blueAlto

Since my post on CCR5 mutations and HIV immunity, several of you have asked so many intelligent, insightful, and surprisingly theory heavy questions around this issue, that I thought I would dedicate a few posts to it in the hopes of answering many of those questions.

Well, no better time like the present!  Therefore for today's post I attempted many of the most frequent questions for this article. Now, it is your turn. Remember, nothing is too off limits, as I strongly feel if I am putting it out there to discuss, I need to answer what reasonably comes up.

Sorry for not posting this sooner, but the questions were very layered ones, and I wanted to spend a bit of time on them before I responded. I'm gathering from many of the emails there is a potential this could be personally relateable? Many of you wonder how you can still be negative in light of some of your memories around activities.

I'll attack the topic by offering the situations I would recommend a patient tested for CCR5, and then get into specifics that relate to the ethics of CCR5 as a routine test.

It needs to be kept in mind that the majority of MD's and others practicing primary care in America, and specifically if it is a family practice situation with no further post graduate training or certification in HIV care, the response you are likely to hear is "Uhm….CCR what"?

I don't exaggerate. My intention is not to pat myself on the back when I state that my reality of public health training is six plus years of undergrad and post grad education and critical care paramedic certification. By virtue of that, my field of knowledge surrounding new treatments is, by necessity, very broad. An unfortunate reality for a number of doctors is that beyond medical school and internship, the opportunities for continued quality education are not held in high regard, or not seen as important by the ones who manage the profession.

So, ones chance of getting a health worker who knows that CCR5 has something remotely important to do with HIV, as well as one who is professionally supported by structures that would make that test an option, are not likely to happen if one is outside of a major city and without a graduate medical training program. Therefore, even though it is a completely unacceptable reality in 2008, this is not changing anytime soon.

Now that we're done with the tone of the professional environment backdrop, if you came to me and asked about a test for a mutation of CCR5, I would answer according to the following guidelines that are now being supplied. Keep in mind, the practitioner must personally request the assistance of these guidelines from the CDC. Therefore, it is unlikely they are being used by most medical practices.

1. You have within the past three familial generations, an ancestry that is tied to Northern Europe . (found in UK, Scotland, Ireland, Scandinavia, Germany, Switzerland, Austria and Russia). If you didn't have that trait any partial or full lineage from those places, then you aren't a candidate for testing as it is not thought to exist in anyone but those mentioned. Reasons for the solidity of belief in this area is the interesting connection those who share the mutation have with rats of centuries past England. Specifically, immunity to bubonic plague. HIV immunity is directly related to that which provides immunity to the black death. The discovery of this on anthropological grounds lead to the discovery of CCR5 in HIV immunity.
2. A history of more than three high risk sexual activities with an HIV + individual or one that is likely to be thought +, resulting in the same number of HIV negative test results. Over a minimum of 18 months. Reasons for the time line would be that 94% of people, if they are going to seroconvert, do so at 3 months. 99.9% of people will do so at 6 months. So we need to wait to see each time, if in fact it will be a negative test.
3. In a case like myself, an extended history with someone HIV positive but unaware they were infected (for me it was three years), with consistent unprotected sex, and a confirmed negative result post six months as well as currently, lends itself to an overwhelmingly strong suggestion of immunity and would justify a lab result right away.
4. Never say never.  In other words, if I as a health care practitioner don't quite see the need, however my patient seems particularly stoked on the idea he or she may be immune, I'll normally recommend the test be ordered. The exception would be the small minority of patients who have a vested interest in the drama around waiting for a test result. That may sound strange, but anyone in the field can tell you the first time they had a shrieking, crying "my life is over" client come in for an HIV test, or any other test that references a condition where there exists a lot of judgment and stigma. By the fifth or sixth time in the same amount of months, it's clear attention is the motivation.  And this is specific to every aspect of health care, not just HIV.
   

You ask about cost, and yes that is a factor as it is well into the thousands, as it is a detailed genetic mapping and typing that is used very, very rarely.

Lastly, the reason that this has never been pushed as an issue in a patient advocate sense, is similar to the current flap over PEP, (post exposure prophylaxis - the HIV "morning after pill"). This is discouraged as many think we would be tacitly validating unsafe choices. Or so goes the current mantra / shame based morality play.

If you haven't guessed, that is what we in public health call "incorrect framing". Because with PEP, we would be providing an alternative for the individual who, for whatever reason, made a choice they would normally not have made. This is not treatment that is geared towards those who routinely practice unprotected sex.

Detractors of PEP, and detractors of CCR5 testing, usually subscribe to the current urban legend that wants us to believe that it's overwhelmingly the "I just slipped up one time" negative guy who has unknowingly been taken advantage of by the drooling, slutty and twisted poz pig. Funny thing is, all the current research overwhelmingly points to other conclusions.

