PrEP Failure


Re-posting an important Twitter thread by Matthew Hodson (Executive Director of National AIDS MAP – UK):

EQQ: Memory Politics & AIDS


In 2016, Rabih Alameddine published The Angel of History, critically acclaimed as a “tale of survival” and a “sprawling fever dream.”  The lasting night-sweats of this “post-AIDS” novel require not-so-considerable investment in character(s) and the pedantic discourse among the Devil, Death, and a variety of angels. Still, the novel poses a timely and looming question at the heart of our queer present:  How do we live with AIDS after AIDS?

Alameddine suggests that “forgetting is an integral part of memory”.  Much as texts become “unintelligible” to audiences of removed historical periods, queer experience(s) exert difference and allow passage into new stages of relevance.  “You cannot forget if you do not remember, and you cannot remember without forgetting.”  Can we understand the process of living with and without AIDS as a process and equal balance of living with while forgetting the trauma (and horrors) of the crisis period?

The Angel of History ruminates upon the cultivation and preservation of queer history. “All AIDS books are out of print because of [post-AIDS generations], because you only read books sanctioned by the petite NPRsie and their indiscreet charm, your fault, your fault, your grievous fault. We refused everything, rejected their heavens and their hells, and you turn around and accept both and you keep saying I do and I do and I do and fuck me more daddy while they shove you in a tiny vestibule and you pretend it’s Versailles.” The crux of Alameddine’s novel returns to the “resolve of memory.” The characters acknowledge the lack of crisis (snidely remarking about daddy fetishes and the non-radical queer Left), signifying a historical shift, or a generational gap. In this way, he portrays the anger and hurt of an AIDS-impacted generation while encouraging a system of thinking (one must remember in order to forget) for progress.

His question stands: How do we live with AIDS after AIDS?  Are our lives without sufficient history after AIDS?  We cannot deny that AIDS created a queer sensibility, affect, and an ethics of care for an entire generation of queers, alive and deceased.  Stressed, now, is this dilemma of remembering.  Can the “post-AIDS” generation learn from ethics of care enacted by AIDS survivors? And is learning enough to radically alter sexual practice and personal care to ensure that other infections (i.e. super gonorrhea) do not send us spiraling into a similar crisis? How do we define an ethics of “post-AIDS care” that takes from historical experience the centrality of sexual and emotional wellbeing while integrating more advanced knowledge about biomedicine? Essentially, what must we take away from the AIDS generation without learning and “forgetting”?

EQQ: Intro


Starting in February 2018, I will use this space to start a regular blog stream, titled “Essential Queer Questions.”  This blog stream will analyse historical, near-present, and contemporary “queer” texts, posing an “essential” question pertaining to queer history, literature, and culture.  Each entry will be brief: 3-4 paragraphs containing a synopsis of a text, histo-cultural relevance, and a succinct proposition of question and analysis.  This project will build toward a larger constellation of questions, posed for queer scholarly, historical and activist cultures.  In undertaking this project, I set out to define critical, often mundane, questions about the semantics and ideologies of queer life.

If you have text suggestions for review, please leave a comment below.

Urgency as Incentive: The Future & PrEP


The UK-based movement in favour of pre-exposure prophylaxis (PrEP) has come face to face with an unreasonable hurdle.

That is to say, activists must now approach selective regulatory policy that rises to meet their feet just as change can occur. England’s National Health Service (NHS) has poured concrete around the base and built the hurdle higher, making it impossible to jump over bureaucratic stop-gaps and once again reinforcing the government’s inflexibility. Dare we recall thirty years of slow improvements to HIV medicine, the NHS’s announcement reminds us that health is afforded, first, to those who ‘need it most’.

The most are more often a few, as the privatised American health system exemplifies. Who are the most in relation to HIV in England? What is the government’s capacity to ensure the health and well-being of its citizens, especially as new statistics reveal a tremendous increase in mental health distress, indebted, in part, to working conditions and social stressors that tamper with one’s access to health itself?

For England, the most are those already HIV positive. The NHS can undertake effective treatment once the virus has been transmitted. Before that, you better use a condom.

