any damage this might do? Didn't think so. How about taking them yourselves for the rest of your lives? No? Quelle surprise.

Seek, test and treat. In a context where an estimated 27% of HIV-infected individuals don't know they are infected, it makes a lot of sense to offer testing in new and innovative ways to reach those who are not being reached. Offer, not impose. In Canada, we impose testing on immigrants and refugees, and I think that is a horrible mark on our reputation as a country. But think about the injection drug users in the Downtown Eastside of Vancouver: have they the power to refuse to be tested if they don't want it? Are they being provided with all the information they need to make that decision for themselves? If they test positive for HIV, are they being rushed into treatment, or being offered information and [unbiased] support to make that decision for themselves? I remember that feeling of toxicity that followed my diagnosis. That is not the time to make an irrevocable decision to be treated earlier than indicated by the treatment guidelines.

Acquiescence is not enough; it takes informed consent.

And what else are we doing to make testing more accessible? Have you noticed that question on an insurance application about whether or not you have been tested for HIV in the past? A yes will get you another questionnaire and the very real possibility that you will be deemed too much of a risk, all for having followed the advice of public health to get tested. We need to make that question illegal if we want to remove all the barriers to testing.

Criminalization and discrimination. Ever notice the zeal with which our police and prosecutors pursue the evil PHAs who might have exposed their 'victims' [tango partners] to a risk of HIV transmission without disclosing their status (or without being able to prove that disclosure)? Leave aside the fact that many of them have knowledge of HIV that dates from the early 1980s and not beyond and ask where are the public health authorities and the weight of their pronouncements? You can't trumpet the necessity of treating everyone with HIV all the time to put an end to this pandemic and then slink away and refuse to insist on the same level of lack of risk in the context of these prosecutions. We're getting the burden of your policies and none of the benefit.

Where is your zeal in investigating and prosecuting the breaches in confidentiality, the illegal dismissals, the denials of hiring, services, housing…? Show me that zeal and I'll be happy to endorse everyone knowing and disclosing their HIV status.

The cynical me is waiting for the case of someone being accused of criminal negligence for not embarking on a treatment regime, or not taking it properly. Court-ordered treatment? It has happened elsewhere in the world for HIV. But we require treatment for infectious TB, you say? There's a little difference between the method of transmitting tuberculosis and that of transmitting HIV that you ought to be considering if you think compulsory treatment might be in the cards. Again, this is 'treat me, erase your own responsibility' and I won't accept the whole burden.

Treat everyone? There's a basic problem with taking this approach today: we haven't even succeeded in treating the people who need it for their own health, let alone those who might 'need' it to protect yours. Tell the people in developing countries, tell the people on the ADAP waiting lists in the United States, that the drug supply has been reallocated to treat everyone with HIV in wealthy countries (where the prices are better for sellers) before they need it to survive, all in the interest of preventing the uninfected from having to think about how to prevent themselves from becoming infected. Seems a little shallow and hollow, no?

So yes, treating people with HIV does work to reduce infectiousness and transmission and would surely help us to eradicate this serious public health problem. But there are a few other problems that we need to solve first if we want this to work.

Under a … Big Top

(I owe the double entendre title to Bob at Positive Lite and Rural Ramblings of the Third Kind.)

Never before have I been such a participant in a festival in this city of — what are they saying…106? — eclectic festivals, but Montréal Complètement Cirque drew me in and kept me most entertained indeed. At this moment, I have been to four shows, with the possible addition of some free outdoor fare on Saturday, so let me comment on each of them.

We can thank being Facebook friends with the festival for this one: a last-minute half-price offer for that day's show! Woo-hoo! The trek to the Tohu (quite far up there) was well worth it. Now I like the Tohu at the best of times, quite a nice space, but this show by Australian circus Circa was truly excellent.

Elements of humour and burlesque, almost fetish with the costumes and their removal as well as the bright red pumps, got us in the right mood. Some excellent circus acts kept us that way. I think the best thing for me was that the three men and three women who made up the troupe blurred the gender role lines a bit: there was plenty of lifting by both genders and plenty of being lifted by each as well.

