POZ March 2015

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H E A L T H ,

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H I V

Beyond Labels Octavia Lewis

Trans people transcend HIV

CONTENTS

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Octavia Lewis, who is HIV positive and transgender, plans to adopt Ethan.

PREVENTION

A NEW PORTAL ON POZ.COM

To finally end the HIV/AIDS epidemic will require more than just care and treatment.

Preventing transmission of the virus is vital.

Go to poz.com/prevention for updates on PrEP, PEP, TasP, microbicides, safer injecting, condoms and related news.

D

CRIMINALIZATION People with HIV/AIDS in the United States and around the world are at risk for prosecution under HIVrelated laws and similar statutes. Go to poz.com/ criminalization for more information and learn how you can help.

POZ DIGITAL

READ THE PRINT MAGAZINE ON YOUR COMPUTER OR TABLET

26 TWO OF A KIND Octavia Lewis and Shawn Lopez show us that love can conquer all. BY ADEMOLA BELLO 30 ELISA TURNS 30 Better HIV testing becomes ever more crucial as prevention efforts increase. BY BENJAMIN RYAN 36 UP IN SMOKE The future of medical marijuana for HIV/AIDS looks hazy. BY RITA RUBIN 5 FROM THE EDITOR More Than a Woman

7 FEEDBACK Go to poz.com/digital to view the current issue and the entire Smart + Strong digital library.

Your letters and comments

8 POZ Q+A

D

Barb Cardell, the chair of Positive Women’s Network USA, on self-empowerment

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15 VOICES

iSTAYHEALTHY Go to blogs.poz.com/istayhealthy or scan the QR code below with your mobile device to learn how you can better track your lab test results and meds, as well as set alerts to take your meds and more!

Theodore Kerr of Visual AIDS interviews Demian DinéYazhi’ of R.I.S.E. about an art poster concerning HIV and Indigenous communities.

16 POZ PLANET

Hannelore Williams explores the pandemic in her 10-part docu-series Dirty 30 • you can pick up what at a gay bathhouse?! • the Southwest Center for HIV/AIDS in Phoenix celebrates 25 years of service • a good clean fundraiser • ’tis always the season to help

18 CARE AND TREATMENT

The CDC takes on “Prevention With Positives” • some oral birth control is safe with ARVs • PrEP on demand shows promise • PrEP use rises among men • high efficacy for PrEP in a British study

20 RESEARCH NOTES

A multipurpose vaginal ring fights HIV, HPV, genital herpes and pregnancy • new potential treatment targets • high hep C cure rates • U.S. “treatment cascade” stats

21 SURVEY SAYS

What are your sleep habits, and are you getting enough shut-eye?

40 POZ HEROES

Gina Brown is a medical case manager in New Orleans. As a member of the President’s Advisory Council on HIV/AIDS (PACHA), she speaks up for Southern black women living with the virus.

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. 202. POSTMASTER: Send address changes to POZ, PO Box 8788, Virginia Beach, VA 23450-4884. Copyright © 2015 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.

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More Than a Woman

I

T WAS SEVERAL YEARS ago when I had my first experience with a friend coming out to me as transgender. I hadn’t seen her for many years, but I was happy for her transition from the young man I had known to her new self.

For decades I’ve tried to be a trans ally. For those who are not LGBT, that might sound silly: We’re all in the same boat, right?

However, for those of us in the LGBT acronym, having one letter be an ally to another isn’t automatic. We all have biases.

Now add to that all the hurdles most of us assume trans people confront and you’ve got a recipe for hardship. Unfortunately, one of those hurdles is HIV. The virus disproportionately affects trans women, especially trans women of color. Sadly, this isn’t news to folks in the know.

One of those folks is Octavia Lewis, our cover gal. As an HIV-positive trans woman, she knows all too well the common struggles of other trans folks living with the virus. She also can relate to trans folks like her partner, Shawn Lopez, who are trying to stay free of the virus. Go to page 26 to read about their love story as a serodiscordant couple.

All women—cisgender and transgender alike—are welcome at the Positive Women’s Network United States of America (PWNUSA), a national membership group of women with HIV/AIDS. The group builds leadership skills and advocates for social justice and human rights.

Barb Cardell is currently the chair of PWN-USA. Based in Colorado, she has been HIV positive since 1991. Go to page 8 to read our Q&A with Cardell. She shares her personal journey of being diagnosed and living with HIV, her experience with stigma and her belief in self-empowerment.

Gina Brown—a PWN-USA board member and a member of the President’s Advisory

Council on HIV/AIDS (PACHA)—also believes in self-empowerment. She was diagnosed with HIV in 1994. Based in Louisiana, Brown brings the voices of Southern women living with the virus to U.S. policymakers. Go to page 40 to read about her advocacy.

Regardless of gender or orientation, we all share in the hope of ending the epidemic and finding better ways to live with HIV until then. Two other stories in this issue address aspects of that hope: improving HIV testing and expanding access to medical marijuana.

Nearly half of U.S. states have legalized some form of medical marijuana. However, now that four states have legalized recreational weed, the future of prescription pot, especially for people with HIV/AIDS, looks hazy. Go to page 36 for more analysis.

As prevention efforts expand with the use of pre-exposure prophylaxis (PrEP) and the increased frequency of HIV testing required to stay on PrEP, better testing is crucial. Go to page 30 to read about the future of HIV testing on the 30th anniversary of the ELISA.

ORIOL R. GUTIERREZ JR. EDITOR-IN-CHIEF editor-in-chief@poz.com

Want to read more from Oriol? Follow him on Twitter @oriolgutierrez and check out blogs.poz.com/oriol.

poz.com MARCH 2015 POZ 5

FEEDBACK

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.

follow-up response on the Huffington Post.

STRENGTH TRAINING

(WEIGHT) THINKSTOCK; (QUINTO) GETTY IMAGES/BRAD BARKET; (VIREAD) GETTY IMAGES/BLOOMBERG

In his blog post “Why I Still (Kinda, Sorta) Go to the Gym” (November 4, 2014), longterm survivor Bruce Ward writes about how his gym membership has been the one consistency through 30 years of living with HIV and how he’s not ready to give up on hope, happiness and life.

Like you, I’m not ready to give up, even if it sometimes feels like I should. I truly believe going to the gym and staying employed have given me a lot of sanity and hope. I take it easy at the gym and don’t feel too bad if I miss one day.

It’s when I miss a week that I feel awful, but I quickly get back on track. Don’t ever stop or you will rust!

LUIS R

there is always hope and that we must persevere.

EDGAR COLON-HERNANDEZ

Working out eases most of my stress and depression. I have only been out for a little over two years and was diagnosed with HIV last year, on September 10. I felt ashamed, depressed, fearful and stressed all at the same time. Some days I just want to give up. Then I think of all those who sacrificed so that I have my meds today. Plus I have no reason to complain so much as I am a newbie.

You have lived as a survivor for many years. One thing that I hope for all of this is a loving partner. You are awesome, man. Thanks for sharing!

STEVE CHARTER

Thank you for this timely post. I can’t believe I started crying reading it. Anger, depression, stress and fear course though me constantly.

Sometimes in parallel, sometimes just one at a time. I am just trying to figure out how to live or stay alive.

You just told me to stay alive for today and gave me hope in knowing that there are ups and downs.

DAVE

Thank you for this excellent article. Most of it resembles my own life and experiences.

Twenty-eight years after being diagnosed, I’m not ready to give up either, even if it sometimes does become somewhat overwhelming.

Thanks for the reminder that

I sort of agree with his comments about complacency. However, his comments about PrEP are anti-sex. There is nothing wrong with recreational sex.

Sex is not just for reproduction; it is recreational. We do know about long-term effects of Truvada. This medication has been used for a long time in combination therapies. I took it while I was positive. I had no negative effects. I would take it to prevent HIV. TIMOTHY RAY BROWN

Editor’s Note: Brown is the first person cured of HIV. Quinto could have taken this moment to spread a viable prevention message, instead of castigating a generation who wasn’t even born in the ’80s. Having a pretty face and playing an ultra-logical being on movie screens do not make one qualified to comment on things about which one is poorly informed!

MICHAEL LUCIANO

I don’t think Zach is being “sex negative” at all, or indicating he doesn’t have sex. Despite the unfortunate use of the word “recreational,” I think we get what Zach is saying, even if it may not be what we want to hear. I vote to proceed with caution; after all, there are lots of other STIs out there too.

FACUNDO

HIGHLY ILLOGICAL?

The POZ Staff Blog “Zachary Quinto on ‘Laziness’ and ‘Irresponsibility’” (November 12, 2014) highlights the controversial comments made by actor Zachary Quinto about PrEP and HIV among youth in an interview with Out magazine and his

It’s sad that whenever someone—like Quinto—says anything that reads as less than 100 percent in favor of rampaging bareback sex, they’re accused of being “sex-negative.” Taking some personal responsibility to prevent the spread of all kinds of STIs, not just HIV, isn’t sex-negative; it’s common-sense positive.

THANIEL CHASE

I do not understand how the HIV rate is rising with the knowledge we have today.

People are becoming lazy and irresponsible.

ROBERT

DRUG UPDATE

In his article “It’s Time for Tenofovir 2.0” (December 1, 2014), Benjamin Ryan writes about the upgrade to tenofovir (Viread) as part of a single-pill combination regimen with the same components as Stribild. The upgraded version of tenofovir (known as TAF) offers several benefits over the previous version. .

It’s amazing to have the new formulation in the fight. I just wish our lawmakers could force companies to not hold out on developing and releasing these lifesaving drugs. Making it a stand-alone drug or releasing and seeking approval for it when it was developed could have saved lives and complications.

