Chauncey paused, as I am sure he did when he told the same story at Boswell’s memorial service 20 years ago, and said, “He was right. And Jeb was our diva.”

I suppose when someone commands a place in the spotlight, it brings both the adoration of an attentive audience as well as their sorrow during the ensuing tragedy of his death. By this standard, Boswell was indeed a diva.

Boswell joined the Yale faculty at age 28, won the National Book Award at age 33, taught a famous Yale lecture and fathered the concept of lesbian and gay studies here at Yale. In late 1994, at age 47, Boswell also joined the scores of Yale community members who lost their battle to HIV/AIDS.

The Yale AIDS Memorial Project’s website catalogs memories of some of these men:

David W. Dunlap ’74 still remembers a night with Warren Smith ’74, who died of AIDS-related complications: “We got into bed and looked at one another across the space of the pillow. And it was, ‘Are you thinking what I’m thinking?’ And, ‘I think I am.’”

Bill Rubenstein ’82 still remembers John Wallace ’82: “Our senior year at Yale, John and I had been in an American Studies reading group together, and I sat across the seminar table mesmerized by his beauty while everyone chattered on about the social significance of Barbie dolls and ‘Graceland’ and ‘My Mother the Car.’”

Reading over the transcript of Chauncey’s remarks at Boswell’s memorial service, I couldn’t help but notice something: Chauncey lauded John Boswell’s extraordinary gifts and his efforts that helped make Yale the “gay Ivy.” He spoke of members of the University who would yearn for his presence. But he didn’t say that the University would miss him. The implication was that Yale would move on. At first I thought this was an unintentional omission, but then I realized it wasn’t.

Even the most profound experiences and people will fade from campus memory as, year by year, the composition of the student body and the faculty changes. The unyielding churn of the University all but ensures that one’s Yale experience remains personal and not institutional. This produces an unfortunate result: Because the student body evolves, the concerns of a class year or a series of class years, left unruffled on the shelves, fade from memory. Individuals might remember John Boswell, John Wallace and Warren Smith. But Yale University as a body does not; it has moved on from its struggle with HIV.

Yale sacrificed many of its sons to the epidemic, but their identities seem lost in the past.

The University has failed because, like everyone else, it let a welcome shift in the meaning of a positive HIV diagnosis — from acute infection and certain death to chronic illness — absolve it of its responsibility to act. People stopped dying around us, so we have stopped caring, stopped remembering and haven’t taken the active steps necessary to secure an HIV- and AIDS-free generation. It is no longer a priority.

Next month, many young gay men, myself included, will leave this campus and flock to metropolitan areas. Some will move to cities like Atlanta, where nearly half of newly diagnosed HIV cases at Grady Hospital have already progressed to AIDS. Others will take up residence in New York, where a large white and upper-class gay population acts as a buffer to transmission. Some will avoid HIV. Others will help fulfill the prediction that 50 percent of young gay men will contract this race- and class-segmented virus in the next 30 years, likely suffering unwarranted shame and isolation in their post-college years.

But for some reason, on this campus, we relegate the issue of gay men’s health to a tiny office in Swing Space and the generic advice, “Use a condom.”

Yale needs to step up its game. But until then, we, the students, gay and straight, must take up the charge, both here on campus and when we leave. Let’s reclaim the spotlight Boswell left behind. We can be divas too. We can refuse to exit the stage.

A little background: Candidates for PrEP must first fall into a risk group (MSM being the largest of these). Then they generally must check one of a few more boxes, like having contracted an STD or having had unprotected sex in the last six months.

Dr. Andrew Gotlin, chief of Student Health at Yale, summed up precautions surrounding PrEP this way: “It’s certainly not taking vitamin C.”

