The Minnesota Department of Health (MDH)¹, from analysis of data collected by their partner services program, says:

Commonly reported risk factors were meeting partners on the internet, anonymous sex, and no condom use

Now, I don’t want to be the debbie downer, but if I’m not using condoms and am meeting partners on the internet for anonymous sex, then being told to use condoms and being handed a brochure is not going change my behavior.

I’ve been working in sexual health education/testing for nearly a decade, and I have yet to meet a young man that didn’t know he should probably be wearing a condom.  Education is not the problem².  The problem is that having sex without a condom feels really good.  Much better than with a condom.  So much better that, in that moment, the risk of getting syphilis or HIV feels like a pretty equal trade for the feeling of sex without a condom³.

A brochure can not compete against our biologic drive to exchange body fluids.  Ever.

Craigslist Explored

What can compete, however, is sex.  But before I explain, let’s look at a few personal ads from Craigslist (sorry, this is sexually explicit):

22 one fifty 6′ 7cut bottom/vers
gl.ddf, into jo, oral, making out, want to bottom safely
looking for ddf, good shape, top under 30 unless really hot
host/travel won’t respond to replies w/ no pic

Looking for a btm who’s willing to let me go wild….flip on your stomach, put your ass up, I slide in… I am 5’10″, 145lbs, blond, 7″ cut, nonsmoker, DDF, HIV-, popper friendly. Would prefer u be nonsmoker and definitely DDF/neg. Hit me up! Please send age pics.

looking to have some fun now, 29yo hiv+ looking for some fun, vers, oral, body contact, open to whatever, bb or safe cool, lets get together

A few definitions/codewords:

• “bb” or “wild” = bareback, anal sex w/o condoms
• safe = generally anal sex w/ condoms
• ddf = drug and disease free
• neg = HIV-negative
• popper = amyl nitrate
• gl = good looking
• jo = jacking off
• top = insertive partner; bottom or btm = receptive partner; vers = either

So, each of these personal ads share two characteristics: 1) they explicitly state what they want (e.g., “let me go wild”, “bottom safely”, “bb or safe cool”), and 2) they state their HIV or STD status (e.g., “DDF/neg”, “hiv+”).  Of course, not every Craigslist post does this, but many do — if you don’t believe this is an accurate representation, then start browsing (and comment on this post with your findings).

In public health terms, they’re practicing harm reduction by attempting to serosort.  But there are two major questions that are raised:

1. Are you actively ensuring your partner is “DDF”?  Or are you relying on your post to sort out all those who aren’t “DDF”?
2. How do you know your partner knows their HIV/STD status?  When were they last tested?(I’ve met more than one person who assumes they’re HIV-negative, yet has never been tested).

Data-Driven Sex

Qpid.me provides HIV/STD test verification for online dating⁴.  They work with your clinic to get your HIV, syphilis, gonorrhea, and chlamydia test results, and then allow you to share them with whomever you like.  Right now, it’s done via text message, although there are plans to expand soon. So, for example, you can get my test results by texting “Verify John Demo” to 774363.  ”John” is my username, and “Demo” is my access code — this allows me to ensure I’m only sharing my results with the people I want to.

This could be a huge game-changer for sexual health.  Now there’s a tool available to help those no-condom-wearing, internet-using, anonymous-sex-having heathens men serosort using actual, verified data.  And, of course, all of the normal just-want-to-be-close-to-someone guys and gals could benefit from Qpid.Me, too.

Even more important, there’s a sexual incentive to get tested more frequently.  If the status quo is to use self-reported HIV/STD status as a criteria for selecting sexual partners (e.g., “I will only have sex with you if you say you don’t have HIV”), what happens when you can verify the status along with approximately how long ago they were tested?  A potential partner would be more attractive if they’ve been tested more recently, meaning: getting tested = getting laid.  And who doesn’t want to get laid?  (it sure beats having your doctor hand you a brochure about syphilis).

For people living with HIV, you can verify your viral load and also share that with potential partners.  With an undetectable viral load, one becomes less infectious (it is still possible, but less likely).  So, this allows people living with HIV to have informed conversations with their partners about the risk of HIV transmission.  Done correctly, this could actually alleviate some of the stigma of HIV-infection, get more people laid, and decrease HIV incidence.  Win-win-win.

