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rfmcdonald(I blogged briefly on the subject of HIV and AIDS when I got my negative HIV test results back in early August. I don't think I did a very good job, then, though I can claim the mitigating factor that it did take three hours, after I half-staggered from the clinic over to the Grey Region, before I could write anything at all. It's all right to be paranoid, even without cause, when something really is out to get you, but paranoia does not good writing enable.)
The 1st of December is World AIDS Day, as Crooked Timber, among many other blogs and bloggers, notes. The statistics are fairly depressing around the world, given the nascent Chinese, Indian, and above all else Russian epidemics in the Old World and the continued strength of AIDS in sub-Saharan Africa. Only somewhat less worrying, given the smaller proportions of national populations and greater availability of prevenative measures and medical treatments, are the new surges of HIV infection rates in the First and Second Worlds, caused partly by the immigration of HIV-positive individuals, partly by the diffusion of HIV into general populations (at admittedly very low levels compared to southern Africa), partly by new surges of infection among men who have sex with men. Emerging from relative obscurity in central Africa a bit over a generation ago, HIV has now managed to successfully establish itself as a permanent feature worldwide.
This issue is a bit more personal for me, since I belong to a demographic (gay or bisexual male residing in a major urban area) that, if the AIDS Committee of Toronto's statistics are to be believed, is experiencing a 2% growth per annum in the number of HIV seroconversions. Given that this demographic's population growth in the GTA has to be less than 2%, the mathematics implies rather discomforting things about the potential for HIV to spread. That particular unpleasant exercise is mathematics is, of course, as good an example of the pitfalls of blindly extrapolating current trends to the present as any, not taking into account--to name two factors of many--of the impact of new medical treatments (particularly on viral loads, which bear a direct relationship to the chance of HIV seroconversion in the uninfected) or of people who consistently use safer-sex techniques. It's quite suggestive enough, though, to cause concern.
Three points now, for further discussion.
HIV is actually a fairly dificult disease to contract. Imagine that HIV spread as easily as (say) syphillis, or worse yet the flu. John Barnes imagined the latter scenario, in his Century Next Door series. That only one-quarter of the world population in that dystopic alternate history died before a cure was developed strikes me as excessively optimistic of him. The former scenario wouldn't be particularly cheerful, either. We were lucky.
As the authors of this 1999 paper in the American Journal of Epidemiology note, even in a high-risk demographic like American gay men in the early 1990s, HIV seroconversion was difficult. I was surprised by the statistic that the estimated per-contact risk of acquiring HIV from unprotected receptive anal intercourse was less than one percent when the partner was known to be HIV+, and about one-quarter of a percent when partners of unknown serostatus were included. Granted that these statistics conflate a wide variety of encounters with vastly differing risks for seroconverson (a first time with someone you know to have been inexperienced and who has never left his small town, versus, say, an encounter in a bathhouse while you were high on crystal meth), these risks are comparatively low. Too, remember that these statistics were collected in the United States, which has consistently had twice the level of HIV infection as Canada, in the general population as in the MSM population. The risk for Canadians may be still lower than that described by these American statistics.
For a variety of reasons, condoms aren't all that popular with many people. For penetrators, condoms deaden sensation; for the penetrated, condoms prevent direct contact. With risks of HIV seroconversion through unprotected sex being (in the abstracted non-existent average) less than one in one hundred even if you know that your partner is HIV-positive, taking the risk might seem acceptable. How often do you roll a certain number with two pair of die, after all? (That's probably too cerebral an approach for most, though, my emulation. Perhaps as important are simple surface evaluations: Such-and-such a person doesn't look like they're HIV-positive, after all, so why not?)
The problem with this evaluation, apart from the fact that these statistics represent a non-existent average and risk is hardly constant and sometimes you do roll the exact number you're thinking of, is that sooner or later, with enough sexual contacts the possibility of HIV seroconversion becomes a probability. We believe ourselves immortal, though; or, at least, we believe this long enough to learn otherwise.
When I went to the Hassle Free Clinic in July, the pre-test counselling focused on my risk factors. (These were, in case anyone was at all curious, rather marginal. I agreed with my counsellor's evaluation, for I'd done the math.) This counselling concentrated almost exclusively on unprotected anal sex, to the neglect of oral sex which, my counsellor said, shouldn't be considered a worry.
This isn't true: There is a non-negligible risk of contracting HIV through performing oral sex. It's not especially risky, but the mechanisms for infection via oral sex clearly exist and oral sex seems to be a significant if low-profile mechanism for the continued spread of HIV. (If the E strain of HIV-1 common in Thailand ever makes it to North America, given its propensity to spread through comparatively low-risk heterosexual contacts, this may change significantly for the worse.)
