POZ September 2012 by Smart + Strong

A SMART+STRONG PUBLICATION SEPTEMBER 2012 POZ.COM $3.99

H E A L T H ,

L I F E

H I V

Cecilia Chung

Trauma Standing and Triumph Strong Against Four women share their struggles with HIV and violence

Hate and HIV

David Kuria of the Gay and Lesbian Coalition of Kenya fights homophobic hate crimes in Africa.

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POZ.COM AIDS 2012 IN DC POZ COVERS AIDS 2012

The XIX International AIDS Conference (AIDS 2012) took place in Washington, DC, from July 22 to 27, and POZ was an ofﬁcial media partner. Check out our coverage at poz.com/aids2012.

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The POZ Army is a global, grassroots collective of people ﬁghting for the cure for AIDS—and treatment for all until a cure is found. To learn more about how you can help, go to pozarmy.com.

DIGITAL POZ

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Kat Grifﬁth is a survivor of an abusive relationship.

32 HEALING THE HURT Trauma does more than fuel HIV, it also makes living with it harder. But HIV-positive women and their allies in the realms of science, medicine and social justice are ﬁghting back—with programs, education and lifesaving advocacy. BY RITA RUBIN 40 HOT ON THE TRAIL AIDS activists are experts at bird-dogging—the technique of following political candidates and forcing them to articulate their positions and policies on an issue. How will their actions impact the upcoming presidential election? BY BETH SCHWARTZAPFEL 5 FEEDBACK

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Your letters and comments

11 FROM THE EDITOR The Not-So-Weaker Sex

12 POZ Q+A

Jim Hubbard talks about his latest film United in Anger: A History of ACT UP.

17 POZ SURVEY SAYS Take Good Care

21 WE HEAR YOU

high-risk sex? • a new invention aims to make adult male circumcision easier • an online health network tracks sickness • a new PSA inspired by Fifty Shades of Grey

24 TREATMENT NEWS

Clarifying HIV heart disease risk • the push for generics in the U.S. • the latest news on Timothy Brown • improvements for a rectal microbicide • saliva isn’t a deadly weapon

26 COMFORT ZONE Health insurance tips

Readers weigh in on the newly approved in-home oral swab rapid HIV test.

31 WHAT MATTERS TO YOU

22 WHAT YOU NEED TO KNOW

44 POZ HEROES

Protecting married women from HIV • can cash deter young people from engaging in

Repealing the gay blood ban

Richard Holcomb offers a harm reduction outreach program for male sex workers.

POZ (ISSN 1075-5705) is published monthly except for the January/February, April/May, July/August and October/November issues ($19.97 for a 8-issue subscription) by Smart + Strong, 462 Seventh Ave., 19th Floor, New York, NY 10018-7424. Periodicals postage paid at New York, NY, and additional mailing offices. Issue No. 182. POSTMASTER: Send address changes to POZ, PO Box 8788, Virginia Beach, VA 23450-4884. Copyright © 2012 CDM Publishing, LLC. All rights reserved. No part of this publication may be reproduced, stored in any retrieval system or transmitted, in any form by any means, electronic, mechanical, photocopying, recording or otherwise without the written permission of the publisher. Smart + Strong® is a registered trademark of CDM Publishing, LLC.

(COVER) JEFF SINGER; (THIS PAGE) DAVID VERNON

POZ ARMY

FEEDBACK other women who were infected by him. This is why HIV criminalization laws exist. RENEE MEYERS NICEVILLE, FL

SERO-PROSECUTIONS In “Criminal Injustice” (June 2012), three people who faced serious, HIV-related criminal prosecution discussed the impact of HIV-speciﬁc laws and how they backﬁre as protective measures. A big thank you to all of you for the courage to tell your story and to make a positive outcome of it. I am also positive, and the fear of [HIV] criminalization charges has kept me out of relationships, even platonic ones. You all are an inspiration for me to include criminalization in the speeches I give to community groups about preventing and living with HIV. LAURA DES MOINES, IOWA

I completely understand the absolute terror that strikes when [you are] ﬁ rst diagnosed and when you have to share [your] status with potential partners. However, I could never in good conscience have sex without disclosing. I ﬁ led charges against the partner who transmitted HIV to me. Five years later, he is in jail on charges of failing to disclose and not using protection. I know of three

After reading this, I am more concerned about how some people are in the closet with HIV. I tell those that I want a relationship with that I am HIV positive. I do this not because I have to; I do it because I am part of everything around me. I don’t want to hide from sight so I can be overlooked or forgotten. I want to be counted to let others know we exist right by them.

Have an opinion about this month’s POZ? Comment on a specific story on poz.com, post a general comment via poz.com/talktous, or send a letter to POZ, 462 Seventh Ave., Floor 19, New York, NY 10018.

I am a soldier in the POZ Army. I hope my friends join regardless of their serostatus. We need a strong and powerful force to make a resounding statement to the politicians, drug companies, researchers and every citizen in the world. JOHN S. LOCATION WITHHELD

I am a 17-year survivor of AIDS, and I wouldn’t be here if it weren’t for people who fought [to ﬁ nd the effective treatment that I take today]. Now it’s my turn to stand up for those who can’t.

RICHARD B. SALAMANCA, SPAIN

MARK J. LOCATION WITHHELD

I would urge every HIVinfected person to think very carefully about their interactions, whether they are [online or face-to-face]. The authorities who handle these cases or alleged crimes are not like you and me. They also may have endless money and endless time to go after you. Where are the attorneys to help? Where are the people to act up? Being involved in an alleged or real case can be very lonely and isolating. Please be careful as I wouldn’t want you to be where I have been.

OK, all you AIDS activists out there: This is the time for all good men (and women) to come to the aid of our country [and the community of] people with AIDS. Please join me in signing up for the POZ Army so we can ﬁght for AIDS funding in order to continue treatment and to ﬁ nd the cure. [HIV can] happen to anyone. I know because I have participated in thousands of intakes of HIV-positive clients, and believe me: HIV does not discriminate! This is a great opportunity.

RANDALL PORTLAND, OR

THE RECRUITS The article “The POZ Army: How We End AIDS Together” (June 2012) launched the POZ Army, a global grassroots collective of people ﬁghting for the cure for AIDS and treatment for all until a cure is found. For more information, visit pozarmy.com.

PRISCILLA LOCATION WITHHELD

I have been hearing for years now that we are making great strides in the treatment of HIV/AIDS and a vaccine. I have been screaming for years: “What about a cure? Why is no one focused on a cure?” Well it looks like there is

ﬁ nally a serious push for the cure. What a great idea! J. CARA LOCATION WITHHELD

A QUEEN’S APOLOGY In the POZ Blog “Donna Summer’s Letter to ACT UP” (June 12, 2012), following the death of Donna Summer, AIDSmeds founder and advisory editor Peter Staley unearthed a 1989 letter in which the Queen of Disco denied the rumors that she had made antigay comments relating to the AIDS epidemic. She also apologized to her fans for the pain the alleged comments had caused. I wasn’t there, so I don’t know what was said by Donna Summer or the men she was speaking with who then reported her alleged antigay remarks. But I will say this: Her letter seems sincere. GIGI LOCATION WITHHELD

I never believed the hateful comments that were attributed to her. And I believe her when she said that she did not make them. Many gay people have been traumatized by the church and by people who call themselves Christians. When Donna Summer became a born-again Christian, it was natural for some of her gay fans to misinterpret this as rejection, especially at the height of the AIDS crisis in this country. Summer was a wonderful, gifted singer and entertainer whose music brought me a lot of happiness. I choose to remember her that way. DAVID SALYER ATLANTA

poz.com SEPTEMBER 2012 POZ 5

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The Not-So-Weaker Sex

HE RELATIONSHIP BETWEEN TRAUMA AND HIV IS WELL established. Sexual violence, for obvious reasons, makes people more vulnerable to contracting HIV. When a person is forced to have unprotected sex, for example, either in an attack or a relationship where there is a power imbalance, HIV can spread. But even if trauma, violence or abuse doesn’t directly lead to HIV transmission, each has a lingering impact that threatens physical and mental health. The emotional scars of abuse and violence can cause people to make decisions that can put them at higher risk for HIV. During or in the aftermath of abuse, it is often difficult to maintain one’s self-esteem. When you have been attacked, put down, devalued or told by an individual or society that you “deserve” to be treated poorly, it’s hard to tell yourself otherwise. For people who contract HIV (whether through trauma or not), being the object of abuse and violence can make it far more difficult to summon the will and resources to get tested, to seek and stay connected to care, and to muster the sense of empowerment and courage to risk disclosing their HIV status. Disclosure, in turn, can also prevent the spread of HIV—so anything that further helps people feel they can safely disclose is good for individual and public health. Which is why health care providers should screen men and women for HIV if they show signs of physical and/or emotional abuse—and why they should ask those living with HIV about their past and current experiences with emotional abuse and physical violence. Helping people break free of abusive relationships and heal from trauma protects them from contracting HIV. If someone is already living with the virus, overcoming emotional and physical threats can help them access proper care. Screening people in health care settings is one way to slow the spread of violence and HIV. But another way is for friends and families to pay attention and watch for signs of violence. The estimated rate of intimate partner violence among all U.S. women is about 25 percent. For HIV-positive women, that rate is double. Though it can be difficult to ask someone if she (or he) is facing emotional or physical threats, broaching the delicate topic could save a person’s life. And most important, if you are in an abusive situation or relationship—seek help. Know that you’re not alone and that there are people available to assist you. In “Healing the Hurt” on page 32, you will read the stories of four incredible women who have risen above the pain of their own experiences with HIV and violence. They are living proof that what doesn’t kill you makes you stronger. By courageously sharing their stories, they signal to all other women out there in need that safe havens can be found. By overcoming fear and realizing that we don’t deserve to be attacked, beaten or emotionally tormented, we can reclaim our sense of self-worth and dignity. When we allow ourselves to believe we are worth protecting and when we take steps to defend ourselves, we are on the road to a safer future. It is when we move past episodes of pain that we emerge stronger than ever before.

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poz.com SEPTEMBER 2012 POZ 11

THE POZ Q+A

BY REED VREELAND

Jim Hubbard has filmed every NYC Gay Pride since 1978.

Jim Hubbard speaks about his new documentary United in Anger: A History of ACT UP.

