This is an edited transcript of Bill Good's interview with:
Bill Good: A study published in The Canadian Medical Association Journal says gay and bisexual men continue to have risky sex, despite constant warnings about the threat of HIV and AIDS. According to the study, within 20 years, 25% of gay men who are currently HIV-negative could become infected. Steve Martindale is coordinator of the Vanguard Project. Good afternoon.
Steve Martindale: Good afternoon, Bill.
Bill: What is the Vanguard Project?
Steve: The Vanguard Project is an ongoing study of HIV rates and risk factors in young gay and bisexual men in the Lower Mainland. We have almost 1000 young men in the study and the analysis that was published recently in The CMAJ looked at 681 men.
Bill: And the key is that this is an ongoing study?
Steve: Yes. We've been running for almost five years now. We hope to continue and what was published recently is just one of many papers that we're working on.
Bill: We'll come back to the study in a moment. Andrew Barker is coordinator of something called the "Man to Man" Program. Good afternoon to you and tell me what the Man to Man Program is.
Andrew Barker: Good afternoon, Bill. The Man to Man Program is a peer-driven program that provides education, support, advocacy and research for gay men in Vancouver. We operate under a holistic model focusing on sexual health and HIV/AIDS.
Bill: How concerned are you about this study and what it tells you?
Andrew: It's concerning but it's not really news to me.
Bill: Justin Jagosh coordinates education and outreach with The Centre the Lesbian, Gay, Bisexual, Transgender Community Centre and I welcome Justin to the program. Quickly, your reaction to what you know and what you've read and we will get more to the detail in a moment.
Justin Jagosh: Hi, Bill. I think it's a serious topic and I think we have to look very carefully at what are the underlying factors that cause individuals to engage in high-risk behaviour.
Bill: Does it concern you that they still are engaging in high-risk behaviour and does it surprise you?
Justin: Well, it definitely does concern me. I think it doesn't really surprise me, as it's a concern that I've been aware of for some time.
Bill: Steve Martindale, tell me more about the study if you would: why it was done, what did you find out that you didn't expect to and do we see trends emerging here?
Steve: Well we wanted to do this study to look at young gay and bisexual men because there really wasn't anything like it in Canada. The studies that were around were looking more at the older population men who were around in the '70s and '80s and we really didn't know very much about young gay and bisexual men and their risk for HIV infection in this country. Often we would rely on American statistics, from San Francisco and New York and we couldn't be sure that they were translatable to the Canadian situation.
So the study started about five years ago and it involves HIV testing and the participants complete questionnaires, so we collect data on their sexual behaviours and their substance use behaviours. And what we found was that the risk behaviours that these young men were engaging in were more common than might have been expected. We found about half of the young guys would have unprotected anal intercourse with a regular partner in the previous year and about a quarter of them had done so with a casual partner. So those rates were quite high and higher than what some other similar studies had reported.
Then we went on to look at HIV incidence, to see how common HIV was within this community and how quickly it was spreading. And although the rates we found were much lower than they were in the '80s in the gay community, we nonetheless found that they were higher than we would have expected. Initially we found them to be about twice as high as American cities that were reporting from similar communities.
Bill: Do you know why?
Steve: There's a whole series of possible explanations for what's going on. In terms of the trends that we found, when we looked at people who had changed their behaviour from one year to the next most of the participants didn't change their behaviour, they were either at risk or not at risk consistently but of those that did change their behaviour, we would hope to see that more of them were changing their behaviour towards sexual safety and what we found actually was the opposite, that they were twice as likely to start taking risks rather than to stop taking risks.
Bill: Do they tell you why?
Steve: Well it's more of a behavioural study, so we've collected data on what people have done and are doing rather than the rationales. But I think there's a lot of things going on in the community that might help to explain it and maybe some other people want to jump in and talk about some of those things. There are things that have been suggested around too much optimism around the new drug medications for HIV...
Bill: Right
Steve: ...a sense of fatalism or inevitability that young men may have towards, you know, "if I'm gay I'm going to get HIV and there's nothing I can do about it" and the lack of health care or social support that a lot of young people face.
