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The Best is Yet to Come: Achieving Successful Implementation of PrEP is the Next Step in Ending the HIV Epidemic

HIV incidence has a disproportionate impact on gay, bisexual and other men who have sex with men (gbMSM). While only accounting for a small fraction of the Canadian Population (3-4%), gbMSM accounted for 60.9% percent of reported HIV cases in 2017.1 In fact, surveillance estimates suggest that gbMSM are more than 131 times more likely to acquire HIV than other Canadian men.2 Furthermore, intersecting identities and experiences place some subgroups of gbMSM at even greater risk. For instance, a cohort study co-led by Lachowsky of gbMSM running for the past 7 years in Metro Vancouver recently reported that Indigenous gbMSM are 55% more likely to report being HIV-positive than White gbMSM.3 Nationally, 34.5% of new HIV infections were among White individuals, 25.3% were among Black individuals, and 20.1% were among Indigenous individuals.1 Based on the 2016 Census, only 3.4% of the Canadian population is Black and only 4.7% is Indigenous.4 Previous studies have even shown that the diffusion and implementation of biomedical HIV preventions strategies tend to be less effective among gbMSM of colour5,6 – highlighting how multiple intersecting identities contribute uniquely to health inequities.7,8 Further complicating the matter, routes of HIV transmission differ based on ethnicity with Indigenous people accounting for 68.1% of HIV acquisitions through injection drug use.1

At the provincial level the British Columbia Centre for Disease Control (BCCDC) reports that gbMSM, Indigenous people identifying as First Nations, and people who use drugs (PWUD) are at the greatest risk for HIV acquisition.9 In fact, gbMSM account for 57.0% of new all HIV infections in BC.9 Among gbMSM, most new diagnoses of HIV occur in men born after 19809 and demographic shifts in new HIV diagnoses for gbMSM has been observed along ethnic lines with most recent reports show increasing incidence of HIV in Asian gbMSM.9 Together this evidence suggests that HIV is increasingly concentrated in sub-populations that may not be sufficiently engaged by existing health systems.

In 2009, the province of British Columbia piloted its Seek and Treat for Optimal Prevention of HIV/AIDS (STOP HIV/AIDS)10 program in Vancouver and Prince George. The aim of STOP HIV/AIDS was to evaluate the efficacy of Treatment as Prevention (TasP) – a strategy to reduce HIV morbidity, mortality, and transmission through engaging priority populations in efforts to improve HIV testing, linkage to HIV antiretroviral therapy (ART) and retention in HIV treatment.11 After two years of pilot testing, TasP was recognized world-wide and adopted as the predominant model for HIV prevention in the United States, China, and at the international level by UNAIDS.12 In December 2012, the British Columbia Ministry of Health, introduced its strategic framework for implementing best practices for HIV prevention across the province (From Hope to Health: Towards an AIDS-free Generation).13 Within this framework, gbMSM were identified as a priority population for health intervention, with Indigeneity, injection drug use, and rural residence being identified as key intersections.13 While the priority population framework obscures the underlying drivers of inequalities (e.g., racism, colonization, heteronormativity), it does provide a starting point for identifying individuals who should be considered when implementing programs and policies aimed to address HIV. Yet, over the two years following the introduction of the Hope to Health framework, HIV incidence increased 7.6% (5.2 cases/100,000 in 2012 to 5.6 cases/100,000 in 2014)14 and rates of new HIV cases among gbMSM have essentially stagnated. Acknowledging this, the BC Provincial Health Officer issued their 2014 Annual Report examining the drivers of the persistently high incidence of HIV among gbMSM.7 For the most part, the PHO’s report recommended a scale up of existing activities. However, they also called for the assessment of “pre-exposure prophylaxis (PrEP) as a prevention tool for gay and bisexual men in BC”.7 To our knowledge, this was the first public-facing document published by the Province with a recommendation favouring PrEP implementation. At the time, most people were unaware of Pre-Exposure Prophylaxis,15–22 despite major studies showing the efficacy of PrEP in clinical settings.23–26 Nevertheless, community-based organizations undertook a variety of knowledge mobilization activities to increase awareness of PrEP. For instance, the Health Initiative for Men launched their “Get PrEPed” educational campaign (www.getpreped.ca) and the YouthCO HIV & Hep C Society launched their “PrEP works, stigma doesn’t” social media campaign. Over the course of these campaigns, cohort data from the Vancouver-based Momentum Health study reported that PrEP awareness among HIV-negative gbMSM increased from 18% in 2012 to 77% in 2016.6 Yet, despite the four-fold increase in PrEP awareness, only 1.1% of respondents accessed PrEP by 2016. Indeed, without public funding, access to PrEP was limited to those willing to import the drug via online pharamacies (e.g. Vancouver’s Davie Buyer’s club), pay out-of-pocket premiums ($10,000/year), or pay for extended health benefits which covered the drug.