Established safer-sex initiatives are crucial for deterring the transmission of HIV, but nothing is more crucial than to add new tools to the toolbox. Tools approved by a swath of esteemed medical clinicians and supported by MPs across the nation should not be ignored. We must speak out against the injustice of unhealthy regulation.

The law comes up to meet our feet as we stride toward greener pastures. Our greener pastures are a future where HIV transmissions have shrunk to an infinitesimal statistic. The focus on finding a cure, post-exposure prophylaxis, and HIV-positive regulatory medicine(s) is fine and well, but these measures are not enough. The present is not a viable future. Only if we add to regulatory reasoning effective prevention can we then uncover a future that, now, seems lost in the mire of soaring transmissions.

PrEP does not yet symbolise our overdue (and forthcoming) reactionary tactics. At the moment, the little blue pill represents everything bound up in the tenants of HIV’s history. The pill is a reflection of people living with AIDS and HIV (PLWA, PLWH). The pill gestures at the lives we can save in the wake of those who are lost. The pill is a simple tactic; it is the fundamental freedom of a free society, imparted by a government that can and should care passionately about the health of its citizens. The pill represents anger (our anger), because those at risk are not afforded the same preemptive measures otherwise given to patients of cancer and leukemia and irritable bowel syndrome.

PrEP is a blue pill turned red in anguish. Our future, according to the press release, is limited to the efficacy of funding a preventative medicine that could potentially displace ‘other “candidate” treatments and interventions’, as if equal share, over urgency, were the most provocative justification for dropping PrEP from funding on a national scale.

In other words: Where is the urgency? We must ask this of ourselves and resignify PrEP as a reactionary measure against bureaucracy.

This is the process of community building, which activists like Greg Owen and David Stuart continue to engender and employ. As Simon Watney once wrote, we must be cautious to conflate the differences within our queer communities as the wholeness that binds us. Which is to say, perhaps we have no essential ‘sexual’ community or biological binds to connect us, but we have validity in the anger that brings our bodies together. Today, the anger that binds us is the urgency of transmission. That urgency is:

  1. Five men testing positive each day in London.
  2. HIV organisations taking significant blows to their funding, laying off critical educational and administrative staff, and closing spaces in key ‘risk areas’ of the city.
  3. Living with constant anxiety because condoms are difficult, uncomfortable, or forgotten in practice.
  4. Being unable to visit a sexual health clinic because the wait is too long.
  5. Not knowing your status.

Acknowledgement of our urgencies is already undertaken in the medical and charity core. Ian Green, Matthew Hodson, Mags Portman, Michael Brady, Deborah Gold — the voices of reason, the experts — reiterate statistics and demand medical freedom(s) based on dizzying increases in HIV transmission. Their work compels war cries for PrEP. But how can we face an impossible hurdle if even the voice(s) of reason fail to establish the ‘necessary’ level of urgency?

PrEP is not a panacea, but it is an effective solution in the grab bag of measures. We need to turn to PrEP, because it is a ‘future-logic’: that is, a medical technology that signifies the future of health, the future of community, and the future (as Nikolas Rose might say) of life itself. What other purpose does cutting-edge medicine contain if not to allow society to burgeon in such an aggressive way that we can now live twenty to forty years beyond the life expectancy of the nineteenth century?

We can incentivize our urgency as a means to employ PrEP as a preventative measure and re-establish the future. In other words, we must compound our urgency to remain HIV negative, to cut down transmission rates, and to demand greater access to sensible, sensitive, and proven medicines, situating these demands as a promissory note that says the future resumes here.

It is the urgency of transmission that is our incentive. More than the urgency charities and medical practitioners place on statistics and numbers (though those are at the core of our anger), what I want to impress, even briefly, is that our urgency needs to derive from the knowledge that our future stops here when we fail to fight for our health and the health of others. Our future evaporates the moment we feign interest in community health. Believing our own safer-sex practices and drug use exist outside of communities at risk is dangerous at best and intentionally malicious at worst.

Only through our urgency for better health, for community, and for a future beyond HIV, does PrEP become more than simply an expense. Through multiple urgencies, through the enactment of a liveable future beyond HIV, PrEP embodies the core value of human lives — HIV-positive and HIV-negative lives in tandem — all working together for greater health, and less bureaucracy.