Bill: But looking at young people, Andrew, it seemed to me this morning when I was thinking about this, that despite an entire generation growing up with an awareness of HIV and AIDS, far too many aren't taking the threat seriously enough. And we're talking about a generation that has always known about and lived with the threat of AIDS, unlike the older men who came to this at some mid-point in life, their sexual attitudes were already set in place, their behaviour was set in place and suddenly somewhere in the early '80s they discovered it could be deadly. Your generation's really started their sexual lives with an awareness, at least, that there could be a high risk here.
Andrew: Well, that's right, Bill. But I think there's a number of things here to take into consideration and one of that is that even though younger gay men have grown up living with HIV and AIDS, a lot of them haven't seen their friends and lovers dying, as the men in the '80s did. I'm 26 years old and when I came out I met a lot of people and very few of them disclosed that they were HIV-positive. I haven't had friends around me dying of HIV/AIDS so it's not something that is in your face as much for these people. And as much as we'd like to think that everyone's got the information, the education in the public school system in BC is still not up to where it should be and there's been a number of struggles getting into the school system and trying to get that information out.
Steve: And I should also point out that there's never been a national campaign in this country targeting young gay and bisexual men around HIV education. So we assume that people have all the information they need, we assume that the education efforts have been done and really we haven't explored prevention education to the full extent.
Bill: Justin.
Justin: With regards to education also, I think it might be useful to think of unsafe sexual practices among gay and bisexual men and make the analogy to smoking and teenagers. There's been a huge campaign in the last, let's say, 20 years trying to educate people about the risks of smoking and while a lot of people have quit, we see an upsurge in the rise of smoking among young teens. And it might be the case that traditional modes of education, for example with safe sex you know, using a condom, understanding what happens when you have unsafe sex, what are the risks of AIDS that doesn't work anymore and we have to constantly look at creative ways of addressing prevention strategies.
Bill: Smoking is an interesting analogy, because I think most teenagers, whether it's smoking or sex, tend to think they're invincible.
Justin: Exactly. And I think that's part of the problem here as well.
Bill: So HIV is something that may happen to somebody else but it's not going to happen to you.
Andrew: Yes, I think any kid is like that, you know: You're not going to die in a car crash; I'm okay, I can drink and drive; it's all right, I'm not going to get cancer if I smoke now; I can go out and have sex, if I'm having sex with other young guys and they're not sleeping with older guys then I'm going to be okay. So there's a million and one ways of rationalising it and saying, "It's not going to happen to me."
Bill: But is there a difference between those of you who have the information and make good use of it and make sensible decisions and those who you work with, who you see are not? Justin?
Justin: Well, definitely there's a diversity of reasons within the community as to why somebody would engage in unsafe sex. There are some people who don't have the information; I would say those people might be fewer now than before. I think a lot of people have heard of AIDS, they've heard of condoms, they know all the routes of transmission. So I think more and more it's other reasons.
Bill: But Andrew makes an interesting point and Steve, perhaps you can relate to this I'm not sure exactly how old you are but I do remember in the late '80s, there were many of us who worked with people or knew people who were gay or sometimes we discovered they were gay because we discovered they were sick. And people we worked with and people who were neighbours and colleagues did die. Andrew says his friends haven't really experienced that, but even those who aren't members of the gay community saw people literally falling around them at a certain point in time.
Steve: Yes, there's certainly a generational difference, depending on when people were born and when they came out, as to what their experience is with AIDS. And I think Andrew makes a very good point about people either feeling invincible or feeling like it won't affect them and I think the reverse is also true, because I don't think there's any one explanation that works, that helps to explain this situation. The reverse is true in that often people might think that because they're gay then it's inevitable that they're going to get HIV. The two things have been so closely aligned in the media and in the public perception. A lot of people, as you say, are outed or come out as gay when they test positive for HIV or when they start to get ill. A lot of young people will tell their parents that they're gay and the parents' first question is, "Does that mean you have AIDS?" So the two are very closely aligned in people's minds and if they have a sense of inevitability, that there's nothing they can do to prevent it from happening, then why take steps to prevent it?
