Zeitschriftenartikel zum Thema „HIV-positive persons Australia“

Background As financial constraints can be a barrier to accessing HIV antiretroviral therapy (ART), we argue for the removal of copayment requirements from HIV medications in South Australia. Methods: Using a simple mathematical model informed by available behavioural and biological data and reflecting the HIV epidemiology in South Australia, we calculated the expected number of new HIV transmissions caused by persons who are not currently on ART compared with transmissions for people on ART. The extra financial investment required to cover the copayments to prevent an HIV infection was compared with the treatment costs saved due to averting HIV infections. Results: It was estimated that one HIV infection is prevented per year for every 31.4 persons (median, 24.0–42.7 interquartile range (IQR)) who receive treatment. By considering the incremental change in costs and outcomes of a change in program from the current status quo, it would cost the health sector $17 860 per infection averted (median, $13 651–24 287 IQR) if ART is provided as a three-dose, three-drug combination without requirements for user-pay copayments. Conclusions: The costs of removing copayment fees for ART are less than the costs of treating extra HIV infections that would result under current conditions. Removing the copayment requirement for HIV medication would be cost-effective from a governmental perspective.

Background: The widespread availability of direct-acting antivirals (DAAs) is expected to drastically improve the treatment uptake and cure rate of hepatitis C virus (HCV). In this paper, rates of and factors associated with HCV treatment uptake and cure in the HIV co-infected population in Australia were assessed before access to DAAs. Methods: The medical records of patients in the Australian HIV Observational Database who were reported to be HCV antibody positive from 1999 to 2014 were reviewed for HCV treatment data. Patients with detectable HCV RNA were included in this analysis. Logistic regression models were applied to identify factors associated with treatment uptake and HCV sustained virological response (SVR) 24 weeks’ post treatment. Results: The median follow-up time of those with chronic HCV/HIV co-infection was 103 months (interquartile range 51–166 months). Of 179 HCV viraemic patients, 79 (44.1%) began treatment. In the adjusted model, a higher METAVIR score was the only significant factor associated with treatment uptake (odds ratio (OR) 8.87, 95% confidence interval (CI) 2.00–39.3, P = 0.004). SVR was achieved in 37 (50%) of 74 treated patients. HCV genotypes 2/3 compared with 1/4 remained the only significant factor for SVR in an adjusted multivariable setting (OR 5.44, 95% CI 1.53–19.4, P = 0.009). Conclusions: HCV treatment uptake and SVR have been relatively low in the era of interferon-containing regimens, in Australian HIV/HCV coinfected patients. With new and better tolerated DAAs, treatment of HCV is likely to become more accessible, and identification and treatment of HCV in co-infected patients should become a priority.

The experience with human immunodeficiency virus (HIV) infection of a private inner-city sexually transmissible diseases (STD) clinic in Sydney was quantified. Between February 1984 and March 1988, 2073 of the Clinic's patients were tested for antibodies to HIV on 5095 occasions. Of those tested, 538 (26%) were positive for antibodies to HIV: 532 (98.9%) of the seropositives had practised male homosexual intercourse. This is the highest reported seroprevalence of HIV for any primary care service in Australia. Those individuals seropositive because of other risk behaviours were detected by voluntary contact tracing rather than by screening. Female prostitution was not found to be a risk factor for HIV. In general, rates of first HIV antibody tests were adversely affected by threatening legislation, and temporarily stimulated (among lower-risk persons) by a national television campaign. These data suggest that much of the counselling, detection and management of HIV infection in Australia is occurring in private practice, and that STD services (private and public) are at the forefront of the HIV epidemic. This has implications for disease surveillance and control, health services planning and medical education.

Pharmacologic methods of treating and preventing HIV have advanced tremendously in recent years. Understandings of HIV risk and recommendations for risk-reduction strategies have also changed substantially. A majority of new cases of HIV in many developed countries are now acquired through sex with long-term partners who are unaware of their HIV-positive status, rather than from casual or anonymous sexual encounters. Persons with bipolar disorder and substance use disorders are at particularly high risk. Mental health providers who work with LGBT persons and other populations at higher risk for HIV need to understand strategies their patients are using for HIV risk reduction, and to refer appropriate patients for consideration for pre-exposure prophylaxis (PrEP). PrEP is the daily use of an antiretroviral (ARV) medication for prevention of HIV infection in higher-risk individuals. The United States approved tenofovir + emtracitabine for PrEP in 2012; this is under review in several European countries, Canada, and Australia, and is already prescribed off-label in many. Additionally, studies have shown that treatment with ARV medications to an “undetectable viral load” greatly reduces the risk of further transmission by persons already infected with HIV, called “treatment as prevention” (TasP). As of September 2015, WHO recommends early ARV treatment for all persons with HIV, and consideration of PrEP for men who have sex with men. This paper reviews findings from the PrEP studies (especially iPrEx, iPrEx Ole, IPERGAY, and PROUD) and TasP, and looks at their impact on LGBT and HIV+ communities, with relevance for mental health providers.Disclosure of interestThe author has not supplied his declaration of competing interest.

492 Background: Anal cancer is associated with human papillomavirus (HPV), a sexually transmitted infection, which can be prevented by the HPV vaccination. Few countries do recommend vaccination for the male population, but all males are at risk of contracting HPV. This study aimed to identify the latest evidence on the incidence of anal cancer and pre-cancer related to HPV in males globally and to analyze the epidemiological trends. Methods: A systematic literature search was performed using Medline and EMBASE. Studies containing original anal cancer incidence data in males published between January 1, 2008 and March 23, 2018 in English were included. Results: The global incidence of anal cancers and pre-cancers among the general male population was identified in 25 studies with observations ranging between 1968 and 2014. Incidence over time was reported in Australia and Europe. In an Australian national study, anal cancer incidence increased from 0.77 to 1.3 per 100,000 persons from 1982-2005, and in the UK from 0.79 to 1.06 per 100,000 persons from 1962-2002. In Denmark, the anal cancer range increased from 0.20-0.41 to 0.69-1.3 per 100,000 person-years (PYs) from pre-2000 to post-2000, and in France from 0.2 to 0.5 per 100,000 PYs from 1982-2012. In two national US studies, the mean incidence of pre-cancers was 1.5 in the period 1997-2009, and 0.41 from 1978-2007 per 100,000 PYs. The burden of anal cancers and pre-cancers increased the most among high-risk males reported in US studies. For HIV-positive males, mean incidence of cancer increased from 10.5 during 1980-1989 to 42.3 in 1996-2004 per 100,000 PYs, and for HIV-positive MSM, incidence increased from 47 to 270 per 100,000 PYs between 1984 and 2013. The mean pre-cancer incidence among HIV-positive males increased from 1.7 during 1980-1989 to 29.5 in 1996-2004 per 100,000 PYs. Conclusions: This systematic literature review demonstrates the increase in anal cancer and pre-cancer incidences over time in men, especially in high-risk male populations. The burden of anal cancers and pre-cancers increase over time in all male populations highlights the unmet medical need and the importance of preventative interventions such as HPV gender-neutral vaccinations.