In early 2016, PrEP was approved for HIV prevention by Health Canada, and the Federal Non-Insured Health Benefits program (FNIB) made PrEP freely available to First Nations and Inuit people. Yet, uptake and awareness of PrEP under these programs was incredibly low – underscoring the reality that PrEP is vulnerable to implementation failures without a more active approach taken among patients and providers.27,28 A few months later, in late-2016, Vancouver Coastal Health (VCH) initiated a publicly-funded HIV PrEP program targeting HIV-negative partners of newly diagnosed people living with HIV. In 2017, Canadian researchers co-authored the Canadian Guidelines on the use of PrEP for HIV prevention.29 Aiming to raise awareness for PrEP and to urge for the wider scale-up of a publicly-funded PrEP program, the Community-based Research Centre (CBRC) held a community-led research summit in November 2017 hosting HIV-prevention experts from across Canada. In December 2017, the province of British Columbia announced that PrEP would be available through the BC Centre for Excellence’s in HIV/AIDS’s (BC-CfE) HIV Drug Treatment program (DTP), which is funded by the Ministry of Health through the B.C. PharmaCare program.30

Since January 1st, 2018 PrEP has been freely available through the BC-CfE’s DTP to all eligible individuals31 who are: (1) assessed as “high risk” of contracting HIV as per clinical criteria by a licensed physician or nurse practitioner; (2) HIV-negative based upon recent HIV testing; (3) enrolled in the BC Medical Services Plan (directly or through the First Nations Health Authority32) or has interim federal health coverage; and (4) confirmed as having adequate renal function. Unfortunately, the transition to the DTP has meant additional barriers to PrEP for First Nations people, and decreased access. Meanwhile, PrEP is available to Inuit peoples through prescribers and pharmacies without pre-authorization based on risk-status, as required by the BC-CfE.

Non-Inuit patients enter the BC PrEP program through a licensed physician or nurse practitioner who provides an HIV test and confirms eligibility. To meet eligibility requirements individuals must be diagnosed as high risk, which is defined as (1) having a score >10 on the HIV Incidence Risk Index for gbMSM (HIRI-MSM) scale;33 (2) previous repeat use of non-occupational post-exposure prophylaxis; (3) reporting an ongoing sexual relationship with a partner who has an unsuppressed viral load; or (4) diagnoses of syphilis or rectal bacterial infection in the past year. While these restrictions in eligibility reduce access to PrEP, particularly for non-gbMSM, these are based on both empirical studies and those assessing the cost-effectiveness of PrEP.34–36 If eligible, enrolment applications are submitted by prescribers to the BCCfE and 30-day prescriptions are filled. In the Metro Vancouver area, prescriptions are filled by St. Paul’s Ambulatory Pharmacy in downtown Vancouver. Primary care providers may request an alternative pick-up location, such as the physician’s office or a local pharmacy for those living outside of Vancouver. After HIV-negative serostatus is confirmed in follow-up testing, patients become eligible for 90-day refills. At each refill, participants are re-screened for eligibility.

While this program is revolutionary, the implementation of PrEP faces a number of barriers ranging from patient and provider awareness of PrEP to geographic barriers to care for rural and remote people. There is a need to understand these barriers, and more importantly identify the best practices in overcoming them. This will require significant investment and province-wide collaborations between researchers, community leaders, policy and decision makers, and public health leaders. However, if we can come together, then truly, the best is yet to come.

REFERENCES

1.           Public Health Agency of Canada. HIV in Canada, 2017 [Internet]. 2019 Feb [cited 2019 Feb 15]. Report No.: CCDR: 2018;44(12). Available from: https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2018-44/issue-12-december-6-2018/article-3-hiv-in-canada-2017.html

2.           Yang Q, Ogunnaike-Cooke, S S, Yan P, Rhemis R, Schanzer D. Comparison of HIV Incidence Rates Among Key Populations in Canada [Internet]. AIDS Poster Exhibition; 2014; Melbourne, Austrailia. Available from: http://pag.aids2014.org/Abstracts.aspx?AID=3904

3.           Gbolahan Olarewaju. Differences and similarities in measures of mental well-being by race/ethnicity among men who have sex with men in Vancouver, BC [Internet]. The Summit 2018; 2019 Nov 1; Vancouver. Available from: http://cbrc.net/update/11-2018/summit-2018

4.           Government of Canada SC. Census Profile, 2016 Census [Internet]. 2017 [cited 2019 Feb 15]. Available from: https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/prof/index.cfm?Lang=E

5.           Card KG, Armstrong HL, Lachowsky NJ, Cui Z, Sereda P, Carter MA, et al. Belief in Treatment As Prevention and Its Relationship to HIV Status and Behavioral Risk. JAIDS J Acquir Immune Defic Syndr [Internet]. 2017 Oct 4 [cited 2017 Oct 13];Publish Ahead of Print. Available from: http://journals.lww.com/jaids/Abstract/publishahead/Belief_in_Treatment_As_Prevention_and_Its.96831.aspx