IM HUBBARD IS A FILMMAKER, AN ARCHIVIST AND A HISTORIAN of the AIDS epidemic in the United States. He catalogued and curated the AIDS Activist Video Collection at the New York Public Library. Hubbard also cofounded the ACT UP Oral History Project with Sarah Schulman; the project is composed of more than 128 oral history video interviews with the group’s members and collaborators. Hubbard and Schulman teamed up again for his most recent project, United in Anger: A History of ACT UP. The feature-length documentary tells the history of the legendary AIDS activist group using archival footage. Hubbard is also an associate producer of How to Survive a Plague, another film, directed and produced by David France, that tells the history of AIDS activism through vintage footage. Hubbard’s earlier impressionistic films include Elegy in the Streets (1989) and Memento Mori (1995). On April 25, 2012, the day of ACT UP’s 25th anniversary demonstration in New York City, Hubbard was one of the first people on scene to document the protests. Here, Hubbard, a member of the AIDS Activists Video Movement, talks about how activists used art and video to reframe and draw attention to the U.S. AIDS epidemic in the late 1980s and early 1990s.

12 POZ SEPTEMBER 2012 poz.com

I first filmed ACT UP at the Gay Pride march in June 1987 where they did the concentration camp float [to show how the epidemic was exterminating us]. I have filmed [New York City’s] Gay Pride since 1978, and it’s something I do every year. The first ACT UP–organized event I went to was the demonstration [at the Sloan-Kettering hospital] in July 1987. I eventually became a member. My footage of the concentration camp float is featured in Elegy in the Streets, a half hour silent film that explores the public reaction to death and to AIDS. It follows my ex-lover, Roger Jacoby, who was also a filmmaker, who was diagnosed with AIDS in August of 1984 and who died in November of 1985. How did ACT UP succeed in getting its messages heard?

The problem that ACT UP faced was that the powers that be were treating people with AIDS as “the other.” ACT UP [challenged people] to treat people with AIDS

STEVE MORRISON

The Accidental Historian

How did you get involved with ACT UP?

as people. If you think your mother, or your brother or yourself could get this disease, you’re going to think about it in one way. If you think some insignificant group of people far away from you is getting it, [you’re less likely to] care and you’re [less likely] to do anything [to help]. ACT UP forced America to stop thinking about people with AIDS as “the other” and helped people think about gay people as “us” rather than as “them.” How did ACT UP break through to the American public?

[When trying to capture people’s attention,] you have to use tactics that [stop people in their tracks], and that’s what ACT UP did. Certainly, one of the most effective [tools] was their set of graphics. Great graphics grabbed the attention of TV—and TV is what changes America, because Americans believe in television.

United in Anger uses an impressive amount of archival footage. Why did so many ACT UP members, including you, document everything from the start?

The need [to document] was there because the mainstream media wasn’t doing it. People were dying of AIDS, but people were also living with AIDS and the information about [survival] had to get out somehow. You could write brochures and copy them, but there was something more urgent about video. And because video in Hi8 [high-eight] cameras came out at that time, suddenly, it was financially feasible to make video. People were immediately drawn to it. We saw right away that this medium was perfect for getting information out. Filming demonstrations allowed me to look at the way people behave, to look at gesture, the way faces pop out of crowds, the way people relate to each

“People were dying of AIDS, but people were also living with AIDS.” By presenting something that somebody wanted to put on television, ACT UP got [the attention many groups could not]. Die-ins and the use of [fake] tombstones were initially also [riveting]. But at a certain point they lost their effectiveness. That’s what ACT UP’s political funerals were about: They were intended to say, “OK, you stopped responding to the street theater version of death, so here’s the real thing!” Have you ever seen or [touched a deceased person’s] ashes? Cremation was less frequent in 1987 than it is now, so [wielding human] ashes was shocking. Typically when people are cremated, their ashes are treated in a particular way. They are put in urns or scattered very solemnly. So to [display, carry and spread human ashes in public] was shocking behavior. To parade through the streets with a coffin containing a real corpse was also shocking.

other physically—all these things that otherwise would remain invisible or undocumented. Because I was slightly older than most of the AIDS activist video makers, I was filming on 16mm and they were filming on video and were thinking about what was necessary in the moment. DIVA TV [Damned Interfering Video Activist TV] made three edited tapes [of key demonstrations], and there was a group of 30 or more people who actually taped at one time or another. In those videos they were saying: This is what we have to show people right this second. The fact that 25 years later it is still interesting and has retained that vitality is just a wonderful surprise. How did your vision for United in Anger change as you were making the film?

Early on, I was thinking about making an all-encompassing story. But I quickly

realized that wasn’t possible. What was necessary was a succinct telling of the story that gave people an entrée into the subject, something that invited viewers to research it further. For me, the film was created to preserve the history of ACT UP and AIDS activism in the late 1980s and early ’90s. Younger generations have not been exposed to it. The second purpose of the film is to inspire additional activism, whether that’s around AIDS or any other issues. When you’re telling a historical story you’re at the mercy of what was filmed because you can’t show footage that doesn’t exist. The purpose of the timeline [in the film] is to indicate all of those things that are missing and the other [actions] that were really important. Given those limitations, we had to construct not only a narrative arc, but also an emotional arc. I wanted to try to get people to feel what it was like to be in the midst of the [extreme] emotion [one felt at the time]. Why is there no footage in the film of people in hospital beds?

That’s very deliberate. That’s what the mainstream media was showing: “The AIDS Victim.” Guys lying in bed, hardly moving, hardly breathing, covered with Kaposi’s sarcoma. Now if that guy in the hospital bed—as sick as he was—was able to talk and say something, it would have been worth the while [to show him]. I don’t know what good it does to show people at their worst moments; you arouse pity, but pity isn’t a particularly useful emotion. The main tenets of the AIDS Activist Video Movement at the time were to show people living with the disease and how they were fighting it. We also wanted to show that people with AIDS and people fighting in the trenches with them were the real experts on the disease and that their voices should be heard. A necessary component of effective activism is understanding how things work [so you can effectively] change them. This film is not going to change the world. But if it inspires people to action, they could change the world. ■

poz.com SEPTEMBER 2012 POZ 13

THE POZ SURVEY SAYS

BY CRISTINA GONZÁLEZ

Take Good Care

One out of every ﬁve Americans living with HIV don’t know their status, and for all who do, being diagnosed is merely the ﬁrst step on the long road to leading a healthy life. As our April/May POZ Survey documented, many people get diagnosed outside of an HIV-focused health care setting, which in turn means they often don’t get the kind of linkage to care required for optimal health. We asked about when you were diagnosed with HIV and what you did next. Here are your responses.

27% Once a year

28% Never

23%

WHERE DID YOU GET TESTED FOR HIV?

16% 7%

ANONYMOUS/ CONFIDENTIAL HIV TESTING SITE

AIDS SERVICE ORGANIZATION (ASO)

23%

COMMUNITY-BASED HEALTH CLINIC

16%

EMERGENCY ROOM/HOSPITAL

23%

GENERAL PRACTITIONER

MOBILE HIV TESTING VAN

OB/GYN

12%

percent of you received counseling before and after your HIV test.

percent of you did not.

Every couple of years

percent of you got info on how to connect with an HIV specialist or other health care

percent of you found HIV counseling helpful and informative.

provider.

percent of you had someone follow up to make sure you saw an HIV specialist or health care provider.

percent of you did not.

0–1 MONTH

1–7 DAYS LATER

REASONS YOU WAITED MORE THAN A MONTH TO VISIT AN HIV SPECIALIST:

Source: April/May 2012 POZ Survey

48 79 67 48

OTHER

1. I felt ashamed or embarrassed about having HIV 2. I didn’t know whom to see for HIV care 3. I didn’t feel sick 4. I didn’t have health insurance / treatment was too expensive 5. I didn’t want to take medication

Several times a year

HOW OFTEN DID YOU VISIT YOUR PRIMARY CARE PHYSICIAN BEFORE YOU TESTED POSITIVE?

WITHIN THE HOUR

1–2 WEEKS LATER MORE THAN 2 WEEKS LATER

2–5 MONTHS 6–9 MONTHS

SAME DAY

MORE THAN A YEAR 10–12 MONTHS

29%

44%

HOW SOON AFTER TAKING AN HIV TEST DID YOU FIND OUT YOU WERE POSITIVE?

14%

57%

20%

13%

HOW SOON AFTER TESTING POSITIVE DID YOU SEE AN HIV SPECIALIST OR OTHER HEALTH CARE PROVIDER? poz.com SEPTEMBER 2012 POZ 17

WE HEAR YOU

BY REED VREELAND

There’s No Place Like Home

On July 3, the U.S. Food and Drug Administration approved the first in-home rapid HIV test. Made by OraSure Technologies, the OraQuick In-Home HIV Test is an over-the-counter, oral swab test for HIV that gives results in 20 to 40 minutes. It’s estimated that 20 percent of the 1.2 million people living with HIV in the United States are unaware of their status. This is partly a result of barriers to traditional HIV testing. Will this new test help the one in five undiagnosed Americans learn of their positive status? Many health experts agree that the test—likely with a price tag of less than $60—will increase the convenience and frequency of HIV testing. Yet opponents of the new test are concerned that many at-risk people can’t afford the test and that those who receive a positive result at home will not get connected with counseling and care. (The kits come with a toll-free helpline accessible 24/7.) The OraQuick test is expected to be in stores this October, and the test’s impact on the epidemic remains to be seen. Here, POZ readers express their thoughts on how the at-home test could alter the HIV testing landscape. As a person living with HIV and a certified HIV tester, I am 100 percent against this at-home test for many reasons. Realistically, if someone gets a positive result, how many of them are going to call the 800 number and self-report? Denial is also a huge factor here, and it will let the person continue risky behaviors and spread the virus even more. The counseling that comes with the test is vital to make a person understand the virus and [realize] that it is not a death sentence. —Larry Frampton, Knoxville, TN

Overall I am happy about the test becoming available. There will be abuses of it, certainly. I especially fear for sex workers “disposed of” by their pimps. I expect many negative partners will use this test on positive partners who haven’t disclosed. Eventually, poorer people will want the same ability to test their partners. —Jeton Ademaj, Harlem, New York I agree that this test is not a good idea. When I tested positive, I was at least told to go to Cascade AIDS Project and they [gave] me a lot of information and helped find a doctor that specializes in HIV. I would not have received any assistance from a home test. I think that the testing and treatment of HIV should be left up to the professionals. —Keith, Portland, OR

GETTY IMAGES/LAURA JOHANSEN

This is encouraging news in the effort to further impede the spread of HIV. It would be very helpful if such a test could be developed for hepatitis B and C. These two viruses are not only deadly, but can hide for years in a person’s body and be [transmitted] in semen (hep B) and blood (hep C) and a few other ways. For the general public, this [at-home HIV test] would be great, but for those already infected with HIV, being able to test preventively your partner for hep B or hep C could mean the avoidance of a deadly new infection. —Trent, Sparks, NV

I am thrilled for this test—now people will be able to test themselves without ending up on some national database because they went to a doctor or free clinic that is required to [report their results]. It would be helpful if the kits contained contact info for unaffiliated support services that would help anyone with a positive test result, while also preserving their privacy. I think a well-done CD or DVD to address positive and negative results and resources to turn to would better prepare singles and couples for dealing with the magnitude of such news in the most comfortable way possible. —SoulAsylum, Minneapolis, MN

poz.com SEPTEMBER 2012 POZ 21

WHAT YOU NEED TO KNOW

BY LAUREN TUCK

Researchers test bribery for health.