This article reports on the findings of the qualitative stage of a larger project on the mental care needs of people with HIV/AIDS and mental illness (Tender T1176 Department of Human Services, Mental Health Branch, Victoria - Research on the Mental Health Care Needs of People with HIV/AIDS and Mental Illness). The purpose of the larger research was to evaluate the needs and treatment requirements of persons with HIV/AIDS, who also suffer from mental health problems, with a view to developing proposals for improving existing service delivery in Victoria, Australia. The qualitative stage was designed to complement and elucidate data obtained through the quantitative stages of the project. Thirty in-depth open-ended interviews were carried out with service providers including HIV physicians, general practitioners, psychiatrists, clinical and managerial staff of Area Mental Health Services, Contact Tracers and forensic mental health services staff, as well as representatives of community groups such as People Living with HIV/AIDS and Positive Women and carers. The interviews explored the perspective of both service providers and users of such services with respect to needs for psychiatric care and service delivery, ease of access or barriers to mental health services, and the perceived strengths and weaknesses in current service provision. This paper presents the main findings and recommendations submitted to the funding body.

Background Despite combination antiretroviral therapy (cART), the incidence of lymphomas remains elevated in persons with HIV/AIDS (PWHA). While the risk of subsequent primary cancers (SPCs) in the general population is well understood, these data are lacking for PWHA. Underlying aetiologic factors in PWHA, including oncogenic viruses and immunodeficiency, may have a differential impact on SPCs. We conducted a nationwide data linkage study in order to examine the role of lymphoma in SPCs in PWHA in two ways. First, we determined the incidence of and risk factors for Hodgkin lymphoma (HL) or non-Hodgkin lymphoma (NHL) (including chronic lymphocytic leukaemia) in PWHA previously diagnosed with an initial cancer of any type. Second, we assessed the incidence and features of SPCs of any type in PWHA after a primary HL or NHL. Methods Since 1982 Australia has had compulsory disease notification of all new HIV infections and all invasive cancers. We conducted a probabilistic data linkage study between the Australian National HIV Registry, the Australian Cancer Database and National Death Index to identify PWHA diagnosed with an initial cancer, followed by at least one SPC between 1982 and 2012. Follow up commenced from 90 days post the date of first cancer diagnosis at or following HIV diagnosis, and ended on 31 December 2012 or death, whichever came earlier. A SPC was defined as a cancer of diverse site and histology to the first cancer and diagnosed more than 90 days later (in order to mitigate ascertainment bias). The incidence of SPC was compared using Poisson regression. Risk factors considered included: age, sex, HIV exposure modality (such as male-to-male, intravenous drug, etc.) and CD4+ cell count at HIV diagnosis (<50, 50-199, 200-499, >500 cells/µL). Incidence was also compared across various eras corresponding to HIV treatment advances: 1982-1995 (pre-cART); 1996-1999 (early-cART); 2000-2004 (availability of protease inhibitors for HIV); and, 2005-2012 (availability of fusion inhibitors for HIV and rituximab for CD20-positive lymphomas). Results Out of 28,696 PWHA, 3,548 were identified with a first cancer. Among them, 229 SPCs were identified over 27,398 person-years (PY) of follow-up. The crude incidence of SPCs was 8.36 per 1000 PY (95% CI 7.34-9.51). Of 229 SPCs, 88 were lymphomas, comprising 42 diffuse large B cell, 4 Burkitt, 3 T cell, 2 primary effusion, 3 low grade lymphomas and 5 HLs; 29 NHLs were not sub-classified in the Database. The majority of first cancers in the group with SPCs were Kaposi sarcoma (KS) (55%). The incidence of lymphoma as an SPC decreased from 8.10 to 0.79 per 1000 PY from 1982-1995 to 2005-2012 (p=0.003). Median time from first cancer diagnosis to the diagnosis of a lymphoma SPC was 2.0 years (interquartile range (IQR): 0.8-4.0). Median age at diagnosis of a lymphoma SPC was 39 years (IQR: 34-49). The risk of a lymphoma SPC decreased with older age, from 10.68 per 1000 PY in those under 35 to 1.28 per 1000 PY in those above 55 (p=0.003). CD4 count at HIV diagnosis and HIV exposure modality were not associated with the risk of a lymphoma SPC. The incidence of a SPC after lymphoma as a first cancer (n=39) was 5.60 per 1000 PY, versus 9.30 per 1000 PY when the first cancer was not lymphoma (n=190, p=0.004). KS was the most common SPC after an initial lymphoma (49% of cases). Only two myeloid SPCs occurred. Median time to diagnosis of SPC after an initial lymphoma was 2.6 years (IQR: 1.1-6.7). Risk of a SPC after a first lymphoma increased significantly from 4.12 per 1000 person-years in those diagnosed with HIV in the 1982-1995 pre-cART era, to 33.15 per 1000 person-years in patients diagnosed with HIV between 2009-2012 (p=0.005). Conclusion The incidence and spectrum of SPC in PWHA is increasingly important as overall and cancer-specific survival of these patients continues to improve. The incidence of lymphomas as SPC in PWHA has decreased over time, which may be a function of improved HIV treatment and reduced susceptibility to immunosuppression-related lymphoma. However, PWHA diagnosed with lymphoma as a first cancer are experiencing increasing incidence of SPCs, occurring after relatively short intervals. Longer survival is likely contributing to this effect. Importantly, therapy-related cancers do not appear prominent, suggesting HIV-specific factors may play a role. These findings emphasise the importance of SPC surveillance tailored to this special population. Disclosures Di Ciaccio: Janssen: Honoraria.

Abstract Background Human immunodeficiency virus (HIV)–positive gay and bisexual men (GBM) in Australia are well engaged in care. The World Health Organization’s (WHO) hepatitis C virus (HCV) elimination target of an 80% reduction in incidence by 2030 may be reachable ahead of time in this population. Methods We predicted the effect of treatment and behavioral changes on HCV incidence among HIV-positive GBM up to 2025 using a HCV transmission model parameterized with Australian data. We assessed the impact of changes in behavior that facilitate HCV transmission in the context of different rates of direct-acting antiviral (DAA) use. Results HCV incidence in our model increased from 0.7 per 100 person-years in 2000 to 2.5 per 100 person-years in 2016 and had the same trajectory as previously reported clinical data. If the proportion of eligible (HCV RNA positive) patients using DAAs stays at 65% per year between 2016 and 2025, with high-risk sexual behavior and injecting drug use remaining at current levels, HCV incidence would drop to 0.4 per 100 person-years (85% decline from 2016). In the same treatment scenario but with substantial increases in risk behavior, HCV incidence would drop to 0.6 per 100 person-years (76% decline). If the proportion of eligible patients using DAAs dropped from 65% per year in 2016 to 20% per year in 2025 and risk behavior did not change, HCV incidence would drop to 0.7 per 100 person-years (70% reduction). Conclusions Reaching the WHO HCV elimination target by 2025 among HIV-positive GBM in Australia is achievable.

Background In HIV-positive people, sexually transmissible infections (STIs) probably increase the infectiousness of HIV. Methods: In 2010, we established a cohort of individuals (n = 554) from clinics in the Australian HIV Observational Database (AHOD). We calculated retrospective rates for four STIs for 2005–10 and prospective incidence rates for 2010–11. Results: At baseline (2010), patient characteristics were similar to the rest of AHOD. Overall incidence was 12.5 per 100 person-years. Chlamydial infections increased from 3.4 per 100 person-years (95% confidence interval (CI): 1.9–5.7) in 2005 to 6.7 per 100 person-years (95% CI: 4.5–9.5) in 2011, peaking in 2010 (8.1 per 100 person-years; 95% CI: 5.6–11.2). Cases were distributed among rectal (61.9%), urethral (34%) and pharyngeal (6.3%) sites. Gonococcal infections increased, peaking in 2010 (4.7 per 100 person-years; 95% CI: 5.6–11.2; Ptrend = 0.0099), distributed among rectal (63.9%), urethral (27.9%) and pharyngeal (14.8%) sites. Syphilis showed several peaks, the largest in 2008 (5.3 per 100 person-years; 95% CI: 3.3–8.0); the overall trend was not significant (P = 0.113). Genital warts declined from 7.5 per 100 person-years (95% CI: 4.8–11.3) in 2005 to 2.4 per 100 person-years (95% CI: 1.1–4.5) in 2011 (Ptrend = 0.0016). Conclusions: For chlamydial and gonococcal infections, incidence was higher than previous Australian estimates among HIV-infected men who have sex with men, increasing during 2005–2011. Rectal infections outnumbered infections at other sites. Syphilis incidence remained high but did not increase; that of genital warts was lower and decreased.