6.           Mosley T, Khaketla M, Armstrong HL, Cui Z, Sereda P, Lachowsky NJ, et al. Trends in Awareness and Use of HIV PrEP Among Gay, Bisexual, and Other Men who have Sex with Men in Vancouver, Canada 2012-2016. AIDS Behav. 2018 Jan 17;

7.           British Columbia Provincial Health Officer. HIV, Stigma and Society: Tackling a Complex Epidemic and Renewing HIV Prevention for Gay and Bisexual Men in British Columbia [Internet]. Provincial Health Officer’s 2010 Annual Report.; 2014. Available from: http://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/office-of-the-provincial-health-officer/reports-publications/annual-reports/hiv-stigma-and-society.pdf

8.           Public Health Agency of Canada. Population-Specific HIV/AIDS Status Report: Gay, Bisexual, Two-Spirit and Other Men Who Have Sex With Men - Public Health Agency of Canada [Internet]. 2014 [cited 2015 Aug 4]. Available from: http://www.phac-aspc.gc.ca/aids-sida/publication/ps-pd/men-hommes/index-eng.php

9.           BC CDC. STI/HIV Annual Report [Internet]. Vancouver, Canada: British Columbia Centre for Disease Control; 2018. Available from: http://www.bccdc.ca/health-professionals/data-reports/hiv-aids-reports

10.        Gustafson R, Montaner J, Sibbald B. Seek and treat to optimize HIV and AIDS prevention. Can Med Assoc J. 2012 Dec 11;184(18):1971–1971.

11.        Treatment as Prevention [Internet]. BC Centre for Excellence in HIV/AIDS. [cited 2015 Oct 8]. Available from: http://www.cfenet.ubc.ca/tasp

12.        UNAIDS. 90–90–90 - An ambitious treatment target to help end the AIDS epidemic [Internet]. 2014 Oct [cited 2016 Sep 15]. Available from: http://www.unaids.org/sites/default/files/media_asset/90-90-90_en_0.pdf

13.        From Hope to Health: Towards an AIDS-free Generation [Internet]. British Columbia Ministry of Health; 2012 Dec. Available from: https://www.health.gov.bc.ca/library/publications/year/2012/from-hope-to-health-aids-free.pdf

14.        Reportable Diseases Data Dashboard [Internet]. British Columbia: British Columbia Centre for Disease Control; 2017 [cited 2019 Feb 15]. Available from: http://www.bccdc.ca/health-professionals/data-reports/reportable-diseases-data-dashboard

15.        Al-Tayyib AA, Thrun MW, Haukoos JS, Walls NE. Knowledge of pre-exposure prophylaxis (PrEP) for HIV prevention among men who have sex with men in Denver, Colorado. AIDS Behav. 2014 Apr;18 Suppl 3:340–7.

16.        Dolezal C, Frasca T, Giguere R, Ibitoye M, Cranston RD, Febo I, et al. Awareness of Post-Exposure Prophylaxis (PEP) and Pre-Exposure Prophylaxis (PrEP) Is Low but Interest Is High Among Men Engaging in Condomless Anal Sex With Men in Boston, Pittsburgh, and San Juan. AIDS Educ Prev Off Publ Int Soc AIDS Educ. 2015 Aug;27(4):289–97.

17.        Liu AY, Kittredge PV, Vittinghoff E, Raymond HF, Ahrens K, Matheson T, et al. Limited knowledge and use of HIV post- and pre-exposure prophylaxis among gay and bisexual men. J Acquir Immune Defic Syndr 1999. 2008 Feb 1;47(2):241–7.

18.        Mantell JE, Sandfort TGM, Hoffman S, Guidry JA, Masvawure TB, Cahill S. Knowledge and Attitudes about Pre-Exposure Prophylaxis (PrEP) among Sexually Active Men Who Have Sex with Men (MSM) Participating in New York City Gay Pride Events. LGBT Health. 2014 Mar 13;1(2):93–7.

19.        Young I, McDaid L. How Acceptable are Antiretrovirals for the Prevention of Sexually Transmitted HIV?: A Review of Research on the Acceptability of Oral Pre-exposure Prophylaxis and Treatment as Prevention. AIDS Behav. 2014;18(2):195–216.

20.        Lachowsky NJ, Lin SY, Hull MW, Cui Z, Sereda P, Jollimore J, et al. Pre-exposure Prophylaxis Awareness Among Gay and Other Men who have Sex with Men in Vancouver, British Columbia, Canada. AIDS Behav. 2016 Feb 16;

21.        Walters SM, Reilly KH, Neaigus A, Braunstein S. Awareness of pre-exposure prophylaxis (PrEP) among women who inject drugs in NYC: the importance of networks and syringe exchange programs for HIV prevention. Harm Reduct J. 2017 Jun 29;14(1):40.

