world AIDS Day 2007 H Adherence Sexual Dysfunction H Queen of the whole universe
Collective Thinking
“I’ve brought some of my friends” HIV and the new wave of STIs
THE NEWSLETTER FOR HIV+ PEOPLE, THEIR CARERS AND SUPPORTERS NEW ZEALAND ISSN 1170-2354
Issue 68 H December 07
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COLLECTIVE THINKING Issue 68 H December 07
Our kind aren’t kind How strange we are, we people with HIV, and our lack of solidarity. I was at positive centre the other week, talking with and listening to other people’s conversations. They were complaining about another person and on about how this organization and that was for gay men and one for women and not a lot for straight people. Another complained about a separate organization set up to support gay men in particular, but supported anybody with HIV. I have spent a lot of time sitting around talking with positive people, listening and in that time I have heard complaints about gays, women, men and drug users – apologies if I have missed out any group. All manner of petty bickering concerning the advantages that one group have over another. I can’t help wondering if other people suffering from other life-threatening illness split up into different groups, depending on now they contracted their illness and slag off others suffering from the exact same plight. Ok, HIV has thrown together some very different groups of people who probably would not, under normal circumstances, choose to mix with each other, but that could be the essence of our strength. The very diversity of those affected by HIV could actually help us. It is helpful to have your life enriched by the experience of others. We are at our core all the same and at the same time we are all individuals. We are not our behaviors, sexuality, the types of drugs we take; we are not the colour of our skins, eyes, hair or any other superficial aspect of our whole. We are human beings suffering from a life threatening illness, and we are for the most apart, afraid. There is an old Indian proverb that goes along the lines of “How can you know me until you have walked a mile in my moccasins?” so, how willing are we to walk that mile? Now I am not suggesting that a whole lot of gay men try injecting heroin or that straight men should start hanging out in gay bars. But maybe we could try adjusting our glasses to see what makes us similar instead what separates us. What I have discovered about other positive people who aren’t gay like me is that once I got past their initial identity and found out a bit more about them, they became human. I was able to see past my own petty prejudices. Result: my life was enriched. Quite often we complain about the stigmas of HIV and how society is so intolerant to people with this disease. How can we expect society to accept people with HIV if we can’t accept each other? We all want to belong, to be a part of and not apart from. Yet at the same time1 we have to choose the smallest possible denominator, the tiniest group to belong to. In one area of my life which is so personal, so close to my heart: my fears and worries, my living with HIV, I find it difficult to mix because to many of my fellow human beings afflicted with this illness are sitting in different camps moaning about each others. I am so grateful for the individuals who refuse to buy into that and who are human first.
CONTENTS Letter from the editor .................... 3 News ................................................... 4 FEATuRE STORy: The new wave of STIs ............... 10 STIs & sexual networks ............. 14 wORLD AIDS DAy: positive women’s Movie Night ..................................... 16 RESEARCH: STEp study halted ....................... 18 RESEARCH: Adherence and hazardous drinking ..................... 20 RESEARCH: what is IRIS? ................................. 21 HEALTH & wELLBEING: Sexual dysfunction...................... 22 HEALTH & wELLBEING: Flexitime ........................................... 24 HEALTH & wELLBEING: Adherence ...................................... 26 Queen of the whole universe ............................ 30
Aaron McDonald
Collective Thinking, the Newsletter for HIV+ people, their carers and supporters, is published quarterly, by the New Zealand AIDS Foundation. The NZAF registered office is located at: 31-35 Hargreaves St., College Hill, ponsonby. pO Box 6663 Wellesley St. Auckland. Telephone (09) 303-3124 Ideas expressed, and information given here are not necessarily representative of the opinions, nor endorsed by, the New Zealand AIDS Foundation, nor the Board of Editors. Publication of the name or photograph or likeness of any person in Collective Thinking is not to be construed as any indication of sexual orientation, or presence in their body of organisms capable of causing illness. Any similarity between individuals named or described in fiction articles and actual person living is purely coincidental. Publication of any letters, articles, photographs is at the discretion of the publishers and the right is reserved to withhold, alter, edit and comment on any article, letter, advertisement published. The list of subscribers is confidential and is not, sold, rented or leased out to anyone at any time.
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(( LOCAL NEWS ))
NZAF’s Burnett Centre to relocate – K’Rd outreach to be retained
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The NZAF Burnett Centre will relocate next year in order to expand its services and reduce waiting lists. The centre provides HIV testing, counselling and support services from a base in central Auckland, and the Foundation says an increased demand on its services has necessitated the move. “This is a direct result of the burgeoning number of new HIV diagnoses in Auckland, combined with the success of our rapid testing programme,” says NZAF National Positive Health Manager Eamonn Smythe. “This has led to waiting lists, which can only be reduced by increasing staff numbers. Whilst we can afford more staff, there is no space left at the current location to house more counsellors or social workers.” The NZAF Trust Board recently approved the Burnett Centre moving into a dedicated separate space with its own entrance on the top level of a building in Hargreaves St, off College Hill in Ponsonby. This is next to NZAF’s National Office and Northern-based health promotion teams. “We explored a number of options for relocation, with our first focus being on several buildings in the K Rd area where the Burnett Centre is currently located,” Smythe says. “The costs involved with these properties simply didn’t stack up when compared with the College Hill option. Remaining in K Rd would result in our struggling service being forced to make further cuts.” Smythe says he is confident the Hargreaves St location will provide a confidential, accessible space that will best service the diverse communities who use the Burnett Centre’s services; including gay and bisexual men and the HIV positive peer support group Positive Women, who are joining the Burnett Centre in its move. “We believe Hargreaves St is still central enough to act as a hub location for all those who currently travel from the suburbs to access its services, those living in the city centre, and those who travel to Auckland to access this service.” Refurbishment work is set to begin in December and be completed in time for the new Burnett Centre to open its doors in February 2008. Services in the meantime will continue from the Burnett Centre’s current location in Poynton Terrace. The New Zealand AIDS Foundation (NZAF) Trust Board has decided to allocate additional funds to retain community outreach and testing services in the Karangahape Road area. “Karangahape Rd is an important area for us to retain core services,” says NZAF Board Chair Jeremy Lambert. ”The move of the Burnett Centre to Hargreaves St will benefit some service users. However, our communities are diverse and for some, especially young people, being able to access outreach and testing services in the K Rd area has some distinct advantages.”
New counseling services available in Dunedin and Greymouth The first in a series of NZAF counseling services for HIV positive people outside of the main centres has been announced. National Positive Health Manager Eamonn Smythe says counselors have been appointed in Dunedin and Greymouth, with a Northland service to follow before the end of the year. Contact details for the Dunedin and Greymouth counselors are as follows: DUNEDIN: Joan Greaves (03) 477 7788 GREYMOUTH: Pam O’Hara (03) 768 9619 Email inquiries can be made through the NZAF South/ Te Toka office contact: tetoka@nzaf.org.nz
Pan Pacific HIV+ Peoples Conference 2008
COLLECTIVE THINKING Issue 68 H December 07
A conference for HIV positive people in the Pacific region is to be held September 2008 in Auckland. The aim of the conference is to report progress against issues identified in a declaration made at the 2005 Pan Pacific AIDS Conference. The four key issues identified in 2005 were stigma and discrimination, HIV in the workplace, treatments and advocacy. The steering group for the 2008 conference includes Bruce Kilmister of Body Positive, Jane Bruning of Positive Women, Ray Taylor of Poz Plus, Maire BoppDupont of the Pacific Island AIDS Foundation, Maura Mea of IGAT HOPE , and Stewart Watson of UNAIDS. Registrations open in May next year. Visit www.panpacifichiv.com for more information.
HIV Futures report to launch early next year Findings from New Zealand’s largest comprehensive study into the health and social experiences of people living with HIV will be reported in early 2008, say researchers. 261 people have been surveyed for HIV Futures NZ 2, a joint project led by the Australian Research Centre in Sex, Health and Society at La Trobe University, Melbourne, and run in collaboration with the New Zealand AIDS Foundation and HIV positive peer support organisations nationwide. Basic analysis of the data has collected been conducted and the report is now being prepared. “The survey is an extensive one and all findings need to be checked and then contextualised to ensure that they are not misinterpreted,” says project leader Dr Jeffrey Grierson. “Contacts with key stake holders are to take place over the next four weeks, after which the report will be finalised.” Researchers had originally hoped the report would be launched by the end of 2007. “We extended the recruitment period for the survey to ensure that as many people as possible had an opportunity to participate in this important survey, and this pushed the dates back somewhat,” Dr Grierson says. “Given this project only happens once every five years, it is critical that we ensure that all reporting of the findings is accurate and clearly interpreted.” HIV Futures collects information on all aspects of living with HIV, including the effectiveness of treatments, social isolation, relationships, employment, housing and finances. The last study was held in 2002, and researchers are keen to identify whether needs highlighted in the last report have been addressed.
HIV rise brings wave of other sex diseases New Zealand’s HIV epidemic shows no sign of slowing down, with 84 new diagnoses reported by the AIDS Epidemiology Group for the first half of 2007. Gay and bisexual men are the group most affected, both by HIV and a disturbing resurgence of syphilis recorded at sexual health clinics between 2002 and 2006. The New Zealand AIDS Foundation is deeply disturbed by the news, and says these epidemics are linked. “Sexually transmitted infections like this were quite common among gay men in the 1970s, before AIDS, when condom use was rare,” says Douglas Jenkin, NZAF National Campaigns Co-ordinator. “When condom use became the norm during the first wave of the HIV epidemic in the 1980s, rates of STI infection plummeted.”
