World AIDS Day is coming up on December 1st, but in many New Zealand cities you’ll see collectors out on the streets bucket-shaking today. 

Proceeds go towards a wellness fund for people living with HIV, providing various services that are not covered by government or other funding sources; and the New Zealand AIDS Foundation’s health services, at the centre of which are free counselling clinics in Auckland, Wellington and Christchurch and a network of counsellors in regional centres.

The World AIDS Day collection traditionally provides the major annual cash injection for the wellness fund in particular, so I urge you to get out your spare change if you see those collectors on the streets, or consider making an online donation here.

Now that the important spiel is over, it’s time to get onto the all-important theme.  Annual collection/awareness days and weeks are forever having to come up with new themes and slogans to get the public to care.  It’s a competitive market of worthy causes, after all.

This year, the global theme is “Getting To Zero”, and it’s the brainchild of UNAIDS:

Getting to Zero focuses on three inspirational messages; zero new HIV infections, zero AIDS related deaths and zero discrimination. Launched by UNAIDS earlier, this year, these three messages also reflect issues that are at the forefront of New Zealand’s HIV epidemic; HIV prevention initiatives, access to essential treatment and equality for people living with HIV.

For what it’s worth, here’s some spare change from me on what I think has to change in our local environment if we’re going to achieve those three goals:

Zero new HIV infections

The cornerstone of HIV prevention in New Zealand has always remained the condom.  It makes sense: abstinence is unrealistic and “being faithful” (the second plank in the “ABC” method promoted in some countries overseas) is downright delusional, as if the mere concept of monogamy was powerful enough to ward off a virus.

In the latter half of the 1990s, New Zealand came tantalisingly close to zero, with four straight years of 21 new locally-contracted infections from 1997-2000.  Then came the resurgent phase, leading to an all time high of 100 new diagnoses in 2010.  As New Zealand AIDS Foundation head Shaun Robinson himself said, “this epidemic has never been worse”.

The Foundation’s own sexual behaviour studies have continually shown that condom use among gay men is high, but high isn’t good enough if you want to reach zero.  And with the amount of new infections going on, high clearly isn’t high enough.  There are some men not using condoms.

The question is not so much why, as why are we not talking about it?

Unsafe sex has been so successfully stigmatised in community discourse that anyone admitting to it in a public setting is righteously eviscerated.  The Foundation’s prevention campaigns cannot be blamed directly for this climate, as it has always shied away from fear-based campaigning (rightly, as there’s screeds of evidence to show these types of campaigns do not work).

But if the Foundation is guilty of anything, it’s of failing to enter the conversation.  Its most recent prevention campaign, in the form of Get It On, has been wildly successful in penetrating the new hookup environment of apps like Grindr and Scruff, resulting in record mobile traffic to their website (from which gay men can order free condoms).

Soft-selling condoms as a natural and sexy part of sex and ensuring that they’re freely available is a good thing, but I would argue these messages are preaching to the converted.  If you want to get to zero, you have to get to the guys who aren’t using condoms, and they’re not going to tell you why they don’t use them unless they feel comfortable enough to talk to you about it.

Of course, it’s not the Foundation’s sole responsibility to ensure these conversations happen.  But it does have the resources to tease out the psychological complexity behind the weak links in the safe sex chain. 

I witnessed a recent conversation on Facebook where a friend asked why so many gay men seemed not to care about safe sex.  One brave man responded that he’d been barebacking for the last four years and he was fine.  A firestorm ensued.  After a few comments about how the issue of unsafe sex was not as black and white as it seemed, this man became less defensive and admitted that he knew his behaviour was risky and was currently seeing a psychologist about it.

I’d wager that the level of self-awareness among barebackers doing it for “psychological” reasons is rare.  I’ve spoken to guys who have become positive because they at best, didn’t care that much about themselves and at worst, went on self-destructive binges because they felt they deserved to be harmed in some way. 

There’s guys who – genuinely – have problems maintaining an erection with a condom and are really embarrassed about it.

There’s also the Abilene paradox I referred to yesterday, in which someone deplores an idea or behaviour as an individual, but goes along with it in a group setting because they think it’s what everyone else wants to do.