Here's a little taste of the show:

Wunderkammer / Circa | Australie from MONTRÉAL COMPLÈTEMENT CiRQUE on Vimeo.

No more opportunities to see this during the festival, but I have heard they will be back in town in the coming months. DO see it if you get the chance.

I probably had the highest expectations for this show, held in an actual big top (take that, Bob!) in the parking lot of the CBC building, right in my neighbourhood. What's not to provoke expectations: pretty, bendy boys, the promise of percussion…. In the end, this might have been the show I liked the least of my four, although I did like it. Aussies again, and they were handing out free red clown noses in the entry tent!

If I see another show in a big top (just can't get enough of that), I will probably spring for the more expensive seats, as they were actual seats, not slightly padded narrow benches. That didn't help with my appreciation of the show. Then there was the start, very scratch-DJ-esque, which is fine, not really my scene, but it went on a bit long. I almost looked at my watch! (I managed to restrain myself). Eventually, we moved on to some acrobatics, and I felt good about it all again.

All boys, all quite good, with a few little missteps that they recovered from most professionally. We were speculating that the missteps kind of remind us how difficult some of these things are, which can't be a bad thing. Some very entertaining acrobatics, and another feature I enjoyed was seeing some of the performers playing the role of apparatus counterweight, climbing the tent supports to lower the suspended device and rappelling down to raise it back up.

There was a totally amazing beatboxer/graffiti artist who did his thing a bit too long in my opinion, but the multimedia experience of his duelling with the DJ while doing some graffiti on a canvas that subsequently fit into the film of him drawing on a section of the Berlin Wall was impressive. And the drummer was very good with the multi-drums, especially when it became a 360-degree physical workout for him. And can I forget the contortionist? Impressive.

A taste?

Tom Tom Crew | Australie from MONTRÉAL COMPLÈTEMENT CiRQUE on Vimeo.

They still have three shows left as I write this: Thursday, Friday and Saturday the 21, 22 and 23 July. If you go on Saturday, you get a second festival experience at the end, as the fireworks starts at 10 pm and is very visible from that parking lot.

This was probably my overall favourite, but I'm a bit of a fan of the traditionally québécois so that might have coloured my view. Oh yeah, and all the boys had beards and looked like lumberjacks…bendy, bendy lumberjacks. That didn't hurt a bit. The funny hook: handing out free fake beards at the door!

So good traditional sounding Québec music, use of adaptations of circus apparati made with logs and sticks and such, even an outhouse as a prop for the grandpa character and then the three other guys. My favourite pretty much did most of the acrobatics, certainly with the support (and I do mean support) of the others, and there was some excellent dance from one of the two women in the group.

Really edgy was the juggling — with axes! — and the adaptation of jumping through hoops, as the hoops were formed by bending a long cross-cut saw into a hoop with the teeth facing the arrival of the jumper! [Potential] ouch!

I do have to add that we were pretty well entertained by the family sitting in front of us, as one of the daughters (in her 20's) was completely out of control in her enthusiasm.

Here's a little taste, and because I can't resist it's a little clip of them after the show:

Première du Timber! par Cirque Alfonse from MONTRÉAL COMPLÈTEMENT CiRQUE on Vimeo.

No more representations of this show during the festival, but I'm hopeful that we will be able to see more of Cirque Alphonse sometime soon. Love them!

This evening was our last paid show, the Cabaret of Les Sept Doigts de la Main (The Seven Fingers of the Hand). The first half was heavily interrupted by the emcee, who my companion detested most vehemently! I found him mildly to semi-severely irritating, and we were united in our great pleasure that he was absent for most of the second half, after the intermission. I believe he was the creator of the piece, but playing a 'comedic' role of dissatisfied emcee who keeps being distracted and missing the amazing feats of the performers. There was also a mock 'get a piano player from the audience' thing that was really all about introducing the ringer who was supposed to accompany the acts (and did an excellent job, to the point that some of the people behind us thought it was actually a recording).