But there is still a purpose to that dynamic for those who engage it, isn't there? It will usually set up the required level of tension, and often increase the divide between poz and neg gay men even more so than is already present. Funny too, that is also not the reality I see when I spend four hours a week, like I have for the last ten years, taking HIV tests, and in two weeks giving results. And yes, often I am telling someone they are positive.

What I have been finding for many years now, is that most don't need me to tell them, as the result is usually not a surprise. As many have been regularly avoiding condoms and having unprotected sex for years. The reason we often see a problem in high number reports when these men are tested, is because that test is occurring only when they feel as if they can actually face a positive result. That's why many "negative men" haven't been tested in three or more years.

I want to close with a very clear statement. Before anyone climbs up on the tall, shining horse of moral authority and decrees that the above behavior is "bad", please realize that it is in every way considered to be both a normative response to the event, as well as a very human response to the event. In other words, chances are, you are likely to behave similar, given the circumstance.

In light of that reality, the idea that a test for a genetic marker affecting 1% of the population will lead otherwise good little gay boys to go tearing down to the slings at the tubs, I see as misguided and not recognizing what we know about sexual realities and human behavior. There is a long held and brilliant idea that has informed much of our not so brilliant attempts at prevention. It is knowledge = power. Last I checked, that had never become open to variables. We need to ensure it never does.

Sorry the length of this is akin to War and Peace, but it is a bit of a complex issue.

Hello everyone. Yes, i am back. Things are okay. But more about that in the next day or two.

First, happy Canada Day and happy belated Pride week. As usual, Toronto ushered in gay Pride week last Monday with all the parties and fan fare one comes to expect from what is now the largest pride celebration in North America. Take that SF!

For me, pride has a history that is both celebratory as well as deeply painful. Having both the luck to know many wonderful friends, and the misfortune to see many of them die in their prime, the day that we celebrate our community resolve has always been in many ways bittersweet for me. Combine the experience with the very ironic and singular benefit of one very isolating genetic trait I recently discussed, and the reality of community loss, and I often have a difficult time enjoying the revelry around the events. Not to be a complete downer on this topic, I usually of course am able to place those emotions and enjoy what we are coming together as a community for.

My overall point here being, it is not a day on the calendar I approach with glee. Enough said. Though this year was interesting. During the week prior to the Sunday parade, a wealth of cultural and community events occur. Literally, something for everyone. As it is something that I have done since the early nineties, I make a point to attend the candle light AIDS vigil held early in the week at sundown. For the first time in a long time, I was moved and inspired by the tone of the event and the words expressed. Truly celebrating the rich and diverse lives of the men and women who had gone before, several musical selections were employed. The following, an ABBA remake from my one of my favorite Australian films, Muriel's Wedding, seems an odd choice.

I think you will be as surprised as I was, and agree that for a remembrance that is both celebratory and mournful, the choice could simply not have been better.

Part I of this series is recommended reading for anyone interested in the topic.  So is this entry, which provides some important and needed context regarding personal sexual risk assessment.

A Caution:

I'm not usually a fan of cautions or trigger warnings, however this essay contains frank, descriptive examples of drug use, sexual situations, and the dynamics around both. For some people who deal with issues of addiction, descriptions such as these may be triggers that increase the desire to use.  I offer this caution for individuals to use as they deem appropriate.

Some Current Thoughts:

Being truthful in a public recounting of experiences I'm not exactly proud of, has been more difficult than I anticipated. Putting very personal, very private, and very out of character behavior across a web page for all to view and harshly critique is a scary thing to do. Though as I've stated, a truthful inventory of my own experience with what people I know struggle with daily, is in my view, the most authentic gesture I can offer.

Something many of us, including myself, have been guilty of, is navigating relationships through a very easy dynamic of "helper" and "he who must be helped". For those of us who have never experienced true addiction, the rigid, constructed roles of addict and savior, conveniently avoid challenging what has been our own experience. Therefore, never confronting the truth that tells us addiction has very little to do with character, will power, "good" or "bad" people, weakness or strength.

Much more likely, addiction is a result of complicated patterns of genetics, biology, and physiologic affinity. That can be a very uncomfortable truth, as there is no escaping the reality that says, there but for grace go I. For me, the purpose of this essay is to get a little closer to that truth.

Tonight I pick up where I left off in part I. That of it being July 1997, and I am in Los Angeles with my friend D, both of us for the purpose of instructing, and potentially receiving UCLA academic appointments. Soon after arrival, for reasons I detail in the first installment, D and I are at a friends home when we snort our first ever hit of crystal meth. Ten years later, it is still a weekend blur of drug induced and sexually charged July days. Next Monday, I will publish part III, followed by a follow up piece a week later.

Los Angeles CA:  A Monday in July 1997, 6:55 am

Getting up from the couch where I must have just recently drifted off, I survey the room. My friend D, head at the opposite end of the couch, is fast asleep, a neatly collected pool of drool on the pillow beneath his head.

