Bio for @WeMelbourne

For the next seven days I’m guest hosting the @WeMelbourne Twitter profile curated by Sarah Stokely (@stokely). This week also marks the one-year anniversary of the first guest, so I’m feeling the pressure to live up to its full potential. I’m looking forward to showing my appreciation for Melbourne life as I live it.

Rather than clog up your timelines with tweets introducing myself, here are five quick facts about me. I’m borrowing these questions from The Guardian Australia’s weekly profiles of the guest hosts of my other favourite guest account, @IndigenousX, curated by Luke Pearson. This week’s guest is Summer May Finlay so please, hop on over and follow @IndigenousX quick smart.

Where are you from?

I was born at Emily Jessie Mac and grew up in Box Hill. I moved out of home when I was 18 — gay kid, Catholic single mum, you know how the story goes. I lived in the ‘South side’ gay enclave for eight years and the cafe lifestyle just felt soo cosmopolitan, but the drunks on the street every night, not so much. In 2008 I moved to Footscray and I’ve never looked back. Yes, there’s visible drug trade but the users are just another group weaving through the crowds and trying to get by.

On a longer timescale, Dad’s family came to Australia from the Netherlands after some years in Indonesia post-WWII. Mum’s family are Irish Catholic Australians going way back, but I was brought up thinking they were Danish — the nationality or family background of my grandfather’s adoptive father, who may or may not have also been his biological father. Complicated.

What do you do?

I’m a writer by disposition. I work in public and community health, planning ad campaigns and writing funding submissions. I also do community consultation and write policy and strategy documents.

I’ve worked on health issues like HIV, viral hepatitis, and cancer screening, and social issues like racism, social exclusion and stigma. I have worked with communities including gay men, people living with HIV and hep B/C, people who inject drugs, international students, refugees and asylum seekers.

I’m always pushing for projects that work with, rather than against the grain of the community in our priority groups — piggy-backing on the ways in which people swap stories and advice about health and social problems as a way of building community and a shared culture.

What do you plan to talk about on @WeMelbourne this week?

I’m hoping to be led by the @WeMelbourne community on what you’d like to hear about. But I’d love to talk about how the HIV epidemic has changed, how it does nobody any good to cling to old ideas about safe sex, and why it doesn’t help when opinion writers and politicians react with outrage to the idea of prevention strategies beyond condom use.

Why don’t we use condoms for oral sex? What are the alternatives to condoms? Are young gay men ‘reckless’ and older gay men ‘complacent’? Go on, ask me about it.

What issue in your community life do you think is most pressing?

I’m waiting for an Australian leader to stand up and say, 12,000 boat arrivals is nothing — so relax everybody, we got this.

I’ve done a lot of focus groups in my time and I know their limitations. People are not good at accounting for their feelings. The second you ask someone to explain why they feel X about Y, they start thinking too much and coming up with reasons that sound plausible. And what’s plausible is judged in terms of the social environment, so if it’s about politics, they’ll regurgitate what they heard from the public debate. ‘Queue jumpers!’ ‘Illegals!’

If you don’t know this, then focus group findings amplify talkback radio amplifies newspaper coverage amplifies electoral strategy amplifies focus group findings.

I’m willing to bet no political party has ever gone to a focus group in Western Sydney and said ‘would you feel better about boat arrivals if we spent enough on humanitarian settlement in your area so that refugees get a good start on life in Australia?’

People in Western Sydney know that social services are starving for funding; they know that inadequate support leads to school dropouts and crime; they’ve a hidden potential for generosity that any genuine leader would have the moral imagination to call on.

Who are your role models and why?

It will astonish her to read this, but I see my Mum as a powerful social activist. In my teens she edited the newsletter of Women and the Australian Church Victoria and railed against the he/him wording of the new liturgy in our Catholic parish, St Dominic’s, where, despite her activism, they still got her to do the readings every Easter and Christmas.

It takes a particular strength of personality to stand up to 2,000 years of misogynist dogma in your own community, and to speak out against it you have to first crash through all those inner walls of doubt and shame and politeness and self-restraint.

So you build up a head of rage and momentum and when you crash through it can look to the outside world like you’ve exploded out of nowhere… and that can make you look crazy and easy to dismiss.

In my adult life I’m still learning how to slow down and engage more gently and strategically. It’s tough going but I’m grateful for my role models on Twitter and in my community of practice, people who I trust and admire to give me guidance on keeping that trajectory controlled.

What are your hopes for the future?