Not So Sacred Bonds of Marriage Many young women dream about walking down the aisle at their wedding—they imagine the floral arrangements, the dress, the venue. Their visions may extend to include the honeymoon, children and retirement with their husband. But the dreams don’t typically include contracting HIV from their beloved. Unfortunately this is the reality for a growing number of women around the world. The spread of HIV in marriages is often driven by infidelity, but it can also result from people who are unaware of or who conceal their status before tying the knot. In China, according to a report based on a 2011 study conducted in six mainland cities, at least 25 percent of the 48,000 newly diagnosed HIV cases resulted from heterosexual sex transmitted between spouses. The report, which was issued by the National Center for AIDS/STD Prevention and Control in conjunction with U.N. Women and UNAIDS, also found that women account for nearly 30 percent of the 740,00 people living with HIV, and that 62 percent of them were married when they were diagnosed positive. Similarly, in Argentina, University of Buenos Aires researchers found that 73 percent of women who contracted HIV through unprotected sex were infected by their allegedly monogamous partners. In both countries, women who contracted HIV while betrothed said they felt less power than their male counterparts when it came to navigating their sexual relationships. Many reported histories of violence. Disempowerment and low self-esteem in the aftermath of abuse make women less able to negotiate condom use, which heightens their risk for contracting HIV. Also, lack of disclosure laws in these nations means that HIV-positive people don’t have to divulge their status to their spouses. Clearly, women need protection from HIV in marriage. An option on the horizon is a vaginal microbicide, a topical gel containing HIV medication that a woman can apply without having to ask her partner to wear a condom, which can be construed as an admission of infidelity. Here’s to HIV having no place in “till death do us part.”

22 POZ SEPTEMBER 2012 poz.com

Typically, bribery is a form of persuasion used by people outside the law. But recently, the tactic was employed by researchers at the Massachusetts Institute of Technology Poverty Lab to secure health for generations to come. The scientists conducted an experiment that used conditional cash transfers (CCT)—payments to encourage a certain behavior— to deter young people in Tanzania from engaging in risky sexual activity. Over the course of one year, 2,399 participants ages 18 to 30 were tested every four months for chlamydia, gonorrhea, trichomoniasis and Mycoplasma genitalium; they were also tested for HIV, herpes and syphilis at enrollment and the 12-month mark. If all tests were negative, the person was paid, depending on the arm of the experiment, $10, $20 or nothing. If any result returned positive, the participant received free treatment and counseling. In the group that received $20, the rate of sexually transmitted infections (STIs) dropped by 19 percent. But among those paid $10 or in the control group, risk increased by 19 percent and 13 percent respectively. The conclusion? More money equals fewer STIs.

(COUPLE) ISTOCKPHOTO.COM/CHRISTINE GLADE; (COINS) GETTY IMAGES/ANTHONY BRADSHAW

Mo Money, Mo Health

HOT DATES / September 18: National HIV/AIDS and Aging Awareness

(“MANY SHADES OF GAY”) COURTESY OF SAN FRANCISCO AIDS FOUNDATION

Easing the Pain of Adult Male Circumcision?

Despite its many challenges, voluntary adult male circumcision has become a successful and well-documented tool of HIV prevention in the developing world. So much so that in 2007, the World Health Organization and UNAIDS prioritized 14 African countries in which to scale-up voluntary adult male circumcision. Their goal? Nearly 20 million male circumcisions. Within three years, only 2.7 percent of that target had been reached. This is not surprising: Adult male circumcision requires convincing a man to electively undergo surgery on his penis; the procedure is expensive; and it requires skilled medical workers, sutures and anesthesia. But an Israeli designed invention named PrePex may be a game changer. The device clamps the foreskin between a rubber band and a plastic ring to cut off circulation so that the foreskin dies and, after a week, either falls off or is painlessly clipped away. A study in Rwanda showed that the tool takes three minutes to apply and remove and can be done by trained nurses and eventually community health workers. What’s more, PrePex doesn’t require sterile settings. It’s a blood less procedure, and the pain caused by initial placement can be eased with ibuprofen. A challenge with adult male circumcision is that the men must wait until the wound from the procedure has healed before having sex—if not, they could possibly face a higher chance of contracting HIV. PrePex will allow men to return to sexual activity more quickly without this increased risk.

Fifty Shades of HIV?

The highly erotic Fifty Shades trilogy explores the relationship between wealthy businessman Christian Grey and his young lover Anastasia Steele. The couples’ sadomasochistic sexual connection has become a topic of conversation on the tips of tongues around the world. Leveraging the wild success of the international best-sellers, the San Francisco AIDS Foundation and the San Francisco Department of Public Health have created “Many Shades of Gay”—a new public service campaign that encourages gay and bisexual men to get tested for HIV regularly. The multimedia effort allows gay and bisexual men to create an avatar of themselves. This digital mini-me then sends reminders via email and text about HIV testing. He also finds testing locations and helps provide HIV-positive guys with information and ways to connect to care. In Fifty Shades, Christian and Anastasia unabashedly embrace their predilections for pillow talk and bondage. In a parallel universe, “Many Shades of Gay” sends a similar message of acceptance: It doesn’t matter what you’re into— but you should get an HIV test every six months.

Digital Disease Detector

Allergy, cold and flu seasons are upon us, and an innovative way to stay healthy is to use Sickweather, a new online network that screens health-related status updates on social media and posts illness trends to a map detailed down to the street level. The service scans sites like Twitter and Facebook for 24 different symptoms using an algorithm to detect disease outbreaks. (Luckily, it can weed out outbreaks of “Bieber fever” among the pop star’s fans.) Although HIV isn’t currently tracked, as people become more open in their online lives a tool like this could help reveal more accurate numbers of those infected worldwide.

Day / September 27: National Gay Men’s HIV/AIDS Awareness Day

Capiton goes in this space.

A map shows social media mentions of disease symptoms.

poz.com SEPTEMBER 2012 POZ 23

TREATMENT NEWS

BY LAURA WHITEHORN

Useful info on heart health

Clarifying HIV Heart Disease Risk Recent reports suggest that compared with their negative peers, people who have HIV also have a higher risk of cardiovascular disease (CVD, including stroke, heart attack and clogged arteries). The stats alone could stop your heart: One study indicated that positive people are 20 percent more likely than the general population to suffer a stroke. But the way the stats were reported makes them sound more dramatic than they are. That 20 percent relative risk is different from an individual’s actual, or absolute risk, which depends on each person’s combination of risk factors. (You can check yours at http://hp2010.nhlbihin.net/atpiii/calculator.asp.) Still, people with HIV should take extra care of their heart and blood vessels. A few suggestions for starters:

Antiretroviral HIV meds cost as much as $25,000 a year in the United States, but only hundreds of dollars in the developing world. Why? Generic versions of some HIV drugs are available internationally via the President’s Emergency Plan for AIDS Relief (PEPFAR) and other global health progams. With more than 750,000 Americans with HIV not getting treatment and given that part of the reason is cost, we need to make drugs affordable for the 30 percent of HIV-positive Americans who have no insurance. Waiting lists remain for AIDS Drug Assistance Programs (ADAPs); federally subsidized government funding for AIDS is under attack; and more and more states are cutting back on Medicaid. U.S. Senator Bernie Sanders (I-Vt.) has proposed one solution. In May, Sanders submitted a bill to Congress to create a $3 billion prize fund for developers of new HIV meds. The money would be given in exchange for allowing a new drug to go generic right away, replacing the patents that currently keep prices high. At press time, the bill—the Prize Fund for HIV/AIDS Act— remained in committee.

1. Take your HIV meds (in one study, women with fewer than 350 CD4 cells who were not on treatment were at highest risk for stroke). Which HIV drug combos work best for people with CVD risk? Search “hyperlipidemia” at AIDSmeds.com to find out. Also, be sure to ask your doctor about drugs to control blood pressure, high levels of triglycerides and cholesterol, or any other CVD-related risk factor you might have inherited or acquired. 2. Exercise moderately and regularly. 3. Eat fresh fruits, veggies and whole grains; limit high-fat foods, especially red meat. 4. Try to keep your body mass index (BMI, a measure of healthy weight; calculate yours online at nhlbisupport.com/bmi) between 18.5 to 24.9, definitely not over 29.9; and strive for a waistline at or under 35.5 inches (men) or 33.5 inches (women). 5. If you smoke, stop.

24 POZ SEPTEMBER 2012 poz.com

Senator Bernie Sanders (I-Vt.)

(ILLUSTRATION) GETTY IMAGES; (SANDERS) GETTY IMAGES/ISSOUF SANOGO

Generic Drugs in the U.S.?

Is He or Isn’t He Cured? Real Answers to the Case of the Berlin Patient

Timothy Brown: not HIV positive

The short answer: Yes, Timothy Brown, otherwise known as “the Berlin Patient,” remains cured of HIV. You probably remember the story. Brown, who was living with HIV, needed risky, costly stem cell transplants for leukemia. He got the transplants in 2007 and 2008 from a donor who had a genetic mutation that made his cells virtually resistant to HIV. Brown acquired the resistance along with a healthy immune system, and he was declared cured of AIDS—a world first—in 2010. Since then, the generous and groundbreaking Brown has submitted himself to repeated medical tests to monitor the minutiae of his body’s microbiology. Recently, samples of his blood cells and rectal tissue seemed to reveal some fragments of HIV. However, the viral fragments did not match the genetic makeup of the HIV that caused Brown’s original infection, and debate ensued about whether the fragments actually resulted from lab contamination. And none of the fragments were capable of reproducing (essential for HIV’s survival in a host). The remaining viral particles do raise the question of whether Brown’s cure was in fact sterilizing (eradicating all HIV from the body) or functional (cutting the level of virus in the body so low that it can’t cause disease, eliminating the need for HIV meds). Either way, it seems the latest developments in Brown’s case provide grounds for more research, but not alarm.