ANONYMOUS

The marketing antics of Gilead are not going to reduce the cost of HIV drugs anytime soon. At least the anti-PrEP crowd will no longer be able to tout resistance as an issue (it never really was). Less drugs, fewer side effects, all good! But the cost of HIV drugs will continue to rise.

DICK KEISER, DEERFIELD BEACH

Not only have they sat on this development while my kidney function numbers decline, they refuse to release TAF as a standalone drug. If I want it, I have to switch to their choice for my regimen, not my doctor’s or mine. Where is Gilead’s social responsibility? Where is legislation to protect consumers from this horrible behavior?

ANDY FYNE, SAN FRANCISCO

poz.com MARCH 2015 POZ 7

POZ Q+A

BY ORIOL R. GUTIERREZ JR.

The attendees of Speak Up!, PWN-USA’s first national summit

SISTERHOOD IN ACTION The chair of Positive Women’s Network USA reflects on self-empowerment for all women with HIV/AIDS.

B

ARB CARDELL IS THE CHAIR OF THE BOARD OF DIRECTORS OF the Positive Women’s Network United States of America (PWN-USA), a national membership group of women living with HIV/AIDS. Founded in 2008, PWN-USA builds leadership skills and advocates for social justice and human rights.

Based in Boulder, Colorado, Cardell has been HIV positive since 1991. She became a PWN-USA member in 2009. She was appointed to the Colorado Coalition for HIV Care and Prevention in 2011 and was elected vice chair of the coalition in 2012, the same year she started Colorado’s PWN-USA regional chapter.

In addition to her role at PWN-USA, she serves on the steering committee of the U.S. People Living with HIV Caucus, a group of organizations, networks, client groups and individuals with HIV advocating for people living with the virus.

In this POZ Q&A, Cardell shares her personal journey of being diagnosed and living with HIV, her experience with stigma and her belief in self-empowerment.

How does PWN-USA use self-empowerment to help women?

When we talk about HIV, it’s a self-perpetuating loop. Look at some of the social drivers that have put women at risk of HIV—poverty, intimate partner violence, low self-esteem. When we become HIV positive, all these things that put us at risk also disempower us.

Self-empowerment is about acknowledging who we are, how we got here and how coming together can move us forward in a way that can help not just ourselves, but also our sisters living with HIV and our sisters at risk for HIV. As women speak for ourselves and we’re heard, we find that so much can

8 POZ MARCH 2015 poz.com

change in our lives. We realize that perhaps abusive situations and a lack of quality health care are no longer things we’re willing to live with.

In 2015, we’ll continue to organize around the annual National Women and Girls HIV/AIDS Awareness Day, which is March 10. We’re also partnering with the Sero Project and the HIV Is Not a Crime conference to organize regional meetings to fight HIV criminalization laws.

In many ways, what I’ve learned about self-empowerment from PWNUSA—looking at the root causes, how people get to being at risk for HIV and also what affects their lives after they’re living with HIV—has informed not just my advocacy but other women who have come to the table in Colorado, and has then informed Colorado strategies.

Tell us about your stigma survey.

I’m part of the Colorado Organizations Responding to AIDS, a statewide group of organizations and advocates that forms a common message on advocacy

for and by people living with HI V. Three years ago we created a stigma survey and a campaign called “Compassion: Ending the Stigma.”

Every year we conduct the survey online. It’s an attempt to measure how educated people are around HIV issues.

We have a comments section. Watching the comments shift as people’s knowledge base shifts has been fascinating.

The most recent was a communitybased survey. We worked with Anne Stangl [of the International Center for Research on Women] to create it, so it’s based on what they do in Africa, as well as the St ig ma I ndex f rom Lau rel Sprague [of the Sero Project].

In Colorado, people are not saying that they feel like men who have sex with men [MSM] are socially judged— whether that’s true or not, that’s the perception. However, when you ask that question about sex workers, [we see that they are] very strongly judged.

People who inject drugs are also very strongly judged.

In some ways, messaging around MSM has been effective. In other ways, we need to shift messaging on other key populations who are at risk of or are living with HIV. Data from the latest survey will be used to inform the Colorado HIV/AIDS Strategy, which we wrote with a partnership between the Colorado Department of Public Health and Environment, AIDS service organizations and community providers, as well as people living with HIV.

BOTH IMAGES: COURTESY OF PWN-USA

How can we fight against stigma?

There’s no easy solution. At PWNUSA, we see stigma as one of the root causes of the continuation of the HIV epidemic. It comes from ignorance and fear. Until we make sure every person in the United States understands how HIV is transmitted, and how it is not, we will continue to have stigma.

Until our churches start addressing all of the beliefs that they have around so many people who are different— whether they’re gay, whether they’re trans, whether they’re women, whether they ’re whatever—when you have churches that see people as “other” and

able to be judged, we’ll have stigma.

As HIV-positive people, we know everybody has a story of being stigmatized and judged. We stop sharing those stories because we’re tired of sounding like we’re whining, or we don’t want people to think that we want them to pity us, or we don’t want to be victimized, or we don’t want to be seen as a “strong survivor.”

PWN-USA shares stories of women who are strong and are advocates and are out about their HIV status, so women who are not out can see that there are other women who can do this and then begin to believe that they can. We work at identifying and addressing the fear, as well as sharing and breaking down the isolation for women.

You can’t say everybody who’s HIV

Barb Cardell

like me; based on all the assessments, it wasn’t me.

The pernicious thing about categorizing groups of people who are at risk of HIV is that there are people who do not fit those categories. We need to focus on these high-risk groups, but we also need to realize there are people like me who fall through the cracks.

My husband and I had been married for about six months when I found out I was HIV positive. I was 29, and the doctors told me I had five years to live. I called him and said, “I’m HIV positive and I think we should get divorced, because I don’t want you to have to go through me getting sick and dying.”

He said, “I want to be with you as long as you’re around. Promise me you’ll be healthy for 10 years.” On my

“As women speak for ourselves and we’re heard, we find that so much can change in our lives.”

positive should tell everybody they’re HIV positive, because there are safety issues. But when we have people who are open, people see that that’s possible, more and more people know somebody who’s HIV positive, which means that they’re educated—it’s that spiral.

40th birthday I said, “OK, I guess you got your 10 years.” Then he said, “I want 10 more.” In 2014, I celebrated my 50th birthday and he remains HIV negative. I wouldn’t have had as good a journey if we weren’t still married. In many ways, I feel blessed.

Please share your HIV journey with us.

What keeps you motivated?

I was infected in 1991 and lived two more years with HIV before I got tested.

Some of my gay friends needed to get tested and weren’t, so I told them we were going out for drinks and dragged them to get tested with me.

It was dumbass luck that I found out I was HIV positive. The friends I tested with were all HIV negative. I’d been a buddy for people who were living with HIV and dying of AIDS-related illnesses since the late ’80s, so it wasn’t that I didn’t think HIV could happen to people

I do a lot of public speaking in schools. I have letters from kids who knew somebody with HIV and never knew how to talk to them but felt like they could after I had presented. Or I talked to somebody HIV positive and I helped them feel like they were a little less alone.

It’s so easy to get frustrated when you don’t see immediate results, but we’re all in this together and we all can make the world a better place. I love being in sisterhood with my HIV-positive sisters and our allies. ■

poz.com MARCH 2015 POZ 9

united states

2015

SEPTEMBER 10 - 13

visit us at:

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VOICES

BLOGS AND OPINIONS FROM POZ.COM

QUIET AT TIMES

In this edited excerpt of a blog post titled “HIV/AIDS Is Quiet at Times in Native Communities,” Theodore Kerr of Visual AIDS interviews Demian DinéYazhi’, founder of Radical Indigenous Survivance & Empowerment (R.I.S.E.).

T

(POSTERS) R.I.S.E.

he powerful poster [centered above] by R.I.S.E., an Indigenous artist/activist/warrior collective, was released on World AIDS Day, December 1, 2014.

What made you create the poster?

What inspired its creation is the absence of art production in Indigenous communities that broaches HIV/AIDS. Using the inspiration of World AIDS Day, Day With(out) Art and November’s National American Indian Heritage Month, I began working on a large, textheavy poster that lays out a few facts.

I wanted to link thriving and struggling Indigenous communities to taboo issues like HIV/AIDS. I also wanted to challenge other Indigenous artists/activists to create a space for HIV/AIDS in their communities and ceremonies that simultaneously takes into account the impacts of colonization, disease and government neglect in the hopes of healing.

The same goes out to HIV/AIDS and queer artists/activists: I want all of us to challenge the work we make so it includes Indigenous voices.

“Survivance is an active sense of presence, the continuance of native stories, not a mere reaction, or a survivable name. Native survivance stories are renunciations of dominance, tragedy and victimry.”

Every morning Indigenous Peoples of the Americas wake up in the colonized lands that stretch from Canada to Tierra del Fuego, and in those first few moments of the day they are making a political statement of resistance.

The issues that R.I.S.E. is dedicated to addressing fall under the categories of decolonization, indigenization, feminism and political activism, and we do this through curatorial inquiry, public interventions, wheatpaste/street art and by creating free digital posters for download at burymyart.tumblr.com.

Survivance is a part of our agenda.

Empowering our community and dedicating ourselves to our artwork is another part. It’s a lifelong battle that must be fought to ensure the perseverance of land and people, but also to re-establish the relationship of the people to the land. It’s not just an Indian thing; it’s a human necessity.

What is the meaning of “Survivance”?