I’m hoping to write up some of the lessons we’ve learned in the Australian response to the HIV epidemic and export them to the world.

Hep C stigma as a pharmaceutical marketing device

A new campaign funded by Janssen-Cilag P/L under the Hepatitis Australia brand uses Hep C stigma to drive users to its product.

Update 31/7/13: Hepatitis Australia has announced they’ve removed the video. Well done all who expressed their concerns to Hep Aust and Janssen-Cilag P/L.

Update 1/8/13: And they’ve uploaded a new version!  See the video below.  Thanks to Lyn Carruthers for pointing this out.  What do you make of it?  Feel free to post your thoughts in the comments.

[youtube=http://www.youtube.com/watch?v=C8Bh-L__9rs]

Continue reading “Hep C stigma as a pharmaceutical marketing device”

Biomedical prevention: a revolution with empty streets

This post responds to Kane Race’s invitation to comment on PrEP as a provocative object. As this is a blog about prevention strategy, I want to look at the discursive context in which this object is being offered to gay men. PrEP has been posed as part of a biomedical revolution in HIV governance.

The revolution is offered as the solution to three failures:

  1. Of condoms to completely prevent HIV transmission;
  2. Of gay men to use condoms all the time as required by (1);
  3. Of social marketing and community education to achieve (2).

The revolution is being sold to political purchasers (who provide needed funding, policy support, regulatory sign-off) as the way to achieve ‘bold targets’ — in the United States, an ‘AIDS free generation’, in Australia, ‘Ending HIV by 2020’.

The logic is that policy countenancing anything less than 100% condom use is politically unpalatable, but desperate measures are needed: crisis framing and battleground metaphors, you know the drill.

But premising the revolution on the failure of education leaves it in an odd position when it comes time to sell it to the population, i.e. the assemblage of social networks and identities formerly known as the Gay Community.

I’m reminded of two earlier revolutions:

  • Negotiated safety, or the ‘Talk Test Test Trust’ campaign, led by ACON in 1996. The first time the HIV sector admitted to the gay public that non-condom strategies could be effective as HIV prevention. It followed intense debate in the HIV community sector over whether this was a step that should be taken and how to codify the strategy in a clear and simple message to reduce the risk of failure (McNab, 2009). Unlike in America, where some HIV doctors to this day recommend monogamy in and of itself as a prevention strategy, the Australian pedagogy on negotiated safety acknowledges and responds to the diversity of relationship types, different extents of being ‘open’, uncertainty (‘are we going steady?’), and ‘infidelity’, by emphasising both relationship agreements and ongoing communication.
  • PEP roll-out, when the availability of Post-Exposure Prophylaxis was first publicised to the gay community in Victoria in 2005.  The State Government funded the Alfred Hospital to develop a service, which initially saw gay men going to the Infectious Diseases clinic during business hours or the Emergency Department after hours.  The Alfred then contracted the Victorian AIDS Council to develop a social marketing campaign after the fact.  This treats social marketing as a fancy name for ‘advertising’, rather than a consumer-centred analytical approach that can contribute insights at every stage from designing an accessible service to motivating people to use it (see Lefebvre, 2013).

    Social research has subsequently shown much higher awareness and uptake of PEP in Sydney compared to Melbourne, with Sydney providers welcoming ‘frequent flyers’ (as one clinic director put it, ‘better for someone who struggles with condoms to remain HIV-negative’), while Melbourne providers were more likely to be judgmental (‘it’s not a morning-after pill’).  In Melbourne, doctors at gay community clinics now provide access to PEP in partnership with the hospital-based service, saving a trip to the E.D. and providing far greater ‘cultural safety’ to people accessing it.

The takehome message? Engage with community educators and stakeholders from the very start.

That’s not happening with the ‘biomedical revolution’.  Why would it?  See failure (2): ‘education has failed’.

The biomedical revolution in Australia has more or less ignored PrEP — it’s still subject matter for policy analysts, the position you have when you’re not planning to do anything.  It has focused instead on early detection and early treatment.

Analytically speaking I’m a functionalist: I don’t look at what organisations say, I look at what they do.  That’s essential in this era of strategic communications.  Take focus groups, the mandatory starting point for any new project or campaign.  It says ‘community consultation’ on the tin, but open it up: you’ll find market research, undertaken in private, intended to extract information, not have two-way dialogue.