To ensure maximum efficacy, patients must take the pill daily. (This seems easy enough, but if you are a man, grab a female friend on birth control and ask if she’s ever missed a pill.) Once someone starts treatment, they must meet with their prescribing physician to monitor progress every three months. Patients certainly don’t want to miss these appointments: They are scheduled to ensure that some of the known side effects of antiretroviral treatment (like kidney disease and early-onset osteoporosis) do not set in, or that, in the event that the patient contracts HIV, the virus does not become resistant to the drugs. Toxicity of antiretroviral drugs has fallen dramatically as treatment has advanced, but the risks must be noted.

What’s more, starting treatment presumes a healthcare market that offers patients reasonably priced drugs and access to healthcare providers. Beyond these baseline challenges, achieving effective, widespread usage will require surpassing political hurdles.

The demographic of young MSM, one of the groups with the most alarming increases in HIV incidence, extends from age 13 to 24. This means that many young MSM must request PrEP under their parent’s insurance — with no right to privacy in their medical records. To get treatment that might prevent the contraction of HIV, young men will have to disclose their sexual orientation not only to their physicians but also to their parents, a prospect that is daunting for many well into adulthood, never mind adolescence.

Privacy carve-outs for young women seeking birth control are enshrined in many of our laws. As long as the person seeking contraception does not pose a risk to herself or a risk to others, privacy is respected, even when the patient is a minor. Given the novelty of PrEP, similar carve-outs do not yet exist for young men’s health, and patient assistance programs that might help young gay men acquire the drugs are few and far between. Young gay men bearing the brunt of the current HIV epidemic are left to fend for themselves if they remain in the closet.

Further, talking about the doctor’s office presumes that someone can even afford treatment. Yale Health generously covers Truvada as PrEP for students enrolled in the health plan, but not all commercial insurers cover PrEP as readily. Some insurance companies require pre-authorization for case-specific requests, and many plans include high co-pays. And in the event that you do not have insurance due to unemployment or your state withholding Medicaid expansion funds, you can pretty much forget about getting the drug: The cost of treatment can be as high as $13,000 a year.

Even further, the Supreme Court’s decision in Burwell v. Hobby Lobby, which allows closely held for-profit corporations to deny contraception coverage, may end up getting applied to the drug. Religious-based opposition to sex between men remains strong, and efforts to deny coverage for PrEP might find refuge in our courts.

As we search for the most effective ways to tackle the HIV epidemic, PrEP will play an important role. But as my conversations with activists and medical professionals have revealed over the past weeks, every time someone says, “PrEP,” they should say “TASP” (treatment as prevention) twice.

Effective testing and treatment remain the primary mechanisms for eradicating the virus. Getting the HIV-positive population on a treatment plan toward viral suppression is drastically easier than persuading the much larger MSM community to take a drug every day. We shouldn’t rely on PrEP as a saving grace, but rather embrace it as an option for those most at risk. The bulk of our resources should go towards continuing to use treatment as prevention. If we succeed with TASP, there will be no need for PrEP.

Our HIV crisis:
What if?

By Kyle Tramonte, Staff Columnist

Published on March 4, 2015

 

I would venture a guess that, for those who undergo routine STI testing, it is not uncommon to play the “What if” game — “What if I have an STI (be it gonorrhea, chlamydia, whatever)?”

The answer to that question is pretty simple for most sexually transmitted infections: You get on antibiotics for three to seven days, clear up the problem and hopefully learn a lesson regarding unsafe sexual practices. But for many men who have sex with men (MSM), the “What if” game includes the question “What if I am HIV positive?” A week’s worth of antibiotics certainly is not the answer.

Tyler Curry, senior editor at HIV Equal Online, confronted this reality when he unexpectedly received a positive diagnosis. “Trying to hide your status is like being in the closet again,” he told me. “Now, it was a much smaller closet to wrestle with given that the population of HIV-positive people is smaller, but it was still a new type of closet.” The problem with smaller spaces, though, is that they more frequently induce claustrophobia. A positive HIV diagnosis can be isolating.