"Get up sunshine", I slap D's ass hard enough to elicit a brief head rise from the pillow. 

To my right, through an open door to what I assume is a bedroom, I notice three naked bearish guys, one heavily tattooed, one tightly muscled and the third rather fat. They are in what seems to be the climactic moments of a rather verbal threesome.

Making my way to the bathroom, I wipe the sleep from my eyes as I realize the tightly muscled guy is Paul, the friend we have been staying with since arriving in LA on Friday. Though I have no clue who the other two are. Nor do I have any clue who's apartment we are in.

"Fuck"! I mutter under my breath to no one in particular, as I glance at my watch.

It's Monday morning, and D and I have exactly one hour and five minutes to get our combined asses behind a podium at UCLA. A task not especially daunting, however given our experience of the past two and a half days, it would appear to be a task of monumental proportion. And we are, I'm realizing, in Silverlake; the farthest east one can get on Santa Monica Blvd. before it ends.

Standing naked in an unfamiliar bathroom, splashing cold tap water on my face, I get a whiff of what I assume to be my scent. One which tells me my lateness reclassifies as a secondary priority, given the unpleasant odor of beer, sweat, sex, and what seems to be ammonia emanating from my pores. Yet another of the pesky side effects wrought from our spontaneous weekend indulgences. Side effects that, over the next several hours, I will become intimately familiar with.

Realizing I need to get it the fuck together fast, I adjust the tap handle to a slightly less than freezing temperature. Standing under the cold stream, it all seems to hit me at once. The all over muscle soreness, the very present aching teeth, a result of forty eight hours of unaware grinding, and what I'm noticing to be a very red, chafed, and extremely tender cock. One that is oddly semi stiff, given the "shower as Arctic" water temperature. That's not surprising I think, remembering the Viagra I popped last evening to combat yet another of the ever present side effects our new friend Tina has offered. I successfully resist the desire to stroke off yet another load.

Hoping out of the cold shower, I quickly dry, making a conscious attempt to not dwell on my other slightly painful sensation. The one which results from my asshole playing host to more cocks in one weekend than it had in the previous year. Not exactly a large number, given the days in a year. Though I remind myself we are talking days, not years. The pitt in the stomach grows with that realization.

For the first time in the past forty eight hours, I take a critical inventory of my face in the bathroom mirror. And honestly, given the events, it's actually not as bad as I am expecting. Though the eyes are what concern me. Beyond feeling like I have embedded several small bits of sand under the lids, I am troubled by the rather intense, unblinking presentation the mirror reflects back.  It's a reflection with a distinct vibe of "wound too tight".

Fuck it. I need to get my ass in the car, do some serious speeding (no pun intended) and with any luck, come up with some semblance of an excuse as to why we are late to present a two hour lecture for fourth year paramedic students.  An evaluated lecture, one with the potential of being awarded visiting alumni faculty status. Thinking of the topic D and I chose for our presentation, "Therapeutic Approaches To Behavior In Crisis". I can't help letting out an ironic little giggle.

Literally kicking D's ass into and out of the shower in record time, I then get dressed in what I am realizing are my none too fresh smelling clothes from yesterday. Awkwardly, I interrupt the grunting, sweaty, and as of yet, uncompleted and unclimaxed three way fuck fest. I need to ask Paul where he'll be hiding the key for us when we return.

Attempting to momentarily take his focus off the fat but very woofy bear aggressively plowing his ass, I manage to get Paul, who's ankles amusingly appear to be glued to the wall behind his head, to let us know the key will be under the dog house in the backyard. Thanking Paul, I offer a hasty goodbye to the three carnally focused bears. I'm still at a loss as to who the hell the other two are. Though a passing thought which tells me that may not be all I'm drawing a blank on, is, at this early hour, more than slightly revolting.

Five minutes later, unsuccessful at our attempt to break the sound barrier with a rented Chevrolet Malibu, we are both sweaty and sketchy, still slightly spun from our last bump. D and I begin referencing events of the past two days, deciding that since Friday night, it has been a sometimes weird, sometimes wonderful, but always slightly twisted downward trajectory of strange repetitions; snort meth, have sex, obsess on a task, accomplish absolutely nothing, snort meth, obsessively pontificate on literally everything, not eat, snort meth, have more sex with more people....Repeat....Multiple times.

With a sarcastic chuckle, D asks, "What the fuck are we doing bud"?

As always, I don't miss the just under the surface vibe in his statement.  A vibe of more serious weight than was his intention.

Groaning, I offer, "The fuck if I know".

And as D knows me just as well as I know him, he is aware of what only a few other human beings would have been able to recognize in my response. That beneath the attempted tone of bored indifference, there exists a completely sincere statement and question.