Or take campaign websites, like the one for Ending HIV: the label says ‘interactive’, but the functionality is restricted: click here, add your name to a pre-written message, sign up to receive messages.  Visitors are offered a subject position that is wholly passive: trust us, we’re the experts.  Sign here to indicate your consent.

I think gay men are smarter than that, and I’d expect them to remain more or less disengaged from ‘revolutions’ that started without them.  On a hunch, I did a quick free-text search on Recon.com, one of the largest sites for men into kink and fetish.

As any user of personals sites knows, meeting other men is only part of their purpose; they are equally important as a safe space for fantasy and identity play. I searched for the term “prep”, as the search functionality isn’t case sensitive. I was curious to see whether HIV-negative men are responding to PrEP as a provocative object by taking it up in this form of play, or as part of their ‘bid’ to other men to meet for different kinds of play.

  • Eighty-eight profiles had ‘prep’ across two separate searches on username or profile text (I didn’t de-dupe, as I’m not doing research and didn’t want to make a table cross-referencing usernames–too creepy).
  • Six profiles were clearly talking about PrEP i.e. pre-exposure prophylaxis, some inviting people to ask them about it, one describing his reference as (paraphrase) an obligatory community service announcement.
  • Seventeen used it to mean preparing or preparation, sometimes as part of the sexual fantasy encounter.
  • Fifty-one profiles referred to prep as a look: a conservative, buttoned-down aesthetic derived from ‘prep school’ and sometimes contrasted with other aspects of identity such as kink or punk or ‘jock’ (athletic).

In this Not-Research exercise I’m more interested in the diversity of usages, but the numbers tell a story as well — we’ve a long way to go before there’s anything like ‘revolutionary’ visibility of PrEP in relevant spaces like this one.

The danger is not that lots of people hear about PrEP and want to give it a go; the danger is that they don’t — that we miss this opportunity to discuss as a community what it will mean to live with endemic HIV.

Instead, we have a revolution from the top down — from the privileged speaking positions of biomedical science and population health — rather than one in which community is involved from the very beginning.

It is framed as an epic battle — ‘bold targets’ and fuck yeah science! — instead of as a mundane and everyday matter of epidemic governance and community health.

And instead of accepting that all prevention strategies are partially effective — including condom use — those who become positive are seen as signs of failure.

This isn’t revolution.  It’s the unsustainable same old.

The condom ad that doesn’t sell safe sex

Just to bookend my post about the lame new safe sex ad from THT that somehow fails to sell condoms, here’s a condom ad from Ansell that doesn’t sell safe sex.

Niall over at Dangerous Minds considers this a terrible failure; I’m not so sure.  Ansell are in the business of selling their condoms, not safe sex generically, and their strategy here is differentiating SKYN condoms from all the others.  It’s sex-positive and it’s honest: it says no more than what most condom users feel about them.

Unlike the THT ad this one makes an explicit statement about benefit: they’re different, ‘this changes everything’, and of course there’s the name SKYN (‘skin’).  If someone else who hates condoms sees this ad, tries the product and likes it, there’s your safe sex outcome.

And while I’m not wild about the sexy half-naked woman making ‘come hither’ eyes, I’m pretty damn sure this ad is targeted at men, who still (in this century!) tend to buy condoms.   And at least it’s showing a woman who’s definite about what she likes and dislikes.  Just… what is she lying on!?  Is that bedspread denim?

Just one teensy-weensy little irony here… SKYN condoms are the worst condoms I have ever used.  They’re the only condoms I have ever found actually painful.  I get that for the receptive partner all condoms can dry out and get grippy and become uncomfortable/painful.  The trick is to apply reapply a good water-based lube before you feel any discomfort.

BUT – and here’s where it gets weird – I was the penetrative partner.  We used them several times, and I suspect the thinness of the synthetic latex enables it to fold, causing crinkles that pinch the skin.

At the time, we were heading towards a relationship but it was still casual and we hadn’t been mutually tested yet, and the sheer discomfort contributed to some occasions of unprotected sex — only the second time in my life I have done that.  But that’s a personal experience and your mileage (inchage?) may vary.

New THT ad takes tired old approach

Britain’s largest HIV organisation, Terrence Higgins Trust (THT), has just launched a new safe sex campaign advertisement, misleadingly titled “Condom Moment”:

New it may be, but it feels awfully familiar.  For reasons I’ll explain, as a piece of marketing it makes literally no sense, but as a safe sex advertisement, it’s totally recognisable.  That’s interesting in itself: it suggests the safe sex campaign has become a genre.  Like harrried-mum-with-air-freshener and car-on-a-winding-road-with-Sting-or-Enya clips.  No longer trying to persuade anyone of anything, you’re just taking up time before you shove your logo in front of the audience to maintain brand recognition.