(Chase M. Ledin, 2016)

When Negative Means More Than Abstaining


HIV makes sex messy. Confusion about who does what, who wants to do what, who can do what, can quickly slip into mystifying jargon. Since HIV makes us talk about the ‘tough topics’ we weren’t taught to appreciate in secondary school, sometimes we’d prefer not to talk at all. But perhaps the mess has less to do with HIV. As numerous activists and organisations have pointed out recently, something is bubbling in our actions and mentalities, something that can’t initially be denied by saying: stop. There is something more in our statuses.

We have activists, like Greg Owen, Dan Glass, David Stuart, and others, who are talking about their statuses, who are encouraging us to talk about their statuses–who are more or less putting the rhetorical junctures of ‘status’ and ‘status-making’ on the map. Those people are at the fore of the movement to tackle, unpack, negate, and educate stigmatisation of HIV serostatus. They perpetually ask us to look inward. They say: there’s something we need to acknowledge in ourselves. We have a problem about the way in which HIV is talked about in the media, how gay men (in particular) volley the term like an epithet, and how the government looks idylly toward a cure and consistently fails those most at risk and already living with HIV.

In a recent article in FS Magazine, Matthew Hodson, chief executive of GMFA, enumerated the importance of critically attuned communication about HIV-positive men who have sex with men (MSM). Hodson laid out eight tactics for speaking sensitively, thoughtfully, and ‘appropriately’, some of which I excerpt here:

(1) Don’t ask them how they contracted the virus.
(3) Don’t assume they’re a power-bottom.
(5) Don’t assume he will/does feel inferior due to his status.
(6) Don’t assume he wants to talk about it.

Hodson is clear: assumptions dictate our initial reactions. We read bodies the moment we perceive them, and we create additional gradations when language enters our intimacy. But what’s plain about Hodson’s voice is his position. Hodson speaks on behalf of the HIV-positive activist. He tells us what works, what doesn’t, because the HIV-positive person is, in many ways, the most authentic and accurate voice speaking to the effects, stigmatisations, and emotional trauma of living with a life-long illness.

Surely those experiencing and living with HIV are, first and foremost, subjects of this specific virus. But what peaks my intrigue is the attentiveness to which people living with HIV give their positions on sex, love, and desire. They are, for lack of better words, the ‘go-to’ experts on troubled desire in a prolonged era of HIV and AIDS. And it is through their accounts that we start to see the relative silence on the part of HIV-negative persons.

Is it that HIV-negative men simply don’t care? Is it that HIV-negative MSM are necessarily ill-equipped to speak about HIV, to talk about the men they want (and convince themselves they cannot have) all thanks to a virus, which is now a condition of life? Is it for fear that mixed-status desires border on recognition of our historically racist behaviours? Or is it that we do not challenge or think critically about our negative statuses? Is there a possibility that negativity is, in fact, the lack, the newfangled deviant, and that which much be approached with great expediency?

In a Cap City Kink article for World AIDS Day 2015, Christopher Hetzer expounded upon his experience(s) contracting and ‘dealing’ with HIV positivity. Hetzer provides a telling list of active dating tips for the HIV-positive man. His suggestions range from the mental and emotional effects of dealing with HIV to finding the courage to step back into the dating/sexual ring. He lays bare a clear list of what HIV-positive people can do to keep their mixed-status relationship(s) ‘healthy’:

(1) Take your antiretroviral therapy consistently and correctly.
(3) Be HONEST and RESPECTFUL with all partners.
(4) Continue to talk about HIV, STIs and sex.
(5) Have some CONDOM SENSE!
(6) Be safe when exploring each other’s sexual fantasies.

Hetzer points out a few simple suggestions for HIV-positive partners in mixed-status relationships so that they can make the most of their sexual- and self-knowledge. In this way, Hetzer positions the HIV-positive partner as an active agent in the relationship, cognizant of their status whilst necessarily provoking intimate, and necessary, dialogues about medicine; honesty, respect, and boundaries; condoms; and sexual fantasies. Even emphasis placed on ‘honest’, ‘respect’, and the humourous ‘condom sense’, suggests the frank (and playful) tools one can (and must) bring to a loving mixed-status relationship. Yet there’s a deep implication that the HIV partner takes up the responsibility for talking about and politicising sexual statuses simply because they have the ‘HIV experience’. This may not be true of all mixed-status relationships (dialogue is key), but the initial agentic and explanatory HIV-positive subject is imbued with assumptions that they must speak.