We drive in silence, both realizing the need for discussion, but realizing now is not the time. Since at eighteen minutes after eight, we are in Westwood, pulling into the visitor parking at UCLA Medical Center. Ahead of us, two hours of intensely evaluated teaching. As if to signal the direction our luck is about to take, just before turning the hall to where the lecture theater is located, D suggests I roll the sleeves up on my button down. To hide the rather large and obvious cum stain on the right cuff.

Where normally such a suggestion would be offered and met with a smirk and a good measure of unrestrained laughter, a terse "Shit!" is my only response, as I hastily roll up my sleeves....

With the title above, I am referring to the comment left by RealSanDiegoWoman in my post entitled HIV Prevention: Consider The Context

The reasoned and considered response offered by that reader?

Sick! How you can say it discordant responses to crisis. Big words for fucking depravity. I no a few "gay" men who went out and got it because they thought the HIV in the come was going to feel even better than the regular come. SICK!

Let's look a little closer at that comment. While it is not her usual hate fueled, hate filled invective, due to its way of the projectile vomiting arc, its unsophisticated message is not just lost on the reader, but any and all weight of argument her points may have possessed, is also lost.

At any rate, in her comment RealSanDiegoWoamn states:

"I no a few "gay" men who went out and got it because they thought the HIV in the come was going to feel even better than the regular come. SICK!"

Just to clarify RealSanDiegoWoman, when you say "it", I assume you mean HIV. When you say "come" I assume you mean sperm, and when you state you "no", I assume you mean "you have made the acquaintance of"?  The accepted way of spelling and using those terms would be something to keep in mind for future reference, since an invective full of grammar, spelling and usage errors, tends to often be absent its intended punch.

Though as I said, there is an element in your point that is certainly steeped in fact Real SD.  Yes, there are in fact a very small number of gay men who have erotically charged the narratives around infection and transmission of HIV, often turning it into this weeks take on hot, dirty verbal.  And yes, there are a small amount of men who do in fact engage that pursuit in their daily life. Not my cup of tea, but then, I don't take on the gay communities various narratives as a personal crusade.  But it does point to something that needs to be looked at more closely, and that's the real causation of infection, and the dynamics driving that infection.

You know, normally I would just ignore your bigoted howls, but because they lead into something I see as urgent in this discussion, I will play along and address your comment.  I am going to say that the number of situations to which your dramatic example applies, is certainly not high enough for you to disparage ideas around new approaches in an ongoing and increasingly larger public health problem spanning almost three decades.

But as I said, you do touch on a wider issue, and that is "discordant responses to a crisis".  The theme of the piece you were responding to.  As I explained in the piece, these are the type of responses people engage when you expect them to do just the opposite.  It's seen with high frequency in individuals who are experiencing post traumatic stress disorder.  They will frequently seek out, then engage the exact things that will make their condition worse. That is the underpinning of PTSD.  The theory being that whatever the trigger was, or is, the reality of it is so huge, and so terrifying, that the most palatable response for an individual is to hasten the onset of it.  Bringing it on but with some level of control that would have been absent without the discordant response to crisis.

Food for thought RealSanDiegoWoamn.  Do you not think it remotely possible that a twenty six year history of death on a scale of war time, experienced by a core group of people who are not accepted as equal citizens of their own country in some fundamentally essential ways, would at all add to responses over time that are off the norm?  Don't answer now, just please consider it.

In an odd way, RealSanDiegoWoman has solidified my decision to finally address this specific topic.  Look for a post referencing it soon.

Check out this amazing article written in September of 2007 posted to Lifelube, the HIV prevention blog. Unfortunately, I just came across the piece recently.  In it, David J. Malebranche, MD, MPH, Assistant Professor at the Division of General Medicine at Emory University’s School of Medicine, Atlanta, Georgia, writes about gay black men, HIV prevention, and the systemic race issues and racism that continue to cause devastation in the lives of gay and non gay black men in America.

The issues are complex and multi layered, and in my view, many of them can only be addressed by someone familiar with, and most importantly, part of the community they are trying to reach. Dr. Malebranche is that individual, and he offers wisdom, insight, and a keen understanding of racial dynamics in framing and setting out priorities for black, gay men's health. 

From The Truth in Black & White by David Malebranche:

All of this is not new and neatly plays into age-old stereotypical notions of Black masculinity that emphasize heterosexual and physical/athletic prowess over traditional masculine definitions like education, employment and responsibility that are reserved for White men. These definitions began with slavery, where our only roles we to work and breed, and it continues today on the auction blocks of professional sports’ drafting process, where predominantly Black athletes are bought and sold to predominantly White owners of sports franchises.

But one needs to look no further than the media to see how, particularly in this field of athletics, the predominantly White media still manages to establish double standards that brainwash Black men into believing that everything they do is wrong, while White players can act in a similar fashion and not be punished or held accountable for their actions with a similar level of public scrutiny and outrage.