(BROWN) TOBY BURDITT; (GRAFFITI) ISTOCKPHOTO.COM/RICARDO DE MATTOS

More Safer Sex

Despite efforts to promote sex education and condom use, HIV rates are not declining. It couldn’t be clearer: We need other options to stem the tide of sexually acquired HIV cases. So it is nice to report that an experimental rectal microbicide (a gel containing HIV drugs to block HIV transmission) has been improved. The gel, containing Viread (tenofovir), had issues associated with side effects that undercut its effectiveness as well as its tolerability in the MTN-007 trial. Researchers developed a low glycerin version of the gel, and voilà— fewer problems. Next: a trial in South Africa, Peru, Thailand and the United States to test the new gel.

Common Sense Rules the Court

In June, a New York appeals court overturned the conviction of an HIV-positive man for assaulting a police officer using “a dangerous weapon,” a.k.a. his saliva. There has never been a documented case of HIV transmission by spit. Yet people with HIV have repeatedly been prosecuted on the grounds that they intended to harm someone by spitting on them. Although the court did not rule on whether saliva can transmit HIV, the decision still sets an important precedent: In New York, body parts and fluids cannot be considered weapons. Here’s hoping future rulings will address the fact that saliva doesn’t spread HIV. That would debunk a harmful myth that stigmatizes HIV and discourages testing.

poz.com SEPTEMBER 2012 POZ 25

COMFORT ZONE

BY CRISTINA GONZÁLEZ

Making Cents of Health Insurance

Finding Health Insurance

Start by visiting the U.S. Department of Health and Human Services’ website— finder.healthcare.gov— which provides a list of tailored resources. First, you answer a few basic questions (age, location, preexisting conditions), and then the site generates a list of plans (with contact information and estimated pricing) and allows you to compare insurers, both federal and private. It’s a great way to start gathering information, understand price ranges and get a sense of what’s available to you in your state.

Decoding Health Insurance

26 POZ SEPTEMBER 2012 poz.com

We all need a little help sometimes, and it’s especially true when dealing with insurers. The vocabulary can be hard to understand and the red tape too tangled to unravel. But don’t despair. Many states offer help through federally funded Consumer Assistance Programs (CAPs). Their knowledgeable staffers can walk you through confusing policies, intricate forms and unclear claims, all through phone or email. They can also help you appeal an insurance

denial or put you in touch with local agencies for immediate relief. Go to healthcare.gov and click on “Get Help Using Insurance.” You’ll find a list of numbers for your state, and if your state doesn’t have a CAP, the site will give you info for other resources. Help is on the way!

Getting Care in Real Time

Let’s be real, sometimes you need access to care right now. That cold has gone from bad to worse, or maybe you have a cut that won’t heal. Forget the myth that just because you don’t have health insurance you’ll

be turned away at the doctor’s door. First, know that an ER will never turn you away but you should only go in true emergencies— you will receive a (hefty) bill later. If you have time, check out federally funded health care centers, which provide you with basic treatment, even if you don’t have health insurance. You simply pay what you can afford, based on your income. Locate one at findahealthcenter.hrsa.gov. In addition, the Ryan White HIV/AIDS Program exists to help people with HIV/AIDS get care, even if they can’t pay. To find a counselor in your area, simply log on to aids.gov/locator.

GETTY IMAGES/G.P. KIDD

In late June, the U.S. Supreme Court largely upheld the constitutionality of the Affordable Care Act, which will require most Americans to purchase health insurance or pay a penalty. With the elections just months away and Republican presidential candidate Mitt Romney vowing to repeal the law if elected, the fight for affordable health care for all is far from over. Individual mandates, preexisting conditions, Medicaid expansions—though it may seem impossible to figure it all out, know that you have options and there are people out there willing to help. Most important, know that you have a right to be treated for HIV/AIDS regardless of your insurance status, no questions asked. Here's how to figure out what type of health insurance you need, how to get new coverage, and how to seek emergency care if you need it.

ISSUES

Treatment

SEPTEMBER 2012

Adenovirus-based vaccines against HIV: A look at how the immune system could be trained to combat HIV Dr. Pablo Penaloza-MacMaster

The first cases of HIV infection were documented in the early 1980s and quickly gained overt attention from the public, not only because of HIV’s potential life-threatening symptoms, but also because of its associated social stigma. Nowadays, HIV infection is gradually becoming a more treatable condition, similar to diabetes or high blood pressure, but still represents a major cause of illness and death in many parts of the developing world. Hence, the quest for a vaccine still remains a holy grail in the field of vaccinology. Finding an HIV vaccine has been one of the greatest challenges in vaccine research. Almost three decades of arduous investigation have taught the scientific community many lessons about the immune system and how vaccines typically work. Here we outline the basic principles of vaccination, and explain the rationale behind the next generation of promising HIV vaccine candidates based on the use of alternative (rare) adenoviral vectors. The history of vaccines started back in 1796 when an English physician, sir Edward Jenner, used pus scraped from cowpox blisters to vaccinate people against smallpox. The out-of-the-box idea was used to prime the immune system with a less virulent, genetically related virus, in order to induce immune memory to the deadly smallpox virus in humans. This was the first vaccine ever created, and shortly after, using a less virulent or attenuated form of a pathogen was popularly applied to prevent other diseases, including polio, measles, yellow fever, and rabies. This resulted in effective, life-saving vaccines that drastically increased life expectancy in the human population. However, in the case of HIV, high mutation rates are associated with spontaneous increase in virulence, rendering the approach of using live or attenuated viruses inadequate and dangerous for a vaccine.1,2 Currently, a great deal of focus in vaccine research has been centered on the elicitation of immune responses using viral vectors that serve as a “Trojan horse” to deliver vaccine antigens to the immune system.3,4 The Merck

(STEP) vaccine trial consisted of a modified cold virus (adenovirus 5 or Ad5) expressing several proteins derived from HIV.5 It is thought by many scientists in the field that the failure of the STEP trial may have been at least partially due to the presence of pre-existing immunity to Ad5, which is widely distributed among humans.6 According to this hypothesis, when volunteers were vaccinated with an Ad5 vector expressing HIV genes, pre-existing Ad5specific immune responses quickly neutralized the Ad5 vector before it had a chance to deliver and express its cargo of HIV antigens to the immune system. In layman terms, imagine a hypothetical village that has been previously attacked by hostile colonizers on white horses. After continuous assaults, the village would have trained an army of highly specialized soldiers acting as gatekeepers to quickly obliterate anything that resembles a white horse. As a result, it would be very difficult to deliver an important message to this village if an amicable emissary rides a white horse into the village. The emissary on a white horse would be confused with a hostile invader, and both the white horse and the emissary would be quickly annihilated before the message could be released to the village. So it would be wise to utilize a novel, alternative transport system, perhaps a black horse, to allow the emissary to infiltrate the village in order to express an important message (thus bypassing the pre-existing defenses geared against white horses). Now, think of immune defenses as the village’s soldiers, and the seroprevalent Ad5 viral vector as the white horse from the example above. Up to 90% of people in some populations have been exposed to Ad5,6 so most individuals have pre-existing immune responses that quickly counteract Ad5, limiting the efficacy of this viral vector to deliver vaccines antigens. Adenoviruses are a class of virus that most commonly cause respiratory illness, with symptoms ranging from the common cold to bronchitis. However, some adenoviruses cause infections in the tonsils and intestines with

In the case of HIV, high mutation rates are associated with spontaneous increase in virulence, rendering the approach of using live or attenuated viruses inadequate and dangerous for a vaccine.

no symptoms at all. These viruses constitute an excellent vector delivery system with potential use in vaccines and gene therapy due to their high insert capacity. In other words, scientists can stuff many foreign genes inside adenoviruses without losing viral viability. As a result, one can clone many HIV genes inside the adenoviral genome in order to elicit a potent and broad anti-HIV response. We like to think of adenoviral vectors as computers with a lot of memory capacity. They allow us to install many programs at once without the fear of failing or crashing. Adenoviruses are quite diverse. There are 65 different serotypes of adenoviruses, which display distinct ranges of seroprevalence in the human population, and many of these serotypes are currently being explored for their potential use as vaccine vectors. Thus, the toolkit for making adenoviral-based vaccines is quite ample, so even if the population acquires immunity to one vector, we may be able to substitute with another vector. The reason why most people have higher pre-existing immunity to Ad5 compared to alternative or rare Ads is not fully understood. One possibility is that Ad5 vectors are able to cause a prolonged infection in the host, compared to rare Ads, which may cause a more transient infection. Persistent infection normally results in constant shedding of the virus, and greater chance of transmission to new hosts, thus increasing the prevalence of the virus in the community. A great portion of vaccine research is focused on identifying novel viral vectors with low seroprevalence, which would circumvent the issue of neutralization by pre-existing immunity, mostly in the form of antibody responses.6–8 Some rare adenovirus serotypes that have been identiﬁed are Ad26, Ad35, and Ad48 (and the list is growing). Due to their low seroprevalence in the population, vaccines based on these vectors may be able to efficiently deliver HIV antigens to jump-start the immune system without being immediately cleared from the body upon vaccination. It is possible that speciﬁc adenoviral vaccines would have to be tailored based on the prevalence of that adenovirus among particular populations. Most importantly, the immune system would then be able to develop immune responses to HIV antigens without actually being exposed to HIV. There is growing evidence that rare adenovirus-based vaccines may offer additional advantages over Ad5 at triggering immune responses beyond the issue of preexisting immunity.8–12 This could be because different viral vectors engage the cells in the body in very distinct ways.13–18 Their tropism and life cycles may explain their distinct elicitation of immune responses and the observed biases in the location of immune responses following vaccination.14,19,20 Ad5 enter cells using a surface receptor called CAR (Cocksackievirus and Adenovirus Receptor), which is expressed in epithelial cells and red blood cells. On the other hand, rare Ads such as Ad26, Ad35, and Ad48 target CD46, which is an immune receptor important for complement-mediated immune responses.