What I want to suggest is that we must politicise the negative accounts of status. HIV-positive narratives are only one way to think about HIV; there are more we can include. HIV/AIDS statuses are not the only form of sexually-transmitted disease that asks us to think deeply about our desires and sexual actions. But it is through the perpetual, and now increasingly devastating, HIV/AIDS epidemic that the age-old binary again comes to light: the normal and the deviant; the ‘clean’ and the ‘dirty’; the sexually promiscuous and the (‘non-adulterous’) committed; and the knowing and the unknown.

The assumptions indebted to such binary thinking are now available to the public thanks to decades worth of critical queer theory concerning racism, identity politics, gender, and sexuality. To extend such research into the public sphere, I believe it is important now to think about HIV in terms of negativity. HIV and AIDS are charged with positive (and dialectical) implications that have pervaded media and medical speak since the rise of the epidemic in the 1980s. Each day since we have had to negotiate our actions based on status. Status is a subject marker we all have, we all access and negotiate, and which changes over time. That is, status follows us through all stages of life.

It is through status that we often negotiate and talk about our sexual actions. For that very reason, it is necessary for MSM not to rely only on HIV-positive men to control the movement and dissemination of desire marked by positive statuses. In fact, in doing so, we engender an ideological system of racism: a hierarchy of desires predicated upon status, desire, and comfortability — which is to say, we claim not only that the HIV-positive subject is in some way different than the HIV-negative subject, but also that the HIV-positive subject must inform us of their difference.

Perhaps there is no difference. Or, perhaps HIV-negative MSM are the difference. Perhaps those who are without HIV stigma are the gap that substantiates the divide between positive and negative desires. Just as we cannot control who we long for, who we lust after, and/or who we love, we rarely can determine the impulse of status. Status, I contend, is everything: everything to the modern sexual body, which is now overwhelmed with the potential to desire. Status is indebted to desire.

It is by putting pressure on the divide between HIV-positive and HIV-negative agency that we can sift through the negative representations we inadvertently (and sometimes inevitably) place upon people living with HIV/AIDS, and bring about more positive behaviours and desires. In doing so, we begin to see who is tasked with talking about HIV/AIDS and who can simply abstain from agency. No one should be exempt from agency. Desire is an act of agency. It is a force. If it is true that most people desire, we cannot demand that HIV-positive persons teach us about their desires. We desire, too. We cannot remain quiet once we have learned, and we cannot ruminate about experiences which aren’t ours or which we can’t necessarily change.

HIV-negative MSM have desires, and they can (and should) be positive. Positive desires proliferate at the moment when we learn so much about others that we find ourselves in the cracks they open in themselves.

Positive desires are informed. That is, the desires we find in self-revelations are often the most intimate, the most complex, and (I would argue) the most fulfilling. Focusing on the status of HIV-negative persons is one lens through which we build fulfilling definitions of status, desire, and intimacy. It’s also a crucial educational tool that we can do at the individual level. Holding to account our HIV-negative positions ensures that everyone has access to desire. We can further come to terms and act upon ourselves, in a sense, by politicising and appreciating our desires for what they are: not as opposition to HIV-positive statuses, but as statuses that are self-contained and multiple.

The task of rethinking status is as simple as turning positive-dependent agency on its head and asking HIV-negative MSM to stand out in support of sex regardless of status. At the same time, we must acknowledge that status is everything. Status doesn’t disappear because we say we are blind to status. Language erases, in a sense, but erasure doesn’t mandate self-realisation. So it is here, at this paradoxical occupation, that we can confidently ask HIV-negative MSM to reflect how their status effects, reflects, and adds to HIV-positive desires. Those who are negative can support positive lives by legitimating HIV-positive desires, by fighting for sex-positive medicines (including PEP and PrEP), and making a concerted effort to learn about, engage, and disseminate information about positive sex.