That sucks because it seriously constrains your options for future innovation.  It’s like the joke about two old men who’ve been fishing together for so long they have numbered their jokes.  “No. 45! — and they both fall about.  A new guy tries it on, “no. 92!” and they scratch their heads: “Are you sure you’re telling it right?”

As marketing this piece makes no sense because it’s a condom ad that fails to sell condoms.  It starts with couples getting frisky in unusual places, then presents a slow-motion montage of grim faces, frowning, anxious, fearful, awkward, pulled out of the moment by a rising crescendo of worried whispered thoughts.  As a fairly think-y person, this resonated with me; it often takes me a while to shut down my brain and just get in the moment.  But then the ad ends and coloured text appears, telling the viewer to use condoms.  And that’s not an ending, it’s a Powerpoint slide.  Whatever happened to ‘show, don’t tell’?

The ad could have shown one of the partners whipping out a condom and the other showing visible relief and redoubled enthusiasm as their worries evaporate and they get back into the moment.  You know, actually marketing the product, i.e. condoms, and the benefit, worry-free sex.  Instead, they stuck to the genre of the safe sex PSA, concluding with an imperative textual instruction.  At which point I was literally shouting at my screen and calling for the campaign manager’s head… I really need to dial back my coffee intake.

In the comments, someone objected to the stereotype of gay men getting it on in a toilet, and THT made a very telling remark in reply:

We agree it would have been fantastic to have more couples in different locations, but – with a limited budget and tight schedule – we understand why the team who donated the clip had to focus on the most visually compelling shots.

As a social marketer this rang some Big Ben-sized alarm bells for me.  ‘Donated’ is not a good word in this context.  It’s hard enough getting an agency you’ve commissioned to stick to the brief, as I have personally and recently experienced, but it’s even trickier when the agency is donating the work.  You need a lot of clarity in the roles each party will play in co-constructing the message.

In this film, there is some evidence of front-end input of focus group or interview findings on the reasons people give for not using condoms, but it flubs the ‘product P’ — one of the most basic elements of the marketing mix.  It looks like the film maker was either briefed badly or didn’t take the brief, but it ends with the THT logo and so they’re ultimately responsible for it.

Capturing diffusion in action

In social marketing, diffusion is the hidden premise in nearly all our campaign strategies.  After all, we set population-wide objectives for campaigns only funded enough to reach a tiny fraction of society at large.  So if only 1-in-10 or 1-in-100 of our target audience actually sees our message — and I’m being optimistic here — how could that influence the other 9 or 99?  The implicit assumption is usually that our message will ‘diffuse’, i.e. spread onwards and outwards through word of mouth.

There’s a theory that supposedly describes how this happens: Rogers’ (1962) Diffusion of Innovations theory.  He studied how farmers came to adopt new technology for automated farming, and why some picked it up really early and others waited a really long time.  He graphed the adoption curve and divided it into segments: innovators, early adopters, early and late majority, laggards.

The implication for someone who wants to start a trend is that you need to identify the early adopters in a population — people who have LOTS of social connections — and convince them, and then the other segments will follow like dominoes.  This was certainly the message of Malcolm Gladwell in his book The Tipping Point, and both Gladwell’s and Rogers’ theories have turned up in massive RCT studies of community-level HIV prevention interventions, like Project Accept (Khumalo-Sakutukwa et al, 2008).

The problem is both theories are wrong.

Rogers just takes the normal curve and labels the standard deviations A, B, C, etc, and then assumes because A before B therefore A causes B.  Post hoc ergo propter hoc.  Gladwell assumes spread is determined by characteristics of well-connected, charismatic people (like himself).  But as Duncan J Watts demonstrated in real time using 16 separate bunches of real people downloading, sharing and rating digital music tracks, it’s not about particular well-connected individuals, it’s about having a large proportion of easily influenced people that matters (Watts, 2001).

To use a disease metaphor, we’re not looking for superspreaders like Typhoid Mary — it’s about what proportion of your population are vulnerable (ie. not immune) to the message you’re trying to spread.  This poses all sorts of really interesting questions for campaign planners.

One is:  what would information immunity look like?

And another: how would I track diffusion of my idea?