Also, every virus has specific pathogen-associated molecular patterns, referred to as PAMPs, which trigger particular “danger signals” in the body. Some of the danger signals that are induced by specific vaccine vectors may be more suitable for generating a response against HIV. Because of these reasons, different viral vectors “tickle” the immune system in unique ways, stimulating specific receptors that influence the generation of immune responses.20,21 Consistent with this notion, we have shown that rare Ads can offer protection upon a challenge with SIV (Simian Immunodeficiency Virus) in monkeys.9,11 In addition, it was reported that a vaccine using rare Ads (but not Ad5) as viral vectors protected monkeys against an Ebola challenge.8 Despite all the evidence showing enhanced responses with rare Ad vaccines, currently there are no approved vaccines that use adenoviral expressing vectors in humans. This is because we first need to better understand these viral vectors to make sure they are safe in humans. Interestingly, we have preliminary data in naïve mice (devoid of pre-existing Ad5 immunity) showing that vaccination using the common Ad5 serotype as a viral vector generates cytotoxic T cells with impaired recall responses in many tissues, including the gut mucosa and lymphoid organs. Intriguingly, vaccination of mice with alternative adenoviral vectors results in a more potent recall response at these sites, which are niches of active HIV replication in humans.22,23 HIV typically enters the body at mucosal surfaces, so recruiting an ample army of anti-HIV immune defenses to these sites by vaccination could offer preemptive sterilizing protection upon viral challenge. So at least when it comes to a vaccine, location and size do matter significantly. In conclusion, vaccines consisting of alternative (rare) adenoviral vectors may offer substantial benefits over common Ad5 vectors to prime immune responses. Differences in vaccine efficacy may be explained not only by pre-existing anti-vector immunity, but also by the intrinsic biology of the viral vectors. The use of alternative adenoviral vectors has thus re-invigorated the field of HIV research, and has provided new hopes for an HIV vaccine. But regardless of the outcomes of the only HIV trial currently under way, it goes without saying that safe sexual practices and responsible adherence to antiretroviral therapy will remain critical in minimizing the incidence of infection, morbidity, and mortality associated with HIV infection in our community.

Vaccines based on adenoviral vectors may be able to efficiently deliver HIV antigens to jump-start the immune system…without actually being exposed to HIV.

Dr. Pablo Penaloza-MacMaster is currently a postdoctoral fellow working on HIV vaccine candidates in the laboratory of Dr. Dan H. Barouch at Beth Israel Deaconess Medical Center, an affiliation of Harvard Medical School in Boston, MA. For more information, please contact ppenaloz@bidmc.harvard.edu. For a full list of references, please visit: gmhc.org/research/ treatment-issues

GMHC

SEPTEMBER 2012

Curing HIV infection, an effort renewed Nancie M. Archin and David M. Margolis

Introduction A cure for HIV infection has long been a distant wish for millions of patients across the world. Thirty-one years ago, when the first case of what was to become one of the worst human health crises in history was reported,1 researchers raced to find a treatments and a vaccine to stop the spread of this deadly disease. Although it was briefly hoped that antiviral therapy could cure infection, a sober and methodical quest for approaches to eradicate infection has now begun in earnest. This article will examine previous attempts to eradicate infection, challenges inherent in finding a cure for HIV, and the promise in a new approach using a drug called vorinostat.

Early attempts at ﬁnding a cure The introduction of combination anti-retroviral therapy (ART) in the mid-1990s heralded in a new era in treatment of HIV infection. Initially, it was postulated that a patient receiving ART could be cured by a few years of intensive ART.2 However, in 1997, with the discovery that a reservoir of infected resting CD4+ T-cells persists despite effective ART, it was estimated that it would require decades of therapy to cure an individual of HIV.3 With over 50,000 new cases of HIV infection a year in the U.S. alone, and greater than 30 million people living with HIV world-wide, the challenge of providing lifelong ART to all those that need it has reinvigorated interest within the scientiﬁc community in the quest to eradicate HIV infection. HIV preferentially infects and replicates in activated T-cells, leading to the depletion of these cells over time. Without ART to block viral replication, CD4 cell depletion culminates in the development of AIDS. Within days of an individual acquiring HIV infection, a population of T-cells known as resting CD4+ memory T-cells becomes infected with latent or dormant virus [3]. In large part, this is believed to happen when an activated T-cell is infected and reverts to a resting state, which must occur before viral replication within the cell can result in the death and clearance of the infected cell. This “dormant” virus then exists as an integrated pro-viral DNA within the genome of resting CD4+T-cells, essentially a foreign viral gene hidden within the human DNA, not susceptible to any currently available therapy, and invisible to immune surveillance. Therapy interruption, even in individuals with years of viral suppression, then results in a rebound of virus, new rounds of infection, and eventually, clinical disease.4,5 Thus, any therapies that seek to eradicate HIV infection must target this long-lived population of latently infected T-cells. However, targeting this population of cells is not an easy task, as there are no markers on the cell surface

that identify infected resting T-cells and differentiate them from the vast pool of uninfected cells.

Vorinostat and other experimental HIV latency treatments The discovery of vorinostat (suberoylanilide hydroxamic acid, SAHA) spanned three decades. Initially a compound called DMSO, commonly used in the laboratory as an anti-freeze during long-term storage of cells, was noted to cause cancer cells to terminally differentiate and die.6 Researchers discovered that chemicals derived from DMSO were potent anti-tumor agents, eventually resulting in the synthesis of SAHA or vorinostat. This drug is a member of a class of drugs called histone deacetylase (HDAC) inhibitors and was recently approved for the treatment of cutaneous T-cell lymphoma, a type of cancer.6 HDACs are natural human enzymes that repress the expression of genes, causing them to become dormant. HDAC inhibitors block the action of HDACs and allow genes to be expressed. Our laboratory and others have discovered that by treating latently infected resting T-cells that were taken from people who are HIV-positive with an HDAC inhibitor such as vorinostat, we could induce the expression of HIV from dormancy. We therefore theorized that vorinostat could be used in a clinical setting to force HIV out of dormancy as an initial step to try to flush out virus that remained latent in T-cells. At the University of North Carolina, Chapel Hill we recently performed a small pilot study in patients successfully treated with ART. It was first measured whether vorinostat could induce virus expression from the cells of these patients in the laboratory. The patients donated blood and CD4 T-cells were isolated from their blood and treated with vorinostat. Once it was established that the cells of these patients responded to vorinostat treatment in the laboratory, the patients were brought into the clinic and given a small dose of vorinostat to assess safety and tolerability of the drug. This safety dose was followed by a standard cancer therapy dose several weeks later, and we compared detectable virus expression in their resting CD4+ T-cell reservoir before and after the vorinostat dose. A signiﬁcant increase in virus expression by the resting CD4+ T-cells after this single dose of vorinostat was observed. This suggests that vorinostat could indeed disrupt latency in a clinical setting. Whether or not multiple doses of vorinostat could lead to a decline in the pool of latently infected cells in these patients remains to be determined and is an active area of research.7 Recently, it has been suggested that although vorinostat may induce the expression of virus from latency, the cells expressing virus may not die or be cleared by the immune response, as one would hope. In response to this potential challenge, our laboratory and others are beginning to study the potential role of various strategies aimed at enhancing the anti-HIV immune response. Thus, one can envision a curative strategy in which a patient is given

Any therapies that seek to eradicate HIV infection must target this long-lived population of latently infected T-cells.

GMHC.ORG

ISSUES

Treatment

Editor: Robert Valadéz Assistant Editor: Elizabeth Lovinger Associate Editor: Nathan Schaefer Art Director: Adam Fredericks GMHC Treatment Issues is published by GMHC, Inc. All rights reserved. Noncommercial reproduction is encouraged. GMHC Treatment Issues 446 West 33 Street, New York, NY 10001 gmhc.org © 2012 Gay Men’s Health Crisis, Inc.

multiple doses of an agent to disrupt latency, such as vorinostat, along with an immune-enhancing therapy to insure the clearance of all infected cells.

Obstacles to curing HIV In a substantial proportion of treated patients, very low levels of viral RNA can be detected by research assays.8–11 This low-level viremia does not appear to lead to drug resistance or failure of therapy, and appears to represent expression of viral particles without effective rounds of new replication.12,13 but is nevertheless a potential additional obstacle to viral eradication. Additionally, other reservoirs of persistent infection despite ART have been reported that could reignite HIV infection. These reservoirs have not been defined as well in patients on successful, suppressive ART. Naïve T-cells have been suggested to harbor persistent replicationcompetent HIV, but the frequency of these cells appears low.14 Macrophages have long been identified as another cell type capable of supporting persistent infection despite ART. Macrophages and monocytes are long-lived cells that may serve as potential sites of persistent viral expression, surviving with ongoing low levels of virus release in patients on ART.15,16 A minor subset of CD16+ monocytes have been shown to be more permissive to HIV-1 replication compared with the major CD14highCD16compartment, and HIV-1 was identified within the CD16+ monocytes of patients after full suppression on HAART.17 However, it has yet to be clearly documented that these cells carry quiescent provirus in vivo for many months, as can resting CD4+ T-cells. This is an important distinction, as viral persistence in a cell that is expressing viral proteins or particles may be addressed by improvements in ART or the antiviral immune response. Recent reports have demonstrated the recovery of replicationcompetent HIV immediately post-mortem from follicular dendritic cells in patients on ART.18 and suggested that

hematopoietic stem cells are a source of persistent HIV.19 However, these observations are controversial.20–22 One of the most daunting tasks facing researchers as they attempt to cure HIV is to ensure that any curative therapy reaches sanctuary anatomical sites where virus infection may persist. For instance, the central nervous system (CNS) could potentially serve as a reservoir of persistent infection as the blood brain barrier may limit access of anti-retroviral drugs and immune surveillance, and so this may present a challenge to clearance of HIV in CNS cells such astrocytes and microglia.23,24 A cure for HIV cannot be achieved without tackling the potential that these sites may be a source of virus that can rebound in the absence of anti-retroviral therapy.