By way of positive sex, we learn more about what it means to have desire at all. Desire makes most of us whole, in a sense, only if we are informed and curious about our bodies (inside and outside), and what these preventative medical measures can do to enhance our chances to live happily and healthily. Prescribing a one-sided politics — that is, by focusing solely on HIV positivity as the authoritative voice on desire in the age of epidemic — allows HIV-negative men to abstain from thinking about positive desire. We must attempt to close this particular sexual division in our queer communities.

On PrEP & the Problem of Access


Just this week, San Francisco startup, Nurx, launched a new service to provide prescriptions for pre-exposure prophylaxis (PrEP) via smartphone. In what seems an almost-expected next step for providing access to PrEP, co-founder Hans Gangeskar said the company is providing this service because ‘[PrEP is] not as widely available as [it] should be for the populations who need [it].’ Effectively, Nurx will streamline the process from health survey and blood sampling to prescription and delivery, by making all materials accessible through a simple mobile application. A new technology for an needing market. Check.

This new technology makes abundantly clear how the market is responding to our needs. And not only that, such technology almost buzzes in response to resolute anger concerning accessible medicine (both for sexual health and more generally) here in the UK. Just as well, this new access appears increasingly open; it purports to provide exponential networks of connection for many of the people in the ‘high-risk group’ regularly tied to PrEP. But let’s not chew our tongues with glee just yet.

The problems circumscribed in PrEP, not especially the moralistic onanisms, but rather issues of accessible economics, appear obfuscated within public discourse. A public discourse, that is, founded upon hundreds of hours of film, travelling photo exhibits, sex education workshops; protests, sit-ins, and marches; Twitter campaigns, rambling Facebook posts, and the occasional personal blog entry. In all this, I hear my fellow activists scream: The epidemic isn’t over. Indeed, the epidemic isn’t over, but who would know unless provoked to ask?

This is first to say, PrEP is tied up in a battle to understand whether or not we occupy a state of emergency.

I write, now, partly in anger that the NHS decided earlier this month that it will not commission PrEP for HIV prevention, contrary to an eighteen-month period of preparatory consultations with key clinicians, counsellors, and community advocates (see Mags Portman’s recent blog post). But even more than that, I shudder each time an article appears where access goes uncomplicated. In other words, UC San Fransisco Professor Robert Grant’s statement in the Nurx announcement went without mentioning the pitfalls in its potential accessible network.

“I like that Nurx makes PrEP available to people who may be afraid of doctors or may be afraid of the judgment that they’ve experienced from doctors. We need to work to make medical services as friendly as possible and try to eliminate the shaming that comes with going to the doctor.” -Robert Grant, University of California San Fransisco

Grant makes a key, and correct, claim: preventative medicine and privatised medicine in the United States need to address the psychological stress of visiting the clinic. Not only is it clear that clinicians aren’t always prepared to talk about the socio-economics of sex and its acts, the system, on the whole, is relatively unprepared to talk about ‘sex as a healthy act’ outside of monogamy. Hence, access to information is encrypted, sensitised, blocked, or opaque in the medical system. The shame to which Grant refers is none other than those repressive threads fed from our (hyper)unsexual medicalisation of the body.

Of course, medical care in the U.S. differs from the U.K. in that Americans subscribe to a highly privatised system based on emergency response. The issue is that a large number of needing people, with or without Obamacare, only receive satisfactory or suitable coverage for their needs. That there continue to be people in the U.S. without emergency coverage, let alone cyclical and meticulous coverage, reminds us of the messy state of the medical industry. That a medical mogul can steamroll Americans in favour of a 5,000% price increase says something about the relationship between Americans and the medical industry. And this is to say: The medical industry, not far from medical practice, dictates practice. Practice becomes catered to what sells; people become bound to profit. What happens when profit compounds profit, but those positioned low on the socio-economic ladder are unable to deal with escalating (mind-numbing) compounding profit? They lose.

In the U.S., and even greater in the U.K., the honest problem with PrEP is access. But there’s another form of access I want to address, and that’s access to societal change. PrEP is making waves. Indeed, PrEP will go so far as to revolutionise sexual potential in our era. PrEP will breathe relief into men most ‘at risk’ for contracting (or already having contracted) HIV. PrEP will mean gay men, in particular, can fear a little less a virus that has caused massive devastation in our time. PrEP will engender a new sexual future, one that is not a utopia but is full of desire and potential. PrEP, by all means, will enact societal change.