Survey to plan an online HIV+ community New Zealanders living with HIV are being asked to participate in a new survey which aims to find out whether creating an online community would be beneficial to their lives. The survey - an initiative of Absolutely Positively Positive in Wellington - is now open and will be promoted through the summer until the end of January 2008. Results will be posted on the website in early February 2008. Progress reports will be available just before Christmas and in mid January 2008. The Living With HIV survey explores their present use of the internet and their interest in possible features and services that might be made available through an interactive website dedicated to community building for this diverse range of people. Completion of the survey gives each person an idea of the possibilities that could be realised. People in this virtual community would be able to network with each other and contribute to monthly fora on issues relevant to their lives, hosted by experts. There’ll also be opportunities to make friends, volunteer, and socialize locally through bulletin boards advertising events. Newly diagnosed people will find support and mentoring. The website will cater for the different groups within the population (particularly sexual preference) by partitioning interest groups according to the preferences they define in their initial log-in. People living with HIV can make anonymous submissions to complete the survey. Their responses will be aggregated with others so that no individual can be identified. The results will be used to validate the case that there are authentic needs that might be addressed by the development of an interactive website. The findings will be able create a picture of the pattern of responses according to living location (e.g. main centre urban, provincial city, provincial town, rural district etc), how long since diagnosis, sexual preference, age, gender, ethnicity, employment situation, etcetera. The target user population in NZ is an estimated 1800 people living with HIV, and the survey aims to gather online submissions from a minimum of 1000 of these people. Find out more, and take the survey at http://www.app.org.nz or see hard copy enclosed with this edition of Collective Thinking. Source: www.gaynz.com
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)) INTERNATIONAL NEWS ((
UN Lowers AIDS estimate Chicago Tribune/Laurie Goering
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New UN data on global HIV infections should be used in to guide future funding decisions, several experts said recently. More accurate methodology led the agency to conclude that HIV prevalence has been falling for almost a decade, and that HIV has not jumped from highrisk groups to the general population in China and India, among other findings. Growing global data suggest HIV/AIDS affects primarily sex workers and their clients, intravenous drug users, men who have sex with men and “people who participate in risky sexual networks,” said Daniel Halperin, an AIDS specialist at the Harvard School of Public Health. In Africa, 20-40 percent of adults have several sexual partners at approximately the same time, he said. Since these networks are rare in China and India, controlling AIDS “is really about doing effective HIV prevention with high-risk groups,” Halperin said. Experts suggest that funding for abstinence programs targeting youths could be cut and spent in a more focused way on high-risk groups, such as sex workers, and promoting sex partner fidelity, especially in Africa. “Abstinence programs for youth in India are not a good use of money,” said Halperin. “The idea that you have to convince every Indian couple to use a condom isn’t what needs to be done.”“It would be really a mistake to say we don’t need to fund AIDS anymore, that it’s not a problem,” he said. “But in countries that have a low prevalence and no strong indication the problem is getting worse, spending shouldn’t be disproportionate for one problem.”
HIV-positive gay men in Western Europe disproportionately affected by STIs AIDSmap.com/Edwin J Bernard
Sexually transmitted infections (STIs) – including syphilis, gonorrhoea, LGV and hepatitis C – are disproportionately affecting HIV-positive gay men, according to a review of STIs amongst gay men in Western Europe published in the October 2007 edition of the journal Sexually Transmitted Diseases. The authors conclude that this not only highlights the need to routinely test HIV-positive gay men for STIs and hepatitis C, but also suggests that changes in STI incidence may no longer reflect corresponding changes in HIV incidence amongst gay men as a whole. Since 1996, when the era of effective antiretroviral therapy began, the number of diagnosed HIV-positive gay men who are well and sexually active has increased substantially. In order to understand trends in HIV prevalence and STIs amongst HIV-positive gay men in Western Europe, researchers from London undertook a review of published reports between 1996 and 2006, focusing on twelve countries. The researchers conclude that STIs have been disproportionately diagnosed among HIV-positive gay men in the post-HAART era in Western Europe. Although there were variations between countries and STIs, the majority of HIV-positive gay men diagnosed with these STIs were already aware of positive HIV status. “These findings highlight the need for routine testing for STIs amongst known HIV-positive MSM in Western Europe,” they write. They add that since their findings also suggest that in some settings a large proportion of HIVpositive MSM with STIs were unaware of their HIV status that routinely screening all gay men for HIV would help to diagnose more HIV-infected gay men. They suggest that safer sex messages should focus on more than HIV prevention and also highlight the consequences of STI infection. “These messages,” they write, “should also underline the risks associated with sexual practices other than unprotected anal intercourse with a partner of unknown or discordant HIV status.” For more on gay/bi positive men and STIs, see feature articles on pages 10-13.
COLLECTIVE THINKING Issue 68 H December 07
World AIDS Day viral email Similar linked epidemics of HIV and syphilis have been taking place in Sydney, Melbourne, San Francisco and London. A viral email created by the New Zealand AIDS Foundation with creative agency Hoopernagel is aimed at raising awareness of World AIDS Day. The viral can be viewed at http://www.creativeretouching.net/aidsviral/. The message is simple: Catching a virus is easy. Always wear a condom. “In the Internet-savvy age, we don’t think twice about ensuring our computers are protected from viruses,” says NZAF National Positive Health Manager Eamonn Smythe. “With HIV and STIs on the rise in our communities, we should also be ensuring the health of ourselves and our sexual partners by using condoms for anal and vaginal sex There’s no cure for HIV - only prevention.”
China To Ease HIV Travel Restrictions REUTERS/LINDSAY BECk
Vice Minister of Health Huang Jiefu and the executive director of the Global Fund to Fight AIDS, TB and Malaria announced in November that China will rescind immigration laws that prevent HIV-positive people from traveling to the country. “China has decided to change its immigration laws, scrapping travel restrictions,” said Global Fund’s Michel Kazatchkine. “The new law, which hopefully will be passed in the coming months, will be in line with the global conventions, which recognise that travel restrictions for HIV positive people do not have any public health value.” The restrictions have blocked people with HIV/AIDS from entering China to attend conferences on the disease and are viewed as reinforcing HIV/AIDS stigma. In addition, some Chinese patients have been barred from leaving the country to attend conferences, and some local authorities also impose restrictions. Jiefu did not provide a timeline for the change but said China is committed to lifting the restrictions.
Zimbabwe’s HIV/AIDS Youth Projects Get $2.4 Million Boost XINHUA NEWS AGENCY
A three-year, US$1.9 million (NZ $2.4m) grant from UNICEF-Norway will be used to support sportsoriented HIV-prevention programs targeting Zimbabwe’s young people, according to an article in the staterun Herald. The money will be channeled through UNICEF’s Harare office to the Sports and Recreation Commission. James Elder, UNICEF’s spokesperson in Zimbabwe, said the project is expected to train 900 district committee members and volunteers; cover capacity-building for 400 women and girls; train and support 1,350 peer educators; and educate 170,000 young people about HIV/AIDS. Through sports, young people infected or affected by HIV can access a safe and supportive environment, Elder said.
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)) INTERNATIONAL NEWS ((
AIDS Vaccine Trial Subjects React to Failure Seattle Post-Intelligencer/Tom Paulson
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Seattle area volunteers have mixed reactions to their involvement in a recently halted international AIDS vaccine trial. Testing stopped on Merck & Co.’s vaccine in September after preliminary findings showed it did not stop HIV infection or reduce viral load after infection. In Seattle on Nov. 7, experts at the HIV Vaccine Trials Network conference (HVTN) reviewed STEP trial data that could suggest vaccine recipients are more susceptible to HIV infection upon subsequent exposure. “If I had known this vaccine could diminish my overall immunity [to HIV], I definitely would not have signed up,” said one 40-year-old West Seattle man. All volunteers interviewed requested anonymity. “I wanted to help find a way to combat this virus and I’m still committed to this study,” said a 37-year-old Seattle man. “I’m going to decide to unblind myself,” said a 25-yearold Tacoma man, referring to the procedure in which volunteers are told whether they received the experimental vaccine or a placebo. “It’s hard to know what to do, but I want to know what I’m dealing with here.” It has been difficult for HVTN to get announcements out to volunteers quickly about such an unusual situation, said Sarah Alexander, HVTN’s spokesperson at Seattle’s Fred Hutchinson Cancer Research Center. “People are asking us questions that we don’t have answers to,” she said. “I think it’s important that everyone be as informed as they need to be, but I’m not going to ask to unblind,” said one participant. “If unblinding hurts the study, it would be like my contribution would be for nothing.” Another volunteer said he was not as concerned with his status in the trial as with the effect of the news on HIV vaccine trials generally. “There are millions of people still getting infected, dying,” he said. “We desperately need an AIDS vaccine.” For more on the halted vaccine trials, see article on pages 18-19.
Zambian President Urges Citizens to Accept HIV/AIDS as Reality Xinhua News Agency
Many Zambians are in denial about the reality of their country’s HIV/AIDS epidemic, President Levy Mwanawasa recently told the UN special envoy for HIV/AIDS in Africa. “Our special challenge is that up to date, our people, especially in rural areas, have not come to accept the reality of AIDS, they think they have been bewitched,” he said during Elizabeth Mataka’s visit to Zambia. Such beliefs cause some people to delay treatment — hence the need for stakeholders to promote HIV education, said Mwanawasa. Government, civil society, churches and other entities must step up their efforts to mitigate the impact of the disease, he noted. According to Mwanawasa, Zambia’s shortage of health care workers is also negatively affecting HIV/AIDS control. Despite many attempts at improvement, an inadequate health infrastructure limits the government’s ability to fight the epidemic effectively, he said. Approximately 1 million of Zambia’s 12 million people are living with HIV/AIDS, said Mwanawasa. Over 200,000 of these are in need of free antiretroviral treatment, but so far just more than 100,000 are actually receiving it. 7,000 are children, the president said. Already, more than 90,000 Zambians have died of AIDS-related diseases, leading to the sad phenomenon of households headed by children. “Children are being infected with the virus through mother-to-child transmission, and about half of them die before their second birthday,” he added. “About 130,000 children are in this predicament.”
COLLECTIVE THINKING Issue 68 H December 07
Female Condoms: The Next Generation New York Times/Donald G. McNeil Jr.