Use fire to fight fire.  [insert your own joke about red-heads or gonorrhea].  That is, use sex to fight sexually transmitted diseases by redefining how people have sex.  Instead of having a traditional information campaign or continuing to hand out condoms, actually arm people with a tool to be able to make informed decisions.  Even better, give them a tool to allow them to do something they’re already doing, a little bit better.  By encouraging people to make informed decisions with actual data, you’ll see them get laid more often while getting fewer STDs and getting tested more frequently⁵.  And, most importantly, it requires essentially no change in current behavior.

If you haven’t figured it out by now, Qpid.Me is the health tech start-up I took a job with.  We’re currently in private beta, while we work on building out a bunch of the back-end.  If you’re interested in signing up, head to the website, or comment here/email me — I might be able to hook you up

Seriously, who footnotes a blog post?
1: I pick on MDH because I’m from Minnesota.  They’re actually quite good at what they do, given the constraints of politics.  The issues I raise are pretty ubiquitous among all major public health departments.
2: While I argue education is not the problem, I do believe comprehensive sexuality education in schools would help lower HIV/STI rates.  That’s more of a shift in attitudes than providing students with facts.
3: Of course, I wouldn’t know from first hand experience…
4: Now, if only there were a Qpid.Me for verifying penis size.
5: There are a couple of research studies in the works regarding this, but right now this statement is based on qualitative information from users and theory.

Today was a much more relaxed day, as I have finally bought into the “marathon not a sprint” mentality for this conference.  I also ventured out of the HIV/sexual health into a data and practice session.  But, in summary, here is some of what I learned (~1500 words for 10 hours of conventioning… I think that’s pretty good):

MRSA infections in MSM associated with PNP.  Popular media was very quick to label Methicillin-resistant Staphylococcus aureus (MRSA) as the new “gay STD” but that’s not entirely accurate.  MRSA is spread by close contact with someone who is a carrier or infected, so in a sense, it could be sexually transmitted.  There was an outbreak in men-who-have-sex-with-men (MSM) in New York City in 2006.

Qualitative research by the New York City Department of Health and Mental Hygiene found that this outbreak was caused by three issues:  Party-n-play (PNP – drug use and sex) activities, MRSA misinformation, and stigma.  Participating in PNP caused people to have sex for longer periods of time increasing their exposure.  Also, HIV-positive individuals and PNPers were less likely to use condoms and water-based lube, opting for grease or oil-based.  This has a tendency to clog pores, further facilitating transmission.  Once someone was infected, they’d attempt a variety of home-remedies, including alcohol-baths, peroxide, and lancing the pustule.  This would further insult the skin integrity while not resolving the infection.  Finally, individuals felt MRSA carried an additional stigma, thinking that, as one individual said, it’s just “another gay disease, one more thing conservatives can use” against them.

HIV-positive men mostly feel responsible for preventing HIV transmission. Is an HIV-positive individual responsible for keeping an HIV-negative individual safe?  Or is it always the HIV-negative individual’s responsibility to protect themselves?  A study by Dr. Hugh Klein discussed the locus of control among HIV-positive men who have sex with men with HIV-negative partners.  He found that 70% of HIV-positive men felt they had an obligation to keep their partners safe, while 49% thought it was also the negative partners responsibility (these are separate questions, so they don’t add up to 100%).

Further analysis showed five factors, explaining 21.6% of variance, helped explain HIV-positive individuals external locus of control:  having HIV “burnout”, being younger, partner communication problems, knowing fewer people with AIDS, and being a meth user.  Partner communication was  related to the need to improve communication, making it a two-way street.  Ultimately, most HIV-positive men believe they have a duty to keep HIV-negative men safe, although more than 1 in 6 disagree, and more than 1 in 3 think the HIV-negative individual is also responsible.

Internal ejaculations don’t always happen in unprotected anal intercourse. There’s a general assumption in HIV research and practice that if you’re having sex without a condom, you’re also ejaculating inside your partner (or being ejaculated inside).  This, according to Dr. Klein and Mr. David Tilley, is not always true.  Only 50.2% of sex involved internal ejaculation.