Great stuff here that really gets to the heart of issues involved in black gay men's health and lives. 

In response to yet another "I just can't understand why the fags can't be responsible and use a condom every time", article on the topic of our failed HIV prevention strategies, consider this my response.

Though I should offer a warning.  If you are the type of individual to steadfastly ignore the evidence in front of you, and instead retreat to a position of relative emotional insularity, this may not be the read for you.  As it tends to begin at the place we currently are. I know, what a novel concept.

After twenty six years of a disease, there are some things we can say for sure, and we can be totally at peace with the facts of those assertions.  Lets look at a few, shall we?

Shame, blame, and moralizing ridicule may be wonderful tools to aid in ones perception of personal importance, however as a prevention method for a global pandemic, they actually do little to help.  Many argue, myself included, that they may in fact make the problem worse, by helping to set up dynamics of entrenched and marginalized sub culture, where what eventually manifests as norms in response to unrelenting persecution, are examples of discordant personal and community responses to crisis.

What else have we learned from twenty six years of a plague that has affected the gay community on a scale similar to war time?  We have learned that people are going to continue having sex in the face of a crisis, or under threat of death, or even with great personal risk.  In fact, under these circumstances, many will have more sex than they would in normal conditions.

Another lesson from the past quarter century of public health and epidemiological data?  Abstinence is a rock solid theory on the prevention of HIV, but, like Communism, it just never really works out as planned.  Uganda, for example, has been heralded as the modern example of  "old fashioned values at work".  President Bush gave an unprecedented figure in the high millions to help in that countries fight against HIV.  With of course, a catch.  That condoms be used as only a third line resource; never a first or second line intervention. 

In a country where well over fifty per cent of its female victims acquire HIV through a non choiced sexual encounter, either rape or prostitution out of necessity, the public health professionals would have told you that approach was a recipe for disaster.  It was the correct assumption.  The last stats for the region show HIV infection rates to be up by more than 86%.

I'm going to propose something radical. Radical as in, like radical feminism, relating to the root.  Read it twice if you so require.

If we expect a community, an individual, or a planet for that matter, to respond appropriately in the time of extra ordinary circumstance, then it would be a logical extension that we offer that culture, community, individual, and planet, a standing in society that mandates equality.  That is humanity 101, and is central to the human nature of moral individuals.

This point is so key in this crisis, I cannot understand why we have not been dealing with it from the start.  The gay community of the early eighties was a young and a culturally immature community.  It was also less than five years out of the era which saw Anita Bryant and the Briggs initiative, teachers fired from their positions for being gay, landlords, employers, even stores, routinely deny service to gays and lesbians.  Untold examples of families rejecting their gay and lesbians sons and daughters, brothers and sisters.

July, 1981

Consider what happens when, cruel irony being the bitch that she is, makes her entrance:

Bringing with her a new, fatal in all cases, very disfiguring gay cancer. 

It happens to target a community not accepted in most ways by a very fearful, hostile and intolerant greater society. 

Add on a good fifteen years of unrelenting death.

Don't add in a cure, because there was none.

But please, add in more death. 

Add in grieving and more grieving, eventually experienced as a learned art.

Entire circles of friends - gone.

Cut to 1996.  

For the first time since this crisis began, people start to whisper about hope.

The whisper turns into an official announcement.

New medications. 

People stop dying in massive number.

And, like human beings are known to do, people react in very human ways. 

Many say thank God, I can now forget for a while. 

Many see the beginning of an end they dream, hope, and pray for. 

And a few, see it for what it is....

Cruel Irony: Act II

Rinse, repeat.

Cut to 2008.  Well, what do you know? We have a prevention crisis in the gay community!

Now, please ask yourself:  Is it not possible that the dynamics I describe very briefly above, could have helped in part to create a less than optimal environment in which to self advocate for personal health?  Or, a less verbose way of saying it;  the past two and a half decades have been one hell of a twisted mind fuck for an entire community.  It has known more loss, with an equal amount of non acknowledgment, than most people could ever conceive of. 

Some may ask why the intense detailing.  Because, it shows that our community response to this crisis is not the norm.  The actions people counter with, are, in many ways, only adding to the problem.  Whether it be the right wing fundie, or the puritanical gay man still not over his sexual shame who harshly condemns, or the "not a care about anybody else in the fucking world" methed out party boy who has unprotected sex with everyone from Toronto to San Fran.  Our responses culturally, and our responses personally, are often making this situation worse. 

Strange?  Ironic?  Evil?  Flagrant disregard for life?  Suggesting a lack of humanity?  Hardly.  What these responses demonstrate, are the textbook markers and clinical identifiers of community acquired post traumatic stress disorder. Reacting out of the range of what "should be done", is an entirely normal response given the current context.

The HIV prevention blog Lifelube had an interesting and guardedly hopeful article yesterday, talking about some things that occurred at a conference this past winter. This past February the annual International Conference On Retro Virus & opportunistic Infections met to look at new ways of treating and preventing HIV.