Background: Syphilis has re-emerged and become established in gay communities in most developed countries since the late 1990s. HIV infected men have been disproportionately affected by this endemic, but it is unclear whether this is due to behavioural or biological reasons. We report incidence and risk factors for syphilis in two community-based cohorts of HIV-negative and HIV-positive homosexual men in Sydney, Australia. Methods: Participants were recruited using similar community-based strategies in both cohorts and underwent annual face-to-face interviews. Syphilis screening was offered to all consenting participants at annual visits. Results: In the HIV-negative cohort, 21 men seroconverted to syphilis and one man had a syphilis re-infection during 2001–07, an incidence of 0.49 per 100 person-years (95% CI: 0.31–0.74). In the HIV-positive cohort during 2005–07, eight men seroconverted and one man had a syphilis re-infection, giving an incidence of 3.62 per 100 person-years (95% CI: 1.67–6.48). All nine reported a recent CD4 count of more than 350 cells µL–1. Syphilis incidence was significantly higher in the HIV-positive cohort after adjustment for age (hazard ratio (HR) = 9.20, 95% CI: 3.63–23.31). Unprotected anal intercourse (UAI) with HIV-positive partners was significantly associated with incident syphilis in both cohorts (HR = 4.45, 95% CI: 1.37–14.45 in HIV-negative; HR = 8.67, 95% CI: 1.03–72.76 in HIV-positive). Conclusion: Syphilis incidence was almost 10-fold higher in HIV-positive than in HIV-negative homosexual men, and it was not related to a CD4 count below 350 µL–1. UAI with HIV positive partners was of particular importance in the transmission of syphilis.

Background In Australia, Health Department policies differ on the recommended method of providing HIV results. Traditionally, all results have been provided in person. Our aim was to trial provision of HIV-negative test results by telephone to low-risk clients attending sexual health services and to assess clients’ preferences for delivery method. Methods: During 4 months in 2009 at two sexual health services in Sydney, all clients assessed as low-risk for HIV infection were invited to receive their HIV result by telephone. Non-receipt of results was defined as failure to receive results within 30 days of the test being performed. Results: Of 763 clients tested, 328 (43%) were excluded following risk assessment, 30 (4%) declined to participate and 405 (53%) were enrolled. Among enrolled clients, 86% received their HIV result by telephone within 30 days, 97% were satisfied with delivery of the result by telephone and 93% preferred telephone delivery for their next HIV result. Only one enrolled client returned a positive HIV result. Independent predictors of receiving results within the 30-day timeframe were clinic attendance for sexually transmissible infection screening (P = 0.021), lack of anogenital symptoms (P = 0.015) and not being a sex worker (P = 0.001). Conclusions: In this study of telephone provision of HIV results to low HIV-risk clients, there were no adverse events and clients expressed satisfaction with the process plus a strong preference for telephone delivery of future results. There was a decreased rate of failure to receive HIV results compared with other Australian studies.

Background Gender differences vary across geographical settings and are poorly reported in the literature. The aim of this study was to evaluate demographics and clinical characteristics of participants from the Australian HIV Observational Database (AHOD), and to explore any differences between females and males in the rate of new clinical outcomes, as well as initial immunological and virological response to antiretroviral therapy. Methods: Time to a new clinical end-point, all-cause mortality and/or AIDS illness was analysed using standard survival methods. Univariate and covariate adjusted Cox proportional hazard models were used to evaluate the time to plasma viral load suppression in all patients that initiated antiretroviral therapy (ART) and time to switching from a first-line ART to a second-line ART regimen. Results: There was no significant difference between females and males for the hazard of all-cause mortality [adjusted hazard ratio: 0.98 (0.51, 1.55), P = 0.67], new AIDS illness [adjusted hazard ratio: 0.75 (0.38, 1.48), P = 0.41] or a composite end-point [adjusted hazard ratio: 0.74 (0.45, 1.21), P = 0.23]. Incident rates of all-cause mortality were similar between females and males; 1.14 (0.61, 1.95) vs 1.28 (1.12, 1.45) per 100 person years. Virological response to ART was similar for females and males when measured as time to viral suppression and/or time to virological failure. Conclusion: This study supports current Australian HIV clinical care as providing equivalent standards of care for male and female HIV-positive patients. Future studies should compare ART-associated toxicity differences between ART-associated toxicity differences between men and women living with HIV in Australia.

Introduction: In order to review the requirement for all patients to return for HIV test results, we sought to describe the number of cases of HIV infection detected at Sydney Sexual Health Centre among people who did not disclose known risk factors before testing. Method: The clinic database identified all HIV testing episodes between January 2004 and January 2007, along with gender, gender of sexual partners and test result. Pro-forma medical records were reviewed for each person who tested positive for gender of sexual partners, condom use, and sexual contact with a person from a country known to have a high HIV prevalence and injecting drug use. Results: During the 3-year period, a total of 13 290 HIV tests were performed. In men who have sex with men, 6194 tests were performed and 55 (0.88%) tested positive. In women and heterosexual men 7096 tests were performed, and only four (0.06%) tested positive. All four reported known risks for HIV before testing. Conclusion: Clients with no recognised risk factors for HIV are unlikely to test positive at our Australian sexual health clinic. Providing the option for low risk people to obtain their results other than face to face has advantages for both the clinic in terms of service provision and the clients in terms of time and the proportion who receive their result.

Background Screening for the anal cancer precursor HSIL is not recommended in national guidelines. A recent Cochrane review of HSIL treatment concluded there is no evidence of efficacy. In this context, we aimed to describe the natural history of anal HSIL, and association with human papillomavirus (HPV), in a community-recruited cohort of Australian homosexual men. Methods: The SPANC study is a three-year prospective study in men aged ≥35 years. At each visit, men undergo an anal swab for cytology and HPV genotyping (Roche Linear Array), followed by high-resolution anoscopy-aided biopsy. Anal HSIL is defined as having either anal intraepithelial neoplasia grade 2/3 on histology and/or HSIL/ASC-H on cytology. Results: Among 342 men recruited by March 2013, median age was 49 with 29% HIV positive. At baseline, prevalence of anal HSIL was 50% and 44% in the HIV-positive and HIV-negative groups, respectively (P = 0.303). Among those without HSIL at baseline, HSIL incidence was 28/100 person-years in both the HIV-positive and HIV-negative groups (P = 0.920). Among those with HSIL at baseline, the incidence of change to non-HSIL was 41 and 43/100 person-years (P = 0.851). Men with anal HPV16 at baseline were more likely to develop incident HSIL (57 vs 23/100 person-years, P = 0.010), and less likely to change to non-HSIL (18 vs 61/100 person-years, P = 0.001). Conclusions: Anal HSIL was highly prevalent in these homosexual men. Both incidence of HSIL and change to non-HSIL were common, and were closely associated with HPV16 status. HPV16 positivity may identify men with HSIL at higher risk of anal cancer.

