The years 1997 – 2000 were a period of critical change for the HIV/AIDS epidemic in New Zealand, said NZAF Research Director Tony Hughes during a presentation on the last day of the Pan Pacific AIDS Conference in Auckland last week. Those four years marked an all-time low for new infections among men who have sex with men in New Zealand. The MSM epidemic flatlined at 21 new infections in each of those four years. By 2003, that number had jumped from low twenties to nearly fifty, and the numbers are continuing to rise. What did the Foundation do in over a decade's work to almost eliminate the MSM epidemic, and why are the numbers going up again so rapidly? "We've been fortunate before in that we've been able to see the dust on the hooves of the four horsemen of the apocalypse coming towards us," Hughes said. "The most pivotal things are active involvement of the communities at risk, and scientific analysis of HIV transmission and social research to determine whether campaigns are working." For those wanting to understand anything about HIV infections, it is necessary to know how the virus is transmitted, Hughes explained. Of new infections recorded in New Zealand from 1996 – 2004, roughly half have been acquired by homosexual sex and half by heterosexual. But almost all of the heterosexual cases have been contracted outside of New Zealand. When it comes to over-representation in statistics, it is sexual orientation – specifically MSM – that is over-represented, not any one ethnicity. Despite claims to the contrary during last week's conference from indigenous researcher Clive Aspin, Maori are not over-represented in the figures. However, when breaking down the figures of Maori HIV transmission as Aspin did, there is a critical piece of information he left out: "The overwhelming majority are gay," Hughes said. “This is why the Foundation's Hau Ora Takatapui programme has been essential.” In the early days of the epidemic, the government gave funds to groups in the community that were demonstrably most at risk of contracting HIV. Groups representing MSM, which included Maori, were singled out as best to deal with the HIV epidemic because they were naturally passionate and focussed on the problem, as it affected them directly, in significant numbers. In addition, it was recognised that these groups were less likely to listen to ‘outsiders' telling them what to do. “Strategic campaign planning doesn't get talked about much,” Hughes said. “You can't run effective programmes without being clear about what you need to do.” This means targeting the affected population group with campaigns that speak to them in their language. Naturally, with a topic as sensitive as sex, some are going to be offended. In July 1985, the Foundation's first “traffic light” prevention campaign caused controversy because of the explicit language used to describe sexual acts that were believed at the time to be safe (green), potentially risky (orange), or extremely risky (red). At that time, the risk factors of certain sexual practices were not definitively known. By 1996, it was clear that unprotected anal sex was by far the most likely way MSM were catching HIV. It was also clear that the use of a condom for receptive anal sex reduced the likelihood of catching HIV by a factor of twenty to one. Armed with this information, the Foundation has consistently stuck to advocating for condom use as its primary HIV prevention goal. “For us, the glass is half-full with condoms, for other organisations the glass is half-empty,” Hughes said. “It has worked effectively for us in New Zealand.” Converting this knowledge about condom effectiveness into campaigns has meant creating an environment in which condom use is normative. “It should be what people expect to happen,” said Hughes. “Like when you get in the car and put on a seatbelt – you don't think why you're doing it, it's reflexive.” The advantages of this method has been proven through the Foundation's research. As well as being effective, the results are verifiable. The 2004 GAPSS survey showed widespread acceptability of condom use, with 89% of respondents happy to use them. Unlike more complicated prevention campaigns overseas, which delve into partner's sexual histories and dissect the specific risk factors of sexual positions, “use a condom” is simple and meme-like. The 2004 GAPSS survey also showed it was sustainable as a prevention method, with just about 85% of respondents answering that they always or almost always used a condom for casual sex. “We know some people will not use condoms,” Hughes said. “But this is not a problem for the overall strategy.” However: “HIV treatments have completely changed the context of the work that we do. We need to increase the promotion of condom use and HIV testing among MSM.” Again, the Foundation's own research has shown this. The 89% of respondents to GAPSS who said they were happy to use condoms in 2004 is down from 94% in 2002. Use of the internet to find casual sex partners has almost doubled between 2002 and 2004, and more research is needed in this area. “The internet has changed the frequency with which men hook up,” said NZAF Senior Research Peter Saxton. “Unlike with bars, when people would wait till evenings or weekends, internet hookups can be done any day of the week. We have to get more information on this.” Douglas Jenkin, Team Co-ordinator of Gay Men's Health at the