Public health experts once held high hopes that the female condom would give women worldwide the ability to protect themselves from STDs. But due to a range of problems - the device was perceived as awkward, unsightly, and noisy - it made little headway with females other than sex workers. Six billion male condoms are delivered annually to developing countries, compared to only 12 million female condoms. Now a second-generation version has been developed by the Seattle-based nonprofit PATH. It reportedly offers several advantages: It is inserted using a tampon-like bunched end, instead of a stiff rubber ring. A softer, thinner polyurethane was used to better transmit warmth and provide a more natural feel. Adhesive dots on the outside cling to the vaginal walls, expanding with them during arousal. In testing among couples in Seattle, Thailand, Mexico, and South Africa, more than 90 percent liked the new device’s comfort and ease of use, and 98 percent rated its feel during sex as “OK to very satisfactory,” PATH said. But PATH has encountered a major roadblock to bringing the new female condom to market. While the Food and Drug Administration designates male condoms as Class 2 medical devices, so that they must only pass tests for leakage and bursting, female condoms are designated Class 3. This puts them in the same category as pacemakers and heart valves, meaning that any new design must clear clinical trials at a cost of $3 million to $6 million. “That’s. close to a 100 percent block, because no one’s willing to put up that sort of money,” said Dr. Michael J. Free, PATH’s head of technology. The original product was never able to fulfill scientists’ goal of being a form of protection a woman could use without her male partner’s knowledge. This was the female condom’s biggest failure, and one the redesign process could not correct.
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>> FEATURE
Poz gay guys and STIs By Chris Banks
The resurgent HIV epidemic among gay and bisexual men throughout the Western world has brought back some nasty sexually transmitted infections with it, which is bad news for HIV positive men who’ve decided to give up condoms and serosort (choose other HIV positive partners only) as a sexual partner strategy. Collective Thinking highlights the consequences of STI infection – and HIV reinfection – for HIV positive gay and bisexual men.
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Consistent use of condoms for anal sex brought New Zealand’s HIV epidemic among gay and bisexual men down to record lows in the late 1990s, and kept other STIs under control as well. However, with HIV among gay and bisexual men now in a resurgent phase both here and in other Western countries, rates of STI infection are increasing in parallel, with HIV positive gay and bi men disproportionately affected. What’s more, at least one disturbing new STI has emerged: LGV. Receptive anal sex (bottoming) without a condom carries the highest risk of HIV infection, due to the dense collection of cells inside the anus which act like a sponge for absorbing infected blood and seminal fluids, including precum. The same is also true for other sexually transmitted infections. Some HIV positive gay and bisexual men may believe their diagnosis allows them the freedom to have condomless anal sex with other HIV positive partners. Unfortunately, HIV doesn’t have the courtesy to close the door behind it once it enters the body, and the consequences of STI infection (and HIV reinfection) for the HIV positive person can be very severe.
SypHILIS This medieval infection, almost eliminated throughout the 1990s, has made a vicious comeback
in communities of gay and bisexual men all over the world since 2001. It stays in the body for years, progressing through several stages until – if left untreated – it may cause damage to almost all the internal organs and the brain, causing blindness, paralysis and death. Syphilis is curable with penicillin injections or occasionally orally administered antibiotics, although authorities such as the World Health Organisation and the Centers for Disease Control have noted that syphilis may be harder to treat in HIV positive people. An American study, published in the October 21, 2004 edition of AIDS, showed that syphilis infection in HIV positive men is associated with an increase in viral load and reduction in CD4 cell count. Ulcers produced by syphilis in its primary and secondary stages also make HIV four times easier to transmit. During an infamous outbreak of syphilis in 2001-02 in Dublin, the largest per head of population in recent times, a strain of the disease was identified which was resistant to oral antibiotics in up to 88% of cases, a strain which has since emerged in epidemics in other cities. For this reason, pencillin injection is the first line of treatment on New Zealand and sometimes only one injection is needed. Other antibiotics may be used if men are allergic to penicillin Aidsmap.com has noted reports on a number of
COLLECTIVE THINKING Issue 68 H December 07
syphilis cases in HIV positive men where ulcers did not heal, the syphilis bacteria were still detectable, or – most disturbingly - neurosyphilis developed after standard therapy had been completed. Neurosyphilis has serious effects on the brain and nervous system, and usually only appears during the final stage of syphilis, up to ten years after the initial infection. In some rare cases, HIV positive people have been known to exhibit symptoms of neurosyphilis within the first 12 months of syphilis infection. Syphilis has been described as “The Great Pretender” for its ability to mimic the symptoms of other diseases. In HIV positive people, this can manifest as a cluster of unusual ulcers at the secondary stage which may be mistaken for an attack of genital herpes. The primary stage of the illness may carry no symptoms at all. In major UK cities, it is now standard practice at
be unaware you have it and are passing it on to other sexual partners Infections via the penis and anus among gay and bisexual men occur directly as a result of unprotected anal sex, as gonorrhea is present in both semen (cum) and rectal fluid. Laboratory tests have shown that these discharges cannot pass through an intact latex condom, so properly used condoms and water-based lube provide a high degree of protection against infection and transmission. Being infected with both HIV and gonorrhea increases the likelihood of HIV transmission to a sexual partner, so this is especially important. Infection through the throat as a result of oral sex is less efficient but nonetheless a reality for gay and bisexual men, and can also be asymptomatic. Regular screenings for gonorrhea are advised (every 3 – 6 months if you have a lot of oral sex) as part
HIV clinics that serve large populations of gay men to screen for syphilis every three months at the same time as routine CD4 counts and viral loads. Syphilis is transmissible via anal and oral sex, both insertive and receptive. Always using condoms for anal sex will substantially reduce your risk of infection, but due to the risk of transmission via oral sex, regular check-ups are also recommended. Online resource: www.gettested.co.nz
of an overall sexual health check-up in addition to consistent condom use for anal sex.
GONORRHEA Known colloquially as “the clap”, gonorrhea can be acquired through the anus, penis and throat. Characteristic symptoms of infection through the penis include a greenish discharge and pain when urinating. Symptoms of gonorrhea acquired through the anus (rectal gonorrhea) can include inflammation, pain, constipation, and a discharge of mucus and pus, but it can also have no symptoms initially. On rare occasions, gonorrhea infection in HIV positive men has been noted to have spread beyond the original point of infection to other parts of the body, manifesting as a rash or even arthritis, although there is no data to suggest that complications like this are more common in HIV positive men, although in people who are immuno-suppressed the risk of spread to joints may be higher. Some infections can carry no symptoms, so you may
CHLAMyDIA Chlamydia is also acquirable through the anus, penis and throat, and symptoms (if they appear, and in 50% of males they don’t) are similar to gonorrhea: a milky discharge from the penis, especially in the morning, a burning sensation when urinating, and in some cases, swelled testicles. If you are infected via anal sex, there may be soreness, discharge, or no symptoms at all If left untreated, the roll call of possible outcomes for men is unpleasant: inflammation of the prostate gland, scarring of the urethra, epididymitis (inflammation of the ‘cord’ behind the testes) and infertility. Acute proctitis (inflammation of the rectum lining) is caused by chlamydia in gay/bi men who choose to have anal sex without condoms. Symptoms caused by proctitis include rectal pain and bleeding, mucous discharge, and diarrhoea. HIV positive men with chlamydia are made much more infectious, with 8-10 times more HIV being shed in semen and rectal secretions. If you have rectal chlamydia, your chances of getting HIV increase by a factor of ten to twenty, raising the spectre of reinfection for positive men.
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>> FEATURE
As with gonorrhea, infectious discharges cannot pass through a latex barrier, so properly used condoms and water-based lube provide protection against infection via anal sex. Regular screening is also advised due to the possibility of oral infection.
HERpES Herpes is a virus that causes blisters or sores, and there are two types. Type 1 most commonly affects the lips, causing cold sores (although it can also affect the genitals), while type 2 mainly affects the genitals (although it can also affect the mouth). Both types are common within the population, and 80 to 95% of HIV positive gay and bisexual men are known to be infected with type 2 herpes. There is no cure for the herpes virus, only to control outbreaks and treat its symptoms which recur in HIV positive people more frequently (particularly in the
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anus), with greater severity, and for longer periods of time. It can occasionally affect the throat, colon and other organs, including the eye, liver, and lung. In rare cases, herpes can cause inflammation of the brain which is potentially fatal. Infection with type 2 herpes doubles the risk of becoming infected with HIV through sexual transmission, meaning the HIV negative sexual partners of co-infected HIV positive people are at high risk and positive men are more susceptible to HIV reinfection. Shedding (the discharge of the virus from herpes ulcers) is higher among men with lower CD4 cell counts. Condoms are not such an effective barrier to prevent herpes, as the virus can be shed from asymptomatic skin not just when there are lesions present. However, it is still important to use condoms or to abstain from sex when lesions are present.
HpV (THE wART VIRuS) This is primarily spread between men via anal sex, and causes the appearances of warts in and around the genital area. Warts appearing in the anus can be mistakenly diagnosed as haemorrhoids. HIV positive men are particularly hard hit by anal warts, which can appear in greater numbers, be larger in size, and recur more often after treatment. HPV can also lead to anal cancer, which is as prevalent
among gay men as cervical cancer is in women. The Gardasil vaccine, available in New Zealand from your GP at a cost of $450, has been demonstrated to have 100% effectiveness in protecting against certain strains of the wart virus, but due to its commonality (most sexually active people will have been infected with one strain or another), the vaccine is most effective in those who have yet to become sexually active. The effectiveness of condoms in preventing HPV transmission was demonstrated in a study published in The New England Journal of Medicine in 2006, which followed 82 female college undergraduates reporting their first intercourse with a male partner during the study, or within two weeks of its start. The results were impressive, with women whose partners always used a condom being 70% less likely to acquire an HPV infection than women whose partners used condoms less than 5% of the time.
HEpATITIS C When sexually transmitted, Hepatitis C is seen almost exclusively among gay HIV positive men. It is a persistent blood-borne infection which can lead to chronic inflammatory liver disease. Many people with Hepatitis C don’t have any symptoms. In HIV positive people, Hepatitis C is serious because it leads to liver damage more quickly, and may also make your HIV more difficult to treat. It can be treated by taking a course of drugs over a period of 6-12 months, during which time you’ll be advised not to drink alcohol (it may be recommended that you abstain for life, depending on how badly your liver has been damaged). Fisting is the sexual practice most commonly associated with sexual transmission of Hepatitis C, although unprotected anal intercourse is also a factor. As with HIV transmission, gloves for fisting and condoms for anal sex are essential in preventing infection. Vaccination against Hepatitis types A and B is also recommended.