Bill: The numbers are quite stunning. According to the BC Centre for Excellence in HIV/AIDS and this is for people who may not think that this is of particular interest or concern to them 10,000 people in BC are living with HIV today, 6500 of those living in downtown Vancouver, maybe another 2500 in the Downtown Eastside not diagnosed or taking medication. When you telescope those numbers out five or ten years and think of the implication to health care and the health care cost that's involved not to mention the human cost it's pretty staggering.
Steve: Yes and I think people need to put that kind of thing in perspective, when you look at the outrage that was heard in response to the recent thing about [federal Minister of Multiculturalism and the Status of Women] Hedy Fry funding lesbian and gay groups and people getting all upset about tax dollars being directed there. But if that kind of support for young people helps prevent a few infections with HIV, we save the health care system hundreds of thousands of dollars per person.
Bill: It's estimated that every person who is diagnosed with HIV and AIDS will cost the health care system in the neighbourhood of $150,000 over the remainder of their lifetime.
Steve: And that figure's probably going up because the new treatments are increasingly effective, which gives people a lot longer
Bill: If you're talking 10,000 people, simple math tells you that's probably a billion and a half dollars down the road that we already know is going to have to be spent.
Justin: And we should also add that not only will it cut health care costs, it will also improve the quality of life of the people, the prevention strategies will, so I think for that reason alone, that should be upheld as a very strong value in our society.
Bill: Let's take some calls and see what people are thinking on this topic. Kevin, hi.
Caller #1 (Kevin): Thanks. Admirable to have the guests you've got there, Bill, but I have three points. One is, you'd have to be living in a cave in this society to not know what unprotected or protected sex is. The fact is that when you have the chief medical officer saying that condoms only work nine out of 10 times and most people's general practitioners suggesting that, it's no wonder that we have an epidemic on our hands and it's obvious to most of us what safe sex really is. However, that community does not want to hear that message and so is searching for another kind of cure.
Bill: Kevin, hold that, because I know you've got other points to make but Justin is anxious to speak to your first one.
Justin: Yes, I just wanted to address that I think when we do read articles about increasing rates of HIV among gay and bisexual men, there is this feeling of panic about why aren't we practising safe sex but we have to recognise that there are a multitude of factors that underlie these behaviours. Growing up different in a society is a relatively stressful thing and issues around housing, issues around homophobia, discrimination, a lot of internalised homophobia which is self-hatred can prevents people from practising safer sex. So it's very easy to say that it's just disregard but I would say that that is a very superficial and inaccurate analysis of what's going on.
Kevin: Well, okay, lack of housing doesn't cause AIDS but I appreciate your response to it. The other thing is, just getting back to the education part of it, going into the schools, see, when I smoke a cigarette, I don't run the risk that I will die of cancer from smoking one cigarette or a cigarette, however, when we say to somebody, "Don't drink and drive," we don't say, "but if you're going to drink and drive, here's how you mix your gin and tonic." We don't say, "Don't play with guns but if you are going to play with guns, this is how you load the shotgun." But when it comes to sex, we say, "Don't have sex or don't have this kind of sex," but if you are going to have sex, we give them a whole manual on how to have it "safe," when in fact even the health industry says that is not a fail-safe method. We know it's not: condoms slip, they break, they don't get put on and people lie, they say, "Oh, ya, I used a condom, gee I don't know how I got HIV." We know what causes HIV, we know what causes AIDS yet none of us are prepared to take the responsibility for our own actions and we want to place it on society or this "homophobic" thing or housing or whatever or different upbringings, when in fact I think all of your guests, Bill, know that there really is only one cure to it and hey I would love to see a cure of it, because there is a lot of innocent people being hurt and killed by this but I think that there's an obvious answer and I think they need to 'fess up and say, "We know this kind of safe sex doesn't work." And let's not preach it to the school kids, because it's a fallacy.
Bill: Steve?
Steve: Well I think your caller's wrong, because we know that condoms prevent HIV, so if he thinks condoms don't work, he's simply wrong. Condoms do work, the problem is that they're not being used as frequently as we would like to see them used. So the issue is not the effectiveness of condoms. There are a lot of other issues and he's wrong also when he says housing doesn't cause AIDS, because lack of housing is a very big issue for people: if you don't have a roof over your head, are you really that concerned about a disease that may take you down 10 years from now? Your concern is going to be where are you going to sleep tonight, where are you going to get food. People have a lot of other concerns. HIV is not the only health issue in this community.