Achieving viral suppression requires summoning the courage to get tested and then adhering rigorously to a prescription drug regimen for life. Imminent death is no longer the certain result of HIV. But while the virus has transitioned from “plague” status in the eighties and nineties to a chronic and manageable illness today, we as a society have struggled to catch up in terms of how we perceive the virus.

Fear about how individuals will react at home, discrimination in the workplace, the implications for a future love life and concern for one’s own personal wellbeing are completely understandable responses for a person with HIV.

Still, regardless of how much we empathize with these concerns, a counterproductive tendency exists in both the gay and straight communities. Most of us feel that only those who are HIV positive need to understand the virus, which results in condemnation out of misplaced fear. And, as Curry notes, this can lead people to try to “escape” a positive diagnosis through purposely avoiding testing or hiding their own status from those closest to them.

Despite the presence of antiretroviral drugs (ARTs) on the market for nearly two decades, 44 percent of Americans believe that treatment does nothing to help prevent the spread of HIV. And while the portion of Americans who report knowing someone who died of AIDS or currently has HIV has increased in recent years, only about half of people surveyed in a 2012 study from the Kaiser Foundation report being “very comfortable” working with someone who has HIV or AIDS.

To point out what might seem obvious to some but nevertheless eludes others, unless you are having unprotected sex or sharing needles with someone who is HIV positive, you are not at risk for contraction. Either the workplace is a lot more interesting than I previously thought, or ignorance is a major culprit in the “othering” of HIV-positive individuals.

Misinformation and stigma propagate themselves in many different forms. Regardless of how stigma presents itself, though, we must make a conscious effort to root it out.

Efforts to fight stigmas come in many forms. The easiest place to begin is a linguistic adjustment. Stop describing yourself as “clean” when you talk about your own status. You are either “negative” or “positive,” and “positive” does not always mean the virus is transmittable.

Breaking down HIV laws by state

(Yale Daily News)

Reforms to the judicial system prove a little less accessible to the general public. At least 33 states currently have laws related to exposure and/or transmission of HIV, and five states lack state laws but are on record as prosecuting individuals on HIV-related grounds. Some of these laws are genuinely rooted in preventing the malicious and purposeful spread of HIV, but many are not.

Take for example Texas, which in 2008 convicted a homeless man of assault with a deadly weapon after spitting on a police officer while HIV positive.  The CDC has no record of HIV transmission via saliva. Many states have similarly uninformed statutes, prescribing harsher sentences for HIV-positive people when there is no risk of transmission. These laws should have no place in our country.

Last, we must make every effort to inform the public about the realities of HIV. This is, of course, difficult given our historical predisposition to condemn sex between men. Nevertheless, it is a prerequisite to crafting a society that confronts HIV rather than runs away from it. We must incorporate information on HIV among MSM into our sexual education programs.

We can begin to defeat stigma today. As an exercise, play a modified version of the “What if” game: What if your brother or best friend received a positive diagnosis? Would your response be constructive or destructive? If you think it would be destructive, revisit what you know about HIV and make some necessary changes.

In the fight against the HIV epidemic in America, anything that encourages people not to seek regular testing or to hide their status must go, including our fears and unawareness.

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Our HIV crisis:
All incidence is not equal

By Kyle Tramonte, Staff Columnist

Published on February 18, 2015

 

Despite representing only 13 percent of the U.S. population, African Americans account for nearly half of all new HIV infections each year. Rates of transmission among injecting drug users, black women and black infants born to seropositive mothers continue to decline, but HIV incidence among gay and bisexual men who are young and black has charted a steady rise.

Centers for Disease Control and Prevention estimates are jarring: Their numbers suggest that one in five black men who have sex with men (MSM) living in a major city already has HIV. Forty percent of these cases will progress to AIDS. This is all compounded by the fact that black MSM are the most likely demographic subgroup to date other members of their own race.

Yet, if we ask Americans where the virus destroys lives, a majority will point beyond our borders.