Abstract Relationships and sexuality education for young people in Australia and elsewhere is a controversial topic. Numerous studies in Australia have focused on curriculum, policy, teachers, schools, sexting and other behaviours, and knowledge regarding sexually transmitted infection (STI)/human immunodeficiency virus (HIV) and pregnancy prevention. Few large-scale national studies have engaged with young people about what they want out of their sex education, and what they suggest would be most valuable for future programs in Australia. Data for the study included qualitative comments about experiences of sex education (n = 2316) provided in a national survey of adolescent sexual health. An initial thematic inductive analysis identified comments falling into two dominant themes: positive and negative experiences of their sex education. Results indicate that young people in Australia are articulate and understanding of the gaps in their sex education. A majority of comments highlighted negative experiences. These comments primarily discussed issues of delivery (timing, environment, person) and content quality (comprehensiveness). A minority highlighted positive commentary also around delivery (environment, person) and content quality (comprehensiveness). The findings of this study illuminate contemporary adolescent concerns regarding their experiences of education. Understanding these experiences can inform future curriculum development, teacher training and the design and implementation of policy.

Abstract Background Microelimination of hepatitis C virus (HCV) among people living with human immunodeficiency virus (HIV) may be feasible in Australia, given unrestricted access to direct-acting antiviral (DAA) therapy from 2016. Our aim was to evaluate progress towards elimination goals within HIV/HCV-coinfected adults in Australia following universal DAA access. Methods The CEASE prospective cohort study enrolled adults with HIV/HCV, irrespective of viremic status, from 14 primary and tertiary clinics in Australia. Annual and cumulative HCV treatment uptake, outcome, and HCV RNA prevalence were evaluated, with follow-up through May 2018 (median follow-up, 2.63 years). Factors associated with DAA uptake were analyzed. Results Between July 2014 and March 2017, 402 participants who were HIV/HCV antibody positive were enrolled (95% male [80% gay and bisexual men,], 13% cirrhosis, 80% history of injecting drug use [39% currently injecting]). Following universal DAA access, annual HCV treatment uptake in those eligible increased from 7% and 11% per year in 2014 and 2015, respectively, to 80% in 2016. By 2018, cumulative HCV treatment uptake in those ever eligible for treatment was 91% (336/371). HCV viremic prevalence declined from 82% (95% CI, 78–86%) in 2014 to 8% (95% CI, 6–12%) in 2018. Reinfection was reported in only 5 participants for a reinfection incidence of 0.81 per 100 person-years (95% CI, 0.34–1.94). Conclusions High uptake and effectiveness of unrestricted DAA therapy in Australia have permitted rapid treatment scale-up, with a dramatic reduction in HCV infection burden and low reinfection rate among people living with HIV, suggesting that microelimination is feasible. Clinical Trials Registration NCT02102451.

Objectives HIV diagnosis rates in men who have sex with men (MSM) began increasing in Australia 10 years ago, and there has been a major resurgence of syphilis. We determined predictors of HIV positivity and seroconversion among MSM in Victoria, Australia. Methods: We conducted a retrospective longitudinal analysis of data from MSM who underwent HIV testing between April 2006 and June 2009 at three primary care clinics. Logistic regression was used to determine predictors of HIV positivity and seroconversion. Results: During the study period, 7857 MSM tested for HIV. Overall HIV positivity was 1.86% (95% confidence interval (CI): 1.6–2.2). There were 3272 repeat testers followed for 4837 person-years (PY); 60 seroconverted and HIV incidence was 1.24 (95% CI: 0.96–1.60) per 100 PY. Independent predictors of HIV seroconversion were: an infectious syphilis diagnosis within the last 2 years (adjusted hazard ratio (AHR) = 2.5, 95% CI: 1.1–5.7), reporting six or more anal sex partners in the past 6 months (AHR = 3.3, 95% CI: 1.8–6.3), reporting an HIV-positive current regular partner (AHR = 3.4, 95% CI: 1.1–10.6) and reporting inconsistent condom use with casual partners in the past 6 months (AHR = 4.4, 95% CI: 1.7–11.5). Conclusion: Our results call for HIV prevention to target high-risk MSM, including men with a recent syphilis diagnosis or a high numbers of partners, men who have unprotected anal sex with casual partners and men in serodiscordant relationships. The HIV incidence estimate will provide a baseline to enable public health officials to measure the effectiveness of future strategies.

Background: Integrase inhibitors (INSTI) are a newer class of antiretroviral (ARV) drugs that offer additional treatment options for experienced patients. Our aim is to describe treatment durability and virological outcomes in treatment-experienced HIV-positive patients using INSTI-based regimens. Methods: All patients in the Australian HIV Observational Database who had received an INSTI-based regimen ≥ 14 days as well as previous therapy were included in the study. We defined two groups of treatment-experienced patients: (1) those starting a second-line regimen with INSTI; and (2) highly experienced patients, defined as having prior exposure to all three main ARV classes, nucleoside reverse transcriptase inhibitor, nonnucleoside reverse transcriptase inhibitors and protease inhibitors, before commencing INSTI. Survival methods were used to determine time to viral suppression and treatment switch, stratified by patient treatment experience. Covariates of interest included age, gender, hepatitis B and C co-infection, previous antiretroviral treatment time, patient treatment experience and baseline viral load. Results: Time to viral suppression and regimen switching from INSTI initiation was similar for second-line and highly experienced patients. The probability of achieving viral suppression at 6 months was 77.7% for second-line patients and 68.4% for highly experienced patients. There were 60 occurrences of regimen switching away from INSTI observed over 1274.0 person-years, a crude rate of 4.71 (95% CI: 3.66–6.07) per 100 person-years. Patient treatment experience was not a significant factor for regimen switch according to multivariate analysis, adjusting for relevant covariates. Conclusions: We found that INSTI-based regimens were potent and durable in experienced HIV-positive patients receiving treatment outside clinical trials. These results confirm that INSTI-based regimens are a robust treatment option.

Background Gonorrhoea notifications continue to rise among gay and bisexual men in Australia and around the world. More information is needed on infection trends, accounting for testing and complimented by demographics and risk practices. Methods: A retrospective cohort analysis was undertaken using repeat gonorrhoea testing data among gay and bisexual men from 2010 to 2017, which was extracted from a network of 47 sexual health clinics across Australia. Poisson and Cox regression analyses were used to determine temporal trends in gonorrhoea incidence rates, as well as associated demographic and behavioural factors. Results: The present analysis included 46904 gay and bisexual men. Gonorrhoea incidence at any anatomical site increased from 14.1/100 person years (PY) in 2010 to 24.6/100 PY in 2017 (P<0.001), with the greatest increase in infections of the pharynx (5.6-15.9/100 PY, P<0.001) and rectum (6.6–14.8/100 PY, P<0.001). After adjusting for symptomatic and contact-driven presentations, the strongest predictors of infection were having more than 20 sexual partners in a year (hazard ratio (HR)=1.9, 95% confidence interval (CI): 1.7–2.2), using injecting drugs (HR=1.7, 95%CI: 1.4–2.0), being HIV positive (HR=1.4, 95%CI: 1.2–1.6) and being aged less than 30 years old (HR=1.4, 95%CI: 1.2–1.6). Conclusions: Gonorrhoea has increased dramatically among gay and bisexual men in Australia. Enhanced prevention efforts, as well as more detailed, network-driven research are required to combat gonorrhoea among young men, those with HIV and those who use injecting drugs.