Future perspectives The only case of curative therapy to date involves Timothy Brown, known as “the Berlin patient.” Mr Brown received a stem cell transplant containing a deletion in the CCR5 gene (CCR5 delta 32) as part of a gene therapy procedure for leukemia. CCR5 is a receptor found on the surface of T-cells, macrophages and other immune cells and is required for the entry of HIV into cells. Patients who have a mutation in this gene are naturally immune to HIV infection.25 During the gene therapy procedure, Mr. Brown’s own immune cells were ﬁrst destroyed and then replaced with stem cells containing a deletion in the CCR5 gene (CCR5 delta 32 variant).26 His immune system was then replenished with immune cells that have a deletion in their CCR5 genes, thus rendering his cells resistant to HIV infection. Given this precedent, researchers have recently engineered a series of enzymes called zinc ﬁnger nucleases (ZFNs) to excise CCR5 from CD4+ T-cells ex-vivo. These cells are then infused back into the patient with the hope of replacing the patient’s own CD4 T-cells with clones that are CCR5 negative. Clinical trials using this curative approach are ongoing.27,28 As researchers move forward with the quest to eradicate HIV infection, it is likely that we will learn more about the persistence of HIV and our directions and opinions may change. Total eradication of infection (“sterilizing cure”) may be possible using traditional small-molecule chemical drugs, with or without the help of immunotherapeutic approaches such as vaccines or antibody therapies. A “functional cure” might be achieved in which there remains residual virus genetic material, but ART is no longer required to halt disease progression and prevent infectiousness. Given the limited access to ART for millions across the world, these approaches will have to be developed with a global scale of implementation in mind as the need exists everywhere and is more acute where resources are less plentiful. Such welcomed solutions to the HIV pandemic can only be achieved if we mount a sustained and dedicated effort. Nancie Archin, PhD and David Margolis, MD are researchers at the University of North Carolina, Chapel Hill. For a full list of references, please visit: gmhc.org/research/ treatment-issues

GMHC

SEPTEMBER 2012

WHAT MATTERS TO YOU

BY CRISTINA GONZÁLEZ

OVERTURNING THE GAY BLOOD BAN

DREAMSTIME.COM/CRAIG COLVIN

1. THE ISSUE

Men who have had sex with men at any time since 1977 are banned from donating blood in the United States. The U.S. Food and Drug Administration (FDA) instituted the ban in 1983, at the beginning of the AIDS epidemic. It was an effort to protect the nation’s blood supply from HIV because at the time, the largest number of cases were among gay men. Why does the ban remain? According to the FDA, there are three reasons. First: Men who have sex with men (MSM) have an HIV prevalence (that’s the total number of cases of a disease present in a group at any given time) that is 60 times higher than that of the general population. Second: Detecting HIV in a blood sample can be challenging, especially during the window period (the time between being infected with HIV and when most tests can detect the virus; for most people this is between four to six weeks). Third: There are more than 20 million blood and blood-product-related transfusions in the United States every year, so even an infinitesimal chance of accidentally transmitting HIV is significant. Four other sub-populations are banned from donating blood, either indefinitely or temporarily: injection drug users, people who have received transplants of animal tissue or organs, people who have traveled outside the United States within the last year, and people who have had sex in exchange for money or drugs.

2. WHY THIS MATTERS TO YOU The ban discriminates against gay men. It singles out all

MSM and makes no allowances for men who are in committed, monogamous relationships or those who are tested regularly for HIV. It further discriminates against MSM since it doesn’t prevent donations from people in other high risk groups (like heterosexual men or women who have had multiple partners). The ban is also based on outdated science. Modern HIV tests can often detect the virus within 12 days of infection. And the risk of getting HIV from a transfusion or a blood product has nearly been eliminated in the United States because of improvements to donor screening and testing. Blood screening tests fail to detect HIV less than one in a million times. Lifting the ban on MSM donating blood would not only help destigmatize HIV and de-link MSM from HIV, it could also set scientific precedent for the approval of other medical practices still unavailable to HIV-positive people, such as donating organs to others living with the virus.

3. WHAT YOU CAN DO ABOUT IT

Demand equal donation rights. In 2010, more than 40 organizations signed a letter to the U.S. Department of Health and Human Services (HHS) saying the ban was unfair and asking the FDA to reconsider; in March, the HHS announced plans to study alternatives; and in May, the Vermont House of Representatives asked the FDA, once again, to reconsider the ban in light of current scientific evidence. Add your voice to the cause. Go to senate.gov or house.gov to find your representatives and how to contact them. Then let them know that you want the FDA to lift its ban on MSM blood donation.

poz.com SEPTEMBER 2012 POZ 31

Healing the Hurt

A recent epidemic of attacks on women, transgender women and people with HIV exposes a link as toxic as the virus itself: Trauma not only fuels HIV, it also makes living with it harder. But HIV-positive women and their allies in the realms of science, medicine and social justice are ready to ﬁght back—with programs, education and lifesaving advocacy.

BY RITA RUBIN

JEFF SINGER

N THE MIDDLE OF THE NIGHT ON MAY 24, fire ripped through the offices of Women With a Vision (WWAV), a New Orleans grassroots organization founded in 1991 to respond to HIV/AIDS in communities of color. The flames destroyed the group’s offices, forcing it to relocate temporarily to a church. Deon Haywood, WWAV executive director, immediately called the fire a hate crime, and after a twomonth investigation, police and fire department officials agreed, categorizing it as aggravated arson. HIV and women’s health activists see the fire as one in a series of violent attacks on women and transwomen, particularly those of color, who are advocating for their rights. The fire did more than destroy property; it also served as a cruel reminder of women’s vulnerability and the violence they experience. “Since the attack on our office, I feel that many of us with Women With a Vision have revisited every trauma that we’ve been through,” Haywood says. “Violence seems to be this normal thing, because we’re used to seeing it.” Yet, few health care providers or advocates are putting the pieces together, Haywood says. “I just feel like people aren’t talking about it enough,” Haywood says. “Most of our movements are separate. The HIV/AIDS community is over there. Domestic violence is over here.” That may be beginning to change, as more Cecilia women speak up—and some researchers seem Chung is a to be listening. powerful advocate for Cassandra Steptoe is one woman who is transgender finding her voice and telling her story. In 1987, safety.

when Steptoe was jailed for prostitution and illicit drug use, she took the local health department up on its offer of HIV testing to inmates. “I’m having unprotected sex, I’m sharing my needles—of course I got tested,” she recalls. Still, she was stunned to learn she was positive. “Many nights I used to just get underneath the covers and cry,” says Steptoe, now 56. “The only thing I could do was continue to shoot dope, because I thought I was going to die. I didn’t tell my kids. I didn’t tell my ex-husband. I didn’t tell anybody.” She avoided seeing a doctor until 2001, when she fled San Jose, California, for San Francisco to escape a drug dealer who’d put a gun to her head. Another woman speaking up is Valerie Holmes. Drawn by payments handed out by New York City public health groups, she got tested several times under fake names starting in 1999. “But I never went back to get my results,” says Holmes, now 46. “I was actively using. I knew if I would have found out [I was positive] I would have had to tell my partner, and that probably wouldn’t have been good at that particular time.” He abused her, verbally at first, physically later. Finally, in 2006, Holmes decided she was ready to face the truth. “My life wasn’t bad, but it wasn’t really where I needed it to be.” She marched into a clinic across the street from where she lived in Mount Vernon, New York. “I just asked for everything.” Holmes asked to be tested for HIV and any other sexually transmitted infection. She was positive for HIV. Holmes says she smoked crack cocaine but never injected drugs, so she believes she contracted the virus through years of sex with a variety of

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men. Her partner, who was HIV negative, accused her of cheating on him. Holmes and Steptoe live on opposite coasts, but they’ve traveled similar paths. Both were molested as children and abused by men as adults. Holmes put off learning her HIV status, while Steptoe kept hers secret for years. Their stories illustrate the interconnectedness of violence and HIV in women, a relationship that researchers are beginning to recognize can affect their health for years. Scientists have long known that sexually and physically abused women have a greater risk of contracting HIV. Now, a growing body of research shows that once they are positive, traumatized women don’t do as well in treatment and are more likely to engage in risky behaviors. “It appears that trauma, especially in women, is a key driver of every aspect of the epidemic,” says Edward Machtinger, MD, Steptoe’s doctor and director of the Women’s HIV Program at the University of California at San Francisco. The estimated rate of intimate partner violence among all U.S. women is about 25 percent, shocking in itself. Among HIV-positive women, though, the estimated rate is more than twice that, according to Machtinger. “How can you have safe sex in an unsafe relationship?” asks Anna Forbes, who has long worked in HIV prevention. “If asking him to put on a condom gets you a fist in the face, it’s not going to work.” Despite t he g row i ng awareness, fewer than 10 percent of all providers of HIV services routinely screen for intimate partner violence, according to a 2009 report from the federal Health Resources and Services Administration. “I think one of the reasons providers don’t ask about abuse is they don’t feel comfortable or confident about how to treat a patient who’s been abused,” Forbes says. “You have to assume that [abuse] is part of the constellation [of issues in a person’s life] until it’s ruled out.” Providers’ ignorance about how best to care for and treat HIV-positive women isn’t surprising, Forbes says. “HIV started out in the U.S. as a men’s disease,” she says. “The AIDS world is still working off that paradigm and still isn’t adapted to working with women.” But women represent a growing proportion of the HIV/ AIDS epidemic in the United States. Today, they account for at least 27 percent of all new diagnoses, up from 8 percent in 1985 and 14 percent in 1992, according to Machtinger. And, he says, more than three-quarters of women who are newly diagnosed with HIV are black, like Steptoe and Holmes, or Latina. Studies show that black women, both positive and negative, also experience disproKat Grifﬁth portionately high levels of violence. contracted HIV after a “Why is there less funding right now for peoviolent relationship. ple with HIV? Why is there less press about the

epidemic?” Machtinger asks, then offers an answer. “I would have to say [it’s because] the people being infected right now are much more disempowered.” Machtinger’s institution recognized early on that its AIDS clinic wasn’t meeting women’s needs. “The AIDS clinic was pretty much designed for men,” he says. “The women who were coming in were very different. For the most part, we were seeing poor women, women who were under-educated.” And, compared with men, women were less likely to acknowledge they were living with HIV. “That made it very hard for them to take their medicines, to come to clinic,” Machtinger says. ”It made it very hard for us to refer them to all of their needed services. They didn’t want to go through being outed and feeling stigmatized. It was very hard for these early HIV-positive women.” Even today, the stigma of HIV weighs more heavily on women than on men, Forbes says. “With women, it’s still much more ‘you must be a whore or a tramp,’” she says. Besides, women have too much other stuff to worry about than their own health. “It’s almost part of the culture of being female,” says WWAV’s Haywood. “You automatically never

DAVID VERNON

Trauma, especially for women, drives every aspect of the epidemic. think about yourself. There’s always somebody else we’re caring for.” A violent partner can wield a woman’s HIV status like a weapon by threatening to take her children away if she speaks out about being beaten, Haywood adds. Certainly, not all victims of intimate partner violence are women. But “women have a more submissive role in this world,” says Gail Wyatt, PhD, a UCLA psychologist who has pioneered research into the relationship between violence and HIV in women. HIV positive or not, she says, “we usually have more dependence on a partner for our survival.” Something as simple as the need for their partner’s health insurance traps some HIV-positive women in abusive relationships, says Kat Griffith, a 42-year-old Metamora, Illinois, woman who contracted HIV from her college boyfriend and was diagnosed 20 years ago. “A lot of times, men will use their medications against them, like holding them for ransom,” says Griffith, who helped the National Network to End Domestic Violence develop a curriculum to teach health care providers about the intersection of violence and HIV/AIDS. Griffith’s parents divorced when she was 5, and she says, her mother was either drunk or working throughout most of Griffith’s childhood. While the man who infected her was not violent, Griffith says, her high school boyfriend was. “There is

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no question in my mind that the traits that led me to the violent relationship are some of the same traits that kept me from protecting myself,” she says. “I could have easily contracted the virus as a teenager, when I had such low self-worth that I would do whatever drugs someone wanted me to do. I was not taking care of myself. I was a bit self-destructive.” Her college boyfriend mistakenly thought he’d been tested for HIV when he underwent surgery before he met her, Griffith says. Although “he [slept around] before he met me” and didn’t pressure her to have unprotected sex, they eventually stopped using condoms, a move Griffith thought significant enough to note in her journal. They learned he was HIV positive in 1992 when he was diagnosed with AIDS. Griffith tested positive a few weeks after that; her boyfriend died in 1994.