A very clear transitive relationship exists: Socioeconomic issues associated with poverty — limited access to health care, housing and HIV prevention education — undoubtedly increase the risk of infection. The poverty rate is higher among African Americans than other racial and ethnic groups. Therefore, we should expect baseline incidence of HIV among black Americans to be higher than for other groups.

But while nearly all accept this reality, sensationalized characterizations of the black community promote misconceptions about the primary reasons for high incidence.

Take for example the false claim that HIV/AIDS is a product of irresponsibly foregoing condom usage. Black MSM confront a great paradox in HIV incidence: Meta-analyses from researchers at the CDC showed in 2012 that black MSM reported fewer high-risk behaviors than MSM of other ethnic groups. Still, at the time the authors published their study, black MSM had three times the chances of testing HIV positive and six times the chances of having undiagnosed HIV. Disparities in condom usage on racial and ethnic grounds do not provide a real explanation for this crisis.

Incarceration due to the war on drugs has of course disproportionately affected people of color. But pointing the finger at male-to-male transmission in prisons to explain the crisis is similarly incorrect. From July 1988 to February 2005, Georgia implemented mandatory HIV testing upon prison entry and subsequent voluntary testing by request or by clinical indication. Of those found to be HIV positive in Georgia prisons and jails, 91 percent were positive upon entry. The real danger of living with HIV in prisons is not the risk of infecting another inmate, but the stigma and abuse that stems from a positive diagnosis.

HIV/AIDS in the black community, in many ways, is not an isolated crisis but rather the child of a more familiar one. It is the same American dilemma of historical racial subjugation. When considering America’s HIV crisis among African Americans, especially MSM, we must look back to that first relationship between socioeconomic status, HIV incidence and black Americans’ persistent struggle to overcome structural inequalities.

Years of discrimination in housing and other resources, inadequate sexual health education in our crumbling public schools and persistent racism are the primary culprits in this crisis. And while mass incarceration doesn’t cause HIV incidence to explode in prisons, it certainly affects those who are not jailed. The women and men left behind in society must encounter a numerically restricted sexual network, increasing the chances that they will come into contact with an HIV-positive individual in small, high-prevalence communities.

HIV will not disappear without an offensive strategy. There are many factors that contribute to the crisis, but expanding access to high-quality health care is the integral first step to decreasing the racial disparity in incidence. The concept of following through on the “treatment cascade” or “care continuum” is vastly important — individuals must be diagnosed, then linked to care, then remain in care, then eventually achieve viral suppression to prevent transmission. The problem is that far too many black MSM are unable to access medical care with the frequency that other groups do.

EDITOR'S NOTE:

The first step in combatting the HIV/AIDS crisis begins with knowing one’s own status. If you or someone you know would like to receive free, confidential HIV testing, please call 203-936-8669.

The Affordable Care Act, in part, tried to address this crisis by eliminating discrimination practiced by insurance companies based on pre-existing conditions and by expanding Medicaid. But almost 20 states continue to deny Medicaid expansion, which would help those most vulnerable to HIV infection break into the care continuum and receive treatment. This is most potent in the South, where nine states have denied expansion, where African Americans are twice as likely to be uninsured and six times as likely to have HIV. And, according to a recent complaint filed with the Department of Health and Human Services, a number of insurance providers are actively discouraging HIV-positive individuals from enrolling in their plans through adverse tiering practices.

For many young black men who have sex with men, access to our health care networks is a question of life or death. We must confront this reality and take steps to ensure that they live.

 

 

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Our HIV crisis:
Young and at risk

by Kyle Tramonte, Staff Columnist

Published on February 4, 2015

 

In most students’ minds, the HIV/AIDS crisis was an event of the past: a bleak time of public condemnation of men who have sex with men, a searing recognition of the absence of legal and human rights afforded to affected communities and, for many, a period of intense sadness and fear. Yet the belief that HIV in America is no longer a public concern couldn’t be further from the truth.