ObjectivesSexually transmitted infection (STI) notifications are increasing among older individuals. Many older gay and bisexual men (GBM) are sexually active and have multiple partners. We aimed to investigate the prevalence, incidence and predictors of anal chlamydia, anal gonorrhoea and syphilis in older GBM.MethodsThe Study for the Prevention of Anal Cancer (SPANC) was a prospective cohort study of HPV infections and related anal lesions among community-recruited GBM age ≥ 35 years in Sydney, Australia. At baseline and subsequent annual visits, recent STI diagnoses were collected via questionnaire (‘interval diagnoses’) and STI testing occurred (‘study visit diagnoses’). Baseline STI prevalence was calculated using study visit diagnoses. Incidence of anal chlamydia and gonorrhoea was calculated using interval and study visit diagnoses. Syphilis incidence was calculated using interval diagnoses. Univariate and multivariate analysis using Cox proportional hazards were undertaken to investigate the association between risk factors and incident STI.ResultsAmong 617 GBM, the median age was 49 years (range 35–79) and 35.8% (n=221) were HIV-positive. At baseline, STI prevalence was: anal chlamydia 2.3% (n=14); anal gonorrhoea 0.5% (n=3) and syphilis 1.0% (n=6). During 1428 person-years of follow-up (PYFU), the incidence (per 100 PYFU) of anal chlamydia, anal gonorrhoea and syphilis was 10.40 (95% CI 8.82 to 12.25), 9.11 (95% CI 7.64 to 10.85) and 5.47 (95% CI 4.38 to 6.84), respectively. In multivariate analysis, HIV-positivity, higher number of recent condomless receptive anal intercourse partners and baseline methamphetamine use were associated with each STI. Sex with ‘fuck-buddies’ was associated with anal chlamydia and gonorrhoea. Age was not associated with any STI.DiscussionThere was a high incidence of STI among SPANC participants. Age should not be used as a proxy for sexual risk and older GBM require a detailed sexual behaviour and recreational drug use history. Interventions that specifically target STI risk among older GBM should be considered.

Abstract Background Gay and bisexual men (GBM) are a key population affected by human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection. We aimed to measure HCV treatment effectiveness and to determine the population impact of treatment scale-up on HCV prevalence and incidence longitudinally among GBM. Methods The co-EC Study (Enhancing Care and Treatment Among HCV/HIV Coinfected Individuals to Eliminate Hepatitis C Transmission) was an implementation trial providing HCV direct-acting antiviral treatment in Melbourne, Australia, during 2016–2018. Individuals with HCV/HIV coinfection were prospectively enrolled from primary and tertiary care services. HCV viremic prevalence and HCV antibody/viremic incidence were measured using a statewide, linked, surveillance system. Results Among 200 participants recruited, 186 initiated treatment during the study period. Sustained virological response in primary care (98% [95% confidence interval {CI}, 93%–100%]) was not different to tertiary care (98% [95% CI, 86%–100%]). From 2012 to 2019, between 2434 and 3476 GBM with HIV infection attended our primary care sites annually, providing 13 801 person-years of follow-up; 50%–60% received an HCV test annually, and 10%–14% were anti-HCV positive. Among those anti-HCV positive, viremic prevalence declined 83% during the study (54% in 2016 to 9% in 2019). HCV incidence decreased 25% annually from 1.7/100 person-years in 2012 to 0.5/100 person-years in 2019 (incidence rate ratio, 0.75 [95% CI, .68–.83]; P < .001). Conclusions High treatment effectiveness by nonspecialists demonstrates the feasibility of treatment scale-up in this population. Substantial declines in HCV incidence and prevalence among GBM provides proof-of-concept for HCV microelimination. Clinical Trials Registration NCT02786758.

Abstract Objectives Incidence of anal cancer is highest in gay and bisexual men (GBM). A better understanding of the natural history of anal high-risk human papillomavirus (HRHPV) infection is needed for anal cancer prevention. Methods The Study of the Prevention of Anal Cancer was a 3-year study of Australian GBM, aged 35 years or older. We examined incidence, clearance and risk factors for 13 HRHPV types tested for at baseline and 3 annual visits. Results In 525 men with ≥ 2 visits, 348 (66.3%) acquired ≥ 1 incident HRHPV infection. HPV16 incidence rates were similar, but non-16 HRHPV incidence was higher in HIV-positive (51.8/100 person years, PY) than HIV-negative men (36.5/100 PY, p < 0.001). Annual clearance rates of HPV16 (13.21/100 PY, 95% CI 10.53-16.56) were lower than for other HRHPV types. HRHPV clearance rates were not associated with HIV overall but were significantly lower in those with a lower nadir CD4 (<200 cells/µl) for HPV16 (p=0.015) and other HRHPV types (p=0.007). Conclusion The higher incidence of non-16 HRHPV types, coupled with the lower clearance of non-16 HRHPV types in those with past impaired immune function, is consistent with the greater role of non-16 HRHPV in anal cancer in HIV-positive people.

I was one of the earliest cases of COVID‑19 in Australia. When I infected my partner, a trans man with cystic fibrosis, he was nine months pregnant. He birthed the baby during our nine days of forced isolation in hospital, making medical history as the first COVID-positive person to give birth outside of China, and the first documented non-caesarean birth in the world. Unfortunately, this was not the happy event it should have been. Our experiences while in the hospital were deeply traumatic, and since recovery we have been subjected to ongoing stigma. The post-COVID body is “othered” by medical professionals and the general public, treated with an acute suspicion reminiscent of ableism or fatphobia towards non-normative bodies. These experiences of exclusion and alienation echo the stigma directed towards the HIV-positive community during the height of the AIDS epidemic and the historical bio-medical regulation of queer bodies as second-class citizens. Drawing on theories of queer temporality, we consider the liminality of living in a “post- COVID” body—on the threshold of wellness and social contagion—as a queer time-warping experience. We call into question normative narrations of healthy/diseased bodies by considering the post-COVID body’s treatment as continually contagious.