LGV LGV was previously known as a tropical disease, before a documented outbreak in nine Western European countries (notably the UK and France) in 2006. New Zealand reported its first diagnoses earlier
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this year. 75% of all reported cases are among HIV positive gay men. Easily transmissible by unprotected anal sex, it is a form of chlamydia which causes inflammation of the rectum and flu-like symptoms. Like syphilis, it progresses through several stages, the first of which involves the appearance of lesions. The secondary stage is truly horrifying – severe pain in the groin caused by an inflamed gland, which is visible through the skin and takes on a blue colour. A wave-like motion can be felt within 1-2 weeks of this stage, which can lead to rupture through the skin. The Western European outbreak had its origins in the Netherlands in 2004. Men infected with the disease there developed gastrointestinal bleeding, inflammation of the rectum and colon, and other problems not usually associated with LGV or other STIs. A large number of these men were engaging in
unprotected anal sex and attending sex parties in the year before they were diagnosed. LGV can be effectively treated with antibiotics, but treatment can take longer to have an effect in HIV positive people, and symptoms of this disease can linger.
REINFECTION For those who have experienced the trauma of an HIV diagnosis, acknowledging the possibility of reinfection is difficult. Being infected with one strain of HIV does not make you immune to being infected with another – strains of HIV can differ as much genetically as humans do to mice. Although the number of cases of reinfection reported worldwide are rare, they share one thing in common: almost all were among gay men who had had unprotected anal sex. Some reported cases of reinfection have involved HIV positive men being infected with a different strain of HIV which is not only resistant to the patient’s current treatment regime, but to all treatments that currently exist. Viral load increases, CD4 cell count falls, and progression to AIDS is accelerated. Based on evidence from cases examined to date, the more recently you became HIV positive, the greater the possibility of reinfection.
A GAY/BISEXUAL MAN’S FIVE-POINT PLAN FOR REGULAR STI SCREENING H Blood test for syphilis, hepatitis B, hepatitis C H Throat culture for oral gonorrhea H Rectal swabs for anal gonorrhoea and chlamydia H Urethral swab for gonorrhea and urine test for chlamydia H For anal cancer screening, get an anal pap smear if your clinician offers this. If not, have your clinician check around the perianal area for abnormal skin changes. Check-ups are advised every 3-6 months for sexually active gay and bisexual men.
A great deal of time and money has been spent educating gay and bisexual men about the dangers of HIV infection, but much less has been spent on awareness of other STIs. Throughout the 80s and 90s, such education seemed less important because the behaviour change model around HIV – condoms for anal sex – worked for other STIs as well. Times have changed. An individual decision to not use condoms for anal sex can have profound effects at the population level when it comes to controlling HIV and STIs, eradicating the gains made following the introduction of anti-HIV medications (HAART). A theoretical model published in 2002 theorised that HAART’s effect of decreasing HIV transmission could be cancelled out by an increase in unsafe sex at the population level of only 10%. Regardless of HIV status, those who associate condom-free sex with freedom need to be aware that such associations come at a steep price.
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>> FEATURE
An STI has just rated you as “HOT”…
The sexual landscape has changed. Sexual networks are now different. Gay and bisexual men who don’t adjust to these circumstances could soon get a nasty surprise… 14
People often think of STIs at a micro or personal level – “I haven’t changed how I have sex therefore my risks of acquiring an infection are the same as they’ve always been”. But another way to understand patterns of STI acquisition (and therefore individual risk) is to take a macro or population perspective. That is, what other people are doing, and who they’re doing it with. STIs thrive in certain conditions and not in others. After being introduced into a population, STIs survive in a community of linked people if there is a small core of very sexually active individuals. These men act as an engine room of epidemics, because the sexual connections they forge make it easier for STIs to spread quickly and deeply through the network. It’s the size of this core, and the way they’re linked to other men, that helps shape the course of a sexually transmitted disease epidemic. It determines the pathways of transmission; where it will meet resistance (high levels of condom use, low rates of sexual partner change, early diagnosis) and where the weak points are (low levels of condom use, rapid partner change, late diagnosis or undiagnosed infections).
In the 1970s and early eighties, STIs were rife among gay and bisexual men. In 1984, 38% of a cohort of gay men in Sydney reported a history of syphilis alone. From the mid-1980s and early nineties, gay communities took up condoms against HIV in one of the most effective public health responses in history. Not surprisingly, condoms partially acted as a “circuit breaker” for other STIs as well, and rates of most STIs declined through this period. In other words, STIs exploited gay men’s high sexual connectivity in the seventies, but the uptake of safe sex helped prevent the same STIs from repeating this assault on our communities a decade later. As we know, many men who were both highly sexually connected and who didn’t use condoms for anal sex also acquired HIV - rates of HIV went from zero to almost 50% in just 5 years among a cohort of high-risk homosexual men in San Francisco. Before the arrival of new treatments for HIV in 1997, many men who’d had a lot of unsafe sex became unwell and died. Thinking about STI transmission from an ecological perspective, the high mortality of men in these core groups removed them from the sexual network and effectively shrank the size of the epidemic’s “engine”. Rises in condom use, and the withdrawal of many highly sexually connected gay men from sexual networks because of AIDS, were largely why STI epidemics were declining among MSM during those latter years. So how have things changed? What does the landscape look like now? Can this help explain why we’re seeing resurgences of STIs in homosexual men around the world, including New Zealand?
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By Peter Saxton, NZAF Senior Researcher
STIs thrive in certain conditions and not in others. After being introduced into a population, STIs survive in a community of linked people if there is a small core of very sexually active individuals. These men act as an engine room of epidemics, because the sexual connections they forge make it easier for STIs to spread quickly and deeply through the network. Post-1997, the new HIV treatments (which have been a great success in terms of improving positive men’s lifespan and wellbeing) and Internet dating (which increases choice and the frequency of exchanges in the sexual marketplace) have without doubt combined to create a new STI environment among gay and bisexual men. Men infected with HIV are living longer and are having active sex lives. The Internet is creating new opportunities for hooking up; enlarging the core group, and altering how these men locate and mix with other, less sexually active men. It potentially completely rearranges the patterns of connectivity between men who are infected with an STI and men who are susceptible to infection. STIs adore these conditions - it’s as if we’ve built more bridges and superhighways and added new on ramps and off ramps. With Internet networking and HIV treatments here to stay, the implications for individual and community health are the same: Everyone needs to be more vigilant with condoms and sexual health checks, whether you’re positive or negative. This is especially true for energetic guys who have a lot of sexual partners – the “fast lane” lads. But it also applies if you stick to a small number of partners, because it’s practically impossible to know whether your partner’s partner’s partner is very sexually active too. In fact no matter which end of the sexual partnering spectrum you’re at, you might unwittingly be only two degrees of separation from a guy whose preferences are quite different from your own. Greater vigilance isn’t a moralistic response. It’s about self-preservation – acknowledging how STIs spread
through sexual networks, and how we can adjust to thwart them. This is a difficult message to sell, because the consequences of HIV infection aren’t as visible these days, and men often won’t reveal that they’ve had (or have) an STI. In the 2006 Gay Auckland Periodic Sex Survey (GAPSS), 40.8% of men reported a lifetime history of at least one STI, with 8.0% reporting an STI in the previous 12 months. The most common of the recent STIs were gonorrhoea and chlamydia (both 3.3% in the last year), with around 1% reporting syphilis. On the bright side, gay and bisexual men are generally diligent about sexual health checks – 43.2% claimed to have had one in the previous 12 months, being lower among men with fewer sexual partners, men aged 40 and over, and Asian men. As we head into summer, you can make a big dent in your own risk and the risk of everyone who’ll ever be sexually connected to you if you take two simply precautions – use a rubber for anal sex, and go for a full sexual health check. No matter who you are… Peter Saxton, Senior Researcher at the NZAF Research, Analysis and Information Unit, delivered a plenary paper at the NZ Sexual Health Society Conference in August on the re-emergence of STIs and HIV infection among MSM in the post-HAART, post-Internet-dating environment. Slides from his conference paper can be viewed at this link: http://nzshs.org/content/nzshs/24/2-24.htm The report of the 2006 Gay Auckland Periodic Sex Survey can be viewed here: http://www.nzaf.org.nz/files/2006%20GAPSS%20 Report.pdf
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>> WORLD AIDS DAY
POSITIVE WOMEN’S MOVIE NIGHT On November 28 as a prelude to World AIDS Day, Positive Women hosted a Movie Night at Auckland’s Academy Cinema, in conjunction with Oxfam New Zealand, World Vision, YWCZ and Child Fund. Two powerful documentaries were screened which told the stories of women and children whose lives had been impacted by HIV and AIDS. The makers of both documentaries were on hand to answer questions from the audience.
IRENE “Irene” tells the story of Irene Malachai, a nurse and mother of four, who is the only openly HIV
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positive person living in Vanuatu. The 26-minute documentary was made by New Zealand journalist Ingrid Leary as part of a series of “Positive Lives” profiles for the Pacific Island AIDS Foundation (PIAF). The film is simply presented, allowing Irene to tell her story on-camera with few cutaways. It started in 2002 when she went to the doctor after coming down with a series of disturbing symptoms: influenza, night sweats, and weight loss. Blood was drawn and sent to Australia for testing (no local testing facility was available). An agonising two weeks later, news came back that Irene was HIV positive. The diagnosis was to turn her world upside down. Irene had been breastfeeding her youngest daughter, unaware of her status, and was soon to learn that she too was HIV positive. Her husband, initially supportive, changed after he himself went for an HIV test and came back negative. He left her soon after. The stigma and discrimination Irene experienced within her own community was heartbreaking. Buses would drive past Irene and her daughter if the driver saw them waiting at a stop. She was forced to resign from her job as an anaesthetist, and relies on the government of New Caledonia to fund ARVs both for her daughter and herself, which they travel to Fiji to get. The film makes no mention of how Irene acquired HIV, a fact which Ingrid Leary says was deliberately left out. Leary says the media’s incessant focus on how HIV positive people acquired their infection was responsible for the creation of two classes of people: villains and victims, something which she finds
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incredibly unfair. Earlier in November, Leary won the Pacific prize in the annual New Zealand Media Peace Awards both for “Irene” and its companion documentary, “Peati”, which chronicled Samoan community worker Peati Malachi. Both documentaries were made in three languages, English, French and Bislama, to ensure the widest audience possible. “Irene” caused controversy in Vanuatu when its launch in December 2006 was aborted at the last minute by the government, who claimed that it painted their Ministry of Health in a bad light. PIAF went on to organise its own independent launch for the film, which Pacific Media Watch reported was attended by non-government organisations and local media including a television network. “Any so-called documentary that is required to go through consultation with a government department is not a documentary, it is propaganda,” Leary told media at the launch. “Our documentary is not intended to be the definitive word on HIV in Vanuatu. It is one woman’s story, told in her own words. If the Government feels threatened by that, it does make one wonder what else it is trying to hide when it comes to HIV and AIDS.” At the Positive Women move night, an emotional Maire Bopp-Dupont of PIAF told the audience that life is sadly still not easy for Irene, who struggles to support her four children and is still isolated within the community. She said that any funds raised from the evening distributed to PIAF will be re-distributed directly to Irene.