Bill: Andrew?
Andrew: I think another issue to take into consideration is that even though people may have the information although I would guess that a lot of people don't have the information growing up, about how to have safer sex a lot of people don't have the skills or the ability to negotiate sexual safety. For instance, if you have a young person who's just come out and he's very insecure in himself and someone suddenly says, "Hey, I'm willing to have sex with you," if that person doesn't bring up using a condom, then the young person might not be able to feel comfortable saying, "What about a condom?" Because then he might say, "Sorry, you;re out of here."
Bill: A lot of straight kids have gotten pregnant, despite what education they may have had
Andrew: Exactly.
Bill: A lot of kids smoke, despite the education that's there. Young people don't always or even often, necessarily, follow the education model at that age.
Steve: We know that education works, we know that behavioural interventions and education works to a point. It works for some people and it works to a certain extent. But in and of itself it's never going to be enough and as you point out, with smoking and with teenage pregnancy and any other issue education only goes so far. People need more than just education; they also need support to implement sustained behaviour change over time in their lives. And with callers like we've just had, obviously people aren't getting the kind of support they need from people like that.
Bill: We want to get back to your calls and we'll do that right now, because we just have a few minutes left. John in Richmond, hi.
Caller #2 (John): Yes, hi. This program reminds me of something and I guess it's what I would call "the human condition," whether you're heterosexual or homosexual, whatever you are. They had a guy on "60 Minutes," he actually taught programs, just like these guys, he had lost friends due to AIDS and he said he took risky sex. He admitted it on the program and they said what was it? And, basically, it wasn't knowledge, it was just passion. He got caught up in the moment and that can unfortunately happen to anybody no matter what their inclination is in life.
Bill: A lot of very judgmental people seem to forget that. They must have short memories. Justin, you wanted to make a point.
Justin: Yes, I think it's true, that's a very good point. Risk is a part of life and to some extent it's something that some people want to do; they want to shake up their lives a bit. But I also want to talk about the broader issues affecting gay and bisexual men, because I think a lot of times in news, journal articles and shows like this, we always talk about AIDS and HIV but unfortunately that overshadows other issues that affect the community, for example like alcohol and drug use and abuse. I think there is a huge problem with substance abuse as well as domestic violence. There are issues with regards to power dynamics in gay male relationships and issues around body image and self-esteem. These are issue that aren't addressed and I think that it's important to address them. I think we may see HIV/AIDS as the problem but we have to address the underlying factors as well.
Bill: Well if it's any help, 20 years ago, 25 years ago people weren't talking about it on the radio. People your age weren't speaking to it, probably weren't even coming out and talking about their lifestyle or their sexual orientation. Andrew, you wanted to make a point.
Andrew: Yes, just to follow up what Justin was saying, that's actually a change we've made in the Man to Man Program over the last few years. Traditional HIV/AIDS prevention work was to hand someone a condom and say, "Use this or you're gonna die." And that worked for a while, while people saw people around them dying but when we're not seeing that so much today, people take it as a bit of an affront and there might be a bit of a tendency to rebel and say, "Don't tell me what to do." So what we're trying to do now is give people the information and then empower them to make informed decisions that are right for their lives, however that's best going to fit for them.
Bill: A final thought from Steve.
Steve: I think the last caller makes a very good point around the human condition and passion. One of the reasons that came out in our study around people not protecting themselves was that they were in relationships or that they were in love with somebody. And that's the same for gays or straights: you get together and maybe you start using condoms initially and after a while you stop because you're involved with the person. And that might help keep you safe, if you're both monogamous and it might not, because people often find out that surprise, surprise they both end up with HIV.
Bill: I thank you all.
For more information, contact:
Bonnie Devlin
Vanguard Project Coordinator
608 - 1081 Burrard Street
Vancouver, BC, Canada, V6Z 1Y6
Tel: (604)806-8306
Fax: (604)806-9044