22.        Doblecki-Lewis S, Lester L, Schwartz B, Collins C, Johnson R, Kobetz E. HIV risk and awareness and interest in pre-exposure and post-exposure prophylaxis among sheltered women in Miami. Int J STD AIDS. 2016;27(10):873–81.

23.        Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al. Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men. N Engl J Med. 2010 Dec 30;363(27):2587–99.

24.        McCormack S, Dunn DT, Desai M, Dolling DI, Gafos M, Gilson R, et al. Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial. Lancet Lond Engl. 2016 Jan 2;387(10013):53–60.

25.        Molina J-M, Capitant C, Spire B, Pialoux G, Cotte L, Charreau I, et al. On-Demand Preexposure Prophylaxis in Men at High Risk for HIV-1 Infection. N Engl J Med. 2015 Dec 3;373(23):2237–46.

26.        Volk JE, Marcus JL, Phengrasamy T, Blechinger D, Nguyen DP, Follansbee S, et al. No New HIV Infections With Increasing Use of HIV Preexposure Prophylaxis in a Clinical Practice Setting. Clin Infect Dis Off Publ Infect Dis Soc Am. 2015 Nov 15;61(10):1601–3.

27.        Krakower DS, Mayer KH. The Role of Healthcare Providers in the Roll-Out of PrEP. Curr Opin HIV AIDS. 2016 Jan;11(1):41–8.

28.        Hankins C, Macklin R, Warren M. Translating PrEP effectiveness into public health impact: key considerations for decision-makers on cost-effectiveness, price, regulatory issues, distributive justice and advocacy for access. J Int AIDS Soc [Internet]. 2015 Jul 20 [cited 2019 Feb 23];18(4Suppl 3). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4509900/

29.        Tan DHS, Hull MW, Yoong D, Tremblay C, O’Byrne P, Thomas R, et al. Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis. CMAJ. 2017 Nov 27;189(47):E1448–58.

30.        Ministry of Health. Preventative medication will protect people at risk of HIV. 2017 Dec 28 [cited 2019 Feb 15]; Available from: https://news.gov.bc.ca/releases/2017HLTH0114-002108

31.        Guidance for the use of Pre-Exposure Prophylaxis (PrEP) for the prevention of HIV acquisition in British Columbia [Internet]. Vancouver, Canada: British Columbia Centre for Excellence in HIV/AIDS; 2018 Sep [cited 2019 Feb 15]. Available from: http://cfenet.ubc.ca/publications/centre-documents/guidance-for-the-use-pre-exposure-prophylaxis-prep-prevention-hiv-acquisition

32.        Eligibility and MSP [Internet]. [cited 2019 Feb 15]. Available from: http://www.fnha.ca/benefits/eligibility-and-msp

33.        Smith DK, Pals SL, Herbst JH, Shinde S, Carey JW. Development of a clinical screening index predictive of incident HIV infection among men who have sex with men in the United States. J Acquir Immune Defic Syndr 1999. 2012 Aug 1;60(4):421–7.

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Trans Research Supports Trans Rights Regardless of How Sex and Gender Is Legally Defined

For those of you who would like to understand more about the recent political discussion of trans people, I wanted to share with you my thoughts as a researcher who studies sex and gender.

First, let me state unequivocally that trans people exist! For most of us, it is true that our biological sex (cis-male, cis-female, trans-male, and trans-female) and genetic sex (XX, XY) match our neurological experience of masculinity and femininity -- a construct we describe as "gender." However, in some cases, the development of the brain and genitalia diverge with the brains of transmen adopting characteristics similar to genetically-sexed males, and the brains of transwomen adopting characteristics similar to those of genetically-sexed females. This contradiction between one's internal neurological experiences and their expressed gender leads to a dysphoric state that can cause depression and anxiety.

Currently, the best clinical guidelines for addressing gender dysphoria are to help individuals align their expressed gender with their experienced gender. In many cases, sex reassignment surgery is also needed to align one's biological sex with their experienced gender. Doing so, reduces the negative health consequences of dysphoria.

Yet, myths regarding the pliability of gender-linked neurology, lead some to believe that treatment of gender dysphoria should focus on aligning neurological characteristics with other sex-linked traits such as the manifestation of male or female sex organs. These practices are not widely accepted and the weight of evidence suggests that the neuroplasticity of the brain is insufficient to change the way one experiences or perceives their gender.

While I am a researcher and not a legal scholar, it is my opinion that laws regulating, interfering with or restricting scientifically supported treatments for gender dysphoria (such as changing one's gender expression or undergoing sex reassignment) are unconstitutional under the Due Process and Equal Protection clauses of the 14th amendment. Simply put, trans people have the right to pursue medically necessary treatments without being arbitrarily denied life, liberty, or property -- just like you or me. The administration of justice should not interfere in the decisions between trans patients and their doctors and trans people should be afforded equal protection under the law to live and be recognized according to their experienced gender -- just like you or me.