In his writing on the issue, Anishinaabe scholar Gerald Vizenor states,

What was it like creating the poster?

I woke up at 4:30 one morning and knew I wanted to make a poster. I started off

as a writer, so most of the images that come to mind are text-based.

Sometimes I include photography, Native-inspired designs, and appropriated photographs or designs, like with the ongoing #decolonizefeminism series [see examples above] that utilizes appropriated images of Indigenous women with original text.

In this case, I originally was shooting for an upside-down triangle, because queerness is heavily embedded in my politics. But I realized that I wanted to distract the reader by creating an abstract image. I wanted to infect the reader’s mind with an image that was aesthetically rigid. The use of repetition allows the reader an entry point into any line. It allows for a gradient of meaning and it creates a cohesion that ties and binds all the issues addressed. I also was influenced by traditional Diné (Navajo) songs, which use repetition as a way to speak of continuity.

It is our duty as human beings of this living continent to make radical changes to the way we think of history, health, creating diverse communities, and our relationship to living organisms.

Hopefully we can all work together to ensure our own acts of survivance.

—Visual AIDS blogs.poz.com/visualaids

poz.com MARCH 2015 POZ 15

POZ PLANET

BY TRENTON STRAUBE

THIS TIME, IT’S PERSONAL Hannelore Williams explores today’s pandemic in her docu-series Dirty 30.

Before filmmaker and actress Hannelore Williams (Blue Bloods, One Life to Live) left the United States to volunteer at an HIV shelter in South Africa, she decided to research the epidemic. Realizing how much she didn’t know, she was inspired to get educated and to turn that process into a 10-part docu-series called Dirty 30. (The title references the 30th anniversary of AIDS, which is when Williams began the project.) Sleek and current as a music video, the series was filmed on three continents and is broken into subjects such as “Black Women and Single Motherhood,” “Monogamy and Sexual Healing,” “AIDS Inc.” and “Men: The Straight and the Gay.” POZ spoke with Williams as she was posting episodes of Dirty 30 on YouTube, a platform she hopes will reach the widest audience.

Whose voices did you want to capture?

I went for one of three people to interview: 1) people infected or affected directly by the pandemic, 2) experts, workers and scientists in the field, and 3) your average person who has an opinion about HIV. I did this because I wanted to see where we are today with the virus. People who

don’t consider themselves part of this pandemic are still a part of it. We all play a role in where we are today.

Are you concerned when an average person’s viewpoints might come across as politically incorrect or at odds with prevailing wisdom? For example, several interviewees mention men on the down low in a disparaging context, but researchers have shown that these men are not responsible for the high HIV rates among black women. I let people speak honestly about how they

feel, to hold a mirror up to our preconceived notions. When I present an idea that might be statistically incorrect, I place an interview or factoid to balance it or show the other side of that statement.

I do this because these “ideas” don’t just belong to this one person; they represent a large group of people who feel the same way. If you can relate to those statements, then maybe Dirty 30 [will] introduce you to some other ways of thinking. Then maybe we can have a productive dialogue around stigma and see some growth and healing.

You Can Pick Up What at a Bathhouse?! e?!

A vending machine at the Flex Spas gay bathhouse in Los Angeles offers free atthome oral HIV testing kits. It’s part of a pilot program in collaboration with the University of California, Los Angeles’s Global Health Program and the AIDS Healthcare Foundation (AHF). A previous study found that guys liked the vending machine option because it offered convenience, confidentiality and credibility. For example, the men could even take the test home and use itt privately whenever they’re ready.

Researchers like the option too. It provides vides 24-hour access to testing and also targets ets men at very high risk for HIV. “It’s our hope that vending machine test kits will create much-needed awareness and be a gateway to more comprehensive sexual health screening,”

16 POZ MARCH 2015 poz.com

For a pilot program, vending machines at a bathhouse in Los Angeles offer free at-home oral HIV testing kits.

says Mark M McGrath, a policy and research analyst for AHF. “Thus far, the vending machine has exceeded the traditional method of testing in this venue, which relies on health department trained personnel and has limited hours of availability.”

(WILLIAMS) COURTESY OF HANNELORE WILLIAMS; (VENDING MACHINES) COURTESY OF AHF/HECTOR TORRES III

What was your goal in taking on this project? To make a series about HIV that I could relate to. There are amazing films and documentaries out about HIV and AIDS, but none of the ones I have seen reflected how it has affected my family and friends.

Williams at the Mandela House in South Africa

Hot Dates / March 10: National Women and Girls HIV/AIDS Awareness Day / March 20: National Native

’Tis Always the Season to Help

Parsons is home to Southwest Center and related services.

PHOENIX RISING (PARSONS CENTER) COURTESY OF SOUTHWEST CENTER; (COAL) COURTESY OF PLANTING PEACE; (SELFIES) COURTESY OF PETER STALEY AND JACK MACKENROTH; (SCROLL) THINKSTOCK

Southwest Center for HIV/AIDS celebrates 25 years of service.

This year, Southwest Center for HIV/AIDS in Phoenix marks a major milestone: a quarter-century of service. But it has many other reasons to celebrate.

Last year, Cindy Hallman-Quenneville and Bruce Weiss took the helm of Southwest Center as executive director and deputy director, respectively. And the previous September, the AIDS organization moved into its brand-new home at the remodeled Parsons Center for Health and Wellness, which also houses the McDowell Clinic. Hallman-Quenneville says Southwest Center partners with the clinic so it can offer HIV-positive clients access to premier health care and support services, including behavioral health, nutritional education and medical case management. For convenience, there’s even an on-site pharmacy.

A snapshot of clients and programs: About 80 percent of the center’s clients are male and 33 percent are heterosexual; 45 percent are Caucasian, 34 percent

Latino and 16 percent African American.

“Our outreach, education and prevention programs are something we are proud of,” Hallman-Quenneville says, noting that their nutrition programs can truly improve their clients’ quality of life.

What’s on the horizon in 2015, aside from anniversary celebrations? “I am excited to help launch new wellness programs that will enhance the overall care a patient receives,” says HallmanQuenneville. “In addition, the center is working to expand services to youth.”

One of the standout programs at Southwest Center is Positive Peer Prevention (P3), which provides low-income teenagers with on-campus education about HIV and other sexually transmitted infections. This year’s goal is to reach 3,000 youth. Southwest Center also provides families the chance to go to camp for a week. As Hallman-Quenneville says: “It’s a time for the children to be just that: children!”

GOOD CLEAN FUNDRAISER

We all hate phrases like, “I’m clean, UB2,” which is slang for, “I don’t have HIV, but if you do, then stay away because you’re tainted.” So HIV activist Jack Mackenroth decided to clean up that mess of a message by launching the Shower Selfie fundraising campaign. The concept is simple: Take a familyfriendly shower selfie and post it on any social media platform along with the hashtag #weareALLclean; make a donation to an AIDS organization (include the link to it in your post); then nominate three others to take the challenge.

It looks like the campaign went, dare we say, viral. “In one o week, the hashtag #weareALLclean had over 26 million m social media impressions,” Mackenroth says, adding a that “on the financial front it was not so strong.

In a week we made about $7,000—but not bad considering the average donation was $10.” The campaign kicked off to coincide with World AIDS Day, but Mackenroth says that a re-launch r is in the works. So get Peter Staley ready r to hit the showers!

HIV/AIDS Awareness Day

Jack Mackenroth

Video of a sermon by Arizona pastor Steven Anderson went viral right before World AIDS Day. “All homos are pedophiles,” he ranted. “They’re filled with disA box of coal for ease because of the judgment of Pastor Anderson God. If you executed the homos, like God recommends, you wouldn’t have all this AIDS running rampant.”

The sermon reached the folks at Planting Peace, which offers support to the LGBT community and operates orphanages in Haiti for HIV-positive kids. “It is difficult to stop individuals like Pastor Anderson from spreading vile messages,” acknowledges Planting Peace president Aaron Jackson. “However, we can take his message and turn it into something positive for the co m m u n it y i m p ac te d by h i s words.” So Planting Peace launched a campaign to raise AIDS funds and send lumps of coal to Anderson on Christmas.

The public got into the spirit. So did Santa. He left a note (printed below) with his gift to Anderson, and it’s sure to spread cheer long after the holiday season.

Dear Steven,

shenanigans, out your recent When I heard ab at you topped th t in my mind ub do no as w there er, I extend my hty list. Howev ug na ng ’s ar ye is th to you for havi congratulations S gratitude and ID A for er $20,000 helped raise ov u truly are a Yo t. en tm ea d tr awareness an al. unique individu r ll you, whateve reply, ‘Truly I te rs he ot br “The King will e es th of the least of you did for one me.’” ine, you did for m and sisters of 5:40 MATTHEW 2 as!

Merry Christm rd’s work, ue to do the Lo in May you cont

Santa

CARE AND TREATMENT

BY BENJAMIN RYAN

Some Oral Birth Control Is Safe With ARVs

The CDC’s new guidelines for HIV prevention strategies include linking people to care.

CDC TAKES ON “PREVENTION WITH POSITIVES” The Centers for Disease Control and Prevention (CDC) has taken its 32-page 2003 guidelines on HIV prevention strategies for people living with the virus and expanded them into a 240-page, multifaceted tome.

The previous version focused more narrowly on issues like behavioral risk factors, sexually transmitted infections, needle sharing and partner notification.