When examining factors related to internal ejaculations, they found four issues that explained 18% of the variance: knowing people who died of AIDS, use of the internet to seek partners, perceived accuracy of their partner’s HIV status, and a negative attitude towards condoms.  They also found significant associations with other risk activities, including felching and snowballing.  If you don’t know what those are, you should probably google them from your non-work computer.  This information makes a very compelling case for encouraging harm reduction — people may not be practicing “safer sex” by using a condom, but they are taking steps to reduce their risk of HIV infection by at least not allowing their partner to ejaculate inside them.

“Boys must be men, and men must have sex with women.” Dr. Scott Rhodes did a qualitative study of risk taking among African American, Latino, and White MSM.  His findings, similar to what I learned from yesterday’s sessions on HIV, seemed to show a lot of similar issues among different groups of people.  Latino men reported loneliness and social isolation, largely related to being secluded in rural North Carolina where their jobs and families were.  African American men reported feeling isolated from their church.

Condom use was also an issue.  One African American man said that “condom use is antithetical to love.”  And, dealing with their own coming-out process left feeling a bit overwhelmed and not ready to also use condoms:  ”having sex with another man is a step in the right direction.”  Participants also expressed that alcohol/drug use was sometimes used an excuse — if someone “didn’t want him to cum inside him, he wouldn’t” let it happen.

This study suggested a number of recommendations for HIV prevention, including implementing a coupon system for non-department of health testing venues, using more social media, implementing chat room interventions, and operating hotlines and websites specific to MSM of Color.

Submissive men use condoms (or don’t) when their partner tells them to. Continuing research that Dr. David Moskowitz has previously done relating to leathermen and condom use, he explored the relationship between being more dominent or submissive (i.e., sexual control) and condom use.  I’ll be honest — this is one of the few presentations where I got a bit lost (mostly because I was just so concerned about how power bottoms fit into this picture).  However, my take away was that dominent men are in control of whether condoms are used.  Further, when someone is in their non-preferred role (e.g., dom men being submissive), they’re more likely to eschew condoms.  This suggests that perhaps condom negotiation should be done prior to sexual activity — perhaps condoms should be discussed when chatting online or in a bar, so there’s less pressure to have that conversation in the heat of the moment, after you’ve already been tied up.

Data-Driven Public Health Practice.  My one non-HIV session that I went to  Ms. Ami Shah with Mount Sinai in Chicago talked about their use of data to implement public health changes in the community.  They received a Robert Wood Johnson grant to do local, neighborhood-level surveys relating to health.  They did this in a about 10 neighborhoods in Chicago, based on certain ethnic/racial groups or mixes of interest.  This data allowed people to identify local issues, create private-public partnerships, generate news coverage, and help inform elected officials about public health issues.  Some Jewish Synagogues, now having data about obesity rates in their children, implemented programs to reduce childhood obesity.  Another community in northern Chicago found poorly controlled diabetics in their neighborhood, so some diabetes centers opened up in those neighborhoods.

In New York City, they produced local data based around 10 metrics, and then provided data back to the individual neighborhoods.  Their rationale is that neighborhoods become empowered by having access to their data, and then the Department of Health and Mental Hygiene becomes empowered to help the neighborhoods with issues.  This work has informed elected officials about needs in their communities, and has led to policy changes.  For example, New York City, already saturated with food carts, is allowing 1000 “green carts” in designated neighborhoods in order to provide healthier food options to citizens.  Certain farmers markets have “health bucks” which provide a $2 voucher for every $5 EBT transaction.

King County, the county containing Seattle, has developed CommunitiesCount.org.  This was the product of a community process to develop indicators for local municipalities.  This information is made available back to the municipalities to allow them to inform elected officials and budget decisions.  As they continue developing their web presence, they intend to make this data available in a more user-friendly and dynamic manner.

This presentation sparked a lively conversation with some of the presenters, myself, and a few former classmates of mine from the University of Illinois-Chicago.  We discussed the need for public access to raw data, and the desire to put this data into the hands of the neighborhoods.  As one of my former classmates pointed out, she doesn’t have the staff in her health department to analyze all of the data.  But if local colleges or Schools of Public Health (or even high schools!) were to take on data projects using *real* data, they could get a much stronger bang for their buck and even further empower their local communities. NYC has started doing this, and King County has plans to do similar work.