In summary, gender is a real neurologically-rooted personal experience that should not be subject to the whims of public opinion. Arbitrary and prejudiced beliefs regarding trans-identity should be completely irrelevant to laws and policies regarding trans people. Everybody deserves to be respected and afforded human dignity, regardless of whether their biological and genetic sex is consistent with their expressed and experienced gender.

I hope this helps some of you understand better why the Trump administration's plan to erase trans people by adopting a strict definition of sex is causing so much anger. At the root of this issue is a shared interest in protecting our lives from undue government interference and ensuring that all people have the same opportunities for happiness regardless of what seeming challenges our bodies throw at us.

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Moving Past the Gay Blood Donation Ban: A Time for Re-evaluation

While blood utilization rates are difficult to estimate, existing evidence suggests between 41 and 71% of individuals will need blood at some point in their lives. Causes for blood transfusion include acute injury, surgery, chronic liver disease, bleeding disorders (e.g., hemophilia), or anemia. To meet the demand for blood products, Canadian Blood Services (CBS) estimates that nearly 100,000 new donors are required annually. Tasked with managing the supply of blood products, nationally organized blood collection agencies (BCAs), such as CBS and Héma-Québec (HQ), provide chronic and acute blood users with safe and reliable sources for blood transfusion. However, the sustainability of these voluntary, non-remunerated blood donation schemes rely on the civic participation of blood donors. Currently, however, CBS estimates that less than four percent of Canadians participate in blood donation and evidence suggests that donor participation rates are declining in other North American jurisdictions.

Hoping to improve the sustainability of the blood supply, hundreds of studies have been conducted to investigate factors associated with donor participation. In 2013, a literature review and meta-analysis by Bednall and colleagues showed that prosocial motivators are salient antecedents to blood donation. Based on these findings, Bednall et al. noted that public opinion of blood supply services and normative attitudes towards blood donation play an important role in shaping donor rates and preventing blood supply shortages. Given the documented political and civic engagement of blood donors, it is therefore vital that BCAs have concerned themselves with managing public perceptions towards blood donation and blood supply services. This is, of course, in addition to their responsibility to control transfusion transmitted infections (TTIs) and their goal of minimizing potential societal harms resulting from differentiating blood deferral guidelines.

At the intersection of these diverse and sometimes contradictory mandates, men who have sex with men (MSM) are routinely deferred from donating blood due to elevated incidence of HIV in this population. Presenting itself as a significant and increasingly salient public relations concern in which real risks must be balanced against meaningful civic and social values, the MSM deferral policy has been regularly identified as a liability to promoting voluntary blood donation. For example, Haire, Whitford, and Kaldor (2017) report that the existing 12-month deferral for MSM – which is endorsed by several developed countries, including Canada, the United Kingdom, and Australia – poses a challenge to BCAs by hampering civic trust and providing a basis for donor noncompliance to blood safety protocols. Furthermore, these behavior-based deferrals – much like travel- or health-related deferrals (e.g., prescription drug use, low hemoglobin) – are a known long-term deterrent to blood donation. While less than 5% of all deferrals are given to MSM, the perceived discrimination against this vulnerable population is concerning to many, including the BCA’s who are charged with maintaining the safety of the blood supply. As such, CBS has continually sought to align its MSM deferral policy with existing epidemiological evidence and international standards. As a result of these efforts, CBS has twice revised its blood deferral policy for MSM. In 2013, a 5-year time-based deferral was implemented and in 2016, CBS further reduced its deferral to 12-months. Empirical evaluations of these changes show that they have had no impact on HIV rates and advocates suggest that additional reductions in the deferral period are warranted based on the weight of existing evidence. Furthermore, some have suggested that the deferral policy amounts to a 12-month abstinence requirement for MSM, which is unlikely to significantly change donor participation in this group. Thus, MSM are excluded from the benefits of participating in blood donation. Given the notable social capital wielded by MSM as well as their capability in mobilizing potential donors through annual gay pride parades and other LGBT-focused events, the blood deferral guideline represents a significant missed opportunity for promoting civic participation in maintaining Canada’s blood supply.

Rationalizing shorter time-based deferral policies for MSM, the use of antibody testing and nucleic acid amplification testing to screen donated blood samples has greatly reduced the risk for TTIs. While testing alone is not a satisfactory screening mechanism for HIV, when blood products are appropriately screened using these tests, HIV can be identified with nearly 100% sensitivity in as little as 7 to 15 days after an initial infection occurs This suggests that, with regards to HIV, the existing blood deferral policy is 24 to 52 times longer than what is needed to maintain the safety of Canada’s blood supply. Furthermore, it is important to note that behavioural risk among MSM is not uniform. MSM who are in monogamous long-term relationships as well as those who do not engage in anal sex or who use condoms during anal sex are unlikely to acquire HIV. So while MSM in general may be at elevated risk for HIV, donation from some sub-groups of MSM effectively poses no additional risk when compared to the risk from those in the general population. Recognizing this, several countries (Portugal, Spain, and Italy) have transitioned to a behaviour-based deferral which does not specifically target MSM. This highlights the need for more sensitive and specific deferral criteria that go beyond MSM status and explore the risk-factors that actually predict recent, non-detectable infection.