The new effort stresses that HIV-positive people are central players in the effort to fight the spread of the virus. It includes factors such as prevention through the use of antiretrovirals (ARVs) and the importance of effectively linking people with HIV to medical care and keeping them in care. The new guidelines also address conceiving a child, access to health insurance, stigma, poverty, mental illness, substance abuse, housing and laws criminalizing HIV. The CDC advises clinicians to offer ARVs to all HIV-positive patients, regardless of CD4 count—not just because treatment greatly reduces the likelihood of transmission, but also because of the apparent health benefits of starting treatment earlier. Additionally, it encourages health care providers to educate patients about pre-exposure and post-exposure prophylaxis (PrEP and PEP) for HIV-negative people.

Praising the new guidelines, Jeff Bailey, director of client services at AIDS Project Los Angeles, says that “integrating prevention in the medical setting” through the various strategies outlined in the CDC document “is an important, viable strategy that’s supported by evidence and which can reduce the incidence of new infections.”

18 POZ MARCH 2015 poz.com

Current World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) guidelines caution HIV-positive women taking antiretrovirals (ARVs) not to use oral contraceptives if other birth control methods are available, because some ARVs are thought to reduce their effectiveness. However, new research finds that some forms of oral birth control may indeed be OK to use with ARVs, suggesting that these guidelines may be overly broad.

There are basically two forms of birth control pills: combination medications that include estrogen and progestin, and methods based just on progestin. The previous studies that informed the WHO and CDC guidelines were based only on combination birth control pills.

Researchers examined the blood levels of the oral birth control norethindrone, a progestin, in HIV-positive women taking Norvir (ritonavir)-boosted Reyataz (atazanavir), and compared them with a group taking norethindrone along with ARVs previously shown not to change levels of the contraceptive. As it turns out, boosted Reyataz actually raises norethindrone levels compared with the other ARVs. “Researchers and practitioners have been extrapolating data from these other formulations [of contraceptives and ARVs] and applying them to this particular formulation,” says Ganesh Cherala, PhD, an assistant professor of pharmacy practice at Oregon State University, who was a corresponding he study. “For the first author on the ve data that that time we have on actually extrapolation ke sense.” doesn’t make esearch is still Future research needed to determine if the s of the raised levels ol pills birth control e would make them more effective.

PrEP USE RISES AMONG MEN

ALL IMAGES: THINKSTOCK

PrEP On Demand Shows Promise A study of “on demand” PrEP abruptly canceled its placebo arm when the protocol showed high efficacy in preventing HIV. The IPERGAY trial involves 400 high-risk MSM in France and Canada who were randomly assigned to receive either a placebo or Truvada, with instructions to take two pills two to 24 hours before they anticipated having sex and two separate single-pill doses a respective 24 hours and 48 hours after sex.

The study’s data safety monitoring board found that those taking PrEP enjoyed a “very significant” reduction in risk for contracting the virus that was “much higher” than the 44 percent found in the iPrEx trial. (iPrEx was published in 2010 and first proved PrEP’s efficacy among MSM.) “This is not a strategy to be used alone,” cautions Jean-Michel Molina, MD, PhD, the study’s principal investigator, “but it should be delivered with comprehensive care and monitoring.”

Molina says he and his team will present more specifics about the study at the Conference on Retroviruses and Opportunistic Infections (CROI) in Seattle in February.

New data indicates that the use of Truvada (tenofovir/emtricitabine) as pre-exposure prophylaxis (PrEP) is on the upswing in the United States, with the demographic of users trending increasingly male. Gilead Sciences, which manufactures Truvada, conducted an analysis of pharmacy data from January 2012 through March 2014 and found that 3,253 people went on PrEP during that period, including 1,057 new prescriptions filled during the first nine months of 2013 and an additional 880 between October 2013 and March 2014.

These data have critical limitations. They are drawn from only about 55 percent of U.S. pharmacies, reflect only a limited proportion of prescriptions p ffilled through Medicaid, and do not factor in people taking PrEP as part of a study. Further, given the accelerating national interest in PrEP, the figures are already well out of date. The Gilead analysis can, however, help give a decent impression of changing trends over time.

By comparison, a single clinic, Kaiser Permanente Medical Center in San Francisco, reported having more than 500 patients on PrEP in December, compared with 250 during midsummer of 2014 and 40 in 2013.

The proportion of men taking PrEP has increased ncreased since Gilead’s previous report, which covered PrEP use through rough September 2013. During the first half of 2012, 46 percent nt of new PrEP prescriptions were among men, compared with 73 percent from October 2013 through March 2014.

Characterizing Gilead’s figures as “an interesting esting snapshot,” Jim Pickett, director of prevention advocacy at AIDS Foundation of Chicago, says, ys, “It does make sense that men are making up a bigger proportion. I would expect that to continue. Where are the numbers going up? They’re going up in one population.”

HIGH EFFICACY FOR PrEP A British pilot study of PrEP among high-risk men who have sex with men (MSM) and among transgender women showed such high efficacy for Truvada that those in the arm of the study that deferred administering PrEP for a year were invited to take it immediately. The PROUD study includes 545 participants who were all offered regular testing for HIV and sexually transmitted infections as well as condoms and safer-sex support. This is the only way Britons can obtain a PrEP prescription at present.

PROUD’s goal is to determine if it is feasible to conduct a larger study about PrEP’s use among MSM in England, a trial that would address questions about: the intervention’s efficacy and cost effectiveness; MSM’s interest in taking Truvada, their adherence levels and their tendency toward riskier behavior on PrEP; and if PrEP users run the risk of drug resistance should they contract HIV.

The researchers initially calculated that they would eventually need 5,000 study participants to come up with statistically significant results.

Sheena McCormack, MSc, a professor of clinical epidemiology at Imperial College ege in London and the study’s ’s chief investigator, says her team “never expected ted to see a result” with this his small study. “That is s only possible under er two conditions. You ou can only have a level off benefit that makes the he data monitoring board oard stop your study dy if: a) PrEP is incrededibly effective; and b) the rate e of HIV is much higher than we e thought. So it’s ’s sort of good news and bad news.” s.”

RESEARCH NOTES

BY BENJAMIN RYAN

TREATMENT

CURE

CONCERNS

A Multipurpose Vaginal Ring

New Potential Treatment Target

High Hep C Cure Rates

U.S. “Treatment Cascade” Stats

A vaginal ring has shown promise in protecting against HIV, genital herpes, human papillomavirus (HPV) and pregnancy in a primate study. Researchers gave rhesus macaque monkeys vaginal rings containing either a placebo or various combinations of agents, including: levonorgestrel as a contraceptive; and a combination therapy called MZC to protect against SHIV (an HIV-like human-monkey hybrid virus), HPV and herpes symplex virus type 2 (HSV-2). Next, the monkeys were repeatedly exposed to SHIV and HSV-2. Four of the 12 monkeys with the rings containing MZC plus levonorgestrel acquired SHIV. Meanwhile, all four of the monkeys with the rings containing just the contraceptive and two out of four monkeys that received the placebo rings contracted SHIV. Data also suggested that the rings with MZC lowered the risk of HSV-2 by 25 percent. Tests of the blood levels of the preventive elements suggested the rings may also help prevent pregnancy and HPV.

Researchers have identified a new potential treatment target: Ssu72, a human protein that spurs dormant HIV-infected cells into an actively replicating state by interacting with a virusgenerated protein known as Tat, without which HIV cannot live. Ssu72 is a phosphatase, an enzyme that binds to Tat to help to begin viral transcription; Ssu72 also creates a kind of feedback loop that accelerates this process. Another protein, CycT1, interacts with Tat similarly but is needed for normal human cell function, making it a less-than-ideal drug target.

Ssu72, on the other hand, isn’t needed for developing RNA for most human cell genes. Researchers are hoping to target Ssu72 in order to prevent viral replication. They are also studying whether low levels of the protein result in HIV-infected CD4 cells entering a resting state.

In a recent trial, Gilead Sciences’ newly approved Harvoni (ledipasvir/ sofosbuvir) cured hepatitis C virus (HCV) in nearly all people who were coinfected with HIV and genotype 1 of HCV. The trial included 50 coinfected participants, about a quarter of whom had advanced fibrosis, although none had cirrhosis.

The 37 participants who were on antiretrovirals (ARVs) to treat HIV were taking Truvada (tenofovir/ emtricitabine) with either Sustiva (efavirenz), Isentress (raltegravir) or Edurant (rilpivirine). After 12 weeks of Harvoni treatment, all 13 of those not taking ARVs were cured of hep C, while 36, or 97 percent, of those taking ARVs were cured. Harvoni has been found to raise levels of Viread (tenofovir, a component of Truvada), but the researchers did not detect significant abnormalities.

However, three people did have transient protein in their urine.

Compared with various other high-income Western nations, the United States fares remarkably poorly in getting people with HIV diagnosed, into stable care, on treatment and to an undetectable viral load. In a recent analysis of “treatment cascade” figures in the West, estimated national HIV diagnosis rates ranged from a low of 71 percent in British Columbia (figures for all of Canada were unavailable) to a high of 86 percent in Australia, with the United States at 82 percent. The United States had the lowest linkage to care rate, at 66 percent, and by far the lowest rate of HIV-positive people retained in care, at 37 percent, compared with a high of 81 percent in Denmark. A low of 33 percent of Americans with HIV are on treatment, compared with a high of 67 percent in the United Kingdom. The U.S. viral suppression rate is also the lowest at 25 percent, compared with a high of 62 percent in Australia.