36 POZ SEPTEMBER 2012 poz.com

Recent violence was the main factor related to HIV treatment failure. needed to fully explore its potential in HIV-positive women, both transgender and non-transgender. Even if an HIV-positive transgender woman is open about her status and willing to seek care, she’s unlikely to find it— even more so than a non-transgender woman, says JoAnne Keatley, a transgender woman who directs the Center of Excellence for Transgender Health at UCSF. “If you were a transperson living with HIV in most places in this country, it would be very difficult to find a physician who has the requisite skills to care for your medical needs,” Keatley says. “They need help kind of wrapping their brains around dealing with issues of different-bodied people.” When transgender women are victims of trauma, law enforcement officials often side with the perpetrators who defend themselves by saying, “Oh, you know, this is a dude that fooled me,” Keatley says. Cecilia Chung, a trans woman who now serves as a health commissioner in San Francisco, says she conCassandra tracted HIV when raped by another jail inmate. Steptoe Chung had always known she wanted to transi- ﬁnds power in telling her tion to becoming a woman. Born in Hong Kong, story of HIV Chung moved with her family to San Francisco and abuse.

JEFF SINGER

CSF established the Women’s HIV Program in 1994. Machtinger came on board in 2000 and became director in 2004. People in the program can talk about housing issues with their social worker, child-rearing with the family case manager, medications with a pharmacist and preventive health with their gynecologist—all in one morning. Despite the comprehensive care provided by the program, though, Machtinger noticed that a fifth to a quarter of the patients were faring poorly. “We realized there was something missing in our model,” he says. “It was very frustrating.” That doesn’t surprise UCLA psychologist Wyatt. “These are people who usually don’t want to go to the doctor,” she says. “They’re very suspicious of people touching them and asking them questions about their histories.” Even when it’s performed by a doctor, a pelvic or breast exam might trigger post-traumatic stress disorder, she says, adding that “a lot of women say taking [their daily HIV] medicine reminds them that they are positive,” stirring up unwanted memories of how they contracted HIV. To identify factors linked to why people fail to stay on HIV treatment and why they engage in risky behaviors that could spread the virus (and expose positive people to additional infections), Machtinger and colleagues at UCSF and Massachusetts General Hospital analyzed data from 113 HIV-positive and transgender and non-transgender women. In an interview with a trained female counselor, each woman answered 97 questions about an array of characteristics and behaviors that could be associated with their health and whether they were likely to engage in behaviors that could infect others. “What we came up with was a big surprise to us,” Machtinger says. Being threatened or abused or subjected to violence within the past 30 days was the single biggest factor linked to both risky behaviors that could spread HIV and to the failure of antiret-

roviral therapy. “A light went on for me and our program,” he says. “It wasn’t just any trauma that resulted in these outcomes, it was recent trauma. Recent trauma is something that we might be able to do something about.” Toward that goal, Machtinger’s program conducted a pilot study of a program called Seeking Safety, a cognitive-behavioral therapy developed by a Harvard psychiatrist to treat people with post-traumatic stress disorder (PTSD) who are also addicted to drugs and alcohol. The UCSF researchers adapted Seeking Safety to treat HIV-positive transgender women, who have disproportionately high rates of PTSD as well as substance abuse. Machtinger and his colleagues selected 12 of the 25 Seeking Safety modules that they thought would work best for their patients. Seven women enrolled in the study, and they were asked to attend 12 weekly sessions, one for each module, conducted by two social workers. The modules covered such topics as “PTSD: Taking Back Your Power,” “Healthy Relationships” and “Taking Good Care of Yourself.” Six of the seven women completed at least seven sessions, and at the end of the study, participants’ PTSD, sense of HIV stigma, and drug and alcohol use had declined overall. While the pilot study found Seeking Safety showed promise, the researchers say larger studies are

in 1984. After graduating college in 1991, Chung, now 47, began the process. “I decided that was something I could not hide from myself anymore.” Neither her family nor her employer accepted the changes in Chung. “I had a fallout with my family because they did not know how to deal with my decision to transition,” she says. “Also, because there were no legal protections for transgender people, I quickly lost my job.” She had been a court interpreter. “I think some of the judges became uncomfortable.” Chung was on the verge of becoming homeless. “It was pretty overwhelming in a short period of time,” she recalls. “The change for me from being male to coming to my womanhood was a very painful journey.” She turned to crystal meth, because her fear of needles prevented her from using injection drugs. She lived in cheap hotels in bad neighborhoods. Sometimes she slept in her car, when she still had a car. To survive, Chung depended on what she calls “the street economy,” which is what led to her arrest. Still, Chung feels lucky. She learned she was HIV positive not long before the first HIV drugs became available. And she lives in San Francisco, whose city health department for years has run Transgender Tuesday, a clinic that provides care for transgender individuals.

STEVE MORRISON

assandra Steptoe and Valerie Holmes are proof that helping HIVpositive women deal with and recover from trauma can improve their lives in multiple ways. About three years ago, Holmes went through a program called Healing Our Women, developed by UCLA psychologist Wyatt for HIV-positive women who’ve experienced trauma. Healing Our Women is made up of 11 weekly two-hour sessions led by specially trained facilitators as well as peer mentors—other HIV-positive women who’ve been through the program. Participating in the group enabled her to open up about her past, Holmes says. “In order for me to get better, I needed to let it go and try to forgive the people who had done what they did to me.” She learned how to build skills and solve problems. “It was about me dealing with me, so I could get to know how to deal with my partner or partners.” After completing the sessions, Holmes facilitated Healing Our Women groups through Project Street Beat, which is Planned Parenthood of New York City’s HIV prevention and care program for women, men and teens who live on the streets. Through the project, she also visited clients in their homes and escorted them to the doctor. “I made sure that they have what they need.” Steptoe, who had hidden her HIV status for so many years, has now told her story to thousands through performances with a group of HIV-positive women directed by performance artist Rhodessa Jones. “Dr. Eddy,” as Steptoe calls Machtinger, came up with the idea of a collaboration between UCSF’s Women’s HIV Program and the San Francisco–based Jones. Jones is founder and director of the Medea Project, which her website describes as a theater workshop “designed to achieve personal and social transformation with incarcerated women.” “I have a hypothesis that nondisclosure, not being out, puts women at risk for further victimization,” Machtinger says. “There’s so little visibility of HIV-positive women out there. Now we have these women who have come out publicly.” Machtinger introduced Steptoe to Jones several years ago. “I didn’t know anything about performing,” says Steptoe, who can now be seen on YouTube. The more she tells her story, Steptoe says, the more empowered she feels. In the past, she says, she’d “ride [relationships] until the wheels fall off.” Support from Jones and her fellow performers gave her the courage to leave her second husband, an HIV-negative man she’d met at Narcotics Anonymous. He had Valerie started to use drugs again and beat her. The jubilation in her voice Holmes found health was clear when she said their divorce was final in June. “I don’t have through to live with shame. I don’t have to live with stigma,” Steptoe says. a healing “Having HIV is not a crime. It’s a health condition.” ■ program.

Returning to Health

If you are living with HIV and violence, there are many ways you can get help. For example, Deon Haywood, executive director of Women With a Vision, says story circles, a form of consciousnessraising or group therapy, encourage women to relate their experiences and hear from others in similar circumstances. “Story circles,” Haywood says, “center the voices of people who are often made invisible in our society. They engender a sense of community and promote healing and collective action.” Here are a few resources to start with. For more in your area, search the directory at poz.com. Resources mentioned in this story: Women With a Vision wwav-no.org 504.301.0428 Healing Our Women Project Street Beat plannedparenthood.org/ nyc/15223.htm ppnyc.org 212.965.4850 Center of Excellence for Transgender Health University of California at San Francisco transhealth.ucsf.edu 415.597.8198 Other national resources: National Domestic Violence Hotline thehotline.org 800.799.7233 National Center for Transgender Equality transequality.org 202.903.0112 The Well Project thewellproject.org 888.616.9355 Positive Women Forum forums.poz.com

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40 POZ SEPTEMBER 2012 poz.com

HOT

ON THE

TRAIL

AIDS activists are experts at bird-dogging, following political candidates and peppering them with questions about their positions on HIV/AIDS. In the upcoming presidential election—where one candidate threatens to eviscerate federal support for health care and the other advocates protecting it—activists wonder: Should we release the hounds? BY BETH SCHWARTZAPFEL ILLUSTRATIONS BY ALEX FINE

ER BROWN HAIR PULLED BACK IN A PONYTAIL, A twentysomething woman at Mitt Romney’s October 10 town hall meeting in Hopkinton, New Hampshire, asked the presidential candidate, “Will you commit to putting 6 million people on lifesaving medication by 2013 in an effort to end the worldwide AIDS epidemic?” She was referring to incumbent president Barack Obama’s World AIDS Day 2011 pledge to increase to 6 million the total number of people treated for HIV under the President’s Emergency Plan for AIDS Relief (PEPFAR). Rather than answer the young woman’s question, Romney changed the subject. “Here’s what I’m going to do to balance the budget,” he said. Soon another question was lobbed at Romney, this time by a young man in the far corner of the town hall. “I would like to know if a Romney administration would be committed to continuing the tradition laid forth by the [George W.] Bush administration in terms of [how to] fund PEPFAR and the Global Fund [to Fight AIDS, Tuberculosis and Malaria],” he asked. And then another, from a young woman elsewhere in the room: “This is a follow-up on the questions about HIV/AIDS funding,” she began, before Romney finally snapped, “I’ve got nothing more for you on that.” Meet the bird-doggers, a tenacious group of HIV activists who pursue political candidates at local and national campaign events as relentlessly as a pointer on the scent of a quail, hurling questions about HIV policy and funding at contenders from all parties. As the 2012 elections approach,