Yet, consensus has not been achieved with regards to optimizing donor eligibility guidelines; nor is there agreement regarding the best screening mechanisms for identifying deferral candidates. Indeed, while the CBS’s 2012 Ipsos Survey indicates that a revised deferral policy is massively popular among MSM and young potential donors (key groups with low donor participation rates), it is unclear how the emergence of alternative risk reduction technologies, such as pathogen reduction/inactivation systems, might change the debate regarding MSM donor eligibility. Additionally, it is unclear whether changing donor deferral guidelines will significantly impact donor behaviour. As such, there is a need for further evaluation of the MSM donor deferral and screening policy – particularly from the perspective of potential donors and blood-users. Such an evaluation would ideally engage multiple stakeholder groups – including MSM, blood product users, prospective donors, and current donors who are routinely screened for deferral.

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Sex, Drugs, and Depression: The Synergy of Concurrent Health Conditions and the Need for Whole-Patient Care

Lots of studies looking at HIV transmission have focused on condom use and the factors associated with reduced condom use. However, as the risks for HIV have evolved, new outcomes have taken center stage. So-called, "seroadaptive strategies" are now highly prevalent in the gay community and are used by gay and bisexual men to prevent HIV acquisition and transmission. Because of these strategies, condom use is no longer the best indicator of HIV risk. In fact, the Momentum Health Study finds that condom use is not associated with seroconversion. Instead, new cases of HIV are predicted by condomless anal sex with partners who have a different or unknown HIV status.

Examining what factors are associated with this new outcome is important, which is why a recent analysis by the Momentum Health Study looked at whether depression and substance use were associated with "serodiscordant or unknown condomless anal sex." Both of these factors have often been identified as predictors of condom use, so it is natural to assume that they might also play a role in this new outcome. For instance, you can imagine that if your high, you might forget to ask someone's status. Or if you're depressed, you might not have the self-concern to even care.

So, in examining these relationships, here's what we found: only at the highest levels of depression and substance use were men at increased risk to engage in condomless anal sex with serodiscordant or unknown status partners. While this is somewhat good news (i.e., having poor mental health or using drugs alone are not driving HIV transmission), it also highlights the existence of a core group of vulnerable men whose drug use and mental health may be impacting their ability or desire to prevent HIV.

There are obviously lots of ways to take these findings, but for me they highlight the need for better screening to identify concurrent patterns of substance use and mental health conditions. This is particularly so given our observation that individuals who have multiple concurrent health problems are more likely to engage in behaviours which might put themselves or their partners at risk for HIV. Therefore, identifying those individuals with the greatest need, perhaps through the use of a clinical screener or through one-on-one conversations, is the first step to providing integrative patient-centered prevention and care. Once needs are clearly identified and appropriately assessed, our hope would be that specific steps can be taken to help these individuals cope with and manage their mental, physical, and sexual health. For instance, doctors specializing in mental health and substance use should familiarize themselves with the prescription guidelines for HIV-prevention strategies such as "Treatment as Prevention" (TasP) and "Pre-Exposure Prophylaxis" (PrEP) -- which can be used to eliminate HIV transmission and acquisition among at-risk individuals. By integrating these and other preventative sexual health measures into routine care, we can better help those who might not be accessing these services through traditional sexual health clinics -- allowing us to "cast our net wide", so to speak. 

Of course, many clinicians are not necessarily comfortable managing the many and varied health conditions of their patients -- especially given the broad spectrum of conditions that their patients may face. While this partially speaks to the need for medical schools and continuing education departments to integrate mental, substance use, and sexual health training into their curricula, we know that "this is not the panacea we are looking for." Concurrently, clinicians need to identify integrative services offered in their region to which they can refer their patients who exceed their capacity to treat. To assist them, public health departments should develop referral guidelines that balance the need for integrative care against the availability of these services. If such a balance is not easily achieved, more services should be provided or incentivized. This is how we achieve patient-centered care, by treating people as whole people not just as people with depression, or people who have sex, or people who use drugs. Whole people. My hope would be that changes such as those outlined above, might ultimately make it easier for people to access the care they need.