So highlights of the first half. Really good choreography of the ensemble in the setting of a speakeasy (where is the line between modern dance and circus? Is there one?). Really good trapeze guy who did some excellent asymmetrical stuff that I loved, and the woman on the Russian bar (okay, since it isn't called the Russian pole we can all stop snickering like adolescents) was really breathtakingly graceful and strong.

The second half, which we enjoyed much more. Montréal in 2011. The music was upbeat and varied, the comedy stronger and the acrobatics no less impressive. There's a special place in my heart for the cigar box juggler, who plied his trade to a remix of an old hip-hop song that sounded like the best of soundtracks from an old Mickey Mouse movie. We all laughed when the trapeze guy came over to hand him a stack of boxes and then steal a quick kiss on the cheek while his hands were full, feigning swooning afterwards. We also enjoyed the teeterboard action, the boys in tutus talking about what made them feel like men (funny) and then the two guys with the Chinese hoops (tumble through, many levels of hoops).

And let me just compliment the music again. There is a fabulous singer who could belt out a moving ballad, but also do experimental stuff with sampling her own beat-boxy sounds and layering them to make something truly original and beautiful.

A taste of the show:

Première du Cabaret 2011 from MONTRÉAL COMPLÈTEMENT CiRQUE on Vimeo.

This one is still showing every night until 23 July and is totally worth seeing. We kind of wanted to be on the floor, although we had chosen tickets on the balcony, so think about that if you go. And the emcee in the first half? Having thoroughly dissed the character, I have to give credit to the individual. He is the artistic director of this troupe and the show as a whole was brilliant.

I will be back next year, a true fan of a festival at last!

Living With Henry

Well, I had a lovely evening tonight. After a very productive committee meeting day in the Queen City (despite my well-known anti-monarchist views), I joined my colleagues from PositiveLite for a lovely casual dinner and a play at the Toronto Fringe. Then three of us went off for dessert…er, desserts…in the Village. Shall we focus on the play, then? May contain spoilers!

Living With Henry bills itself as a musical drama that explores the fear, complications and realities of living with HIV/AIDS. It does those things, and does them from the perspective of a protagonist who is still living at the end with his life and its challenges stretched out before him. In that sense, it is very contemporary and not at all the tragic portrayal of HIV that we are used to seeing (or we were, before HIV faded into obscurity for those in the developed world not intimately connected to it).

Several things struck me as being a bit unrealistic, given my own experiences. Having ignored his doctor's advice to start treatment and giving up on his medical follow-up, he finds himself at the hospital with PCP pneumonia (an AIDS-defining illness) and a low CD4 count. Readers of this blog might find that story familiar, as that was actually the situation of my diagnosis, except that I had 4 CD4s and this guy had 7 (twice as healthy?). Oh yeah, and I wasn't threatened with a tracheotomy and a month flat on my back in the hospital, but a simple oral antibiotic and a single overnight to help me get my oxygen levels up after the bronchoscopy. I also didn't emerge after my recovery to announce that I no longer had AIDS (HIV positive again), but now rather pronounce the irrelevance of the AIDS label in a world where one's health can come and go and come back again. These, however, are minor elements in a play that I enjoyed immensely and I can entirely understand the dramatic importance of exaggerating this small moment in the play to communicate the seriousness of the disease.

Overall, I would have to agree with one of my companions: the message was a bit simple for people who are involved in the HIV movement. But it really is a useful message for those whose familiarity with things HIV is at a lower level.

I really did enjoy the play. I don't always like musicals, and I can't say I liked all of the music in this one, but there were a number of beautiful songs, clever duets and snappy tunes that still told the story as it need to be. And the dancing! There was some really good choreography, and I was howling with laughter during the bathhouse tango number. The other double-entendre dance moment was his doctor dancing with the Sustiva and the Truvada, and dancing like she was a part of the number.