None of this is going to come up in a casual conversation, particularly in an environment where you feel it’s unsafe for you to do so.  I’ve heard stories of ambassadors for safe sex not practicing what they preach; I’ve also heard stories of the harshest public critics of men engaging in unsafe sex being seen barebacking in sex venues.

Quite a lot to talk about, isn’t there?  And at the moment, the only zero we’ve got is the big round hole in the donut where the open and honest discussion should be.

Zero AIDS related deaths

Treatments for HIV are getting better every year.  Recent studies have even shown that the life expectancy of a person with HIV who starts early treatment is not much shorter than an HIV negative person.  For the first time in the history of the epidemic, an AIDS-related death for an HIV positive person is not the inevitable conclusion to their life – it could be something as “mainstream” as organ failure.

The majority of AIDS-related deaths occurring in New Zealand are due to two things: people presenting far too late in the infection stage for treatment to be of much use, and people becoming resistant to existing medication (sometimes due to lack of adherence) and moving to the AIDS stage that way.

The first problem can be tackled by consistent testing for HIV, so infections are picked up early.  The AIDS Foundation’s clinics were the first in Australasia to introduce rapid, finger-prick testing where you get a result back in twenty minutes, yet the majority of new HIV diagnoses still come via GP’s offices.

More could be done to promote the great service that the Foundation’s clinics provide, and I’m pleased to have been able to take part in developing a new testing promotion campaign that will soon be launched.

More could also be done to educate GPs about issues around gay men’s health and HIV.  I still know some men who have two doctors – their regular GP and the one they go to for sexual health checks.  Men in general are already mistrustful of doctors, let alone the added stress of coming out to your doctor and talking openly about bum sex and related activities.

The power of stigma and ridicule keeps many men silent, and I was reminded again of how alive and well this is in New Zealand when I sat in the cinema a few weeks ago and saw the trailer for “Sione’s 2″ – the sequel to one of the highest-grossing local films of recent years, “Sione’s Wedding” – which contained two unfunny gay jokes, one as the punchline at the very end.

The second issue, of resistance developed due to lack of adherence, is one very close to my heart.  For several years, I co-edited “Collective Thinking”, the AIDS Foundation’s quarterly magazine for HIV positive people, with the late Aaron McDonald.  Aaron was in his mid-30s, and was ill for most of the time we were friends.  At various stages, he’d been diagnosed with both Bipolar I and Bipolar II, and he never stuck to taking his pills.

By the end, he was onto the emergency stuff, a new drug which had to be injected several times daily, but his immune system eventually gave in.

The mental health of people with HIV is a serious issue, and when an almost-100% compliance rate is required for your medication to keep you alive, it doesn’t take too many depressive phases for your life to be put seriously at risk.

Which brings us neatly to…

Zero discrimination

It’s here, there, and everywhere – and it’s bloody ugly. 

It’s a sign of how far awareness of mental illness has come in just the last decade that I know many men who are happy to be public about their experience of mental illness but keep their HIV status to themselves.

Those that are out, particularly the younger guys who have yet to develop a tough skin (if that ever really happens), face a tough road if they decide to be honest about their status.

One positive friend of mine has been asked on dating sites if it’s ok to be in the same room as him.  The ignorance of how HIV is transmitted is breathtaking, almost as much as the power this virus still has to act as a bogeyman – provided it can be personified.

Some men seem happy to say “no” to safe sex with a positive person as soon as they find out, yet are lost for words when it’s pointed out that there’s no difference between this encounter and the last five encounters they had with men where HIV was never discussed.

If we don’t discuss it, it isn’t there.  And if we do…well, we cross the street to avoid it, not only deluding ourselves about our immunity but making someone feel like absolute shit in the process.

And this is just discrimination from within the community.  There are still stories of discrimination from services, despite this having been illegal under the Human Rights Act since 1993.  Oh, it may come in a subtle form – such as a dentist telling you they can only book you in as the last appointment of the day (so the room can be appropriately nuked afterwards for the ‘safety’ of tomorrow’s patients), or being treated for something routine in hospital and finding all the staff suited up ready for the next Ebola outbreak.  But it’s there.

Fear and blame are its two major sources.  And once again, it’s open, honest conversation – coupled with a genuine will to care – that’s the solution for both.

We may not get to zero with it, but we’ll get a whole lot closer.