While that can certainly be a dry conference to say the least, one thing that does sound like it was positively revolutionary, in that it was something we have just never heard before, was from Dr. Ron Stall, MD, School of Public Health, University of Pittsburg....

A question posed to the doctor on the issue of gay men's prevention campaigns and the efficacy of preventing new HIV infections, was telling for two reasons; as much as it was for a certain two part answer. First, he talked about incidence rates; that is, the infection within a community over time, given certain variables. For urban gay men, the news does not look good. Consider:

The incidence rate is 2.4% Well, what does 2.4% mean? What does 2.4%, in particular, mean over long periods of time? So using a closed cohort of young gay men at the age of 18, none of whom were infected at 18, but calculated an incidence rate of infection of 2.4% per year as these men moved from age 20 to age 40. The model that we constructed yielded an estimate that at about age 25, about 15% of the men would be HIV positive; by age 35, about a third; and by age 40, about 41%...

That is pretty sobering. When asked why we were in effect doing so crappy at this as a culture, Dr. Stall paused, and offered this (emphasis mine): 

"I think gay men are doing as well as any group of human beings could ever do, in view of the onslaught that's happened over the past quarter of a century due to this epidemic. Men are having a hard time staying consistently safe every single time we have sex. But that's true of all men. What we need to do is look at what's happening around contextual issues, and areas where we can help promote health among gay men that would increase the efficacy of our prevention efforts, and increase our ability to do a better job with HIV prevention. I don't think it's helpful to engage in a blaming-the-victim kind of analysis. There are much smarter ways to promote health in these communities than blaming victims."

Wow. There is something very new. An HIV prevention expert making sense on an issue that over the past twenty six years we have managed to completely screw up. I have talked about it at length here many times, but from working on a volunteer basis in prevention and public health for over ten years, we have yet to do something effective for this disease besides throw condoms at it. Which, as we know, have done a marginal job at prevention.

The doctor not only frames the crisis in new terms that we can operate from, but he also drives home the point that we need to define risk again, as this is a measurably different disease in 2008, that it was in 1981. Like it or not, that does speak to risk and risk perception. Dr. Stall suggests, among other things, "reducing a community viral load".

While that approach may seem counter intuitive, and may serve to only create more unsafe sex scenarios, consider that those who don't use condoms regularly have made a very conscious decision to do that. it is nor a decision that will be changed by us refusing to use any other option. Reducing a community viral load is a strategy that gets aggressive treatment to those in need early on, thus decreasing the infection potential in a large pool of the infected. Thus, over time, reducing on a large scale the number of new HIV infections.

While these are all still very new and untested approaches, we have been needing new approaches and new conversations for a very long time. This is very good news from one very dynamic and progressive public health professional. The full transcript and abstract from the studies Dr. Stall references can be found here.

Late last night, just as I was getting ready for bed, the phone rang. It was a friend from San Francisco who passed on the sad and shocking news that my friend, Matthew Barrymore, had died from complications from AIDS. He was fifty six. I say shocking, as it's been assumed Matthew had been HIV positive since the late seventies at least. And until very, very recently, this was a possibility no one had considered for quite some time.

Matthew Barrymore was one of the first cases that made up a file sent to the CDC in July of 1981, documenting several cases of gay men with strange and rarely seen problems related to their immune systems. Since then, he had done remarkably well. There were several ups and downs in the early years, though time and time again, he rallied and beat the odds. In 1996, when we saw the first transition in the epidemic, the advent of triple combination therapy and protease inhibitors, Matthew had been a case study.

I first met Matthew in 1986, when I was seventeen. Ironically that was the year that became my introduction to all that HIV would be in my life. I had spent three months in LA with my uncle Roger and his partner, my "other uncle", Anderson. Besides my father, Roger would prove to be the defining male figure in my life.  Big, athletic, handsome, a successful film professor at USC, and proudly, unapologetically, openly gay.

It was a great summer, proving to mark the first ueasy steps into the world as an out, gay person. I had finally told another human being I was gay, and Roger, by telling me he had a form of cancer that was common to gay men, was preparing me in advance for his death. I learned later from Anderson that Roger had been told it would be six months at the most. It turned out to be four years.

Matthew Barrymore was my uncle Roger's best friend. He was there when he died, as was I, and he wrote and read the eulogy at his memorial. He was on board the boat when, two months later, we gave my uncle to the ocean that had defined the landscape of the place he called home. Six years ago this past December, Matthew had also been the one to make the late night phone call telling me Anderson had died.

In the year 2000, Matthew, a state award winning elementary school teacher for over twenty eight years, accepted a position as an art history professor at a university in San Francisco. Over the last eight years, I had been to see him three times. I recall on each trip I was more assured than the last, that the man who loved color, as we used to call him, was truly in a place he called home. I say that both literally and figuratively. So much so, that his sense of connection became my sense of inspiration for a passage in my first novel, The Peculiar Comfort Sound Provides (as of yet unpublished). 