1997 was a bad year for celebrities. Deng Xiao Ping and Mother Teresa died of old age, Gianni Versace was shot, Princess Diana killed in a car accident, John Denver's plane crashed, Michael Hutchence hung himself and Sonny Bono died in a skiing accident. In each case, the essence of the news story is the extinguishment of life and the consequent extinction of the body. So-called journalism ethics usually prevent photographs of dead bodies (especially when mutilated). However, recently we saw, on the front page of The Courier-Mail, an unnamed Albanian lying in a pool of blood with a clear bullet wound in his head; the lack of photographs of dead celebrities' bodies is therefore political as much as it is influenced by the editors' sense of propriety. Live celebrities fulfil a particular function; what, then, are their bodies made to do in death? I. Versace / Cunanan Gianni Versace was shot on the front steps of his Miami mansion in July 1997, after a morning walk to the local cafe for magazines and coffee. He received two bullets in the head and was pronounced dead on arrival at the local hospital. Ten stories in four magazines carried only two small photographs of paramedics attending Versace on a gurney, despite its obvious newsworthiness. Live Versace is surprisingly absent from the accompanying photographs, where he appears alone, with celebrities or with family (including his lover) just 15 times in 68 photographs. Intriguingly, Versace's body is similarly expunged from the texts. The word 'body' itself also only appears twice in relation to Versace; only one report mentions his cremation and his ashes' return to Italy. Versace's blood, spilling down the steps, appeared much more frequently (textual references plus photos: n=15). Most magazines reported a fan who tore Versace ads from a magazine and sopped them in the designer's blood, but there are no photos of this bizarre act. At no point does any article actually describe Versace as homosexual, although most note that when he was ill in 1996, the press assumed he had HIV/AIDS (in fact, it was cancer). His lover, D'Amico, only appears twice and is only once referred to as such; elsewhere he is a 'companion', 'life partner' and even 'significant other'. What Versace did have, frequently discussed in safe monetary terms, was his business -- a respectable living entity accessible through, importantly, the discourse of family. Anxiety about the continued survival of the eponymous body corporate partially covers the extinction of Versace's fleshly body. So where is Versace's body? The photograph tally gives us an important clue: his alleged murderer, Andrew Cunanan, appears in more photographs (n=16) than the celebrity victim. Importantly, although they supposedly met at an opera, any link between Versace and Cunanan is implied only by the proximity of descriptions of their respective lives. Some texts explicitly suggest the opposite (Time 32): "yet Versace in mid-life, it turns out, was a tempered bon-vivant, a high-glitz homebody. He remarked, 'You can go to a restaurant if you want, but things are always better at home.'" Cunanan's perverse body permeates the texts, too. All stories decribed his career as a "worthy companion" to older, wealthy gay men; all mention his mother's incorrect claim that he was a prostitute. There were 29 references to his preference for "kinky sex" and bondage gear found in his apartment and 41 to a mythical "gay lifestyle" (including references to the "gay scene", "gay bars", "gay hangouts", his alleged work as a gigolo and so on). A suggestion that he might have been HIV-positive (later disproved) also occurred repeatedly. New Weekly devoted its coverage entirely to Cunanan, purporting (however inaccurately) to explain "the lust for fame and rich men that perverted" him (cover); it alone asserted Cunanan had worked as a transsexual prostitute. Increasing Cunanan's apparent perversion were repeated stories that he did this to support a wife and child. Cunanan's sexuality is directly associated with his crimes (see also Crowley): variations on the word 'killer' ('assassin', 'murderer', 'gunman') appear as many times as references to 'kinky' sex. Versace, on the other hand, becomes corporeal; he exists in terms of money, his family, and, finally, in terms of death (passive and active variations of that noun appeared 58 times). In life, Versace's (gay) body was transgressive; in death it was mutilated. By leaving the (transgressive, dead) body out altogether, Versace's narrative became a prosocial tale of capitalist success, a handsome, benign family man destroyed by the 'evil' of a perverted gay lifestyle (Crowley). II. Michael Hutchence Michael Hutchence hung himself -- accidentally or deliberately -- on the door-closing mechanism in his hotel room in November 1997. There are, of course, no photographs of his corpse. However, unlike Versace, Hutchence's body is liberally scattered throughout the text. Direct references to it appear 12 times, including three to his "naked body". We are told in every story that Paula spent 20 minutes alone in the Glebe morgue with his "body". References to his sexuality are also prominent, with variations on the theme (for example, "Michael Hutchence was sex on a stick" -- NW 23) appearing 30 times overall. There were articles on "his harem", featuring photographs of various girlfriends over the years, and Yates's description of his as "the Taj Mahal of crotches" appears repeatedly. Evidently, excessive heterosexuality is more acceptable than transgressive sex. This is quite clear from the determined "suicide" narrative. The British tabloids suggested that Hutchence died practicing autoerotic asphyxiation, a not inconceivable claim, given that some 1000 American men die annually of this practice (see Garos) and in light of Hutchence's apparently overwhelming sexuality. Australian magazines, however, only mentioned that possibility three times in 23 articles from 7 magazines. The assumed fact of suicide was mentioned (directly and euphemistically) 30 times. Suicide is apparently more acceptable than autoeroticism, and it certainly "fits" the Hutchence narrative. The only reason offered for Hutchence's apparently perplexing suicide was despair over the enforced separation from his family. Family is overwhelmingly important in the Hutchence narrative. Photographs of him with Paula and their daughter Tiger Lily, or Paula's and Geldof's three daughters, appear 25 times -- more than Hutchence appears alone (n=21). The total number of photographs of Hutchence with other people only amounts to 27, despite his high-profile career and high-profile lovelife for 18 years before he met Yates. Yates is Hutchence's "lover" more often than D'Amico was Versace's, but she was also his "soulmate", his "girlfriend" and, most often, "the mother of his child". Mention of Hutchence's familial role -- 'daughter/s', 'father/hood', 'dad', 'family' and so on -- appear 44 times. (The only comparable frequency is variations on 'death' such as 'died' or 'dead', not including references to suicide.) This, then, is where Hutchence is recuperated -- the excessive sexuality which, unsaid, may well have led to his death -- disappears completely in family life. Live Hutchence was a sexual wildcard; dead Hutchence is a role model of responsible domesticity. III. Mother Teresa Unlike Versace or Hutchence, Mother Teresa's body caused no trouble when it was alive, and, conveniently, wasn't mangled in death. Six of fifteen photos of her were of her dead body, including a close-up enlarged across two A4 pages. Also included are photos of people holding photos of her, which fits Wark's suggestion that re-presentation helps to create godliness (26). (Interestingly, Diana was the only other 1997 death treated the same way, confirming Frow's point that some deaths are qualitatively different and providing a point for further analysis.) There are photographs of people touching Teresa, and this is mentioned in the text (n=6) more times than her dead body itself (n=3). Interestingly, the fact that she died of a heart attack is nearly absent from the accounts (n=2), although her metaphorical heart looms large (n=9). It is the only part of her live body which was narratively significant. One reason that Mother Teresa's dead body is able to be present, in both pictures and photos, is that her flesh did not need to be replaced with pro-social narrative. Instead, her (tiny) body in life did what society wants women's bodies always to do: she was not just Mother Teresa, but a 'mother' to us all (n=8), chaste (n=3), and always described with diminishing adjectives (n=14). There was none of that pesky female sexuality to deal with, though gender was undeniably significant (she was described as "a woman" 11 times), and of course, it is there in her very name (shortened often to Mother, rather than to 'Teresa' -- she was a role, not a person). The only discourse more powerful -- and intimately connected -- is saintliness (n=38). The sexless (selfless), tiny, maternal body can be displayed, in death, as an icon of the good female. IV. Conclusion In their lifetimes, Michael Hutchence and Gianni Versace both displayed transgressive sexual personae, Hutchence's being excessive and Versace's being 'wrong'. In death, the media deals with this, unsurprisingly, by replacing the now absent bodies with a pro-social narrative. This is taking Foucault's proposition that the body is ultimately the site where ideology is practiced to a whole new realm, since ideology was forced to wait till the bodies stopped to reclaim them for its own. It also reinforces the sense that a "free" (live) body is somehow beyond ideology (Hutchence was apparently practicing just this when he died). Soon after Versace, Diana's death prompted stories of why the good die young (Bulletin 23 Sep. 97, 71-2). However, this article shows that, patently, the good live to 87 and those who die young often don't "come good" until they die. References Becker, Karin E. "Photojournalism and the Tabloid Press." Journalism and Popular Culture. Eds. Peter Dahlgren and Colin Sparks. London: Sage, 1993. 130-153. Crowley, Harry. "'Homocidal Homosexual': Media Coverage of the Versace Murder Case." The Advocate 741 (2 Sep. 1997): 24+. Frow, John. "Is Elvis a God? Cult, Culture, Questions of Method." International Journal of Cultural Studies 1.2 (1998): 197-210. Garos, Sheila. "Autoerotic Asphyxiation: A Challenge to Death Educators and Counselors." Omega -- The Journal of Death and Dying (Farmingdale) 28.2 (Feb. 1994): 85-100. Wark, Mckenzie. "Elvis: Listen to the Loss." Art and Text 31 (Dec.-Feb. 1989): 24-28. Citation reference for this article MLA style: Rebecca Farley. "The Word Made Flesh: Media Coverage of Dead Celebrities." M/C: A Journal of Media and Culture 2.3 (1999). [your date of access] <http://www.uq.edu.au/mc/9905/dead.php>. Chicago style: Rebecca Farley, "The Word Made Flesh: Media Coverage of Dead Celebrities," M/C: A Journal of Media and Culture 2, no. 3 (1999), <http://www.uq.edu.au/mc/9905/dead.php> ([your date of access]). APA style: Rebecca Farley. (1999) The word made flesh: media coverage of dead celebrities. M/C: A Journal of Media and Culture 2(3). <http://www.uq.edu.au/mc/9905/dead.php> ([your date of access]).