20 POZ MARCH 2015 poz.com

(VAGINAL RING) GETTY IMAGES/N. AUBRIER; (OTHER IMAGES) THINKSTOCK

PREVENTION

POZ SURVEY SAYS

BY JENNIFER MORTON

The Big Sleep

7%

Getting a good night’s sleep is vital to our overall health and well-being. Yet a majority of people living with HIV say they have problems sleeping. POZ recently asked you about your sleep habits and whether or not you are getting enough shut-eye. Here are your responses.

EXCELLENT

20%

28%

40%

FAIR

33%

HOW LONG DOES IT TAKE YOU TO FALL ASLEEP?

15-30 MINUTES

POOR

HOW WOULD YOU RATE THE OVERALL QUALITY OF YOUR SLEEP?

27%

6%

5-15 MINUTES

MORE THAN 30 MINUTES

40%

GOOD

NEVER

6% 0-5 MINUTES

27%

39%

OFTEN

ALWAYS

28%

SOMETIMES

N OT D IS T U

R

(TV) THINKSTOCK

PL

EA

PL E A

DO

N OT

DI

S

33% 78% hen id w , a s u p of yo wake u u o he y hit t u o y ze snoo n. o butt

TIP: If you have trouble sleeping, avoid watching TV or using electronicc devices like your computer, tablet or cell phone before bedtime.

SE

RB

OF YOU FALL ASLEEP IN FRONT OF THE TV.

O

TU

40%

D

B

SE

DO YOU GENERALLY WAKE UP DURING THE NIGHT? DUR

of you said the quality of your sleep has changed since your HIV diagnosis.

Source: March 2014 POZ poz.com MARCH 2015 POZ 21

Shawn and Octavia, both transgender, care for two boys.

TWO OF A

KIND

OCTAVIA LEWIS AND SHAWN LOPEZ SHOW US THAT LOVE CAN CONQUER ALL.

I

N MANY ASPECTS, OCTAVIA LEWIS AND SHAWN LOPEZ are like most couples forging a life together. Introduced about four years ago by friends, the pair recently moved into a twobedroom apartment in the Bronx, New York, where they’ve already started a family. Marriage is on the horizon.

In many other aspects, Octavia and Shawn are unique.

They are helping raise two very young boys, Ethan and Messiah, who arrived from Children’s Village, which places vulnerable children in homes. What’s more, Octavia and Shawn are a serodiscordant couple—Octavia contracted HIV in 2006 from an unfaithful partner, and Shawn is HIV negative. They’re also transgender.

Speaking with POZ on a recent cold Sunday evening, the couple talk openly about their past journeys and future hopes. Throughout the conversation, Shawn holds Ethan on his lap, trying to soothe the toddler. The couple plan to adopt the 18-month-old boy, whose biological mother is mentally challenged and whose father is unknown.

Sitting beside Shawn is Octavia, an African-American woman who at 6-foot-1 towers over her fiancé. Originally from Georgia, Octavia has never lost her Southern accent and sense of hospitality. As they talk about their lives, it’s clear that, on some levels, the couple represent the all-too-common

BY ADEMOLA BELLO | PHOTOGRAPHY BY BILL WADMAN

poz.com MARCH 2015 POZ 27

ways that HIV often intersects the lives of transgender people, while at the same time, their story sounds like the only one of its kind you could ever encounter..

IT IS NO SECRET THAT TRANSGENDER WOMEN (THAT is, male-to-female transgender people) are at high risk for HIV. In fact, the prevalence of HIV is higher among this population than other high-risk groups, including men who have sex with men (MSM), injection drug users and sex workers. A meta-analysis published in the Lancet Infectious Diseases journal found that, worldwide, nearly one in five transgender women are living with HIV. In the United States, that number is slightly elevated: 21.6 percent. But data from the Centers for Disease Control and Prevention (CDC) put this statistic as high as 27.7 percent.

A closer look at the breakdown of HIV prevalence among the transgender population is revealing. According to a CDC fact sheet on HIV and transgender people, “In New York City, from 2007– 2011, there were 191 new diagnoses of HIV infection among transgender people, 99 percent of which were among transgender women. The racial/ethnic disparities were large: Approximately 90 percent of transgender women newly diagnosed with HIV infection were blacks/African Americans or Latinos.

Over half (52 percent) of newly diagnosed transgender women were in their 20s. Also, among newly diagnosed people, 51 percent of transgender women had documentation in their medical records of substance use, commercial sex work, homelessness, incarceration, and/ or sexual abuse as compared with 31 percent of other people who were not transgender.”

Why is HIV so prominent among this population? Jennifer M. Barge, director and founder of TransHealth Coordinators, a group that offers education to medical practitioners while also helping the trans community attain better health care options, offers some insight. “The alienation from family and friends leaves us feeling unloved,” Barge says.

“Add rejection and even abuse from partners, and you end up with a vulnerable person who just wants to make their life work.” Another reason, she says, is that “culturally, if you want to be ‘the woman’ then you need to be subser- Shawn and Octavia found support vient to ‘the man,’ have from their family members. and if he does not

28 POZ MARCH 2015 poz.com

want to wear a condom, then no protection is used.”

Other factors are well documented to be more prevalent among the transgender population and to increase their risk of acquiring HIV. An issue brief on the topic published by amfAR, the Foundation for AIDS Research, includes these factors: low self-esteem and body issues; sexual risk behaviors (such as the unprotected receptive sex Barge mentions); injection drug use, including hormones and injecting silicone; the presence of sexually transmitted infections; inadequate access to good health care; violence; and sex work.

OCTAV I A LA MEN TS TH AT SO M A N Y WOMEN OF trans experience turn to sex work. She explains that because they don’t have equal employment opportunities, it’s often one of the only ways they can pay for food, rent or surgeries.

“I used to do commercialized sex,” Octavia acknowledges. “It’s not something I’m proud of. I did it because I had to pay my way to school.” She earned her master’s degree from DeVry University and is working on her doctorate at Capella University.

Speaking honestly, even about topics such as sex work, is part of what Octavia does as an advocate and educator. As a member of Trans Women of Color, she has spoken about HIV/AIDS issues for events at the Apollo Theater and at New York University. “I educate those who want to be allies,” she says, noting that she uses every platform available to get her messages across—and that includes being an active parent in her community.

Before transitioning, Octavia lived as a gay man and dressed in drag. It was during this phase of her life that she contracted HIV in 2006 through her gay partner. When her HIV test came back positive, she went into a depression—she had watched two friends die of AIDS-related illness—and she even thought of suicide. Luckily she met mentors and had family members who helped her out of the darkness; they also inspired her to start living as Octavia. In 2011, she relocated to New York City and rebooted her life, committed to giving back to others in need. Today, Octavia, who turned 34 this February, works full time as an educational specialist in transgender programming at Hetrick-Martin Institute, helping LGBT youth prepare for college.

Her friends say Octavia’s boundless optimism plays a big part in her success. “Octavia is a person that always believes God or the universe will find a way for things to work out for her,” says Kim Watson, a family friend and co-founder of the transgender group Community Kinship Life (CK Life). “That mind-set won’t allow her to stay down, even when life hits her with something like HIV.” Watson describes Shawn in similar terms: “They are both stubborn, but in a good way. They’re a unique couple because they do what makes them happy and not what others expect them to do.”

“THEY’RE A UNIQUE COUPLE BECAUSE THEY DO WHAT MAKES THEM HAPPY.”

SHAWN, 47, A NATIVE NEW YORKER, HAD HIS FIRST trans-related surgery in 2011. Octavia has also undergone surgeries as part of her journey. Despite the life-altering importance of these procedures, in 42 states health insurance companies can legally discriminate against transgender people.

Such a lack of equality and a dearth of health care workers educated about trans issues are yet other factors that put transgender people at risk for HIV. It is difficult to say with certainty whether or not Shawn’s HIV-negative status is typical of other transgender men (i.e., female-to-male transgender people). The topic is understudied. “Compared to transgender women, little is known about HIV risk and sexual health needs among transgender men,” the CDC notes. “One meta-analysis of 29 studies involving transgender people showed that only five of them had separate data concerning transgender men.”

In general, though, health surveys fail to take into account gender-variance factors, which makes collecting data on the transgender population that much more difficult. This problem was illustrated in fabulous and personal detail at the most recent United States Conference on AIDS, where Orange Is the New Black transgender star Laverne Cox recounted her own experiences while taking part in a recurring HIV study in New York City.

On the survey, she had to be categorized as a man who has sex with men (MSM) because its parameters didn’t allow her to identify as a transgender woman. “Trans folks are not going to go into a study that disavows and erases their identity,” she told the audience. “We need more studies to acknowledge who we are. That is so fundamentally important.”

The good news, wrote Jason Cianciotto and Marcel Byrd of GMHC in a recent POZ opinion piece, is that the United States is equipped to include transgender people in HIV care and research. A number of long-established organizations are currently providing treatment and care for people living with HIV. “The infrastructure already exists that can support transgender-specific initiatives,” they write. “We need these agencies to prioritize prevention and treatment for transgender people and the funding to make it happen.”

OF COURSE, SHAWN AND OCTAVIA DON’T DEFINE themselves or their relationship in terms of statistics and research. To Shawn, he and his fiancée are just “two kind, loving people.” Currently they have a domestic partnership, but they do plan to get married once they’ve completed all their surgeries.

In the more immediate future, they’re looking forward to warmer-weather activities—going to the movies, restaurants and beaches—and of course lots of time with family.

Octavia dreams of becoming the director of an HIV clinic. “I understand what it’s like to be a consumer,” she says, “and then I understand what it’s like to be HIV positive. I also have experience as a health care professional.” She’s a self-proclaimed “unapologetic woman” who advises other transgender people to live their authentic truth without shame or regret.