There’s a lot of exciting things happening and there’s an overwhelming amount of information out there.  So, even though I can’t possibly go to every session and poster presentation, I think that’s ok.  The networking, conversations, and socializing have been inspiring; and the presentations have been enlightening.  I’m excited for the conference to wrap up, the opportunity to really process everything that’s happened, and then to get back to work.  It’s our world to change, as Dr. Cornel West said, because we are the American Public Health Association.

Most interestingly, there were a few themes that I realized in the presentations:

1. Everyone is the same, but different.
   There was an entire session on current research for men who have sex with men (MSM). This included a presentation from someone focusing on African Americans, one on Asian/Pacific Islanders, and one on (by convenience) Whites. When talking about their qualitative concerns and issues, they all seemed to be same. Nobody likes getting tested for HIV. It’s really hard to use a condom, particularly when you’re in love. Drugs (especially crystal meth) make sex feel better.

   However, when developing HIV prevention interventions, each population was also clear that they need to be culturally specific. We, as public health professionals and medical providers, need/want to encourage people to be healthier — and that means making people feel comfortable and ready to make changes. So, while the core message may be the same (e.g., “use condoms”, “get tested”), it still needs to be customized for and delivered in a culturally competent manner.

2. Access isn’t enough
   Dr. David Malebranche summed this up very well: “testing facilitators [are] not just an access issue, [they're] a quality issue.”

   Simply having access to HIV testing isn’t enough.  Being tested for HIV is a traumatic experience, so patients need to feel comfortable when going in for testing.  That means making sure that providers are properly trained, staff are open and non-judgmental, the waiting room feels comfortable.

3. Providers suck at taking sexual/social histories
   This came up in multiple presentations.  Providers don’t feel comfortable taking sexual or social histories, and (in some cases) don’t think it fits with the work they’re doing.  That is, it’s not a strictly a medical history, and they don’t have time to ask any other questions.

   This isn’t, as Dr. Malebranche suggested, as simple as asking, “Mr. Jones, have you ever had a penis in your butt before?”  It requires taking time to ask and assess what kinds of risk the patient has.  Knowing this information would then inform the patient and provider about the needs for HIV/STI testing.

4. There’s no one good method.
   Multiple approaches allow patients to choose an option that makes them feel most comfortable. Not everyone wants to get tested at their primary care clinic.  Similarly, not everyone feels comfortable in an STD clinic.  However, some people are willing to work through their discomfort if needed — they may not want to be in the STD clinic, but they know if they test positive, the provider may handle it better than their PCP.

I also learned a lot about gay sex parties in Boston today, through the work of Matthew J. Mimiaga.  As you might expect, there are two kinds of sex parties: safe and unsafe.  The safe (i.e., condoms required) parties are surprisingly well regulated.  Party hosts maintain a listserv of ~1500 men whom they’ve recruited from Manhunt ads, word of mouth, and other websites (although a typical sex party has ~50-60 people).  There’s a screening process — you have to meet certain physical requirements, and sign an agreement that you will practice safe sex.  They enforce condom use by physically checking with flashlights.  Sex parties are typically themed around certain groups:  young men, daddy/son, diapers, etc.  However, parties are not serosorted (i.e., people of any HIV status may participate).  Taking this formative research, Dr. Mimiaga is working on a randomized controlled trial measuring the effectiveness of hosting safer sex parties… and are actually starting to find it to be effective.

Nate Stupiansky used Manhunt to conduct a survey relating to STI diagnoses in over 26,000 men who have sex with men.  Curiously, 37% of respondents reported being in a relationship with one person.  That is, 37% of people who opened an email on a primarily sex-seeking website stated they’re in a relationship with one person.  Why are you on the website then?  But that’s not the point.  His analysis looked at the association between type of sex (insertive or receptive) and odds of self-reported STI diagnosis.  Persons reporting insertive anal intercourse and inconsistent condom use were at 41% higher odds of STI diagnosis.  Persons reporting receptive anal intercourse and inconsistent condom use were at 72% or 65% increased odds.  Most interestingly, people reporting an STI diagnosis in the past two years were at 76% decreased odds of being tested for an STI in the past year.  This is problematic.