At a very superficial level, as Tyler Cowen Horan has shown, it’s possible to measure diffusion of links or hashtags on social networks like Twitter, using automated content analysis tools like OpenCalais and the publically available feed of all tweets for a given keyword.  That will give you a quantitative and social network view of the spread of a particular marker of an idea.  But it won’t give you any clear sense of how people are making sense of it.  That first question — information immunity — complicates the hell out of the second one.

So I was interested to see friends on Twitter discussing changes to the Healthy Kids Check as reported in a Fairfax news article:

Preschool mental health checks by Jill Stark (SMH, 10 June 2012)
THREE-YEAR-OLDS will be screened for early signs of mental illness in a new federal government program that will consider behaviour such as sleeping with the light on, temper tantrums or extreme shyness as signs of possible psychological problems.

In particular, one friend had a problem with the idea that GPs might be using a 3yo wanting to sleep with the light on to diagnose a mental health disorder.  A few different people engaged on three things I discuss here, and there was fruitful discussion about these aspects of the proposal, but my friend kept coming back to the 3yo wanting the light on.  This particular example clearly resonated with this friend’s strong concern about the pathologisation of natural processes in parenting and child development.

For my part, I noted that it’s about identifying known precursors or risk factors for future mental health conditions, rather than the GP diagnosing a current disorder.  This enables a ‘watchful waiting’ approach or possibly a referral to a child mental health expert for further investigation.

My own receptiveness (lowered information immunity) to the idea was increased by having recently read, shared and discussed on Facebook an article about ‘high reactive babies‘ — a temperament with a low threshold for alarm at small changes in environment, routine, noises, smells, that predicts anxiety in adulthood.  This resonated with me personally, as a colicky baby who grew into an anxious adult with a touchy tummy and insomnia.

This research isn’t mentioned in the article but it’s clearly a really important piece of background knowledge needed to interpret the new information; without it, it’s hard to understand why a 3yo wanting the lights on is relevant to anxiety the disorder, rather than just anxiety as a normal and natural emotion known to be experienced by 3yo children in the dark.  From a diagnostic point of view, it’s not the status of the light, on or off, that matters — it’s about the intensity of the anxiety and the strategies the child uses to manage the situation and their feelings.

Another key piece of background knowledge would be knowing that diagnoses are made based on the overall picture — the constellation of elements — whereas a screening tool developed with specialist referral as the intended endpoint will tend to pick out one or two key factors that are present in most cases of the disorder.

Both aspects are presented in the article, but they are laid out sequentially in quotes from different experts.  This is journalistically unexceptionable: one is always going to have to precede the other, and it makes more sense to present concern before response, problem before solution.  The problem lies in how it presents all three quotes as equivalent in authority:

    • Prof Allen Frances, chair of the DSM-IV task force, author of a book titled Am I Okay? (Expressing concern about overdiagnosis of ADD and autism resulting from ambiguous definitions in DSM-IV)
    • Anna Sexton from East Brunswick has children aged 3, 5 and 6 who all sleep with the hallway light on (Concerned this behaviour will be viewed as abnormal)
  • However, Chris Tanti, chief executive of headspace, the youth mental health foundation (Says early intervention did not automatically lead to children being labelled; Quotes figure that only 19% of clients showing signs of mental illness end up with a diagnosis)

I guess you could argue that Chris Tanti gets the last word, but unlike in oral argument (think of the closing statement in a trial), in text there’s no guarantee the reader even finishes the article.

And thinking in terms of information immunity, let’s compare which ‘accounts’ (ways of telling the story) will seem most familiar (a key measure of susceptibility to persuasion) to an audience of parents:  they’ve read lots and lots of articles about ADD and autism and overdiagnosis, and Prof Frances appears to be arguing against his own interests as a diagnostician(+10 credibility points!); Anna Sexton has read the same articles and shares the concern of the credible Professor, so she’s a caring and informed parent;  whereas Chris Tanti is using numbers, talking about a scenario most parents don’t want to imagine ever applying to their kids, and his argument seems to suit his professional interests.  In terms of who the parent-reader sympathises with, it’s two against one.

I’m not taking a swipe at Jill Stark.  This is a conscientious, intelligent, balanced and cogently presented article about a really important policy proposal.  Setting up that closing ‘conversation’ between the quotes about overdiagnosis practically guarantees it will be discussed by parents.  It does better at provoking diffusion than most campaigns in my own field, which often foreclose on discussion by finding and presenting a ‘single [simple] minded proposition’ that nobody can argue with (and so nobody does).