To Rodica, who died first / To Mircea, who continues me [I]In his book Picturing Health and Illness: Images of Identity and Difference, Sander L. Gilman argues that during the nineteenth century the healthy norm perceived as ugly not only those who were deformed, but also those who were ill, ageing, and/or experienced different bodily “loss of function” (53). In the nineteenth century, how much was medicine responsible for defining ugly as ill, deformed, and getting old, versus beautiful as healthy, and then, for the sake of the community’s health, firmly promoting these ideas? Furthermore, with the rise of photographic art, medicine was able to manipulate and control these ideas even more efficiently. According to Deborah Lupton, “The new technology of photography that developed from the mid-nineteenth century became a valuable strategy in the documentation of patterns of disease and illness, and the construction of the sites of dirtiness and contagion” (30). This essay focuses on the skin’s narrative as it presents its story when photographed. William Yang takes photos of his good friend, Allan, who is dying of AIDS. Of interests here is to discuss/approach the photographic art not from its scopophilic angle, that is, not from its perverse and pleasurable voyeuristic angle, but to analyze it side-by-side with Drew Leder’s notion of the “the remaining body.” He believes that in states of severe pain, one’s body “dys-appears,” “from the Greek prefix signifying ‘bad,’ ‘hard,’ or ‘ill,’” and he gives as example the English word “dysfunctional” (84). Yang’s photos offer variations of the “body that remains,” and, as we shall see, of the body that gradually did not remain. Through his work, Yang approaches visually the theme of the ars moriendi of the entropic body in pain as reminder of its mortal, gradually disabling fabric. [II] In the section of his work dedicated to AIDS, Gilman discusses only a collection of posters that have circulated in mass-media, which he researched at the National Library of Medicine at Bethesda, Maryland. Gilman thinks these posters function as the “still images of illness” (174). In other words, he believes these posters may have had an impact on the lay community, although not the intensified, urgent one, as he would have hoped. Because Gilman did not include a single photo of a patient dying of AIDS — although he understood this lack — I juxtapose one of the posters from his book with Yang’s photos taken of his dying friend, Allan, from his project entitled Sadness: A Monologue with Slides. Here I discuss the impact of Allan’s increasingly emaciated body versus the static, almost ineffective quality of the poster in order to consider the idea according to which “AIDS victims are living sculptures. … Both subject and object of art … they combine with their disease to overcome the narcissism of human consciousness. … It is an art of continuous transformation of subject into object and object into subject” (Siebers 220-21). Yang is an Australian artist with Chinese parentage. The images presented in this section originally appeared in print in Thomas W. Sokolowski’s and Rosalind Solomon’s collection of essays entitled Portraits in the Time of AIDS. According to the editors, Yang presented them as “monologues with slide projection in the theatre” (34) because the main actor of this one-man show is dying of AIDS. Yang’s work consists of seventeen slides with short texts written underneath them. In an attempt to respect the body that is dying, the texts are not recited, but the readers/spectators read them subvocally. The brilliance of this piece resides in its hushed tone, which parallels the act of dying when the patient’s body and mind become more and more tacit and lifeless. From one photo to another, and from one text to another, we discover Allan, although we never quite get to know him. The minitexts relate Allan’s story: how he was hospitalized at St. Vincent’s, known as “the AIDS ward” (35); how he decided to return home, into a studio shared with a dealer; how AIDS first attacked his lungs, and so he had to keep next to him “a large cylinder of oxygen as he was often out of breath” (37); how AIDS then affected his sight, and he developed a condition known as “CytoMegalo Virus — C.M.V. Retinctus” that gradually “destroyed the retina” of his eyes (39); how he decided “to go off medication” (46); and, how, finally “he went into a coma. I saw a nurse give him a glass of water but the water just ran out of his mouth” (50). To look at these photos time and time again is to be reminded of Albert Einstein’s vision of the passenger trapped in the train running with the speed of light. That passenger could not sense all that was happening in the train, and especially outside of it, because time moves in its cosmic, non-human, slippery dimension, and thus sensation could not profusely permeate his body. Juxtaposing Einstein’s vision with Allan’s decaying body, I read the latter’s body as if it were coiled up inside his mind just like a snail covers a part of its body under its hard shell. The photos are presented rapidly with no entr-acte in between; in a matter of minutes, time and space seem to collapse. There is no time for a prolonged reminiscence of Allan’s spent life. Allan is dying now, and he does not have time to remember his life. He barely has time to feel his body, a touch, or a kiss on his face, which seems to Yang “to have caved in” (47). Through this work, not only does Yang capture the disturbing moments of a friend dying, but he also touches on the “epidermis” of despair. This “epidermis” is both endotopic and exotopic, meaning that it starts within the patient and then it radiates/extends to his relatives and friends. Yang’s images of Allan dying give the impression that his body levitates, jutting out into space — but unfortunately without much meaning. On the other hand, the posters advertised for AIDS are simple, if not quite embarrassing and disrespectful given the gravity of this illness. They rarely touch on any aspects related to the illness itself, as they allude more to the immorality of homosexual acts. Gilman explains part of the rationale involved in the process of not presenting people dying of AIDS as follows: The image of the ‘positive’ body or the body with AIDS is strictly controlled in the world of the public health poster. Nowhere is an image of the ‘ugly’ or diseased body evoked directly, for any such evocation would refer back to the initial sense as a ‘gay’ disease. … Mens non sana in corpore insano cannot be the motto. For representing the ill body as a dying body is not possible. Such a body would point to ‘deviance from the norm’ in the form of illness. And this association with homosexuality and addiction labeled as illness must be suppressed. … All these images are images not of educating, but of control. (162) The poster chosen for illustration reads “LOVE AIDS PEOPLE,” with AIDS used as a verb and not as a noun; nonetheless, the construction’s subtlety is rather counterproductive. To a certain extent, this poster can be related to Michelangelo Merisi Caravaggio’s The Incredulity of Saint Thomas (1601-02). There, the Apostle touches the actual wound because he needs tactile proof to accept its existence. The act of touching, as well as the skin open by the wound, reveal the fact that “Skin lacks the depth, the interiority we want it to give us. … The flesh we crave as confirmation of our forms cannot do anything but turn us forever out even as we burrow into the holes we find there” (Phelan 42). But the poster presented below brings into focus verbally (therefore propagandistically) how one’s body might be destroyed because of AIDS. Furthermore, the symbol of the arrow is a recurrent motif in the art representing AIDS, especially in light of its religious association with the martyrdom of Saint Sebastian (see for example David Wojnarowicz art works which offer a personal interpretation of the martyrdom of Saint Sebastian). But if LOVE AIDS PEOPLE, and if gay men identify themselves with a martyr, then they might easily fall target to this twisted logic and think of themselves as victims. As Larry Kramer notes, gay men are tragic people partly because they feel responsible for an illness that has been affecting both the homosexual and heterosexual communities: “The continuing existence of HIV is essential for the functioning of the totalitarianism under which gay people now live. It works like this: HIV allows ‘them’ to sell us as sick. And that kills off our usefulness, both in our minds — their thinking we are sick — and in the eyes of the world — everyone thinking we are sick” (65).Gay men have always been a target since, allegedly, they are a menace to the institution of marriage, procreation, and