NZAF, is concerned that men looking to experiment with other men and exclusively using the internet are missing out on the safe sex message. “That sexual behaviour happens in a vacuum. A lot of men advertise on the internet as ‘bi-curious', and they're somewhat vulnerable,” he said. Although the Foundation is in the process of developing ads for display on dating websites, some of them are in denial about HIV. In addition, they don't want their heterosexual customers being bothered with ads they don't see as relevant. One dating website has already rejected an ad for lube, Jenkin said. A questioner from the audience wondered why there should be a co-relation between the internet and unsafe sex. He suggested that, from his experience, people on the net were more likely to be upfront about what they wanted than people you might meet in a bar. However, HIV+ health activist and researcher Michael Stevens, also in the audience, responded that many people aren't upfront about their HIV status on the net "because people won't respond to the profile". Damien Moore, one of the Foundation's health promoters and an HIV testing counsellor, is open about his postive status on the net and said he had received quite violent reactions from some who didn't believe positive people had any place on a dating website, and thought he should leave. When he posted information about HIV transmission and safe sex as part of his profile, he was contacted by the administrators of the dating website he posted on and criticised for being "self-promoting". If keeping the condom message alive on the internet continues to be prohibitive, promoting condoms in the wider community becomes all the more important. A visitor from Australia noted at question time that an AIDS support group in Canberra had sidestepped the problem of prohibitive internet advertising costs and resistence to sexually explicit material in general advertising by devising an advertisement that pictured a condom being placed over Canberra's equivalent of the Sky Tower. It was a campaign which received widespread coverage, he said. But there is still a need for targetted campaigns that speak directly to the target market. Jenkin outlined some of the Foundation's successful campaigns over the years. "Part of my work is to turn the data into something practical, something with a pulse, something that we can relate to," he said. Some of these have been sexually explicit and necessarily so, says Jenkin, like the “Perfect Fit” leaflet which contained photographs showing how to put on a condom. Reticence to talk openly and/or depict the mechanics of sex for health promotion purposes is something he calls “erotophobia”. “If there's nothing wrong with it, then why not show it?” he asked. “Cartoons or drawing instead of photos are often used for material depicting sex. It's something I cannot comprehend.” The “Loved Up” and “Heavy Duty” campaigns focussed on those visiting sex-on-site venues and men involved in the leather scene respectively. “That was an example of niche marketing to the micro-community of leathermen,” Jenkin said. “Research showed they were more likely to get into areas of group of unprotected sex.” Jenkin emphasised the importance of involving the community. All the Foundation's resources have used real models from the community, and the content is extensively focus-grouped with members from the affected target demographics. As a result, sexually-explicit material has been complemented with more ‘romantic' fare targeted at couples, in recognition that “men in love are different from men in heat,” as Jenkin charmingly put it. “With romance, safe sex should not end.” One of the more perennial and popular resources as been the “Toolbox”, a dinky wee box containing samples of various condom sizes and lubes. “If men have a positive experience with condoms, they'll continue to use them,” Jenkin said. The “Toolbox” was created in recognition that when it comes to condoms, one size does not fit all. “If you treat men with some sensitivity, it will work.” Fear-based campaigns have been largely absent from the Foundation's ouvre until recently, when the sharp increase in new HIV infections saw a change in tack. Posters with slogans such as “HIV seriously fucks up your sex life”, picturing cellphones with “no new messages” caused initial concern for Jenkin. “I thought that was a little extreme. But we keep getting feedback from positive men telling us to make the campaigns tougher.” Having said that, it's important to keep focussed on facts and not get carried away by hyperbole. Condom campaigns in the United States have their fingers jammed permanently on the panic button, advocating condom use for just about every sexual act. As a result, a ‘why bother' attitude is more likely to set in. “In America, the erotic menu is so limited,” Jenkin said. “We're far more liberal here – we don't promote condoms for oral sex because it's very low risk, and that's based on evidence.” The Foundation has never been anti-sex, which it acknowledges as a natural part of human interaction. It's a fine balancing act, however, between nurturing a supportive environment and taking on the role of the sex police. "It's about maintaining the sexual freedoms of gay men," says researcher Saxton. "We're saying you can do anything you like, just use a condom when you fuck. That's the most realistic approach." Chris Banks - 1st November 2005