But I’m worried by how that discussion played out in my Twitter stream.  I’d like for Prof Frank Oberklaid, who mentioned sleeping with the lights on, to have some way of knowing that example backfired.   I’d like for the people developing the policy to know there’s concern about a key question — who does the diagnosis, if any, the GP or a specialist?  These are qualitative questions whose answers could feed back into better communication approaches and better health policy, if only there was some way to capture them…

A modest proposal

Imagine you’re about to send out a press release about a new campaign or policy initiative.  You know it’s likely to provoke discussion, perhaps involving issues that are tricky to deal with in a standard health news article format.  You’d like to see the discussion without engaging in surveillance of semi-private spaces like @-response discussion threads on Twitter.  And you’d like the ability to answer key questions arising in the discussion — or at least to signal that you’ve heard and acknowledged them being raised.

This is not a technically difficult problem to solve.  Let’s get a consortium of health communication practitioners and researchers and journalists together; Croakey would be perfect for this.  The consortium builds a website where people launching campaigns or policy initiatives can register and create a landing page with a short URL, which they offer to health journalists to include in their articles.  Readers can follow the URL to a page that lets them ask a question and receive a notification when an answer has been posted.  They can also see other questions that have been asked, and vote on them if they had the same concern.  Answers should be written by experts involved in the policy — they need to be substantive, as people can easily see through tightly-controlled PR responses.

I’d focus on Q&A and voting, as I’ve come to doubt the discursive utility of comment threads  in this hyperpartisan era.  And I’d want to let health journalists in on access to the usage metrics it would generate — after all, they need feedback too on what issues matter and how different article structures influence understanding and discussion of their work.  In this age of the “Australian Vaccination (sic) Network” and climate change “debate”, the need for post-publication opportunities to answer questions and correct misconceptions is screamingly clear.

The status of the LGBTIQ community in 2012

This is a more or less random assortment of articles that interest me, but if I had to pull a uniting theme out of my, um, brain, it would be the status of the LGBTIQ community in the present moment.  That’s in relation to both mainstream politics in Australia and the United States and to the HIV epidemic.

1/ My Croakey post on the Queensland LNP defunding of Healthy Communities

Remember the bad old days when conservatives wouldn’t let teachers even mention homosexuality in case their students caught the gay?  Well, the LNP in Queensland is clearly stuck in that era, claiming that QAHC’s concern for such things as LGBTIQ youth suicide prevention shows it has ‘lost its way’ — even though it was encouraged and funded to do these things by QLD Health.

Campbell Newman’s government has announced plans to replace the HIV prevention programs, but not the suicide prevention ones: it would rather gay teenagers kill themselves than tolerate the public visibility of healthy homosexuals telling them it’s okay to be gay. Which leads me to…

2/ Bill Jesdale’s article on the evolution of his thoughts about gay marriage

One of the most thoughtful contributions to LGBTIQ health debate I’ve read in a long time.  In this account, gay marriage was a fight the conservatives picked with us — as Bill argues, they were looking for a political controversy that would sustain heteronormativity now that the closet doors had burst open.

What we might want to worry about, at this point, is the more sophisticated forms of social control that will inevitably emerge and follow in the aftermath of those blunt instruments, the closet and the fight over gay marriage.  They’re likely to involve new ways of pitting ourselves against each other, instead of LGBT against the Religious Right.  And they’ll be subtle, less visible.  One of them, as gay marriage rights spread around the world, is most likely going to be a new puritanism about promiscuity.

3/  An HIV-negative gay American man talks about taking PrEP

If you’re an Australian gay man, I’d love to hear in the comments if you’ve heard about PrEP yet.

PEP is short for post-exposure prophylaxis, meaning you start a month-long course of 2 or 3 antiretrovirals within 72 hours of a possible exposure to HIV infection.  PrEP stands for pre-exposure prophylaxis, where you take a 2-drug combination with very few side effects — one pill every day — before you have the sex that might otherwise cause your infection with HIV.

Given the expense of the drug, it will only be cost effective if it’s highly targeted, i.e. only available to people who would otherwise almost certainly become HIV-positive anyway.  That’s also why its longer term side effects, like increased risk of bone fracture, aren’t more of a strike against it.

When the debate about this strategy finally hits in Australia, listen carefully for all those people saying ‘why can’t those filthy barebackers just be boring married like me?’  That’ll be that puritanism I was talking about under 2/, above.  Its consequences come through loud and clear in this frank and cogent account of a PrEP experience from an anonymous San Francisco man.