A GRANDMOTHER’S TRIBE The twin stories in “A Grandmother’s Tribe” unfold in the seven days leading up to Christmas, following two Kenyan families as they prepare in their own ways for the festive season. Both families are headed by grandmothers, whose grandchildren have lost their parents to AIDS. Their stories are representative of millions like them. One family lives in a remote village, the other lives in Nairobi, in the largest slum in Africa. Film-makers Qiujing Wong and Dean Easterbrook told the audience that the stories of grandmothers and AIDS orphans in sub-Saharan Africa had been mostly ignored by the media up until now, because their stories didn’t generate enough interest. This, despite the fact that there are an estimated 16 million orphans in the sub-Saharan
region of Africa, 60% of whom are being raised by their grandmothers in some regions. The contrasting environments of the two families make for compelling, if distressing, viewing. Rather than a case of the haves vs. the have nots, it’s the have nots vs. the have even less. The conditions under which the village family live (where the arrival of a new donated mattress for the dirt floor of their home is a luxury) compared to the appalling tin-roofed shacks of the overcrowded slum seem mild. The stories, however, are inspiring, and by the time we reach New Year’s Day, we see there is hope for the future. In the village, the grandmothers have taken steps toward stronger self-sufficiency by forming a farming co-operative, and in the city, Silas Odhiambo (one of the grandchildren who had taken responsibility for looking after his dying grandmother) is studying to become a doctor. Like “Irene”, “A Grandmother’s Tribe” is more than just a film – it’s a campaign. It’s inspiring stories have already raised $65,000 for African grandmothers, including spontaneous pledging of houses at its Vancouver premiere. Wong told the audience that following the screening, a man in the audience asked what it would cost to build a house for one of the grandmothers. The answer was US$3,000 – the man immediately said he wanted to pay for one. His generosity set off a chain reaction, with 10 houses being pledged within minutes. The film’s website www.agrandmotherstribe.com has further details on how you can help: “Developed as a model for “media and social enterprise”, proceeds from ‘A Grandmother’s Tribe’ special screenings, fund-raising & film distribution will be directed, through the ‘A Grandmothers Tribe Fund held in trust by Borderless Foundation NZ’. This Trust will work with community-based projects in Africa that support grandmother initiatives.” The film-makers say the positive response so far is a testament to the power of film to tell a story and have an effect on people’s lives. A film festival tour is now underway so “A Grandmother’s Tribe” can reach its widest possible audience, however the most special screenings will take place at the end of January in Kenya, where the participant families will get to see their stories on screen. ENDS
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>> RESEARCH
AIDS VACCINE TRIAL HALTED The following is a preliminary question and answer document that AVAC (AIDS Vaccine Advocacy Coalition) prepared for advocates to understand the new STEP study data that were made public at the HIV Vaccine Trials Network full group meeting on November 7, 2007. AVAC says it is continuing to expand on and update its analyses, and urges advocates to refer to the additional documents prepared by trial sponsors [available on the web at: http://avac.org/pr_step_study.htm]. Additional questions are welcomed via email at: avac@avac.org
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1.What did we learn from the new STEP study data that were presented at the November 7th meeting of the HIV Vaccine Trials Network? One important and, at this stage, confusing finding was that there were more infections among male volunteers (see questions 4 and 5 below) who received the vaccine, as compared to male volunteers who received the placebo. This trend was more pronounced in volunteers who had high adenovirus titers (this is a measure of pre-existing immunity—those with high titers had naturally high levels of antibody to adenovirus type 5 at the time that they enrolled in the study, before they received the vaccine). 2. Is there anything that we know for sure? We know that the vaccine itself did not cause HIV. It was constructed with synthetic fragments of genetic material which cannot, themselves, cause HIV infection. We know that the vaccine did not provide protection against infection or a reduction in viral load among the male volunteers who received it. We know that when there is any doubt about vaccine safety, it is imperative to err on the side of caution, and that volunteer safety is of the utmost importance. We cannot say for certain that the vaccine itself increased risk of acquiring HIV. We also cannot say that it did not. Under these circumstances, AVAC feels that the field should slow down and take as much time as it needs to explore the underlying causes of the observed trend before launching trials of similar candidates. We know that this is not the end of AIDS vaccine research. While these data are disappointing and deeply concerning, they should not be taken as a sign that the search for an AIDS vaccine is over.
3. Which study volunteers were included in the analysis? The meeting focused on data from the 1850 men in the trial. These were primarily men who had sex with men, and whose risk factors included high numbers of sex partners, partners with known HIV status, and unprotected anal sex. Data on the 1150 women volunteers were not included in the analysis. As of October 17, 2007, there had been only one infection in a woman volunteer in the placebo arm. This does not mean that the vaccine protected women. Instead, the low rate of infections suggests that the women who were recruited were not at high risk for HIV infection. 4. Does this mean that the vaccine increased men’s risk of acquiring HIV? It is possible. But based on the current data, it is impossible to say for sure. Presenters at the November 7th meeting described some of the analyses they had conducted to try to find other explanations. None of these analyses provided an alternative explanation, however here are some of the issues discussed: The small number of total infections (n=82) in the trial. While this number is relatively small, it does allow the trial team to draw strong conclusions that the vaccine did not protect against HIV and did not have an impact on viral load in men who received the vaccine and went on to become infected. These were the questions the study was originally designed to answer. Now scientists are analyzing these data to attempt to answer a question that the study was not designed to answer—namely whether the vaccine increased risk. Some of the ways that they are looking at this question involve segmenting the data into even smaller groups. In some cases, these subgroup analyses involve very small numbers of people, making it difficult to draw firm conclusions. While we must be cautious about drawing conclusions, we must also act on the data we have. Differences in the populations of men with high and low Ad5 titers. There were significant differences in some of the demographic characteristics of men in the high and low Ad5 titer groups. There were significantly more non-white,
COLLECTIVE THINKING Issue 68 H December 07
non-US men in the high Ad5 titer group. This group also had significantly more uncircumcised men and more men under the age of 30. However, in the analyses that have been conducted to date, none of these demographic differences account for the observed trend towards increased rates of infection in vaccine recipients. 5. Is there a compelling alternative explanation for the trend towards increased susceptibility in men who received the vaccine? No, not at this time. The November 7th presentations included preliminary analysis of a variety of variables. These included demographic characteristics, like the ones described above, as well as analyses of patterns of risk behavior reported by participants. In addition, researchers presented a limited amount of data on participant assumptions about whether they had received the vaccine or the placebo. These data helped to address questions about whether volunteers who assumed correctly that they had received the vaccine— i.e., after side effects or local reactions to the immunizations—took more risks than volunteers who received the placebo. Researchers have also looked at preliminary immunology data and compared immune responses among vaccine recipients who became infected and those who did not. There were no significant differences in immune responses to the vaccines in any of the analyses reported. Overall, none of these analyses provided a compelling alternative explanation for the observed trend. 6.Why did the study enroll people with high and low titers of Ad5 antibody? The vaccine candidate MRK-Ad5 used a disabled form of a common cold virus, known as adenovirus type 5, as the vector, or carrier, for synthetic fragments of HIV genetic material. Viral vectors like adenovirus have been used in many HIV vaccine candidates. They are selected for their ability to stimulate a strong immune response to the HIV antigen included in the vaccine. It is hoped that these vaccine-induced immune responses will
provide protection against HIV infection or disease if a person who received the vaccine is exposed to the virus through risk behavior later on. Since adenovirus is a common virus, some people have been exposed to it and have had immune responses to it. The vaccine developers hypothesised that people who had been naturally exposed to adenovirus would have different immune responses to the vaccine, as compared to people who had never been exposed to adenovirus before. Specifically, the trial team hypothesized that people with pre-existingimmunity to adenovirus would have lower or “dampened” responses to the vaccine, which might affect how the vaccine worked. They enrolled people with high and low levels or titers of antibody to adenovirus to test this hypothesis. 7. What happens now? The trial scientists and their collaborators will continue to analyze the data that are available to try to understand what the results are really telling us. They will look at the types of viruses that people were infected with and probe possible differences in the high- and low-Ad5 groups that might have led to the perceived trend. They will also continue to look at immune markers in the samples taken from volunteers in order to understand if and how the vaccine might have increased the risk of infection. 8. What is the role for advocates? It is of the utmost importance that we all work together to communicate what is known and what is not known at this time. The over-riding priority is the safety of the volunteers. We must work together to ensure that the open questions are clearly explained to a wide variety of audiences. We must also ensure that decisions about future trials are made with caution and over a time period that allows us to learn as much as we can from the STEP data. At the same time, we must prepare for moving forward - as we must - even if some questions remain unanswered over the long term.