Regardless of the bubble of lives PrEP will inevitably save, however, our inability to use this medical technology to turn our attention to societal levels outside the middle-to-upper class means that we will continue to replicate medical oppressions of those who need PrEP most. PrEP will be lost to a class who, still much deserving, fails to recognise coalition, solidarity, and change across economic strata. Organisations like ACT UP London, PrEPster, and Positive East; grassroots efforts; and even Twitter campaigns do speak out against economic crisis that never left our community (in fact, through the devastation of the first epidemic, the distance between the queer impoverished and the rich could swallow the whole of England), but they are few in number. Too few of us outside these organisations, within extended and overlapping and social queer communities, who will end up on PrEP the moment it is institutionalised, will give a second thought about how PrEP can change a life.

Whose life could PrEP change for the better? PrEP could oversee the impending decriminalisation of sex work. A nationalised PrEP campaign (already sparsely undertaken by PrEPster) could explode the fight for re-funding massive cuts to HIV/AIDS services, particularly through the NHS. And, perhaps most importantly, PrEP, when incorporated into sex education workshops, could spell a movement towards a sex-positive future. Who knows? PrEP could be the impetus to push for change to sex ed in classrooms across the UK.

None of this matters if PrEP isn’t a mean as well as an end. PrEP can spell anger inasmuch as it can spell passion and pleasure. But we have to learn to care — if not again, so much more than our critics claim we do. We must care in two directons. If we can, we must dismantle our disposition against the political sphere in order to even start a cycle of growth. We must tell our lovers, amidst our acts of fiery love, that our love is still political, for loving means caring for others around us. Loving is a network of communication. Loving is endemic to queerness. We are bound to this claim.

If this is not an urge, it is in the least a plea to recognise which directions PrEP is pointing. In which ways will you access PrEP? In which ways can’t you? How can you help others access PrEP who might need it more than you? When and where can you talk about PrEP? How often do you talk about PrEP with gay men who don’t know what PrEP is or people who would otherwise not know about PrEP? How can you learn to care in the eternity that is this epidemic?

I want to end with a few truisms, which we all must reiterate, unpack, and expound upon in order to move toward a ‘sex-positive future’. Only by recognising what PrEP says can we begin to open up the implications for social change. Let’s begin:

[1] Until education practices concerning safe sex, condoms, and abstinence are revised, altered, or abandoned, PrEP will remain surrounded by myths, stereotypes, and stigma.

[2] Until it reaches the underrepresented populations that are most ‘at-risk’, especially those populations that cannot afford or are in no social situation to accept it, PrEP will remain a bourgeoise preventative medicine.

[3] PrEP is a bourgeoise preventative medicine until it caters to a full spectrum that purports to ‘access life’ in addition to ‘access pleasure’.

[4] To ‘access life’ entails reiterating that HIV ≠ death. Instead, HIV must equal life; but in doing so, HIV becomes a livable procurement of the medical system.

[5] Finally, we are all indebted to the medical system to some degree. To repay our debt, we can only: Act Up, Fight Back, Fight HIV and AIDS.

In order to fight, we must acknowledge there is a fight to be won. The epidemic is not over. The epidemic never was over. We live in an era of epidemic. Live now. And live with us.

(Chase M. Ledin, ©2016)

Y-G Encampment


The walls are made of never-
where, a clear resilient sand
heavy in the air, which picks
at our faces. We were boys
once when we could see age.

If we had fingers, we’d point
in the direction of modernity.
If modernity looked like a city,
we would see it the distance.
Once we were boys, we said.

There’s a mad something in
the walls we cannot see. And
if we choose not to see walls
the city suddenly explodes
a hundred colours we’ve never
seen & we’ll never see again.

Sometimes we hear in riddles
language and sometimes we
don’t. The camp is wall-tight.
We are tight against walls.
We cut. We are cut. Grated
against sand and into sand.

Walls are our only modernity.

(©2016 C.M. Ledin)