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bird-doggers are just one part of a widespread political mobilization led by the HIV/AIDS community. Races with important implications for HIV-positive people range from those for city councils and state legislatures all the way up to the contest for the White House. With that in mind, advocates, activists and policy wonks are designing voter registration drives, scaling up lobbying efforts and planning direct actions. “The stakes are very high,” says Ronald Johnson, vice president of policy and advocacy for AIDS United. With trillions of dollars in cuts to the HIV safety net being used as a pawn in the fallout from last year’s debt ceiling debacle and with the full impact of the Affordable Care Act still unknown, Johnson says, “this is not an election to be on the sidelines.” Indeed, with 28 million positive people going untreated for HIV worldwide—750,000 of them in the United States—the outcome of the 2012 race will have lasting and potentially dire repercussions.

dvocates wistfully recall a time when funding for AIDS was a bipartisan issue. In 1990, the Ryan White CARE Act passed the Senate almost unanimously, 95 to 4, and one of its most vocal proponents was Senator Orrin Hatch, a conservative Republican from Utah. PEPFAR itself—the single largest financial commitment in history by any country to combat a disease—was established in 2003 by then-President George W. Bush, with congressional support from both major parties. No longer. Now the two parties’ stances on issues affecting people with HIV are diametrically opposed. Take the Affordable Care Act (ACA, or “Obamacare,” as the GOP disparagingly

42 POZ SEPTEMBER 2012 poz.com

calls it), a “game changer in making progress against the domestic epidemic and absolutely critical,” says Chris Collins of amfAR, The Foundation for AIDS Research. Democrats, led by the Obama administration, passed this legislation two years ago. Republicans, on the other hand, opposed the bill en masse in the House and Senate (not a single Republican in either chamber voted for it), and at press time, they had voted for the 33rd time to repeal it. Romney has pledged that repealing the ACA would be one of his first priorities as president. More broadly, the two parties’ differing financial philosophies have deep implications for the HIV community. As a result of the debt ceiling fiasco in summer 2011, when Congress could not agree on a limit to the debt the country could amass, and the subsequent failure of the “super committee” (the bipartisan Joint Select Committee on Deficit Reduction), Congress must now find an estimated $1.2 trillion in savings in the federal budget. To do so, Democrats favor a blend of tax hikes and spending cuts. Republicans insist on achieving all of the savings via cuts: no tax increases. Since Republicans are also loath to cut defense spending, “that means it would only be discretionary dollars cut—basically only social service programs,” says Christine Campbell of Housing Works. These include Medicaid, Ryan White and other critical programs that directly fund HIV services. “[Republicans are] going to work at balancing the federal budget on the backs of poor people.” So the choice is clear, right? If you care about people living with HIV or are yourself HIV positive, you should vote for President Obama and the Democrats, right? Advocates will say so behind closed doors. But don’t count on hearing it publicly.

That’s because almost all AIDS service and advocacy organizations register as 501(c)(3) nonprofits, forbidden by law to endorse candidates. There are discussions in the community about founding a new 501(c)(4), or political action committee, to do more straightforward political fundraising and support in the future. For now, organizations must focus on registering voters—something the national movement is gearing up to do on a large scale—and publicizing the issues that matter. “If health care reform is [fully implemented] in 2014, you’ll have access to Medicaid, you’ll be able to get medications at no cost for HIV and for heart disease, diabetes, mental health. But if health reform is repealed, good luck with all that,” says John Peller, vice president of policy for the AIDS Foundation of Chicago. “[Informing people of this] is education we can do without running into trouble around the election laws.”

n a warm evening during Gay Pride week in Boston, the local ACT UP chapter gathered in a South End bar amid rainbow balloons and drag performers. Katrina Ciraldo, a 26-year-old Boston University medical student, unpacked a box of fliers that read, “A TAX CAN END THE AIDS CRISIS” over the iconic image of the charging Wall Street bull. The flier promoted the “Robin Hood tax”—a tax on financial transactions to raise money for social issues such as HIV/ AIDS—and referred to recent scientific findings that have left the HIV community full of optimism. “R.I.P. HIV,” shouted the pages of this magazine. Secretary of State Hillary Clinton said the world’s first “AIDS-free generation is ambitious but possible.” President Obama spoke publicly of the “end of AIDS.” That’s because recent evidence shows treatment can be prevention: Since antiretroviral treatment for people with HIV may reduce sexual transmission risk by up to 96 percent, universal access to meds could be the practical equivalent to ending AIDS. Research toward a cure has also progressed. Whether and how increased access and research will be funded is a crucial question. “If we’re going to educate voters, and get voters out, then we need to do the other part too,” says Health GAP’s Jennifer Flynn. “Which is, show that we’ve actually got numbers. I don’t think elected officials know [how many Americans are actually living with HIV/AIDS]. We have to show them that.” The answer? 1.2 million people. During campaigns, candidates are often more sensitive to public pressure and more open to new ideas. What’s more, those inclined to take a particular position may still need public pressure for political cover. Many activists cite the advice Franklin Roosevelt is supposed to have given labor leaders urging him to create the National Labor Relations Board: “I agree with you,” he told them. “Now make me do it.” That’s why as we go to press, activists are organizing a major march and rally in Washington, DC, during the XIX International AIDS Conference (AIDS 2012). With HIV birdthe eyes of the world focused on DC and HIV for doggers that week, the conference “is the perfect advo- value some of Obama’s cacy opportunity,” says Flynn of Health GAP, policies, they one of the march’s organizers. The We Can End pushyet him to AIDS Mobilization hopes to bring tens of thoudo more.

sands of activists to the capital to call for everything from ending the criminalization of sex workers, drug users and people with HIV; to stopping attacks on LGBTQ people; to providing money for AIDS housing—and to finding a cure for HIV, a move that would truly end the epidemic. At that Boston ACT UP meeting, a dozen people ranging in age and experience from college students to gray-haired veteran activists were planning a teach-in about the tax. “[The teach-in will] illustrate how we are planning to build power over the months until the election to make [the Robin Hood tax] a campaign issue for Elizabeth Warren and Scott Brown,” Ciraldo said, referring to the candidates for Massachusetts’s hotly contested Senate seat. “If we bird-dog them, maybe we can get the financial transaction tax in the news on a statewide level.” But not everyone is comfortable with this confrontational approach. More cautious advocates fear that publicly announcing the ways Democrats have fallen short in their efforts to end AIDS will only give ammunition to the right and alienate potential voters. “This is not the time for a blame game or a lot of negative advertising,” says Kali Lindsey of the National Minority AIDS Council. “There are ways to hold individuals accountable without going on attack mode.” Further, some fear that being too vocal and too critical will cause the AIDS community to lose access to the Obama administration—or any administration, for that matter. “We might piss them off and not be their quote-unquote ‘friends’ anymore and therefore lose our quote-unquote ‘seat at the table,’” as Housing Works’ Christine Campbell characterizes it, with no small amount of frustration. But regardless, history has shown that getting to the table is not an effective end goal. Those who sat at the table with the Obama administration last year to encourage broader access to care were surprised when little more than a month after his December 2011 pledge to expand treatment via PEPFAR, the president recommended an estimated $550 million cut from that program. Both the organization’s officials and the Obama administration claim that the goal of getting 2 million more people into care via PEPFAR can and will be done anyway, but questions remain about what will not be done for people with HIV as a result of the cut. The real issue is not so much whether to be polite or loud, but rather how to recognize some extraordinary steps the Obama administration has made for people living with HIV— such as providing emergency funding for the AIDS Drug Assistance Program (ADAP) in 2011 and 2012—while pushing for more. To people who say: “We need to get Obama reelected, [so] we can’t really yell at him,” Campbell responds, “We need to push him a little farther. [Otherwise] he’s going to stay in the middle. We have to be in the streets, being loud, being visible. Being vocal.” And we have to ensure that every single voter living with HIV (or concerned about it) realizes that Romney’s “I’ve got nothing more for you on that topic” is exactly what we can expect if he wins. Along with his expressed goal of torpedoing affordable health care and his commitment to never raise taxes (ever), a Romney White House would leave virtually nothing for tens of millions of people living with HIV/AIDS. ■

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HEROES

BY LAUREN TUCK

Midnight Cowboy In 2007 after 10 years of injection drug use and professional sex work, Richard Holcomb tested positive for HIV. Today he is substancefree and helps other men engaged in sex work overcome the obstacles he encountered. Holcomb created Project Weber, a harm reduction outreach program for homeless male sex workers in Providence, Rhode Island. As recently as 2009, selling sex indoors was still legal in Providence, making the town a magnet for male prostitution. Project Weber, named in remembrance of a young male sex worker murdered in 2003, provides HIV testing, condoms, sterile injection equipment and referrals for people with addiction. Holcomb also conducts research to shed light on male sex workers—a population that’s understudied and overlooked. He hopes that every city will eventually offer the specialized services found at Project Weber. What three adjectives best describe you? Adventurous, passionate and sometimes neurotic. What is your greatest achievement? Staying clean from drugs and alcohol and rebuilding my life from scratch—which in turn caused me to create Project Weber. What person in the HIV/AIDS community do you most admire? My friend Jimmy, who is also a former male sex worker. Although HIV negative, he has done extensive volunteer work in HIV prevention and has been a great source of hope and support since I was diagnosed. What drives you to do what you do? Not forgetting where I came from and how hard it was for me to get off the street and change my life. I am determined to make it easier for the next generation by providing male sex workers with the resources and services that were not available to me when I needed them.

Where do you go to relax? Every six months I travel to Europe, which is a childhood dream come true. My favorite place is the Charles Bridge below the Prague Castle in the heart of the Czech Republic.

RACHEL HULIN

If you could be any animal, what would you be? And why? I’m always looking for different perspectives on life, so I think it would be nice to see how the world looks from a bird’s eye [view].

SURVEY On the Campaign Trail

Election Day 2012 is just a few weeks away. (It’s Tuesday, November 6, but you already knew that, right?) We’ve heard from the candidates and pundits on both sides of the aisle, and now we want to hear from you. POZ wants to know: How involved are you in this election, and what will be on your mind as you enter the voting booth?

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❑ American Indian or Alaska Native ❑ Arab or Middle Eastern ❑ Asian ❑ Black or African American ❑ Hispanic or Latino ❑ Native Hawaiian or other Pacific Islander ❑ White ❑ Other (please specify):_____

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❑ Making a donation ❑ Signing petitions ❑ Attending rallies ❑ Making phone calls ❑ Registering voters ❑ Canvassing door-to-door ❑ Other (please specify):

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Please fill out this confidential survey at poz.com/survey or mail it to: Smart + Strong, ATTN: POZ Survey #182, 462 Seventh Avenue, 19th Floor, New York, NY 10018-7424