to morality in general. Endocrinology studies have been conducted on gay men, but their results have not been able to say with certainty why some people prefer to engage in homosexual rather than heterosexual acts. According to Jennifer Terry, earlier studies from the 1930s aimed at determining distinct somatic features of homosexuals for the most part failed to produce any such evidence. Most of them focused on the overall physical structure of bodies, measuring skeletal features, pelvic angles and things like muscle density and hair distribution. (144) (Another useful resource is Holt N. Parker’s 2001 article “The Myth of the Heterosexual: Anthropology and Sexuality for Classicists.”) How and by whom are our sexual identities created? Does the presence of one specific anatomical organ delimit one person’s sexual identity? We have been trained into believing that there are only two genders, male and female, partly because of our binary way of thinking. Needless to say, just as in one color there are degrees of its intensity and saturation, so there are in us verbal, behavioral, and sexual tendencies that could make us look and act more or less masculine or feminine. Even more productive is to note the importance of power (control) and the erotic in our lives considering that the photos (and the minitexts) presenting Allan seem insufficient to initiate a dialogue by themselves. Because the eroticized body is what dies, that is, what is put at risk or could become powerless because of AIDS. The body that cannot touch and be touched anymore; the body that cannot control its needs and desires; and, ultimately, the body that is deprived of its pleasures and thus loses its erotic self. Therefore, AIDS is not only a way to redefine our erotic life, but also becomes a reason to question our hygiene practices. Elizabeth Grosz points out that “erotic pleasures are evanescent, they are forgotten almost as they occur” (195). But when erotic pleasures are controlled, as seems to be the case because of AIDS, have we intervened in such a manner as to program our intercourse? Admittedly, AIDS is predominantly linked with one’s sexuality and, hence, it could make one feel too self-aware about one’s needs, as well as rigid and self-conscious in an (intimate) act which, in essence, is all about losing oneself, being uninhibited. In the end, Allan’s sense of identity seems to be imprinted only in the camera’s objective lens. After he died, as Yang remembers, “I read his diaries […]. AIDS was a tragedy that was for sure, but as well he had an addictive personality and his day to day life was full of desperation. I hadn’t realize the extent of this and it came as a shock. Yet there were moments of clarity when his fresh test for life shone” (51). Yang does not say more about Allan’s intimate writings and, as he suggests, it was quite surprising for him to discover a richer, more intimate dimension of his friend. Still, until Allan’s diaries will be released to the public to offer us a more palpable view on his life, we rely exclusively on the selections of photos and minitexts accomplished by Yang, thus being aware that, no matter how exquisite they are, they could only say a few things about this enigmatic patient.[III] After exposing Allan’s gradually collapsing body, we may want to analyze to which extent is dying/death something that reveals our self-centricity. It is by now a truism to say that death is the final moment of our embodiment to which we are denied access. Nonetheless, we cannot stop thinking about (our) death, and the last passage of this essay proposes its own reflection on this subject. Norbert Elias argues that each one of us is a homo clausus (Latin for “closed, self-sufficient being”). He believes that this condition is a consequence of our living an advanced phase in our individualized life. Surprisingly, he relates this self-sufficiency to the ritual of dying. He believes that in highly industrialized societies, a patient may benefit from the most recent technical and medical equipment, but that that person usually dies alone, meaning without his family/relatives around him. On the other hand, as he goes on to argue, “families in less developed states … often go hand in hand with far greater inequalities of power between men and women. [The dying] take leave of the world publicly, within a circle of people most of whom have strong emotive value for them, and for whom they themselves have a such a value. They die unhygienically, but not alone” (87). Elias does not explore this idea in depth, so we are left to wonder what he meant by dying unhygienically, or if he thought that method was better in coping with death. Also, he never mentioned the exact countries/regions he had in mind when he made that remark; therefore, we are left unsatisfied by his comment. Nonetheless, as Elias reminds us, it is important to remember that the traditional death rituals were and are intimate moments (and they should remain like this). The homo clausus idea may be linked with a body that is reaching its final embodiment, and hence becoming a closing-in-itself body. However, how does a body transact and/or negotiate the moments of its final embodiment? The process of sinking in one’s body, to which I refer, is not a visually, aurally, or especially olfactorily pleasant experience. Our deceitful memory misdirects our emotional brains by indicating which subsystem is still functional and open and which has become useless, that is, closed. In this light, we should redefine Elias’s idea by saying that what appears to be a monolithic structure — a body: closed, sealed, and/or self-contained — is in fact a very fluid body; that death does not reveal our self-centricity because that reasoning may generate an absurd idea, namely, we die alone because we have spent a life alone. Consequently, the dying body becomes the margin par excellence, which, because it is completely out of control, does not stop from leaking and/or emitting smells. This theory is confirmed by a study conducted on dying patients, Dying Process: Patients' Experiences of Palliative Care (2000), where Julia Lawton notes that “on a number of occasions, staff kept aromatherapy oil burners running throughout the day and night in an attempt to veil the odour of excretia, vomit and rotting flesh. … I observed that smell created a boundary around a patient, repelling others away” (135). One has to close one’s eyes to vaguely imagine what it must feel like for the medical personnel to keep the vigil of the dying bodies. Nonetheless, the lay community is exposed to photographs of the dying only on rare occasions. According to Gilman, these images are not made public because “The classical model of ‘healthy/beauty’ and ‘illness/ugliness’ is part of a cultural baggage that accompanies any representation of the ill or healthy body” (118-19). While the skin is endowed with the capacity of regenerating itself after it has been wounded, thus effacing time, a photograph of a dying body seems to efface one’s memory of one’s accumulated experiences. Such a photograph makes its contents (that is, the time, location, personal context of the shooting) disappear since its details will eventually fade away. As a corollary, the absent body effaces its photographed version, leaving it few chances to be remembered. The theme of the ars moriendi, as presented in this essay, has demonstrated that what dies is not only one’s body, but also the echoed memory of its erotic self. ReferencesElias, Norbert. The Loneliness of Dying. New York: Blackwell, 1985. Gilman, Sander. Picturing Health and Illness: Images of Identity and Difference. Baltimore: Johns Hopkins UP, 1995. Grosz, Elizabeth. Space, Time, and Perversion: Essays on the Politics of Bodies.New York: Routledge, 1995. Kramer, Larry. The Tragedy of Today’s Gay. New York: Penguin Group, 2005. Lawton, Julia. Dying Process: Patients' Experiences of Palliative Care. New York: Routledge, 2000. Leder, Drew. The Absent Body. Chicago: University of Chicago Press, 1990. Lupton, Deborah. The Imperative of Health: Public Health and the Regulated Body. Thousand Oaks, California: Sage Publications, 1995. Peggy Phelan. Mourning Sex: Performing Public Memories. New York: Routledge, 1997. Siebers, Tobin. The Body Aesthetic: From Fine Art to Body Modification. Ann Arbor: University of Michigan Press, 2000. Jennifer Terry. “The Seductive Power of Science in the Making of Deviant Subjectivity.” Posthuman Bodies. Eds. Judith Halberstam and Ira Livingston. Bloomington : Indiana University Press, 1995: 135-162. Yang, William. “Allan from Sadness: A Monologue with Slides.” Portraits in the Time of AIDS. Eds. Thomas W. Sokolowski and Rosalind Solomon. New York: Grey Art Gallery & Study Center, 1988: 34-51.