Shawn, a proud stay-at-home dad, is focused on raising Ethan and Messiah, no easy task since Ethan is developmentally behind other 18-month-olds and requires therapy twice a week. Shawn would love for his family to own a home someday—and to adopt another child. “My dream,” he says, “is to continue being a father and see that my children’s dreams come true.”

Such aspirations might seem commonplace, even mundane, among most couples; for Octavia and Shawn, though, such dreams are also unique. ■

poz.com MARCH 2015 POZ 29

30 POZ MARCH 2015 poz.com

BETTER HIV TESTING BECOMES EVER MORE CRUCIAL AS PREVENTION EFFORTS INCREASE.

BY BENJAMIN RYAN

THINKSTOCK

IN MARCH 1985, THE U.S. FOOD AND DRUG Administration (FDA) licensed the first HIV antibody test: an enzyme-linked immunosorbent assay, or ELISA, manufactured by Abbott.

For members of high-risk groups, the four years preceding this milestone in the epidemic had become increasingly fraught and perilous. AIDS-related complications were claiming a rapidly escalating number of lives, and many lived in constant fear of a great unknown.

HIV had been identified as the cause of AIDS in 1984. But if someone had no AIDS-defining disease symptoms—checking for Kaposi’s sarcoma skin lesions had become a widespread undertaking for gay men—even the various tests to detect immune disorders still failed to provide clear answers.

This is not to say that the HIV test—which took about a week to provide results and required a blood draw— offered immediate relief to such anxiety, since the antiretroviral revolution that made HIV relatively manageable wouldn’t begin for another decade.

Although the test could reassure those whose results were negative, a positive result was still considered a death sentence. Many preferred not to know.

“WHETHER OR NOT TO GET TESTED WAS a torturous decision, as most people felt there was nothing to do medically if you knew you were positive,” recalls Laura Pinsky, LCSW, who co-founded the world’s fi rst college campus testing site at Columbia University in 1985, and who still directs the Gay Health Advocacy Project (GHAP), as the program is known. (This reporter was an HIV test counselor at GHAP during college.)

Noting that Bactrim was already being used as prophylaxis

against Pneumocystis pneumonia (PCP)—a particularly insidious, AIDS-defining killer—Pinsky says, “Although we at GHAP saw [getting an HIV test] as very much a personal decision, we were attacked for even suggesting that there was some benefit to knowing your HIV status and CD4 cell count and starting Bactrim, or an alternative, early on.”

On the brighter side, by midsummer 1985, U.S. health officials expressed relative confidence that HIV antibody testing was highly effective at clearing the virus from the nation’s supply of transfusion blood. This was a profound accomplishment, considering that an estimated 9,000 people had previously contracted HIV from transfusions.

Additionally, an estimated 5,300 hemophiliacs had contracted HIV from clotting factor transfusions. But changes in the processing of clotting factor had already addressed this issue earlier in the 1980s.

By comparison, fewer than 10 Americans have contracted HIV from a transfusion since the nucleic acid test, which looks for HIV’s genetic material rather than antibodies against the virus, was fi rst used to screen the supply in 1999.

Thanks to the protection provided by this advanced testing technique (not to mention political pressure), in December 2014 the FDA ended its controversial lifetime ban on donating blood for any man who has had sex with a man since 1977.

Under the new policy, men can donate blood if they’ve not had sexual contact with another man within the last year.

THROUGHOUT THE 30 YEARS SINCE THE ADVENT OF the HIV test, researchers have pushed the capabilities of screening technologies, allowing for earlier detection of the virus after infection as well as greater ease of use.

The first rapid test was approved in 1992, followed two years later by the first oral fluid test. Urine tests, as well as home tests requiring samples mailed to labs, hit the scene in 1996. In 2002, a rapid test using a finger prick instead of a

poz.com MARCH 2015 POZ 31

New CDC Recommendations for HIV Testing in Laboratories A step-by-step account of the approach

The CDC’s new recommendations for HIV testing in laboratories capitalize on the latest available technologies to help diagnose HIV earlier after infection—as much as 3 to 4 weeks sooner than the previous testing approach. Early diagnosis is critical since many new infections are transmitted by people in the earliest (“acute”) stage of infection. By putting the latest technology to work in laboratories across the United States, we can help identify more people who are newly infected and take steps to help prevent them from passing on the virus.

STEP 1: “Fourth-generation” HIV test DETECTING HIV SOONER Detects HIV in the blood earlier than previously recommended antibody tests by identifying antibodies and the HIV-1 p24 antigen, a viral protein that appears in the blood sooner than antibodies.

POSITIVE

HIV-negative

DIAGNOSIS

Acute HIV-1 Infection

FALSE POSITIVE

Produces results faster than the previously recommended Western Blot.

Distinguishes between HIV-1 and HIV-2, which the previously recommended Western Blot cannot do—this distinction can have important treatment implications for a patient.

NEGATIVE

DIAGNOSIS

STEP 2: HIV-1/HIV-2 antibody differentiation immunoassay DIAGNOSING HIV-1 VS. HIV-2

NEGATIVE

POSITIVE

NEGATIVE OR POSITIVE INDETERMINATE STEP 3: Nucleic Acid Test (NAT) ACUTE HIV-1 INFECTION OR “FALSE POSITIVE”?

Looks for genetic evidence of HIV, which surfaces seven to 12 days after infection.

Interpret Test Results as HIV-1 or HIV-2

DIAGNOSIS HIV Infection

This graphic contains information provided by the CDC and illustrates key concepts of its new testing approach in laboratories. For more details, please see the full guidelines here: cdc.gov/hiv/pdf/HIVtestingAlgorithmRecommendation-Final.pdf.

blood draw became available, and a year later it was granted what is known as a Clinical Laboratory Improvement Amendments (CLIA) waiver, allowing for its use outside of testing laboratories and inside venues such as doctor’s offices, community-based organizations and testing vans. The fi rst rapid oral fluid home test arrived in 2012.

Health agencies have increasingly advocated expanded HIV testing during the past decade. In 2006, the Centers for Disease Control and Prevention (CDC) recommended routine HIV screening in U.S. health care settings, which the World Health Organization and the Joint United Nations Programme on HIV/AIDS began pushing for on a global scale in 2007.

In 2013, the United States Preventive Services Task Force gave routine HIV screening for Americans ages 15 to 65 an “A” rating, its highest recommendation level. Under Obamacare, this nod means that Medicaid, Medicare and new private health plans should cover HIV testing at no cost to the consumer.

SCIENTISTS SEEKING TO IMPROVE HIV ASSAYS HAVE been up against a formidable challenge because the virus can be difficult to detect when it is most infectious, during

32 POZ MARCH 2015 poz.com

the fi rst 90 days or so of infection. During this period, which is also known as acute infection, viral load is at its peak— that is, until the latter stages of AIDS, when untreated virus will once again rise to highly infectious levels.

After a person gets HIV, it takes two to eight weeks before the body produces detectable antibodies, which are diseasefighting molecules. This gap is known as the “window period,” during which false negative results are possible, since the oldest HIV tests only look for antibodies. Getting tested during the window period and failing to retest later can have significant public health consequences.

“Nearly 50 percent of forward transmission of HIV occurs during the earliest phases of infection, missed by most currently used antibody tests,” says Demetre Daskalakis, MD, MPH, assistant health commissioner at the New York City Bureau of HIV/AIDS Prevention.

Research suggests that, after people test positive for HIV, they typically take significant steps to reduce the risk of transmitting the virus. Plus, antiretroviral treatment that fully suppresses the virus appears likely to all but eliminate the chance of transmission to others.

WHILE MANUFACTURERS OF ANTIBODY tests have steadily improved them over time, shaving down the window period in particular, it wasn’t until 2010 that a test could identify an infection before detectable antibodies arise. This now-common test detects what’s known as the p24 antigen, a protein component of HIV that spurs development of antibodies against the virus.

Consequently, the newer tests that look for p24 have a shorter window period, about three weeks. In addition, because the antigen disappears again after a few weeks, only to return at the onset of AIDS, its presence can indicate if someone is newly infected.

In August 2013, the fi rst rapid test that can detect both HIV antibodies and p24, the Alere Determine, gained FDA approval. And in December 2014, after what James Krellenstein, a founding member of the Prevention of HIV Action Group of ACT UP New York, characterizes as a “long fight,” the FDA fi nally granted a CLIA waiver to this “fourth-generation” test.

“The clinical and public health ramifications of this delay were so significant that in October 2014 a very senior researcher at the Division of HIV/AIDS Prevention at the CDC pulled me aside at an HIV conference and, in private, strongly urged me and ACT UP to do something to expedite the process,” Krellenstein says.

“It is imperative that new, fourth-generation testing technology that detects viral antigen be adopted widely to detect early HIV and open the door to care linkage,” says New York’s Daskalakis.

“Whether by awareness of acute infection and behavior change or treatment to suppress HIV, detection of [acute HIV infection] and using newer platforms for testing may allow us to better interrupt networks of transmission.”

Then there’s the nucleic acid test, which looks for HIV’s genetic material and can detect an infection even earlier than a fourth-generation test, at about seven to 12 days after exposure. It was approved for HIV testing in 2006. However, its use is limited, in part because of a high price tag and a long turnaround time.