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>> RESEARCH
Adherence issues for hazardous drinkers
– can behavioural intervention help? In HIV positive people with alcohol problems, a structured behavioural intervention has now been proven for the first time to have beneficial effects on self-reported adherence to medication, viral load and CD4 count. Participants in a three-year study conducted in New York City were randomly assigned to either an 8-session intervention with a trained counselor using motivational interviewing and cognitive-behavioural techniques. Results were compared against participants assigned to a control group, who attended 8 sessions facilitated by a health educator. Compared to the education sessions, participants seeing counselors showed significant decreases in viral load and increases in their CD4 count at a 3-month followup, and a significantly greater improvement in adherence to medications dosages and dosages per day.
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RECRuITMENT AND METHODS The study took place over a three year period from July 2002 through August 2005, and was designed to evaluate the effectiveness of a theory-based intervention, Project PLUS (Positive Living through Understanding and Support), which aims to improve adherence and reduce alcohol use among HIV positive people who report hazardous drinking. Participants were recruited through a variety of strategies. Flyers were placed in clinic waiting rooms and active recruitment took place at HIV-related community events throughout the New York City area. All participants were required to meet criteria for hazardous drinking – calculated as 16 or more standard drinks per week for men and 12 or more standard drinks per week for women. The 8 intervention sessions were tailored to the needs of each client, who were given a wallet-sized card to selfmonitor their adherence and drinking behaviour, which were reviewed at each session. Sessions 1 and 2 focussed on delivering factual information and the use of motivational interviewing techniques to promote personal responsibility for increasing
adherence and reducing alcohol consumption. Session 3 focussed on analysing trigger events for both behaviours in order to select modules for the remaining sessions which suited the needs of the clients. “Managing HAART Side Effects”, “Drink Refusal Skills”, “Coping With Triggers” and “Increasing Social Support” were among the modules provided. The final session addressed termination issues and relapse prevention, reinforcing skills that had been developed throughout the preceding sessions. The education sessions were matched to the counseling sessions for time and content, but differed entirely in method, focusing on providing factual information and structured discussions about videotapes pertaining to HIV, HAART adherence, and alcohol.
LIMITATIONS Neither of the interventions had a significant effect on alcohol use, and the effects on viral load, CD4 cell count and adherence had not been sustained when participants were reviewed at 6 months. However, the study’s authors are still recommending the intervention be considered for integration into HIV clinics providing comprehensive care for HIV positive people with alcohol problems, and advocating further study into the efficacy of booster sessions or ongoing adherence counseling which could build upon the initial successes of the intervention. The full paper “Motivational Interviewing and CognitiveBehavioral Intervention to Improve HIV Medication Adherence Among Hazardous Drinkers - A Randomized Controlled Trial” was published in the December issue of the Journal of AIDS and is available through the NZAF Library Service.
COLLECTIVE THINKING Issue 68 H December 07
>> RESEARCH
IRIS: Immune Reconstitution Inflammatory Syndrome wHAT IS IRIS?
wHO DOES IT AFFECT?
An inflammatory condition of the immune system, causing symptoms which often mimic an AIDS-defining illness, or other condition seen in people with HIV (e.g. pneumonia, tuberculosis or a virulent herpes attack). In most cases the symptoms resolve after a few weeks, however the syndrome may be severe or be mistaken for true disease progression, and should be properly diagnosed and treated.
People who have had a very low CD4 count (most often less than 50) before starting HAART or have recently had treatment for tuberculosis, Mycobacterium avium, cytomegalovirus or toxoplasma infection are most prone to develop IRIS.
HOw IS IT TREATED?
Paradoxically, it usually occurs in HIV positive patients soon after they begin anti-retroviral treatment and show signs of immunological improvement.
As IRIS is a protective process initiated by the body, continued adherence to HAART (which improves the immune system) may be all that is required to resolve the condition. In addition, steroids (such as Prednisone) or anti-inflammatory agents may be prescribed in addition to HAART until the syndrome clears.
wHy DOES IT OCCuR?
wHy ARE RESEARCHERS INTERESTED IN IT?
When the immune system is kicked back into gear by HAART, it can “over-react” to viruses or bacteria within the body and direct an exaggerated response toward these pathogens, which had previously been ”ignored” by the weakened immune system.
IRIS remains a poorly understood condition, and some researchers see the potential in unlocking its secrets. Bruce Walker, MD, of Harvard Medical School has said that IRIS provides “grounds for great optimism” because it shows that functional immunity can be restored in HIV positive individuals, and that further down the track, researchers could eventually find a way to strengthen immune responses against HIV itself.
wHEN DOES IT OCCuR?
HOw OFTEN DOES IT OCCuR? IRIS is relatively uncommon, and most people beginning HAART will not experience it.
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>> Health & Wellbeing
DYS FUNCTION 22
What to do if you can’t get it up, in, or make it happen quite like you want to?Jack Summerside’s common sense look at sexual dysfunction Originally published in Positive Nation UK, Issue 130, March 2007
Sometimes your body just doesn’t co-operate with your head. And I’m not talking about what happens after a few vodkas. This month we’re looking at sexual dysfunction; medical-speak for when your body or mind stops you getting on with a healthy sex life. Getting or keeping an erection is an obvious form of sexual dysfunction affecting men but it’s not the only kind. There are many others affecting men and women and relating to penises, vaginas, anuses or other body parts you may use regularly or occasionally when you have sex. But let’s start with the obvious one.
Failure to launch The trouble with men, whether we admit it or not, is most of us tend to think the world revolves around our penis. And, when it doesn’t work properly, the world comes to a grinding halt on its axis. Of course it doesn’t really, it just feels like it.
Old red-eye is back Jamie struggled for years with trouble getting an erection. “It was one reason I couldn’t be bothered with condoms, so it’s kind of connected with how I got HIV. I’ve tried Viagra and similar things, but it dries out my sinuses and my eyes go red. So I get an erection, I keep an erection, but I end up all bunged up, looking like the bride of Frankenstein.” For many of us, drugs like Viagra or Cialis have been a boon in enabling us to get an erection, when previously it was hit and miss. Sometimes keeping an erection while you get through the ‘holding pattern’ of getting a condom out, unwrapping it and getting it on the right way round can be more of a challenge than getting the damn thing stiff in the first place. But there are drawbacks to these drugs, not least their effect on blood pressure. Being red in the face with a raging hard-on can be a bit off-putting to a partner, as can a trip to A&E if you use amyl (poppers) at the same time. A common form of sexual dysfunction affecting women is vaginismus. This is involuntary tightening of vaginal
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and pelvic muscles that makes penetration difficult, if not impossible. It can be very uncomfortable, and even painful.
No entry Marie has genital warts around her vagina. “I get regular check-ups and have to get the warts removed with laser treatment. But it means sex can get uncomfortable. When my husband’s inside me I have to brace myself against the pain. I tend to get dry. That makes me more anxious, so it makes me tighten up.” A similar condition called anismus again involves involuntary contraction and tightening of the muscles, but this time around the anus, and can affect men and women. Medical literature tends to focus on this as a cause of constipation, unsurprisingly ignoring the bottom as a sexual organ. But the basis of the problem, and the consequences for sex and penetration, making it uncomfortable, are much the same.
Get to the bottom of it • Find out if the problems have a physical cause • Get yourself checked and treated for things like genital warts, or herpes that cause discomfort or pain when you have sex • Once physical causes are eliminated, consider psychological causes • Don’t grin and bear it. Talk to your partner • Talk to your doctor who can refer you to a specialist for more help.
Not tonight Josephine Napoleon is famous for two things, three if you count trying to take over much of Europe. The first was for turning down Josephine’s sexual advances and the second for having his hand tucked inside his jacket holding his tummy. And the two were connected. He suffered from terrible pain from stomach ulcers, he held his hand over his stomach to soothe the pain, and it was because of the pain he didn’t feel like having sex. Physical ailments stop you feeling sexy. Walter said: “I was diagnosed with peripheral neuropathy with constant pain in my hands and feet. The pain was too distracting for me to feel like sex. It made my body, back and shoulders tighten up. Sex isn’t a high priority when you’re not very agile and in pain.” For many of us living with HIV it can be common to have something niggling away in the background that gets in the way of sex. Physical pain, as well as stress and anxiety can mess up your sleep patterns. And being tired and irritable as a result can make you feel anything but sexual. Lack of sleep and irritability can make you substantially less appealing to a partner too, so it becomes a vicious circle. And that’s assuming you already have a partner. If you don’t; you may not feel much like making an overture to someone if you lack energy. “Come over to my place,
but don’t touch me because it hurts and don’t expect sex ‘cause I don’t feel very sexual. Oh and I don’t sleep well so I’ll be up and down all night and tossing and turning.” Mmm. Doesn’t rank as the world’s best chat-up line. Let’s just say it wouldn’t have worked on Cleopatra. Pain in your hands can be problematic, as a good lover needs to be able to use them as part of making love. If gripping, stroking and (if you like that sort of thing) slapping and tickling is uncomfortable and sets off your neuropathy it makes it hard to let yourself go. Even sex with yourself can be a less satisfying experience than perhaps it was before. There are all kinds of physical issues people don’t generally recognise as affecting a person’s ability to be sexual and to have trouble-free sex. But many of them are treatable. It’s worth mentioning to your doctor that symptoms to do with treatments (such as diarrhoea) or with long-term effects of HIV (fatigue, pain) are having that kind of impact on your personal life. It doesn’t mean they’ll be able to solve the problem, but it might help them think outside the box about how your quality of life is affected.
Turned off Getting diagnosed with HIV can have a profound impact on how you feel about yourself as a sexual being. It’s not uncommon for people to be turned off by the very thought of sex. You can have feelings of guilt that your sexuality got you into a mess, so you suppress your desires. You might have worries about infecting someone else, and the psychological impact can be made worse by the recent crop of court cases. Or the feelings of anxiety about your health and future, regrets about the past and general preoccupation with living with HIV can all play a part in diminishing the sexual dimension of your personality. “I just felt like a leper,” says Robin “I didn’t feel like anyone would accept me as a person, let alone have sex with me. It made me depressed and took away my sex drive. It just vanished. And because I felt I didn’t deserve a sex life because I’d got HIV, I didn’t talk about it or get help.” You most important sexual organ is not below the waist, it’s above your neck. I’m not talking about oral sex here, I mean your brain. Sex has famously been described as one per cent friction and 99 per cent imagination, and that’s pretty much true. The root of many a sexual problem is not the physical state of your body, but your feelings about yourself, about sex and sexuality, and about your partner. Living with HIV doesn’t mean you should sit at home doing a jigsaw or sewing an interesting cushion cover. Sex can and should be a dimension of your life that you can take part in and enjoy. It will never be an HIV prevention success if people with HIV feel it’s necessary to withdraw from such an important part of human life. This just isn’t an option any of us should consider feasible or practical, though sometimes it does seem easier.