Even in the United States, where oral sex seems to be generally identified as relatively low-risk in sexual education literature, there seems to be a tendency to deny that oral sex poses any kind of potential mechanism, despite the evidence. Signorile's skepticism regarding Andrew Sullivan's HIV seroconversion comes to mind. In Canada, oral sex appears (from my admittedly casual survey of the literature) not to feature at all. A one-in-a-thousand chance is still a fairly significant chance, weighed against the consequences. The suggestions of some that the downplaying of the risk from oral sex is a consequence of a desire to still have some unprotected sex classified as low-risk should be considered.
This, I suppose, forms one prong of my much broader issue with HIV education, which strikes me as so completely non-judgemental to risk losing any credibility or effectiveness. Yes, I'm quite aware that people generally are quite sensitive to perceived attacks on their sexual behaviour, and that approaches which done expose people to perceived reproaches can be more positive. Surely, though, people need to be told what is dangerous and what isn't in clear and easy-to-understand/difficult-to-confuse terms. Surely, concentrating on self-esteem is at best only a partial and halting response to the issue, particularly considering that unsafe sex seems to be practiced at least as much simply out of the desire for more short-term sexual pleasure than because of self-hatred.
Unequal power relationships play a major role in the spread of AIDS, perhaps a predominant role: When one partner can't negotiate safer sex with another, whether because the first person's desire is too great or (somewhat sadly, much more common) because the second person refuses to practice safer sex at all, the risks of HIV seroconversion rise significantly. When, as in Africa, unequal gender relations are the rule, with women having to submit to unsafe sex whether because of economic necessity or the constraints imposed by their male partners, it's not surprising that a majority of the people infected end up being women. (One need only wonder what would have happened had HIV appeared in the West of the belle époque, and shudder. One wonders why the Middle East has escaped an epidemic so far--that's good source material for a paper on comparative epidemiology.)
It makes perfect sense that anti-AIDS activists would target the unequal power relations which increase the risk of HIV infection. It also, I fear, makes sense to assume that they will find it very difficult to effect significant change, at least for the short-to-medium term. Gender relations tend to reflect beliefs on the way that the world is ordered. It isn't a surprise that public opinion in the West and Muslim countries doesn't differ on the matter of political and civil rights nearly as much as they do on issues of gender and sexuality. I really have to wonder how much success activists with foreign support entering traditional communities with the express intention of inflicting radical change inspired by foreign models will enjoy. Of course, if the need for change is seen as sufficiently acute, there will be change. The question is simply whether change will come in time to prevent a second massive wave of infections related to unequal power relationship, or not.
I don't want to speculate about the future of the HIV/AIDS epidemic in the world, not least because I have no taste for grisly predictions of the future. All that I can say is that I really, really want to be pleasantly surprised. Here's hoping.
The 1st of December is World AIDS Day, as Crooked Timber, among many other blogs and bloggers, notes. The statistics are fairly depressing around the world, given the nascent Chinese, Indian, and above all else Russian epidemics in the Old World and the continued strength of AIDS in sub-Saharan Africa. Only somewhat less worrying, given the smaller proportions of national populations and greater availability of prevenative measures and medical treatments, are the new surges of HIV infection rates in the First and Second Worlds, caused partly by the immigration of HIV-positive individuals, partly by the diffusion of HIV into general populations (at admittedly very low levels compared to southern Africa), partly by new surges of infection among men who have sex with men. Emerging from relative obscurity in central Africa a bit over a generation ago, HIV has now managed to successfully establish itself as a permanent feature worldwide.
This issue is a bit more personal for me, since I belong to a demographic (gay or bisexual male residing in a major urban area) that, if the AIDS Committee of Toronto's statistics are to be believed, is experiencing a 2% growth per annum in the number of HIV seroconversions. Given that this demographic's population growth in the GTA has to be less than 2%, the mathematics implies rather discomforting things about the potential for HIV to spread. That particular unpleasant exercise is mathematics is, of course, as good an example of the pitfalls of blindly extrapolating current trends to the present as any, not taking into account--to name two factors of many--of the impact of new medical treatments (particularly on viral loads, which bear a direct relationship to the chance of HIV seroconversion in the uninfected) or of people who consistently use safer-sex techniques. It's quite suggestive enough, though, to cause concern.
Three points now, for further discussion.
HIV is actually a fairly dificult disease to contract. Imagine that HIV spread as easily as (say) syphillis, or worse yet the flu. John Barnes imagined the latter scenario, in his Century Next Door series. That only one-quarter of the world population in that dystopic alternate history died before a cure was developed strikes me as excessively optimistic of him. The former scenario wouldn't be particularly cheerful, either. We were lucky.
