Life, Liberty and the Pursuit of... “WHAT?”

1. Life, Liberty and the Pursuit of... “WHAT?” CAPS Conference 2003 Stephan Oxendine CAPS Community Advisory Board

2. Summary of trends among MSM, SF  Number of MSM living with AIDS  Rectal gonorrhea among MSM  Primary and secondary syphilis among MSM  STD among MSM living with AIDS  Unprotected anal sex among MSM  Multiple partners and unprotected anal sex among MSM  Unprotected anal sex with serodiscordant or unknown status partners  Incidence of HIV in a cohort of young MSM  Incidence of HIV among MSM seeking anonymous HIV testing  Incidence of HIV among MSM and MSM-IDU testing, SFGH  Stable, high HIV incidence in MSM seeking STD treatment Source: San Francisco Department of Public Health

3. Trying on CHAPS: Does one size fit all? Will Nutland Head of Gay Men’s Health Promotion Terrence Higgins Trust – London, UK

4. CHAPS • Community HIV and Aids Prevention Strategy • Programme started 1996 • Primary HIV prevention • Funded by Dept of Health • Targets gay men in England

5. The ‘Bristol factor’ To deliver a multi-agency voluntary sector collaborative health promotion programme to develop targeted HIV-specific health promotion for gay men and bisexual men in England

6. How many gay men does it take to …. • Community building? • Empower gay men? • Empower gay men to make choices? • Empower gay men to make healthy choices? • Increase testing? • Decrease undiagnosed infections?

7. Process evaluation “there’s clearly a number of agencies that rely (on different models). It’s hard to see how CHAPS will bring them together because they have a fundamentally different understanding of the purpose of their work and the way it should be done.”

8. A framework in which to plan and deliver HIV health promotion

9. The Issue of Ethics As important as what we are attempting to influence is how it is influenced

10. Fundamental principles • All people, whether they have HIV infection or not, are entitled to a satisfying & fulfilling sex life • All people, whatever their sexual identity, sexual behaviour, or HIV status, are entitled to the same rights and respect as all other people

11. Removing barriers • Direct contact • Equality of interventions • A framework that articulates the removal of barriers to health promotion as valid health promotion in and of itself

12. Public health vs individual health • Principle: all men are equally entitled to having all health promotion aims met • HIV infection not equally distributed

13. Prioritisation • Tension between public health disease reduction and an emancipation health promotion model? • Importance of diversity of intervention under collective strategy

14. Listening to gayculturewith research skillsRick MarchandTerry Trussler

15. Listening to gay culture with research skills What’s… • Community-based research? • Ongoing learning got to do with it? • CBR have to offer health promotion? • The relation between intervention & research?

16. What’s community-based research? • By and for communities • To develop organizational knowledge • For practical purposes – intervention • To inform health promotion planning • To monitor outcomes

17. What’s ongoing learning got to do with it? • • A study-plan-do process • • With broad participation/collaboration • • Enables desired social transformations • • In pursuit of health goals

18. What’s cbr got to offer health promotion? • • Addresses problems systematically • • Provides evidence for planning • • Challenges common assumptions • • Sets baselines • • Creates comparisons

19. What’s the relation between research & intervention? • • Research to inform intervention Or… • • Research integrated with intervention Or… • • Research as an intervention

20. Why Are HIV Infections Increasing Among Men Who Have Sex with Men? Steve Morin, Ph.D. AIDS Policy Research Center AIDS Research Institute University of California, San Francisco

21. Why are HIV infections going up among MSM? • Decreased perception of HIV threat • Decreased communication about HIV • Shift in community norms

22. Why are HIV infections going up among MSM? Decreased perception of HIV threat • New understanding of having HIV as “manageable illness” rather than fatal disease • Fewer visual reminders of AIDS threat • Inflated treatment optimism • Misinformation • Pharmaceutical ads

23. Why are HIV infections going up among MSM? Decreased communication about HIV • Fewer discussion among friends • Decreased media attention • Disclosure to sexual partners; no consensus about recent change