I’m still trying to digest all this (and the information from the awesome social media panel at the end of the day).  There’s clearly room for improvement in the work that we do, and I’m excited to share this with my colleagues back home!  Time to sleep, so much more happening tomorrow…

Dr. Bill Jenkins, one of the people instrumental in ending the Tuskegee syphilis experiment, gave an opening keynote address. Racism, he argued, is the only example of a condition where we study the symptom and not the cause. There’s not a race problem in the US, there’s a racism problem. We need to broach the uncomfortable to start addressing actual determinants of health. And, like Martin Luther King, Jr did, we need to move from being a corporate leader to being a servant leader — and this means putting people before papers.

Dr. Cornel West closed the opening ceremony, in one of the most inspirational, energetic, and entertaining public health speeches I’ve ever heard (I can only hope APHA posts the video for free online). “Justice is what love is called in public [...] Love is a steadfast commitment to the wellbeing of others.”

So, this is my first national conference. My first day really reflected this, as I left the opening ceremony, and immediately tried to do everything. It was an apt twitter user that pointed out that APHA is a marathon and not a spring. However, I’m still glad I managed to meet and chat with other public health people, and learn about interesting topics…

I met the founders of The Positive Project, a Colorado-based organization working to share the stories of people living with HIV/AIDS. They are two therapists working with HIV+ clients who began noticing that many of their clients were experiencing similar situations. But, bound by confidentiality, there was no way for them to share stories. So, they created a website and posted interviews with consented people living with HIV/AIDS. It’s a simple, yet brilliant, idea — this way, people can privately hear the stories of all kinds of individuals living with HIV.

I talked with the a member of the Houston Public Health Department about their use of almost real-time data in responding to a syphilis outbreak.  In 2007, they were 2nd in the nation for Syphilis.  They mapped syphilis cases, clinics/services, and various determinants of health.  This, in turn, influenced where their mobile clinic went.  The clinic ended up serving 1,489 clients that year, and Houston managed to relinquish their position of second highest syphilis incidence in the country.  A true success story for data-driven practice.

I also learned that alcohol outlet density is associated with crime, but not gonorrhea cases.  Medical students like the idea of a Personal Health Record, but not necessarily for them personally.  And the gold standard of lab-confirmed STD cases may underreport compared to self-reported cases in public health research.

I really didn’t know what to expect coming to APHA.  But, I’ve learned that it’s important to focus and plan what you want to do (including planning your wandering time through the Expo).  There are so many passionate people here.  I’m amazed that I can stop at a poster that looks really boring, ask the person what they did, and just through their brief speech I can become energized and excited about their research.  It’s revitalizing, and I can’t believe I haven’t come here before.

The editorial (intentionally) does not spell out any details about what kinds of programs should be done. That’s simply too much detail to fit into the space allotted. Since it couldn’t be done there, I’d like to share a few ideas and examples of ways to truly utilize social media and the internet:

• Advertise online. That seems stupid and simple, but when was the last time you saw a HIV prevention message online? Red door has done this… but I haven’t heard of or seen any other Minnesotan organization doing HIV prevention through online advertising.
• Video contest. The Ryan White program unsuccessfully tried this. One of their major failures was that they viewed the intervention as the end product and not the process. By having a video contest that’s graded by peers, the peers are also receiving the prevention messages. That’s the social aspect of social media :p
• Midwest Teen Sex Show. It’s not a naughty website. It is, however, an example of a way to step away from the overly-sterile messages that sometimes come out of health organizations.
• DC FUK!T. This is a dirty website. But that’s also what makes it so great. It’s essentially a sex ed video you can jack off to. And, there’s some evidence to suggest this kind of approach is effective in certain populations.

Ultimately, my issue is that it doesn’t feel like prevention is evolving to keep up with the epidemic. Prevention workers are already over worked, and there isn’t new money coming in. The internet is still relatively new, and many people that have been working in HIV prevention don’t comfortable on facebook, twitter, youtube, etc. So, in some ways it makes sense that new programs are slow to emerge.

However, we won’t know what works until we try. There’s a group of young people interested in stopping this recent epidemic that has started to meet. The idea is that among this group, we have the skills and resources to develop and execute pilot projects. And, hopefully, we can do things that will raise awareness about this problem. So, if you’re under 30 and interested in finding out more, send me a message.

I think one of the major adaptations is going to be moving towards user generated prevention. This is beneficial for three reasons: the population is most adept at communicating with each other (i.e., 16 year olds speak “teenager” better than most 40 year olds), there’s an innate prevention activity in developing the message, and these types of media campaigns can be dirt cheap.