As the authors of this 1999 paper in the American Journal of Epidemiology note, even in a high-risk demographic like American gay men in the early 1990s, HIV seroconversion was difficult. I was surprised by the statistic that the estimated per-contact risk of acquiring HIV from unprotected receptive anal intercourse was less than one percent when the partner was known to be HIV+, and about one-quarter of a percent when partners of unknown serostatus were included. Granted that these statistics conflate a wide variety of encounters with vastly differing risks for seroconverson (a first time with someone you know to have been inexperienced and who has never left his small town, versus, say, an encounter in a bathhouse while you were high on crystal meth), these risks are comparatively low. Too, remember that these statistics were collected in the United States, which has consistently had twice the level of HIV infection as Canada, in the general population as in the MSM population. The risk for Canadians may be still lower than that described by these American statistics.
For a variety of reasons, condoms aren't all that popular with many people. For penetrators, condoms deaden sensation; for the penetrated, condoms prevent direct contact. With risks of HIV seroconversion through unprotected sex being (in the abstracted non-existent average) less than one in one hundred even if you know that your partner is HIV-positive, taking the risk might seem acceptable. How often do you roll a certain number with two pair of die, after all? (That's probably too cerebral an approach for most, though, my emulation. Perhaps as important are simple surface evaluations: Such-and-such a person doesn't look like they're HIV-positive, after all, so why not?)
The problem with this evaluation, apart from the fact that these statistics represent a non-existent average and risk is hardly constant and sometimes you do roll the exact number you're thinking of, is that sooner or later, with enough sexual contacts the possibility of HIV seroconversion becomes a probability. We believe ourselves immortal, though; or, at least, we believe this long enough to learn otherwise.
When I went to the Hassle Free Clinic in July, the pre-test counselling focused on my risk factors. (These were, in case anyone was at all curious, rather marginal. I agreed with my counsellor's evaluation, for I'd done the math.) This counselling concentrated almost exclusively on unprotected anal sex, to the neglect of oral sex which, my counsellor said, shouldn't be considered a worry.
This isn't true: There is a non-negligible risk of contracting HIV through performing oral sex. It's not especially risky, but the mechanisms for infection via oral sex clearly exist and oral sex seems to be a significant if low-profile mechanism for the continued spread of HIV. (If the E strain of HIV-1 common in Thailand ever makes it to North America, given its propensity to spread through comparatively low-risk heterosexual contacts, this may change significantly for the worse.)
Even in the United States, where oral sex seems to be generally identified as relatively low-risk in sexual education literature, there seems to be a tendency to deny that oral sex poses any kind of potential mechanism, despite the evidence. Signorile's skepticism regarding Andrew Sullivan's HIV seroconversion comes to mind. In Canada, oral sex appears (from my admittedly casual survey of the literature) not to feature at all. A one-in-a-thousand chance is still a fairly significant chance, weighed against the consequences. The suggestions of some that the downplaying of the risk from oral sex is a consequence of a desire to still have some unprotected sex classified as low-risk should be considered.
This, I suppose, forms one prong of my much broader issue with HIV education, which strikes me as so completely non-judgemental to risk losing any credibility or effectiveness. Yes, I'm quite aware that people generally are quite sensitive to perceived attacks on their sexual behaviour, and that approaches which done expose people to perceived reproaches can be more positive. Surely, though, people need to be told what is dangerous and what isn't in clear and easy-to-understand/difficult-to-confuse terms. Surely, concentrating on self-esteem is at best only a partial and halting response to the issue, particularly considering that unsafe sex seems to be practiced at least as much simply out of the desire for more short-term sexual pleasure than because of self-hatred.
Unequal power relationships play a major role in the spread of AIDS, perhaps a predominant role: When one partner can't negotiate safer sex with another, whether because the first person's desire is too great or (somewhat sadly, much more common) because the second person refuses to practice safer sex at all, the risks of HIV seroconversion rise significantly. When, as in Africa, unequal gender relations are the rule, with women having to submit to unsafe sex whether because of economic necessity or the constraints imposed by their male partners, it's not surprising that a majority of the people infected end up being women. (One need only wonder what would have happened had HIV appeared in the West of the belle époque, and shudder. One wonders why the Middle East has escaped an epidemic so far--that's good source material for a paper on comparative epidemiology.)
It makes perfect sense that anti-AIDS activists would target the unequal power relations which increase the risk of HIV infection. It also, I fear, makes sense to assume that they will find it very difficult to effect significant change, at least for the short-to-medium term. Gender relations tend to reflect beliefs on the way that the world is ordered. It isn't a surprise that public opinion in the West and Muslim countries doesn't differ on the matter of political and civil rights nearly as much as they do on issues of gender and sexuality. I really have to wonder how much success activists with foreign support entering traditional communities with the express intention of inflicting radical change inspired by foreign models will enjoy. Of course, if the need for change is seen as sufficiently acute, there will be change. The question is simply whether change will come in time to prevent a second massive wave of infections related to unequal power relationship, or not.
I don't want to speculate about the future of the HIV/AIDS epidemic in the world, not least because I have no taste for grisly predictions of the future. All that I can say is that I really, really want to be pleasantly surprised. Here's hoping.