He was a man that had an innate confidence in himself and in life, and it was something you couldn't help but sense as a very grounding comfort, anytime you were around him. I remember thinking something silly and cheesy, along the lines of "Matthew made the grey days bright". Thankfully, I expanded on that for the novel.

Matthew, this is for you. Though you will be missed, your colors will always shine.

....In a city by a bay light arrives, embracing each of the colors. The light becomes an assurance of day, and on each arrival searches for the colors it no longer reflects. Only some people realize it, and less experience it, but for those who do, they know this city by the bay, both powerfully resilient and incredibly broken, though many colors are long absent or forever changed, those unrecognizable colors can always be seen with full clarity and true image, when realized in the bright light of our own truth....

Tone warning: Pontificaiting rant ahead.

For those of you who have just joined me this year, what I'm about to post is somewhat of an annual tradition. It's a rather critical take on the culture known as Frot, from the term frottage, as in the rubbing of male genitalia to achive orgasm. Though it's not the act that I object to. It's the mindset of the organization and it's self hating, warped set up that positions any other gay sexual engagement re. anal sex, as akin to a mortal offence.

The underpinings of Frot tell young gay men that 'gay is not okay'. But Frot is! Men with men is! Anything that is not a part of the culture of the "buttfuck dictatorship".  And, conviently, that is Frot and nothing else.  Whatever, I call bullshit.  And have been doing so rather loudly for at least six years.

So you are about to get a treat. Ladies and gentlemen, like all cults and warped set ups similar to them, the Frot movement has its leader too. In the form of one Bill Weintraub. The man who takes a no prisoners attitude on his web site, but has yet to say one peep to my face during the last six years while this and similar articles have been published over, and over, and over again. Come on Bill, humor me. By now you should know this by heart. No? Okay then, one more time if you insist.

*** 

Bill Weintraub has the dubious title of founder of the man2manalliance websites. Home to, among other things, many Southern California irritating teenage isms, meant to relate to the "younger gays": kewl, dude, narly, frotorama!, and of course, Like duh! 

As you can see, Bill is also a sophisticated academic. Though I shouldn't be mean. His websites are a sign, he says, of his commitment to help young gay men find an identity. Although the men he hopes to help are usually all too willing to hear his messages of intolerance, prejudice, hate (and I don't use the term lightly) that are at their core, anti woman, anti gay, and generally negating any sense of history, context, or rational approach.

An example of the frot movements rhetoric, very early in any discussion:

"Hey, come on now, no one is trying to ban anal. We just want to let guys know there are options out there. We are men who love men, and all we are asking is that some attention be paid to non penetrative forms of sex, that's all."

That would be the "attempting to bridge the gap" voice of Bill Weintraub, self appointed leader of the "Frot" movement, as well as self defined HIV prevention expert.

While on the surface his request sounds, in the context provided and by virtue of tone, like a reasonable one; that statement is often used by Bill in his plea that the sexual act of frottage, or "Frot" (taken from said word), an act similar to mutual masturbation, ie. rubbing cocks together to achieve orgasm, be given some recognition in the gay mainstream press. As well, Bill would like to see Frot become the primary act advocated for by the HIV prevention community. As theoretically there exists only a very small, if any, likelihood that HIV can transmit via what frot entails.

But that is not providing the clarity needed to make a decision over the value of frot as something that should be endorsed by a culture attempting to free itself from oppressive practice. Or, as something that warrants the endorsement of a public health community tasked with an ultimate goal of viral containment.

In reality, the only "goal" of the Frot movement is one that wants to, and I quote from Mr.Weintraub, "overthrow the butt fuck dictatorship, and seek a complete cultural change".

I would say that demonstrates a substantial shift in frame of reference. So, avoiding the inconsistent, meandering, and invalid theory base of the philosophy of the movement, we need to, although painful, glance over the underpinnings of frot dogma.

The desire of this group to see an ultimate banishment of anal sex from the gay male sexual arsenal, is one both layered and multifaceted. Having everything to do with the movements (re. Bill's) own perception of what is, and isn't masculine. Masculinity, it would seem, is a trait that is next to Godliness. If one doesn't posses it, or doesn't posses the version that is currently defined by the Frot movement, then that person is "a bitter, empty shell of a human being". Funny how the insecurity inherent in letting public beliefs define an identity for you, is for some reason never addressed. 

Instead, the many reasons that anal sex is occurring, on a cultural level, becomes front and center. The main reasons? Because gay men:

1. hate themselves,
2. want to be women,
3. and if they are at all non traditional in masculine deportment, they are a "shallow, dirty, bitter, empty shell of a human being".