 

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Poison & Cure: Drug Use Among Gay and Bisexual Men

From ancient aphrodisiacs to chemsex, drugs have long played an intoxicating role in human sexuality.[1] Among gay and bi- men, cultural ties to drug use date back to the origins of contemporary gay communities, where gay bars, clubs, and bathhouses emerged as touchstones of Western gay love and gay life.[2] Of course, things have changed in recent years: bars, clubs, and bathhouses are no longer the hubs they once were, [3] the monolithic narrative about what is means to be gay has crumbled,[4] and the multiplication of gay cultural identities (e.g., bears, twinks, professionals, artists, gaymers) has called into question the relevance of traditional representations of sexuality and gender.[5] Examining the role that drug use continues to play today, qualitative studies have repeatedly explored the rationale for various patterns of drug use – often highlighting their role in social bonding and stress coping.[6] For many, drug use is inextricably “suffused with romantic, emotional, and communal attachments”[7] – illustrating drugs as what the ancient Greeks referred to as “pharmakon:” both ‘poison’ and ‘cure.’[8]

Exploring the complexity of drug use, the Momentum Health Study recently examined how gay and bi- men in Vancouver use various drugs. For the most part gay and bi-guys were pretty straight-laced (no pun intended): 36.7% exhibited only limited drug use and 25.9% exhibited pretty conventional patterns of use (e.g., tobacco, alcohol and marijuana). However, 11.4% exhibited patterns characteristic of sex drug use (e.g., erectile dysfunction drugs, methamphetamine, poppers, and ecstasy), 9.5% exhibited club drug use (e.g., alcohol, ecstasy, cocaine, poppers, and shrooms), 12.1% reported using common street drugs (e.g., opioids), and about 4.5% exhibited polydrug use (e.g., heavy use use of most drugs).

While these patterns are interesting in and of themselves, they also reveal a lot about the folks who fall into these patterns of use. Just a few examples: Street drug use was associated with homelessness, being out of work, and identifying as bi- or straight. Club drug use was associated with being younger and patronage of gay bars. Sex drug use was associated with higher annual income, higher sex drives, and more group sex. Polydrug use was associated with homelessness and selling drugs. In summary, the way gay and bi- men use drugs reflects much more than just how they get high (or don’t, as is the case for most), it tells a story about how people fulfill their sexual, psychological, social, and economic needs. In other words, drug use is much more than what courts and health departments make it out to be. Isn't it about time that our programs, policies, and yes, research, reflect that?

[1] Sandroni, “Aphrodisiacs Past and Present.”

[2] Bérubé, “The History of Gay Bathhouses”; Israelstam and Lambert, “Gay Bars.”

[3] Simon Rosser, West, and Weinmeyer, “Are Gay Communities Dying or Just in Transition?”

[4] Ahmed et al., “Social Norms Related to Combining Drugs and Sex (‘chemsex’) among Gay Men in South London.”

[5] Rowe and Dowsett, “Sex, Love, Friendship, Belonging and Place.”

[6] Ahmed et al., “Social Norms Related to Combining Drugs and Sex (‘chemsex’) among Gay Men in South London”; Weatherburn et al., “Motivations and Values Associated with Combining Sex and Illicit Drugs ('chemsex’) among Gay Men in South London.”

[7] Amaro, “Taking Chances for Love?,” pp. 255.

[8] Hayes and Gilbert, “Historical Milestones and Discoveries That Shaped the Toxicology Sciences.”

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Dissidents, Dissent, and the Means to Social Harmony
The most dangerous man is one who wants to be heard, knows that he’s not, and thinks that he should be.

In 1861, political tensions over slavery culminated in the American civil war. In the decades prior, Northerners began to increasingly perceive slavery as a threat to republican democracy and Southerners came to believe that emancipation of African-American slaves would cripple their economic and social security (1). In the decade leading up to the civil war, while opposition to slavery was reaching a critical mass (operationalized as total moral disgust for Southerners), a new word – “ignored” – began to enter the American Lexicon. While any association between word-usage and the political psyche of the day would be purely speculative, the rise of the word “ignored” is intriguingly correlated with the emergence of a new social order in which dissent is not only passé, but taboo. It’s one of the ironies of contemporary politics, that in an age of enlightened tolerance, mass communication, and free expression that so many people feel unheard and unempowered: increasingly subjugated to the confines of social prowess and power. But, as one critical theorist put it, “Where there is power, there is resistance.”

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Setting aside unsympathetic southern slave owners for a moment, there are plenty of other examples of social resistance out there: Among the most well-known, radical groups like Al-Qaeda, the Taliban, and Daesh (ISIS), have each struggled against oppressive regimes, foreign interference, and harsh social scrutiny; and, in turn, each of them has turned to violence as a means of resistance. This phenomenon has given rise to a number of social theories: “deprivation theory,” “crisis theory,” “cultural theory” – each focused on understanding the motives and means of resistance. However, a careful scan of the literature reveals that most of these perspectives are pejorative and paternalistic: they frame dissidents as backwards and ignorant; posture them as terrorists or sectarians; and define them by their narrow-mindedness, radicalism, and extremism (2). And while all of these things may very well be categorically correct, they nonetheless do little to actually address the underlying processes that transform disagreement to derangement. In fact, most evidence goes to show that this is hugely counterproductive. After all, groups rely on the strategies available to them; and while violence is the last resort for most, it is almost always available.