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>> Health & Wellbeing
FLEXI TIME Flexibility is a major component of physical fitness, but it is probably the most overlooked, says Susan Warner We tend to take for granted our natural range of movement, and rarely consider the usefulness of stretching unless illness or aches and pains cause us to reconsider. Our muscles have an optimal length which should be maintained in everyday life, but when you exercise, the muscles you use contract and it is crucial that we return them to their optimal length by stretching afterwards.
Get reunited with your toes:
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If you start an exercise programme without incorporating stretching at the end of your routine you are likely to end up with tight, sore, aching muscles and worse, the possibility of future postural and mobility problems. It is just as important to stretch before you work out, to avoid injuries such as strains and pulled muscles. Some of you reading this may not do much exercise at the moment, but perhaps already feel that you could benefit from greater flexibility. Ask yourself: “When was the last time I could touch my toes?” This is especially important as we grow older since we lose muscular flexibility as we age, and need to do work in order to prevent this. For example, lower back and postural problems can be caused by tightness in the hamstrings (the muscles at the back of the thighs). By simply stretching them regularly you may find some of those past aches and pains disappear and your posture improves, not to mention having your toes within reach again. See diagrams below for standing and seated options for a hamstring stretch: If seated: Bend from the hips until tension is felt in straight leg. Hands on floor. Keep knees and hips in line. If standing: Keep feet hip width apart Weight on bent leg Keep knees and hips in line.
Banish aches and pains: There are many postural and muscular problems that can and should be addressed by stretching certain muscles and strengthening others. Muscular imbalances can be easily addressed and improved by taking a good Pilates class. The group environment of classes can also help to get you into regular exercise habits, while making it a pleasurable and fun experience, meeting and making new friends outside of your normal circle. Stretching, like exercise in general, should not be a chore, and just one weekly yoga class would probably give you all you need in terms of stretching the major muscle group, and maintaining and improving your flexibility considerably. And if you really don’t feel comfortable going along to a class straight away, there are a vast range of videos and DVDs available to try out at home (again, be sure that you are warm enough before you start stretching, and if something causes pain or does not feel comfortable, don’t do it). Once you feel more confident you could try a local class so you can receive better professional guidance and help in reaching your goals.
Before and after stretching: If you are thinking of taking up an exercise programme, or already do exercise, you should incorporate two stretching periods into your routine. The first comes after a gentle warm-up: perhaps a brisk five minute walk, as discussed in last month’s cardiovascular article, so the muscles are warmed and easier to stretch. Please don’t stretch cold, un-warmed muscles. For this pre-workout stretch you should aim to target all the major muscle groups: the shoulders, chest, triceps, upper and lower legs. See web-link below for full diagrams and descriptions and stretch each area for around 10 seconds. You can then move on to your main workout (cardiovascular and/ or resistance training)
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and after you have finished, your post-workout stretch should cover the same major muscle groups as well as any specific areas that you may have worked on. This time the stretch should be held for longer, from 15-20 seconds, which will help to return the muscles to their pre-exercise length. If you have specific areas that are tight or inflexible, you can hold the stretch longer to improve the flexibility in those muscles, stretching for 20-30 seconds. Susan Warner is the YMCA’s Positive Health Manager in London.
“We tend to take for granted our natural range of movement, and rarely consider the usefulness of stretching unless illness or aches and pains cause us to reconsider.”
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>> HEALTH & WELLBEING
Adherence to HIV treatment Adherence is the term used to describe the act of following a course of medication in exactly the manner it is prescribed. Adherence is sometimes also called compliance.
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Poor adherence to HAART results in treatment failure, and faster disease progression. In fact adherence has been shown to be the single most important factor in successful HIV therapy.
Wherever medication is given to treat or prevent a condition, it will only be effective if it is taken as intended. However, in HIV therapy, there are particular reasons why adherence is unusually important. The levels of adherence required for Highly Active Antiretroviral Therapy (HAART) to be successful are in the range of 90-95%, and thats much higher than levels which might be adequate with other types of medication. Moreover, HAART is typically taken long-term, and adhering well to therapy for any chronic condition presents its own challenges. Poor adherence to HAART results in treatment failure, and faster disease progression. In fact adherence has been shown to be the single most important factor in successful HIV therapy. The consequences of a failed HAART regimen may be far-reaching. HAART is prescribed in a manner designed to maintain a consistent attack on HIV. If you miss doses, or neglect any other aspect of your regimens requirements, this consistency will be lost. As drug levels in your body fluctuate, HIV is allowed to continue to reproduce. This ongoing replication permits drug-resistant strains to develop, and this can reduce the benefit you’ll gain from other antiretrovirals in the future. Despite the importance of adherence in HIV therapy, our understanding of barriers and enablers of long-term high adherence is quite limited. In part, that’s because it is a difficult area to investigate through commonly-used research methods. However, there is much to be learnt from the study of adherence in other disease settings. Adherence is influenced by many complex factors. Some are quite practical, such as ensuring there’s a reasonable match between the requirements of your regimen and your day-to-day lifestyle. Others are more cognitive and relate to how you perceive your health and medication whether you believe your treatment will do you more good than harm.
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Some of these factors are more amenable to interventions designed to support adherence than others. However, health care professionals increasingly recognise that high adherence to HAART must be actively facilitated. The British HIV Association (BHIVA), in partnership with the Medical Society for Study of Venereal Diseases (MSSVD), have issued recommendations on how adherence should be managed within UK HIV clinics. The key principles which underpin their advice are that: Low adherence is difficult to predict and so HAART should not be withheld on the basis of assumptions about which patients will be high or low adherers. All patients prescribed HAART will require support if they are to adhere successfully. Adhering successfully to long-term therapy is more likely where patients have access to a wide range of supportive interventions. Interventions should be available throughout the time in which treatment is prescribed, and must therefore be integrated into routine patient care. Thinking about adherence before starting treatment Few people find themselves in a position where starting HIV treatment is an emergency, and so doctors advise that thorough planning and preparation are important steps in maximising the effectiveness of a new HIV treatment regimen. Ideally, this should begin well in advance of treatment being prescribed, and needs to consider the wide range of factors which might act as enablers or barriers to high adherence in your case. Though there is much that your health care team should offer to help you on your way, it’s important to remember that in most cases, the primary responsibility for managing adherence will rest with the patient taking the medication. This means that you must feel ready to start and committed to following the regimen as prescribed, being aware that you are likely to be taking your treatment for the long-term. If anything causes you to feel unsure that you can manage this, it’s important that you seek support promptly from a member of your health care team. Make sure the drug schedule fits your life If you find that you are missing your doses during the day discuss this with your doctor as it may be possible to tailor your schedule to make it easier to remember, or to change the medication. Many anti-HIV drugs can now be taken once or twice daily and there are options which
reduce the burden of food restrictions. HAART regimens vary in the number of doses required per day, whether they should be taken with food or without, the number of pills per dose, the size and shape of the pills, and so on. These factors may be more or less important to different individuals, but in general, people adhere better to regimens dosed once or twice a day than those dosed more frequently. Recent research sponsored by GlaxoSmithKline (who make AZT, 3TC and abacavir) reported that when people with HIV were asked to describe their ‘ideal’ HAART regimen, most wanted to take just one or two small pills dosed once a day, without food restrictions, and with a low risk of side-effects (Stone 2004). Evidence from several other studies also shows that people adhere better to regimens that contain fewer pills and that are dosed once daily (Knobel 2004; La Paz 2004). Nevertheless, there seems little sense in making adherence more difficult than it needs to be. HAART regimens are selected on an individual basis by weighing up several key factors: potency, the risk of side-effects, likely viral resistance patterns, the need to avoid harmful drug interactions, and of course, likely adherence levels. Divide up your doses at the beginning of the week Dividing all the drugs up into daily doses and storing them together may help you to see when you have missed a dose, and will also avoid the annoyance of having to open lots of pill bottles and carry them around every day. Devices for storing drugs There are devices such as Medidose, a plastic box with several compartments for each day which can be pre-loaded with tablets and capsules for up to a week in advance by the patient or a helper which make taking a multi-drug regimen much easier although, they can be a bit time-consuming to fill. It is possible to obtain them from retail pharmacies. You can also get little boxes from hardware/DIY stores which are designed for storing nails, screws or other small items. They have lots of subdivisions. You may find that one of these is a cheap alternative. Film canisters may also be useful. However, it’s important to be aware that some drugs have their own storage requirements. For example, indinavir needs to be stored with the special device called a dessicant that is supplied with each pill bottle. The dessicant protects the pills from moisture in the air; if indinavir capsules get at all damp the drug will cease to
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>> HEALTH & WELLBEING
work. The capsules also appear to react with some other anti-HIV drugs when they are stored together, so for the moment the manufacturer recommends that indinavir tablets shouldn’t be stored in the same container as other drugs. If you’re unsure about the best way to store your medication, speak to your HIV pharmacist who will be able to advise you.
LEAVE IT wHERE yOu CAN SEE IT
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Before you start any treatment, it’s important that you understand what to expect in terms of sideeffects, and how to respond should they occur. You should know who to speak to at your clinic if you are concerned, and in some cases, which symptoms need to be reported immediately.
Keeping your pills where you can see them may be a good visual prompt, and some people may even divide the doses up and put them in different places according to where they are likely to be when that dose needs to be taken for instance, beside the bed, beside the kettle or beside the television. Of course, some people do not want the continual reminder that they are HIV positive. For others, leaving tablets about the house may advertise the fact that they are HIV positive, and may be unacceptable.