But the best thing for me was the dramatic device of personifying HIV and the very excellent job that Dale Miller did playing the part. The whole cast was very strong, but this stood out for me as the combination of the device and the performance. He was there, interfering and touching, sometimes just watching or staring down the main character. I'm not doing it justice with my description, but I can't stop repeating how good that was. Of course, the downside of that from a prevention viewpoint was that he looked so cuddly, one would want to have him around, which is not exactly the idea that the movement is fighting for.

I also appreciated that at the end the main character has a very interesting coming to terms with his status. Here the play portrays something about the relationship between HIV and the people who carry it that I have heard described in many a testimonial.

If you're in Toronto between now and 17 July, you should definitely go see this play. Check out the times and other information on the play at their website. Additional photos stolen from PositiveLite.com: thanks Bob!

A little extra comment worth adding, at least as an aside. Attached to each program was the AIDS Committee of Toronto's Pig Pac – a pack of two lubes and two condoms – that bears a message that has proven to be somewhat controversial here:

"It's your choice!

We believe that sex is a spectrum
of possibilities. From pig sex to
vanilla. Bareback to wrapped.

We've got information and
sex positive tips to make your
choices safer and more rewarding.

actoronto.org/gaymen"

For those who decry the effort to reach out and include those who define themselves as barebackers, I can only shake my head in disappointment. No one ever succeeded in communicating a message and winning someone over by starting with judgement and condemnation. Bravo to ACT for being inclusive!

Stability (or Inertia)

Yesterday was National Moving Day in Québec. It's that strange phenomenon of hundreds of thousands of people moving from one apartment to another on the same day that has its roots in various events in history here (read the Wikipedia entry for more detail).

While at least one of my neighbours in this building of six apartments participated in the National Moving Day Parade (it's a parade on every street!) — and looking very B-boy supervising the movers, I must say — I did not have a float for this year's event.

My shaded stairway, pruned free of foliage

This made me reflect on the fact that I moved into this apartment in 1995, fully sixteen years ago! Next year, I will have lived a third of my life in this apartment (roughly), about the same amount of time I lived with my parents growing up (I turned 18 at the beginning of my first year of university).

When I moved here, the "tree" that I hack at mercilessly with the pruners in order to keep it from interfering with my progress climbing my stairs did not exist. In fact, it sprang as a weedling (unintended seedling of a tree) between the concrete of the sidewalk and the asphalt under the stairs, and is now fully two storeys high.

The tree from my second floor front porch

When I moved here, I had no idea that I was living with HIV. I was diagnosed two and a half years later with my infamous low CD4+ count. A year and a half after that, I changed jobs and began working in the HIV/AIDS field in the community.

This is where I was for my first rejection based on my HIV status (well, I can't really blame the guy who didn't want to pursue a relationship with someone he had met just weeks earlier, then radio silence until the guy told him he had been diagnosed with HIV and 4 CD4+s).

It's also the place where I slipped smoothly from slut to social worker to calm down the guy who asked my status after we were done with our series of non-risky manoeuvres (I had to walk him back through everything we had done to explain how there was no risk). Then there was the satisfying moment where I got up on my own high horse to tell him that if it was that important to him, he should ask first.

The — alas! — caged doorway

When I moved in, there were all the elements of casual sex around me: parking lot out back used in the night by people having quickies in their cars; recessed doorway across the street in which many a street performer strutted his stuff for my receptive gaze; and just the positioning between the gay bar area and a once-frequented cruising park. The parking lot is now condos, the recessed doorway has a cage keeping people out and the bar to park traffic seems to be rather sparse, likely a combination of the decline of the bars and the renovations that made the park more open to the view of passers-by and neighbours.

I've been through a few computers and toasters and two TVs and other things too countless to relate. Some other things I have not so much been through, but accumulated. There's where the inertia needs to end: not to move, but to purge and reduce. The mammoth task that's long overdue that I ought to find the energy for sometime this summer.