3 POZ 34 PO P OZ M MA MARCH AR C A CH H 2015 5p poz.com po poz o z .co oz .co co m

HIV TESTING MILESTONES

1981

First AIDS cases identified

1984

HIV discovered

1985

HIV antibody test (ELISA)

1987

Western Blot HIV test

1992

Rapid test

1994

Oral fluid test

1996

Home test (mailed to labs)

2002

Finger prick rapid test

2004

Rapid oral test

2010

Antigen/antibody test

2012

Rapid oral fluid home test

2013

Rapid antigen/ antibody test

GIVEN THE COLLECTIVE POWER OF THESE new and ever-evolving tools, the CDC revised its HIV testing guidelines in June 2014 in an attempt to cut the typical window period by as much as three to four weeks.

The first step in the suggested protocol is a fourth-generation test for both HIV antibodies and p24. A negative result means an HIV-negative diagnosis (which can still be a false negative if someone was infected less than three weeks before). If the result is positive, next comes an antibody test that can distinguish between HIV-1 or HIV-2, which are the two types of the virus.

(HIV-1 is predominant worldwide, while HIV-2 is found mostly in West Africa.)

This antibody test provides faster results than the previously recommended Western Blot assay, which arrived in 1987. If the result of the HIV-1/HIV-2 test is positive, the lab technician determines the type of virus. If the result is negative or indeterminate, the subsequent step is a nucleic acid test. A negative result of that test indicates the fourth generation’s positive result was false, so the diagnosis is HIV negative (with another nod to the window period). A positive result indicates an acute HIV infection.

It’s important to note that no one who gets an HIV test should assume that the complete CDC protocol will be followed. Home tests, for example, still only look for antibodies. Also, there is only one FDA-approved nucleic acid test for HIV, which isn’t available in most public health labs because of various technical and logistical obstacles.

To address this problem, the CDC is testing a program that by 2016 might allow labs that don’t have easy access to nucleic acid tests to farm out their blood samples.

Meanwhile, researchers are developing nucleic acid tests that can be conducted at the testing site and could produce results in just an hour—and perhaps much more cheaply.

The CDC is also teaming up with others in the public health field and with players in the biotech industry to bring new tests to market that may lower the cost of HIV testing in other ways, and also to develop tests that can screen for additional pathogens, such as the hepatitis C virus (HCV), along with HIV. “It’s important to think beyond the laboratory,” Michele Owen of the CDC says. “We also need to be able to reach people at the moment they receive health care with tests that can detect early HIV infection. The CDC is actively involved both in the field and in the lab to identify new testing methods and to develop new technologies to afford the most advanced HIV testing possible.” ■

CREDI CREDIT C CR THINKSTOCK R T

“In this new era of HIV prevention, with more options than ever before, testing remains one of our most important allies,” says Michele Owen, PhD, acting associate director for laboratory diagnostics in the CDC’s Division of HIV/AIDS Prevention. “For those who have HIV, testing is the gateway to treatment and care, and for those who do not have HIV, testing can help link them with important prevention services so they can remain HIV-free.”

More states have legalized recreational pot, but the effects of that remain unclear.

THE FUTURE OF MEDICAL MARIJUANA FOR HIV/AIDS LOOKS HAZY.

BY RITA RUBIN

(MARIJUANA) GETTY IMAGES/ROBERT BENSON; (SMOKE) THINKSTOCK

JAY LASSITER STARTED SMOKING POT AT AGE 19, RIGHT AROUND THE time he learned he was HIV positive. “It was a coincidence,” he says. “Sort of like sex, drugs, and rock ‘n’ roll. It was part of the package.”

When Lassiter was 24 he moved to California, which in 1996 became the fi rst state to legalize medical marijuana. But if he wanted to buy it, Lassiter had to get a letter from a doctor. He could no longer put off making an appointment.

Nearly 20 years later, the now-42-year-old Lassiter credits marijuana with saving his life. “I wanted pot because I liked to smoke pot,” says Lassiter, a political consultant and outspoken advocate of legalized marijuana for all adults, not just those who need it for health reasons.

“I knew that my entry into the world of having access to legalized marijuana was predicated on my HIV status,” he says. “At that point, having access to a drug that I liked to do recreationally provided the incentive for me to face up to this disease and ultimately manage it for a very long time.”

Lassiter, who now lives in New Jersey, says he smokes pot daily, but he really only uses it to help manage HIV symptoms a couple times a month. “I still like smoking marijuana,” he explains, noting that pot does help him sleep and eat better.

When asked if he smokes only legally obtained medical marijuana, Lassiter told this reporter to write that he “smiled sheepishly and had no comment.”

In Maine, Maryland and New Jersey, smoking medical pot is allowed for conditions that might affect people with HIV/AIDS, such as wasting syndrome, pain and nausea, but HIV/AIDS is not specifically cited.

In 19 states and the District of Columbia, smoking medical marijuana is allowed for several conditions, including HIV/AIDS. In New York state, only edible—not smoked—medical pot is allowed for any condition, including HIV/AIDS. Although Alaska, Colorado, Oregon, Washington state and DC also have legalized recreational marijuana, the federal government still deems pot illegal for any use. As a result, some doctors are reluctant to recommend it, and few scientists have studied its safety and effectiveness in treating people with HIV/AIDS and other conditions.

poz.com MARCH 2015 POZ 37

Meanwhile, as more and more states legalize medical marijuana, fewer and fewer people with HIV/AIDS need it to relieve symptoms or side effects, thanks to the development of safer, more effective antiretroviral medications.

SEARCH THE WORD “MARIJUANA” ON THE WEBSITE for Boston’s Fenway Health, an LGBT health care, research and advocacy organization, and you won’t get a single hit, even though Massachusetts has legalized medical marijuana.

“Because we are a federally qualified and funded health center, we are awaiting federal guidance on this issue and are not currently writing prescriptions for medicinal marijuana,” spokesman Chris Viveiros says.

The AIDS Action Committee of Massachusetts has supported legalized medical marijuana since 1996, says executive director Carl Sciortino, who also pushed for it during his nine years as a state representative. “Our community would have significantly benefited from it in the earlier days of the epidemic.”

But by the time Massachusetts voters approved legalizing medical marijuana in 2012, the percentage of people with HIV who stood to benefit had declined, Sciortino says: “It’s not what it was even 10 years ago.”

Still, AIDS Action’s commitment to the cause never flagged, he says, because the organization wanted to support those with other conditions who had a more pressing need for medical marijuana.

In the early 1990s, when doctors fi rst began thinking that marijuana could relieve symptoms in people with HIV/AIDS, “the whole epidemic was very, very different,” says David Hardy, MD, a Los Angeles infectious disease specialist whose practice tended to attract the sickest patients. “We basically were just slowly staving off the virus. The death and dying was very, very high.”

Two of the most common and debilitating symptoms in that era were wasting and nerve pain, and the best help that doctors could offer was to make patients as comfortable as possible, Hardy says.

They could prescribe anabolic steroids or expensive growth hormone to patients who had lost too much weight, he says, “but unless the person could put the food in their mouth and swallow it, even those very powerful weightgaining medications did not work.”

So Hardy turned to a pricey prescription medication called Marinol, the brand name for dronabinol, to help patients regain their appetite. Marinol, also used to treat nausea and vomiting caused by cancer chemotherapy, contains synthetic THC, or tetrahydrocannabinol, the compound in marijuana

that makes people high and gives them the munchies.

The problem, Hardy found, was that Marinol took as long as two hours to kick in, and the high it produced lasted too long. “What people needed was rapid delivery of appetitestimulating medication,” he says. And that could be accomplished by smoking marijuana.

Even before California legalized medical marijuana, Hardy began talking about it with the 30 to 40 percent of his patients who needed to pack on pounds. “I would simply ask the patients: Have you ever smoked marijuana before? If they said yes, I’d ask: How did it make you feel?”

If they said, “‘It made me feel like I could eat a side of beef,’” Hardy says, “I would suggest smoking a little marijuana before their meals. I had no qualms about doing that. These were individuals who truly had a terminal disease.”

If patients told him they’d never smoked pot and felt uncomfortable about starting, Hardy says he would not recommend it.

Research suggested that marijuana also could relieve pain in the hands and feet from peripheral neuropathy, a nerve condition caused by HIV infection as well as early antiretroviral drugs that doctors stopped prescribing a decade ago.

Although he has recommended marijuana for peripheral neuropathy pain, Hardy acknowledges that it’s not clear whether patients feel relief because the drug actually reduces pain or whether getting high makes people feel no, or at least less, pain.

Today, Hardy says, fewer than 30 of his 300 HIV-positive patients have peripheral neuropathy, and they include some long-term survivors with intractable pain in their feet. He is reluctant to ainkillers to prescribe narcotic painkillers sk for abuse. them because of the risk And only perhaps three of his term AIDS patients, all long-term survivors who nearly died and never hey had lost, are regained the weight they ng marijuana to candidates for smoking improve their appetite. d fewer requests “I have had fewer and a,” Hardy says, for medical marijuana,” and he’s increasingly skeptical when patients say they need it.

“You really have to distinguish between the medical use of medical creational use,” marijuana and the recreational Hardy notes. There are 700 medical es around Los marijuana dispensaries

“TO DO MORE CANNABIS RESEARCH, H, THE ONLY LEGAL SOURCE IS THE FEDERAL GOVERNMENT.” 38 POZ MARCH 2015 poz.com

GETTY IMAGES/TOMMY FLYNN

Angeles, he says, and most of their clients have no medical need for it.

NEARLY 30 PERCENT OF THE 500 HIV-POSITIVE patients in the Norwalk, Connecticut, practice of Gary Blick, MD, use medical marijuana. Half of them had either never smoked pot recreationally or only used it a few times, he says.

Medical marijuana sold at the handful of dispensaries in his state is two to four times as potent as what people can buy on the street, Blick says: “It’s purer.”