There are a couple of agencies that are already doing this. The Minnesota Organization on Adolescent Pregnancy, Prevention & Parenting is having a video contest (PDF) regarding general adolescent health. MTV and funny or die recently had a crazy sex advice contest called Say What. The Minnesota AIDS Project/Pride Alive is collecting 10,000 messages, and trying to distribute them to 1,000,000 people. And, of course, Hennepin County and MDH are moving forward on a video contest (it technically ended, but stay tuned for a few announcements).

I think this is the right way to move. We’ve been living in a Web 2.0 world for half a decade, and we’re all getting used to sharing everything we’re thinking and telling other people what we think about what they’re thinking (this would be a good time to encourage you to follow me on twitter…). So, it seems logical that young adults should want to have input into what messages they think are appropriate, and what HIV prevention strategies they think are reasonable.

So, since these contests seem to be a good idea, I want to ensure we’re doing this appropriately… it sometimes feels like these contests are being run by people that aren’t familiar with technology or social media. Submissions should be made online — having to email someone is just annoying. Ideally, a website should post submissions for ranking and comments by other users, as this would fully capitalize on the potential of internet technologies. Campaigns need to be appropriately incentivized; just because YouTube is free, doesn’t mean a $20 gift card is sufficient. Don’t be too restrictive or too quick to censor. The most effective messages may make you squirm:

So despite my few critiques, I’m hopeful this style of health promotion is effective and am excited about what kinds of messages will be generated!

These beliefs don’t have a traditional evolutionary advantage, but as we progress there’s less evolutionary pressure to support the status quo. George Washington professor James Bailey says:

“The adoption of some evolutionarily novel ideas makes some sense in terms of moving the species forward [...] It also makes perfect sense that more intelligent people — people with, sort of, more intellectual firepower — are likely to be the ones to do that.”

The difference in IQs wasn’t great — ranging from 6 to 11 points (standard deviations is typically 15). Participants who identified themselves as “very conservative” had an average IQ of 95, compared with 106 among the “very liberal.”

I’m patiently awaiting the release of the full article, to gain a better grasp of their methods and results. Until then, I can make myself seem smarter (and more elitist) by affirming my belief of liberalism and sexual exclusivity.

We received an epidemiology update, with additional information from the disease investigator (DI) interviews. The DIs managed to interview about 50% of newly diagnosed cases to obtain additional information about risk factors relating to their infection and recent partners. I’m not sure if that’s a high/low/average rate, and we certainly don’t know if the responding population was different than the non-responders (e.g., were non-responders at higher risk than the responders?).

Minnesota saw 35 more cases of newly diagnosed YMSM in 2009 compared to 2008. That increase was driven largely by African American and white youth. About 20% report only having sex with one person in the last year or since their last negative (whichever is shorter?), and about 50% report having sex with 3-4 in that time period. Approximately 20% of young men had sex with BOTH men and women during that time period. 64% reported anonymous sex, 30% reported meeting partners online, ~60% report infrequent condom use, 13% report non-injection drug use (mostly marijuana, some meth), and 25% report alcohol use.

Additionally, MDH and Hennepin County put together a couple of small focus groups for HIV+ and college-aged guys. I’ll eventually post the results of the focus groups, but there were a couple of comments that stuck out to me:
“People are dying with HIV, not from it. Honestly I couldn’t care less if I keeled over and died tomorrow, I’ve had a fun run, people have nine lives… and I’m running out.”
“HIV meds or car payment — good campaign message.”
“When you’re 5 years old you start to experiment too, it’s just human sexuality. We’re here to procreate or to get off basically.”
“A lot of people don’t want to hear about [HIV] and right now a big trend is barebacking.”
“A lot of younger people are sluts.”
“I never had unprotected sex and just recently got really drunk and got date raped and am now poz.”

I don’t think any of this information is earth-shattering. However, it does provide a little data around the situation we’re in. We spent the remainder of the day listening to speeches and breakout panels. Ultimately, it was a good day for networking, but there weren’t many (any?) concrete next steps. Personally, I’m still trying to process the conversations that I had yesterday, and am waiting for clear direction and need to emerge. Any guidance or thoughts would be greatly appreciated…