KEEpING yOuR MEDICATION CONFIDENTIAL Taking combination therapy can present problems for people who don’t want to reveal their HIV status to others. For example, if you have to take a dose while at work, can you go to the toilet and take your pills there, immediately after eating? Do you have a place at work where you can store pills without them being discovered? For example, do you have a lockable desk drawer? Regimens which are dosed less frequently - say once or twice a day - may be helpful to people who do not want to take treatment in their workplace, for example. If you don’t want other members of your family to see your medication, you may need to store it in new bottles which don’t bear the name of the drug. Do take care with this as it’s important that your treatment is not mistakenly consumed by others, and that you don’t become confused about how your drugs should be taken. If you are visiting family or friends for a few days, it is worth noting that drugs which need to be kept in the fridge do not need to be kept refrigerated every moment of the day. In fact, in temperatures under 25 degrees C, ritonavir can be kept out of the fridge for several days but it does need to kept cool in hot weather. If you share a house with people and don’t want to take medication in front of them or visitors, it may help always to keep a bottle of water beside your bed so that you can take your pills in privacy. Alternatively, if it’s medication that you have to take after food, tie it in with visiting the bathroom to brush your teeth.
pRACTISE BEFOREHAND It may help to practise your particular dosing schedule before you do it for real, to give you confidence that you will be able to stick with it. Some people have suggested substituting sweets for drugs, but if you don’t feel this
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seems medicinal enough, or you don’t eat sweets, try vitamin tablets. Try and find some cheap, low dose vitamins, and buy one sort for each drug in your chosen combination. Then try and follow the dosing schedule.
don’t get up in one place, go to work and then come home again every night. They may spend part of the week at a partner’s home, or go out after work, or work shifts, or stay out all night. In these circumstances it’s important to have back-up medication in different places.
SIDE EFFECTS AND ADHERENCE Intense side effects can occur in the first few months of treatment when especially high levels of the drug are present in your bloodstream. After a few weeks the peaks and troughs in blood levels of the new drug become less pronounced, and side effects wear off. This is why some doses of some treatments, such as ritonavir and nevirapine, are gradually increased over several days or weeks. If you have decided that it is worth taking a particular treatment, this is an important reason to persevere for a few weeks (as long as your doctor feels that this is safe) even if at first the side-effects seem unacceptable. During this period you may need to take other treatments to deal with the side effects, such as anti-nausea or antidiarrhoea medicines. Before you start any treatment, it’s important that you understand what to expect in terms of side-effects, and how to respond should they occur. You should know who to speak to at your clinic if you are concerned, and in some cases, which symptoms need to be reported immediately. These issues may also influence the timing of starting a new treatment. It may be helpful to take time off work, and to know that family and friends can be called upon to support you if you have difficulty with childcare, for example. Experiencing side-effects is one of the most common reasons for low adherence. Nausea, vomiting, diarrhoea, fatigue can all act as practical barriers to taking medicine. However, your emotional response to experiencing side-effects may be just as important. If you come to believe that your medicine is doing you more harm than good, you may lose your motivation to take your treatment regularly. If this is how you feel, do speak to a member of your health care team, who may be able to reassure you or discuss options for managing side-effects or changing treatment.
wHAT SuppORT DO yOu wANT FROM OTHERS? This will depend on how much you want to tell others about your HIV status and your treatment, and how often you can stand other people reminding you to take your medication! It may be helpful for friends who know you are HIV-positive to be told what kind of reminders about taking medication you will welcome, and how long for. It may also be worth reminding them that when you start treatment you may have side effects for a while, and that you may not be up to participating in normal activities. Keep some medication at work or other places you spend significant time Some people find that their lifestyle is not regular. They
wEEKENDS OR HOLIDAyS MAy BE DIFFICuLT Many people report that it’s difficult to stick to weekday drug schedules at the weekend. For example, if you’re used to taking your first dose of the day at 8 a.m. you may not want to get up at this time on a Sunday. You may not always eat at the same times at the weekend, and you might go to bed much later. You may find that practicing your weekend medication schedule is far more important than practicing the weekday schedule before you start on combination therapy. Practicing for four to six weekends may allow you to identify the problem factors for taking medication successfully in the ways you spend your weekend, and may lead you to choose a different combination.
wHICH OTHER DRuGS ARE yOu TAKING? Your doctor and HIV pharmacist will be able to provide information on potential interactions between your HIV medicine and any other treatments you may be taking. It’s important to be frank with them if they are to help you. Drug and alcohol use could also present problems if you end up missing doses whilst ‘under the influence’. A significant proportion of gay men taking protease inhibitors at a London clinic reported missing doses because of recreational drug use. At least half of them were deliberately missing doses because they were unsure about interactions with recreational drugs. Talk with your doctor about your recreational drug use and possible reaction with your HIV medication.
wHEN TRAVELLING If travelling by air, do not put medication in luggage which goes in the hold. This is the luggage which can most easily go astray or get lost. Make sure your medication is in your hand luggage. Time zones can also be a problem. If you are in a different time zone for a day or two (for example two to three hours ahead of your normal time), it may be easiest to stick to the normal regimen. Longer trips may require more consideration. Again, your health care team can help you work out a plan before you travel. REFERENCES Knobel H et al. Impact of simplification to a lower pill burden HAART in adherence and risk factors for non-adherence. 15th International AIDS Conference, Bangkok, poster presentation, abstract WePeB5773, 2004. La Paz H et al. Adherence, treatment-satisfaction and effectiveness of once-daily versus twice-daily antiretroviral therapy in a large prospective observational cohort (CUVA Study). 15th International AIDS Conference, Bangkok, abstract WePeB5780, 2004. Stone VE et al. Perspectives on adherence and simplicity for HIV-infected patients on antiretroviral therapy. J Acquir Immune Defic Syndr 36: 808-816, 2004.
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“QUOTES” “They’ve finally got caught with their pants down.” James Chin, former WHO official and public health epidemiologist, comments on UNAID’s decision to cut its HIV infection estimates by six million due to better data on infection rates. Chin’s book, “The AIDS Pandemic: The Collision Of Epidemiology With Political Correctness”, suggests that UNAID has been inflating its AIDS estimates for some years in spite of evidence to the contrary.
“The Writers Guild of America has shown great humanity, empathy and courage by allowing our little evening to move forward.” Elizabeth Taylor expresses her gratitude upon learning that striking TV and film writers in Hollywood will briefly put down their picket signs for an AIDS benefit performance on the Paramount Pictures lot, involving Taylor and James Earl Jones.
“We need to be pretty aggressively counseling, particularly HIV-positive gay men, about practicing safer sex again.’’ David Cooper, director of Australia’s National Centre in HIV Epidemiology and Clinical Research, comments on the resurgent epidemic of STIs among positive gay men throughout the Western world
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“If you have a whole generation who were raised chatting on the Internet, why not try to work with that?’’ 52-year-old Vancouver sexual health nurse Elaine Jones talks about her online health promotion activities: twice a week for two hours, she answers questions and posts information on a gay sex-cruising web site that boasts more than half a million active users. Her avatar is a penis wearing a nurse’s cap.
“Get involved courageously and be determined to carry on. We need to ensure that our churches and mosques are fully involved in the fight against the disease.” African-American AIDS activist Phill Wilson addresses students and NGOs in Cameroon. He has been living with HIV for 26 years.
“Clearly, Coca-Cola knows how to market. It also has distribution networks; maybe we can tap into that core competency.” David Stearns of the New York-based Global Business Coalition, an organization of 220 companies working to fight AIDS in Africa, comments on Coca-Cola banding with the Africa Broadcasting Media Partnership to produce HIV/AIDS awareness messages.
FROM DEATH’S DOORSTEP TO QUEEN OF UNIVERSE By Jay Bennie, GayNZ.com In a triumph of vitality over adversity, Peter Taylor - aka Miss Brazil ‘Coca Cabana’ – has been crowned the Queen of the Whole Universe 2007 in a glittering NZ AIDS Foundation drag fundraiser pageant. Taylor, an HIV positive man and Auckland cafe owner who has several times clawed his way back to life from deadly HIV and tropical illnesses which have left him almost deaf and with limited eyesight, provided a vivacious and show-stopping performance as a Rio showgirl complete with shimmering makeup, feathered headdresses and remarkably shapely legs. Although the early portions of the annual Queen of the Whole Universe pageants are scripted, the latter stages are a genuine contest in which judges, led tonight by Labour list MP Charles Chauvel and including GayNZ. com senior writer Matt Akersten and twice-winner of the contest, Lola Bangaway, chose the winners after a series of dazzling and energetic performances. Miss Morocco, ‘Insultana Polyandre Xpi Ali Docious,’ aka Owen Anderson, was chosen in third place and Miss Germany, ‘Votta Gooden Tight’, aka David Ross, was placed second. The announcement of Taylor’s win received a standing ovation from the audience which packed out the main auditorium of Auckland’s Aotea Centre. Earlier in the show Miss England, ‘HRH Betty Windsor,’ aka Brian Connell, won the Beauty with a Purpose award after dissing Auckland Mayor John Banks. Miss New Zealand, ‘Dusty Rhodes,’ was unplaced, even after chaining herself to the lighting rig to avoid being evicted from the stage during eliminations. Over forty volunteer performers and a large backstage team mounted the slick show which featured dazzling costumes, and flashy and often humorous, drag routines. As the show began, hostesses Buffy and Bimbo announced that almost $40,000 had been raised by this evening’s show, bringing the total the QWU shows have rasied over four years for non-government funded AIDS Foundation projects to just over $100,000.
COLLECTIVE THINKING Issue 68 H December 07
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National Positive Health Manager
New book
OUT NOW! Produced by the New Zealand AIDS Foundation, this small free booklet outlines current information available about HIV and AIDS. Some of the topics covered include;
* What is HIV? * What is AIDS? * How do you get HIV? * Safe sex or risky business? * Condoms * How do I know if I am HIV positive? * When should I test? * Is there a vaccine or a cure? Be smart – Be Informed
g e t yo u r c o py n ow ! Available from your local Healthcare provider, GP, Public Library, Citizens Advice, Family Planning or by contacting: NZAF, 31-35 Hargreaves St, College Hill, Ponsonby, Auckland. www.nzaf.org.nz
Ooooh!, I can’t watch – they are doing it without us again!