He had picked out a space in his office building for a medical marijuana dispensary “when our city said ‘not here.’

Our clients here in Norwalk have to drive pretty much an hour to get medical marijuana.”

Many of them use it as an appetite stimulant because they’ve lost too much weight, says Blick, who regularly smokes it himself to relieve chronic back and nerve pain from spinal stenosis.

His 92-year-old mother, Gloria Blick, started smoking pot in a pipe a couple of years ago, before legal medical marijuana was available in Connecticut, to treat her glaucoma. Now her ophthalmologist recommends it.

Chronic pain from peripheral neuropathy is the main reason Blick’s patients use medical marijuana. While pain isn’t an approved condition for medical marijuana in Connecticut— an omission Blick hopes to correct—HIV/AIDS is. Another common reason his HIV-positive patients smoke medical marijuana is post-traumatic stress disorder (PTSD) related to pain, anxiety and depression associated with their diagnosis, Blick says. diagnosis 16-year study of nearly 3,000 HIV-positive women A 16-y found that tha they used medical marijuana for reasons similar to Blick’s patients. In that study, the proportion of women who said they currently used marijuana declined over time, in 1994 to 14 percent in 2010. from 21 percent p “As they the aged, there was a pretty substantial decline in marijuana use over time,” says lead author Gypsyamber D’Souza, an HIV epidemiologist at the Johns Hopkins Bloomberg School of Public Health. “Recreational drug use Bloomber is higher among younger women.” use of marijuana increased significantly over But daily da period, from 3.3 to 6.1 percent of all of the women in the that perio study and from 18 to 51 percent of the current marijuana users. For Fo D’Souza, that was the most interesting fi nding, particularly because it paralleled an increase in the use of particular modern aantiretroviral therapy. Still, she notes, her study can’t prove prov that better HIV treatment caused the increase in use. daily marijuana mar 2009, D’Souza’s team asked the women if their In 200 marijuana use was medicinal or recreational. Most users reported either purely medicinal use or medicinal and recreational use. The most common reason the women recreatio gave for using medical marijuana was relaxation and stress reduction, which, of course, is also why people smoke it recreationally, D’Souza says. Other common smok reasons were to boost appetite and reduce nausea. reaso

FREQUENT, LONG-TERM MARIJUANA USE CARRIES its own risks, though, according to the National Institute on Drug Abuse (NIDA). “Marijuana use may have a wide range of effects, particularly on cardiopulmonary and mental health,” according to NIDA’s “Drug Facts” publication on marijuana. The drug can irritate the lungs, heightening the risk of infections, and raise the heart rate shortly after smoking, greatly increasing the risk of a heart attack in the following hour, according to NIDA. Plus, marijuana’s effect on HIV progression has been little studied. Because the federal government considers the drug illegal, scientists are reluctant to spend the time and effort needed to clear regulatory hurdles, says Igor Grant, MD, chair of psychiatry at the University of California, San Diego School of Medicine and director of the University of California Center for Cannabis Research.

“To do more cannabis research, the only legal source is the federal government. To get that requires a lot of approvals,” Grant says. “In the past, it was just kind of seen as a kooky thing.”

Some scientists have turned their focus to Marinol and THC. Although the Food and Drug Administration approved Marinol capsules 30 years ago, there’s little scientific evidence to support its effectiveness in treating wasting, and concerns have been raised about the safety of THC in HIV/AIDS, says Patricia Molina, MD, PhD, director of the Alcohol and Drug Abuse Center of Excellence at Louisiana State University. In fact, Molina says, “multiple studies had found that cannabinoids have immunosuppressant effects.”

So she decided to study the impact of THC on male rhesus monkeys infected with simian immunodeficiency virus, or SIV, a primate version of HIV. “The purpose of the study was never to show that THC can treat HIV,” she says. “The main question we wanted to answer was whether or not chronic use of THC would increase viral load or further decrease the CD4-to-CD8 ratio in infected animals.”

But Molina’s study attracted wide media attention because the twice-daily injections of THC the researchers gave the monkeys lowered the risk of early death in the monkeys with SIV, possibly because its anti-inflammatory effects decreased viral replication.

After a follow-up study, Molina’s team published results that didn’t get nearly as much press. The main difference in the design of the second study was that it used female instead of male rhesus monkeys. In contrast to their study of male monkeys, though, the researchers found that THC did not protect the female monkeys from early death or weight loss from SIV. “We still do not have an explanation for those differences” between the male and female monkeys, Molina says, although she speculates that female hormones play a role.

Meanwhile, she says, “I would never advocate marijuana as a treatment for HIV.” Molina says she studies THC to help HIV-positive individuals “make informed decisions regarding frequency, amount and duration of their consumption or, alternatively, of the need to quit or decrease use.” ■

poz.com MARCH 2015 POZ 39

HEROES

BY CASEY HALTER

As one of 25 members of the President’s Advisory Council on HIV/AIDS (PACHA), Gina Brown brings the voices of Southern African-American women living with HIV/AIDS to top U.S. policymakers.

As a board member at the Positive Women’s Network (PWN-USA), Brown also helps create woman-centered approaches to combatting the HIV/AIDS epidemic nationwide. She’s a mother and grandmother, a full-time medical case manager in New Orleans and a student working toward her second master’s degree.

But like many major players in the community health field, Brown started out small when it came to her HIV advocacy.

She was diagnosed with HIV in 1994, two years after getting clean from drugs. She was pregnant and started HIV treatment right away, thanks to some good doctors and an AZT clinical trial.

Brown—who describes herself as the outspoken daughter of a Black Panther Party family—first got fired up about HIV when she took issue with the way her clinic was handling patient privacy.

“They would go to the door and call out your full name!” she recalls. “In New Orleans, we don’t have six degrees of separation. We have two or three, so someone in the room was going to know who they were talking about.” The young mother called up the clinic, demanded increased privacy and ended up getting the policy changed.

Brown came out about her HIV status in 2002.

After years of hiding her diagnosis while working at a pharmacy, she changed course and got a job as a peer advocate with the Family Advocacy, Care and Education Services (FACES) program at Children’s Hospital of New Orleans.

The move from anonymity jumpstarted her career.

Within months, Brown was promoted to full-time case finder, and then to direct services manager at the AIDS service organization.

“I grew up with that whole positive black influence, ‘You are not less than anybody’ thing,” says Brown. One of her favorite jobs starting out was finding people who had fallen out of care and empowering them to take charge of their health.

Since then, Brown has worked for regional heavyweights like NOAIDS Task Force and AIDS United. She also earned a master’s in social work in 2012; her next degree will be focused in the field of nonprofit leadership.

Today, Brown works as a medical case manager at Priority Health Care, a community health organization in Jefferson Parish. She spends her days working with mostly young, newly diagnosed men who have sex with men (MSM) in her home city.

Eventually, Brown hopes to open a mentoring and parenting program in New Orleans for at-risk populations. “I’d like to address the social determinants that drive the HIV epidemic,” she says. “It may take a couple of generations, but if nobody is working at it, we’re never going to move.”

40 POZ MARCH 2015 poz.com

DAYMON GARDNER

Outspoken for Others

SURVEY

6

Have you ever visited an online support group to discuss living with HIV?

❑ Yes ❑ No 7

If you attended a support group or visited one online, how did you find it? (Check all that apply.)

❑ Recommended by doctor or other health care provider ❑ Recommended by a friend or family member ❑ Through a local AIDS service organization ❑ Through my church, temple or other religious institution ❑ Through a government agency ❑ Through an online search ❑ Other (please specify): ___________________

LEAN ON ME

8

❑ To feel less lonely and isolated ❑ To be able to talk openly and honestly ❑ To reduce stress, depression or anxiety ❑ To learn coping skills ❑ To receive positive reinforcement ❑ To seek out information ❑ To share resources and advice

We all need someone to lean on now and then. So it’s important to identify and seek out sources of support in your life, whether through family, friends or a support group. POZ wants to know how you find support.

1

How long have you been living with HIV?

❑ Less than one year ❑ 1–5 years ❑ 5–10 years ❑ 10–15 years ❑ 15–20 years ❑ 20 year s or more 2

Who makes up your current support network?

(Check all that apply.)

❑ Partner/spouse ❑ Family ❑ Friends ❑ Church or other religious community ❑ Co-workers/peers ❑ Doctor/nurse/health care provider ❑ Case manager ❑ Other (please specify): ___________________ 4

9

❑ Yes ❑ No 10

11

What year were you born?__ __ __ __

12

What is your gender?

❑ Male ❑ Female ❑ Transgender ❑ Other 13

THINKSTOCK

What is your sexual orientation?

❑ Straight ❑ Bisexual ❑ Gay/lesbian ❑ Other 14

What is your ethnicity? (Check all that apply.)

❑ 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):___________________

Have you ever attended a support group to discuss living with HIV?

Have you ever visited a counselor or therapist to discuss living with HIV?

❑ Yes ❑ No

Are you a source of support for others?

❑ Yes ❑ No

❑ Yes ❑ No 5

Have you ever visited the POZ/AIDSmeds Community Forums (forums.poz.com)?

How would you rate your current support network?

❑ Excellent ❑ Good ❑ Fair ❑ Poor 3

Which of the following reasons for visiting a support group would apply to you? (Check all that apply.)

15

What is your ZIP code? __ __ __ __ __

Please fill out this confidential survey at poz.com/survey or mail it to: Smart + Strong, ATTN: POZ Survey #202, 462 Seventh Avenue, 19th Floor, New York, NY 10018-7424