Federal research shows that the nation’s HIV rate fell by a third from 2001 to 2011. But, in the same 10-year time frame, new diagnoses of HIV among gay and bisexual men between the ages of 13 and 24 increased by nearly 133 percent. Why is this happening, and why aren’t people paying attention?

Kyle Tramonte — Green on the Vine

We can attribute this lack of awareness at least partially to a diminished sense of urgency surrounding the virus. With the advent of prescription drugs that depress HIV-positive individuals’ viral loads, it slowly fell out of the news cycle. Soon after, the same-sex marriage movement all but replaced other LGBT community issues on the national airwaves. A cohort of young men now face an increased risk of contracting a virus relegated to the past, all while the public looks elsewhere.

Yes, the virus is spread more easily through anal intercourse, making gay men more susceptible. Still, we must recognize that two behavioral trends play an outsized role in the spike in incidence: Gay and bisexual men tend to have more partners and to use condoms less often than our heterosexual counterparts. But, as Michael Specter noted in the New Yorker over a year ago, “HIV is tied up with sex, a basic human need, but also with desire, shame, discrimination and fear. What twenty-year-old man, enjoying his first moments of sexual adventure, is going to be scared because, ten years before he was born, people like me saw gay men writhe and vomit and die on the streets where he now stands?”

According to an article in the News (“Sex isn’t always safe at Yale,” Jan. 23), Yale students cite decreased sensation as a primary motivation for not using a condom. Condom usage among men who have sex with men increased in the 1980s and 1990s as a direct result of the mass death of members of the gay community. But because we as a society no longer see people dying in the street, the split-second decision to forego safety at the expense of pleasure is calculated using a misguided risk assessment.

The nature of HIV testing also provides some answers. Tests that measure the antibodies resulting from HIV infection are subject to a “window period” of six to 12 weeks. If you get tested in the first three months post-infection, you may return negative results. Even further, an individual’s viral load is highest in this time window, making the period immediately post-infection also the most dangerous. Antigen (RNA) tests can return results within one to three weeks of infection, but these tests are more expensive and offered less often.

These numbers are, of course, only relevant to those who choose to get tested; the Centers for Disease Control and Prevention report that one in five infected people do not know they are HIV-positive. The takeaway? Self-reported, medically unsubstantiated assessments of sexual health should be viewed with at least some caution for the benefit of community health.

On this campus, ignorance regarding the state of HIV in America is also a product of the predominantly white and wealthy composition of the student body. A sizeable portion of our peers identify as gay and bisexual, but as long as the HIV crisis disproportionately affects people of color and the economically disadvantaged, HIV prevention will likely remain an issue to be tackled at a later date. We must recognize that HIV is a problem that affects all of society if we are to make a dent in public consciousness.

EDITOR'S NOTE:

The first step in combatting the HIV/AIDS crisis is getting tested. If you or someone you know would like to receive free, confidential HIV testing, please call 203-936-8669.

Nearly six years ago, public health researcher Ron Stall predicted that 50 percent of gay and bisexual men in our generation would contract HIV by age 50. Quality of life for HIV-positive members of our society has improved drastically in the last 20 years, but failure to recognize this degree of incidence in any community is a crime.

In conversations with professors and students, an interesting metaphor arose: If you are standing on the bank of a swift-moving river and see someone floating by, you might try to save them. If you see 10 people float by, it’s probably best you look upstream to see what the hell is going on. In the coming weeks, I will be talking to University administrators, students and public health experts to examine what role Yale and its students can play in addressing the crisis. We have to; people are drowning and few are on the riverbank to even notice.

 

 

Editor’s picks

In needle exchange programs, users led the charge against HIV

Yale researchers who pioneered New Haven’s Needle Exchange Program are celebrating those who made the program possible — the substance users themselves.

Sex isn't always safe at Yale

Exploring the numbers behind sexual health on campus.