24. Why are HIV infections going up among MSM? Shift in community norms • More men looking for unprotected sex, particularly on the internet • Increase in understanding of unprotected sex as an option • Perception that others are being less safe • Peer Pressure to be unsafe

25. Why are HIV infections going up among MSM? What Has Not Changed • Denial, particularly among young men • Sense of inevitability of HIV infection • Impulsive sexual behavior • Commodification of HIV, among poor • Loneliness and low self-esteem • Social power imbalances -- race & class • Drug use, particularly methamphetamine

26. Why are HIV infections going up among MSM? Ranking Prevention Themes

27. Why are HIV infections going up among MSM? Conclusions • Social support systems are critical to maintaining a commitment to reducing risk • Safer sex themes do not have the same appeal as motivational themes • Community-level mobilization, such as training community opinion leaders, has great potential • Awareness of epidemic trends and their consequences is necessary for prevention to reemerge as a community priority

28. TheGay Men’s Health Movement in the United States: What Does it Offer the Next Generation of HIV Prevention for Gay Men?Eric Rofes, Ph.D.

29. The 6 Foundational Principlesof Gay Men’s Health Summits, Projects, or Campaigns 1. Replace the HIV-centric paradigm of health advocacy for gay men with holistic models that integrate (but do not default to) HIV 2. Exit the crisis paradigm of HIV work and embrace understandings, meanings, and implications of HIV for gay men in 2003 3. Challenge deficit-based models for work with gay men and replace them with asset-based approaches

30. The 6 Foundational Principlesof Gay Men’s Health Summits, Projects, or Campaigns 4. Confront structural forces challenging the well-being of gay & bi men strategically and politically. 5.Embrace a “big tent” vision of community, respecting diverse ways of organizing sex and relationships among gay men Shame and guilt are the health hazards, rather than specific sex practices and sex cultures. 6. Launch only efforts that are not overtly or covertly sanitizing, sanctimonious or moralistic.

31. Address the 8 Core Issues Confronting gay & bisexual men of diverse generations, ethnicities, races, locations, and social classes 1. Meanings of anal sex, penetration, & the exchange of semen 2. Relationships between various cultural and class-based masculinities and anal sex practices 3. Understandings, resources, & wounds emerging from childhood experiences with boys & men 4. Sources of resilience, creativity, determination, humor & playfulness in diverse gay men’s cultures

32. Address the 8 Core Issues Confronting gay & bisexual men of diverse generations, ethnicities, races, locations, and social classes 5. Healing from trauma: violence, abuse, homophobia, racism, poverty, AIDS and addiction 6. The relationship between transgression, risk, and the taboo and sexual desires, practices, and subcultures 7. The ways privileged masculinities of youth present challenges to & opportunities for well being as men age. 8. The revival & re-creation of community rituals, social structures, and in the post-AIDS era

33. Implications forHIV Research and Prevention • A powerful Gay Men’s Health Movement may provide a strong foundation for health promotion related to syphilis, HIV, substance abuse, and domestic violence. • HIV prevention may be most effective by not referencing HIV • Challenging HIV-centric thinking may do much to strengthen gay men’s health

34. Implications forHIV Research and Prevention · Non-directive, non-manipulative, non-coercive approaches may be most effective with gay and bisexual men · Sexual meanings and social identities may be central to sexual practices, subcultures, and communities · The Gay Men’s Health Movement is a site to consider as having the potential to catalyze new thinking, create new projects, and mobilize masses of gay and bisexual men

35. Building Social Capital • Safe environment • Opportunities for involvement and connection to community and peers • Opportunities for leadership and advocacy • Opportunities for meaningful skill building and development. • Opportunities for caring and meaningful relationships. Steven Tierney, Ed.D - Director of HIV Prevention, San Francisco Department of Public Health

36. Questions Going Forward • What is a healthy Gay man? • What are his health based responsibilities to his community and to himself? • How willing are we to sacrifice community health to protect the sexual freedom of a minority? • What is the role of community building? • Would would happen if Gay men only had sex with people we like? • Is it OK for Gay men to continue to infect one another and if not why not?