But, what causes someone to take up a dissenting view? How do these individuals escape social pressures, norms, and stigma? How do groups keep themselves from fracturing? What benefits are there to belonging to a dissident group? These are the sort of questions we must consider if we are to avoid the fomentation of anger that is so often consanguineous with social oppression. As it turns out, the answer to each of these questions has less to do with any specific enclave than it does with the interaction between individuals and the broader society in which these pockets of contestation boil.

In recent years, the rapid development of neurobiological research methods have allowed us to understand better the neurological basis of social influence and conformity (3). For example, imagine that you are shown a series of faces and asked to rate them on their level of attractiveness. After rating each photo, you are then shown the average score that face received from others. Later, you are shown that face again. What do you think happens to your rating? If it was independent of others, you’d expect it to be about the same as it was the first time you rated the face; but as it turns out, empirical evidence shows that individual ratings regress towards the mean: we conform our ratings with those of others. More accurately, when we see that our scores are different than the composite scores, activity in the rostral cingulate zone of the medial prefrontal cortex (an area associated with processing conflict) increases, and activity in the nucleus accumbens (an area associated with motivation, reward, and reinforcement learning) decreases. Perhaps most surprisingly though, perceptual representations of visual stimuli in the occipital-parietal network change – people don’t just rate differently after seeing the composite score, they observed differently (And continued to do so due to long-lasting modifications in the amygdala [an area associated with decision making, memory processing, and emotional reaction] and hippocampus [an area associated with conflict avoidance and long-term memory]) (4). This same phenomenon has been documented with respect to group choices, food score ratings, behavior change, song preferences, and more – suggesting a neurobiological foundation for social conformity (5,6).

But what does this tell us about non-conforming behavior? If we are naturally predisposed to correct discrepancies between our own thoughts and the thoughts of others, how can we explain individuals who constantly disagree even in the face of mass-conformity? This is where group politics come in. While neurobiological research is less developed with respect to understanding non-compliance and dissent, some research shows that the effects of neural-conformity are stronger within groups than between groups (7). This is believed to be the case because there is a greater reward (e.g., positive affect, social trust, acceptance, inclusion, social advancement) for agreement with your own social groups than with other groups. However, the emergence of radical dissenters is reliant on more than just the presence of a group who will affirm them. There must also be processes of social exclusion, in which individuals are “other-ized.” Under such circumstances, neurobiologically-driven certainty, particularly that which is contrary to predominant norms, is bound to emerge. This sort of certainty, after all, is a coping mechanism meant to facilitate group safety and solidarity. Thus, we can infer, that social exclusion lies at the heart of controversy and political dissidence.

So, if we understand that opinions and worldviews are largely the product of in-group social conformity, and that exclusivity serves as a mechanism for “other-ing” out-groups, then what should we do about this? We could carry on and try to persuade others to our view. We could try calling them out and stigmatizing their viewpoints. We could show them how right we are and how all the evidence is on our side. I think this is generally what we in the majority try to do. I also think that this is an unbelievably lazy approach, and not to mention a counter-productive one. If we are to prevent danger and dissent, we must actively seek to include those with whom we disagree. Breaking down social barriers is likely the only remedy to social conflict...and that starts with listening.

 

References

1. Dew CB. Apostles of Disunion: Southern Secession Commissioners and the Causes of the Civil War. 35242nd edition. Charlottesville U.S.; London: University of Virginia Press; 2002. 144 p.

2. Douglas M, Mars G. Terrorism: A Positive Feedback Game. Hum Relat. 2003 Jul;56(7):763–86.

3. Stallen M, Sanfey AG. The neuroscience of social conformity: implications for fundamental and applied research. Front Neurosci [Internet]. 2015 Sep 28 [cited 2017 Oct 17];9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4585332/

4. Berns GS, Chappelow J, Zink CF, Pagnoni G, Martin-Skurski ME, Richards J. Neurobiological Correlates of Social Conformity and Independence During Mental Rotation. Biol Psychiatry. 2005 Aug 1;58(3):245–53.

5. Wu H, Luo Y, Feng C. Neural signatures of social conformity: A coordinate-based activation likelihood estimation meta-analysis of functional brain imaging studies. Neurosci Biobehav Rev. 2016 Dec 1;71(Supplement C):101–11.

6. Amodio DM, Frith CD. Meeting of minds: the medial frontal cortex and social cognition. Nat Rev Neurosci. 2006 Apr 1;7(4):nrn1884.

7. Stallen M, Smidts A, Sanfey AG. Peer influence: neural mechanisms underlying in-group conformity. Front Hum Neurosci [Internet]. 2013 Mar 8 [cited 2017 Oct 17];7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3591747/

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