The theory behind these assertions is, interestingly, one that never materializes in print form. But the question remains; how does this translate into having to do with, let alone getting rid of, anal sex?

Let me offer a suggestion.Bill, please pay attention, as this is a solution both simple, and an example of "thinking outside the box":

If you don't want to get fucked....Don't get fucked.

But I digress, since for those who share the following beliefs, what could be simple?

"Passively bending over and taking it like a bitch while you call yourself an asscunt" is cheaply imitating a woman by regarding your anus as a vagina, thus denigrating the role of women as life giver".

"Getting fucked is decidedly unmasculine, more ever is at its core effeminate. Because once again, that by being penetrated you are taking the "fem" role, and the guy fucking you is always the "dom" role, by virtue of being the partner who is insertive".

Anal sex is discussed the following way, with the tone and indictment reserved for the rape and murder of babies:

"Dude!  Like why would you stick your dick in a hole full of smelly poop. HeHeHe!  There is no pleasure in "sex with an anus"! It always hurts like a bitch in heat, and there is always lots of smelly shit on your dick to clean up. Preparation and lube is just more proof that it is not sex because it cannot be spontaneous. It is all in your head and that means that any pleasure is 100% imaginary".

I must commend Bill on finding the most articulate contributors to his website. So I'm guessing "dudes" take home message is that if I enjoy sex via my cerebrum, as well as my body, then that is akin to unicorns, as they are imaginary as well? Oh, but it gets better.

"If you enjoy being penetrated, it is only because the "butt fuck dictatorship"  has told you that to be gay you must enjoy having your man pussy penetrated. They have also told you that you are more like a woman than a man. And this can be proven".

The proof is something that one must search the website for. But it is worth the search. The proof that Bill has for anal sex not giving any pleasure, is this stunning revelation.

"How many guys do you see in the pornos with a hard on while they get fucked?  See, it's not fun"!

I'm so confused. Perhaps Bill or one of his followers could explain to me the theory of why, when one hates "shit sex", one is watching and critiquing "shit sex porn". Really, the level of debate with these people is not dissimilar to "I know you are but what am I".

However the real reason this is not healthy, and is not the best option for gay men, is simply because, anal sex is not sex. It is instead, "sex with an anus". It is not sex, as it is not genital to genital contact. And we all know genital contact being the only marker of "real" sex. No, sex with an anus is fetish. A degrading and humiliating one if a man really values his masculinity. Which, by virtue of bending over and taking it like a bitch, he is lacking.

Frot also states that gay men must have one partner. No more than one, because that is promiscuous. And that is "not healthy for men". No deviation here. If you are part of Frot, the ultimate goal is to find another "cock rub warrior". The kind who values his masculinity and wants an intimate bond with another man.

I suppose though, and it's been stated, that for a married man the rules can be bent. That's because, according to Bill, "most men have sex with men, and more than likely all, are to some extent bisexual". Bill laments this fact on his website, as he can't send direct mailings to the residences of these men, because "virtually all"  the straight men and bisexuals that contact Bill are married.

Now that's masculine Bill! Cheating on your wife. Although you have already demonstrated the role in which you view women. We'll get there soon.

Just so no one thinks I've taken the worst of what Frot has to say, and misrepresented context, all examples are said on the man2manalliance web site, or heroic homo sex  (Frot website).

So please, anyone from the Frot movement, challenge anything that I have said here. Do you really believe what Bill says when he tells you that a condom will only protect you from HIV 25% more than without? Do you believe him when he tells you that the effeminate man who is "a weak, bitchy empty shell of a human being", will be the reason for gay people to never realize full equality? It would seem some of you even believe him when he tells you that if you have anal sex because a man has been "pestering" you consistently, in that case you have been raped.

No, in that case boys, listen up. You have lacked the ability to be decisive, and therefore have failed to articulate what you wanted. That is unfortunate. But that is also not rape. It is not a minor difference.

I find it rather peculiar that Bill Weintraub, with his constructionist takes on "the cult of anal", cannot see how deeply at their core, his beliefs are woman hating. To prove his model of "female and male" sexual dynamics between gay men, as well as framing the insult of heterosexual sex on "mocking of procreation", a concerning belief is obvious. A very concerning one, which by his example, mandates that the ultimate role of a woman, both sexually and inherent in her femininity, is procreative ability.

Bill has forgotten there is a concept called feminism. This dry reminder is for him. Feminism has been present in our culture since the late thirties, early forties, however only came about as a vocal movement in the sixties and early seventies. While the simple goals of equal pay for equal work and reproductive freedom defined the early movement, questions of sexuality, gender definition, gender role, societal construction and a system of patriarchal oppression became central themes. There is, whether Bill likes it or not, many consistent universal truths at the center of gender based, and sexual orientation based, oppression.

I suggest Bill become familiar with them, as his identity as a "gay liberationist" is seriously in doubt