THE DOCTOR IS IN! Demetre Daskalakis Speaks about HIV and "Sexed-Up Medicine"!

Demetre Daskalakis Speaks about HIV and “Sexed-Up Medicine”!

Dr. Demetre Daskalakis knew that a different, outside-the-box approach to HIV/AIDS awareness in New York City was needed– in particular when it came to men who have sex with men.  Daskalakis is Founder and Medical Director of The Men’s Sexual Health Project (M*SHP), a volunteer-run organization which promotes sexual health among men who have sex with men in The Gay Apple.  The core goal of M*SHP is to increase access to sexual health (HIV and STD) testing– making it convenient, free, and sensitive to the needs of the gay and bi male community.  An Assistant Professor in the Division of Infectious Diseases at NYU Medical Center, and an Attending Physician at the neighboring Bellevue Hospital Center, the magnetic Daskalakis is indeed an expert in the field.  He was recognized in the popular NYC magazine “Paper” as a “Do-Gooder” and was honored by Mayor Bloomberg on World AIDS Day 2008 for his pioneering HIV prevention/awareness work in New York City.   When I call Daskalakis a “pioneer”, that’s not an understatement.  M*SHP goes directly to places where gay men meet for sex, including the East Side Club, The West Side Club, and the mens’ only nights at Paddles.  Working with a Harm Reduction model that has been used in adults-only clubs in other cities, these venues not only encourage safer sex practices, but offer free on-site testing for HIV and other STD’s, safer sex counseling, and referrals to follow-up health care.  The program, no doubt considered “controversial” at first, has been a success: Daskalakis states that in its four years, M*SHP has tested nearly 3,000 men so far.

Rather than offer the cookie-cutter style platitudes about safer sex that have been ingrained in all of our mind through the years, Daskalakis pushes for an individualized approach that addresses the larger issue of sexual health, and does NOT sacrifice sexual freedom.   Daskalakis states, “It’s straightforward.  You have to look at what you’re doing and say ‘Why am I doing it?’   ‘Cause when you figure out why you’re doing it, you can create the optimal approach of prevention for you.  I don’t think there’s a ‘one size fits all’.  Would I want everyone at risk to wear a condom?  Yes.  The reality is, people aren’t going to wear condoms all the time.  Do I want everyone who is highly sexually active to get tested for HIV every two to six months?  Yes.  That I can make a difference with! That I know!  Let’s do that, and let’s do it aggressively.  Get yourself treated for STD’s so you don’t have inflammatory things going on that will increase your risk for HIV.  There are all these things you can do.  But at the end of the day, what’s most important for me is awareness and intention.  You have to be aware of what you’re doing, and understand the intention of your action.  If you are doing things with your mind and eyes closed, you’ve got to open your eyes and see what you are doing.  Because then, you can figure out what’s right for you.  If it’s right for you to be a barebacker, there are ways to be a barebacker and be as safe as you can be.  If that’s the path that you’re gonna go down, then there’s a responsibility to yourself and others that you have.  If that’s the path you have chosen, it needs to be chosen with your eyes wide open with all the details.  That’s really why we’re there.  We give people all the facts, all the details.  There’s a big paternalistic drive in medicine to have everyone do things not based on the data, but to do things based on what you think is the right thing to do– and that’s moralistic.  We look at the data and say: The best prevention is condoms.  If you’re not gonna do that, Plan B is PEP (post-exposure prophylaxis).  If you’re not gonna do that, Plan C is this… Some people need to do A, B, and C; and some people, if they’re not gonna do A, at least they can do B and C.”  Daskalakis realizes that part of the challenge is confronting America’s apprehension about discussing sexual matters.  For example, while some studies have suggested that the use of erectile dysfunction drugs increase HIV and STD risk. the doctor sees things in a different way:  “Potentially, the appropriate use and frank counseling in use of these drugs will actually decrease HIV risk.  How many men have I met who don’t use condoms because they can’t keep it up?  Well, if you can keep it up, you’ll keep a condom on to complete a sex act, and you’ll actually use a condom.  But someone has to say that to you!”

Daskalakis gave a no-holes barred interview with Jed Ryan about mission of M*SHP and the current state of HIV/AIDS awareness:

JR: New York City has always been on the “cutting edge” in a lot of ways, but in some ways it’s also very conservative.  When it comes to HIV/AIDS care, we have the best HIV doctors and the best care, and we  also give out free condoms.  But there’s also this conservative element…
DD: Absolutely!
JR: A lot of sex clubs and other sex businesses closed down a while back, and some people believe the City is responsible for that. Is there some kind of ambivalence going on when it comes to sex in the City?
DD: I think that New York– at its core, politically– has elements that are really progressive, but then at the end of the day tends to be very conservative, especially on the topic of sex… and especially on the topic of gay sex.  So, I think that in general, New York has taken sort of this tact of “Don’t ask, don’t tell”, which every now and then flares up into this very aggressive conservative mode where venues are closed, and there’s reduced opportunities where people may find places where they can meet partners and have sex in those locations– whatever “sex” means.  Not necessarily genital penetration or anal penetration, but oral sex or whatever…
JR: Playing!
DD: Playing!  Yeah!  And so I think that currently, there’s a lot of debate between the folks who are the army doing HIV and STD prevention, and the folks who are the over-arching, bigger administrators in various departments throughout the City.  So, I think that there is still not a resolution. There continues to be a schism between the folks who are in the know and the folks who are the political face. That’s sort of a struggle– because at its core, New York is a very conservative place.  Compared to San Francisco, we’re lookin’ pretty conservative!
JR: Even compared to Cleveland, if you can believe that!
DD: It’s absolutely true.  Cleveland has a lot of commercial sex venues, and they have a good relationship with them, and have learned that the best way to deal with them is to partner with them, rather than to antagonize them if you want to keep things above board and not so far underground that you can’t find things.  It’s totally different. They are all licensed– and taxed!
JR: Was M*SHP considered controversial when they first came about?  I imagine the idea of testing people for HIV and STD’s at sex clubs must have been renegade at the time!
DD: Totally.  The thing is, it is renegade to all sides.  It’s not only the people who work for New York City who can be conservative, but also the people who work for commercial sex venues.  They’re very used to people breathing down their necks who are medical, and looking for closure in a very aggressive way.  In some ways, I represent a threat both from the City’s administrative side as well as to the folks who are running these places.  Because, they think, “How can I trust this doctor type, this medical person, this clinical person?”   So, it’s taken a long time to get more and more trust built up where we’re invited to venues more frequently. They might look at me like a narc.  I’m very specifically NOT a narc!  That’s what’s so fun about it.  It’s actually funny that in the core of all the dysfunction of what happened, the dysfunction is why we were able to find a path to actually start doing what we’re doing.  So, the fact that Bellevue and NYU is not a part of the Department of Health but is a separate approach to health care provision, we’re able to have these interactions without the political firestorm.  And from the perspective of the hospitals and medical centers and the medical schools, it looks like really good community service.  So, what happens is: By combining all of the dysfunction and taking the best parts of the dysfunction to create a path, you actually generate a program that can be successful and take you all kinds of places.  So, yeah,  it was really controversial when we started, and even controversial to people on the ground– the people doing the testing and the people getting tested.  When we first popped up at The East Side Club or West Side Club, no one had any idea what to do with us. They were like, “Do we trust them, do we not trust them?”  And now, what happened and what we’ve proven is that we’ve become part of the landscape.  We’re not aggressive at all.  We’re just there.  And by being there, people come to us.  We don’t go to them.  We have never once asked anyone to be tested for HIV.  In the four years we’ve done it, not once have we said, “Hey you, come to us!”  We just exist, make our presence known, and people come to us.  That’s why I think we have been able to survive, because one of the things that you learn with HIV and STD’s is that the bigger HIV epidemic is really a lot of smaller epidemics.  In New York, HIV transmission right now still continues to be among men who have sex with men.  It is the mini-epidemic driving the fire.  Addressing it directly rather than pussyfooting around is the only way to deal with it.
JR: That’s what a lot of people DON’T like to do– address things directly!
DD:  You have to look at it in the face and say “I accept what you’re doing”... or at least “I don’t care”…and then, let’s just create a contextual approach to making this place a safer place for you and the people you’ll be meeting and playing with.
JR: Medicine in general has been a conservative science, maybe because it was governed by straight, older Caucasian men for so long.  Because of that, there was not only some homophobia, but also what some have termed “eroto-phobia” as well, which may have hampered a lot of progress in advances in sexual pleasure.
DD: I think that’s true.  And one of our very specific missions in starting this thing is that we were gonna “sex it up”.  We’re unabashed harm reductionists, and in doing so what that means is that we are comfortable sexualizing the program, and being really happy to deal with people with what they come with to the table.  An appropriate medicine answer with HIV prevention is “100 percent”.  Like, “You have to use condoms 100 percent”, “You have to do ‘XYZ’ 100 percent”… and for us, what we have developed is a sliding scale approach.  If you’re someone who never uses condoms, nothing I’m gonna do in the 20 minutes that we’re together is gonna make you use condoms.  But at least I can give you advice on how to prevent HIV infection if you decide not to use a condom.  So, I feel like we’ve decided very aggressively to become harm reductionists and in so doing so, have used fairly erotic images to get people to see what we’re doing.  We go to very erotic places and have no fear of them.  My staff has no fear.  It’s really fun: When they start, you can tell that they’re a little skittish; but eventually, they’re like, “Whatever!  I can test in a bathroom in the corner.  I don’t care what’s going on out there!”  Or, “I do care, and it’s kind of hot, but my job is to be in here and when they come in, I kind of get what’s going on and get the environment, and so I’m really comfortable telling you what I think is an approach for you to prevent ‘badness’!”  We’re sexed-up medicine.  That is what we do!  I approach this from a nightlife perspective.  I lived in New York in the ’90’s and I was a club kid, and I had every hair color, and I wore platforms.  I approach it looking at myself as a medical nightlife promoter.  So, I am promoting an event.  It’s the same thing as promoting for Disco 2000 in the ’90’s.  This is what it felt like.  Same thing.  It’s just that now, I come with a skill set that makes it fun to sort of figure out a way to integrate and contextualize medical prevention in a fun setting.  I really feel like I learned the majority of my bedside manner by being a nightlife person.  I can talk to anybody, no matter what!

JR:  I like what you wrote somewhere, that it would be great to become fashionable and chic to get tested, and not something you “have” to do.
DD: Right!  It’s being a part of that club that is comfortable enough to walk into these venues and sit down and do this.  It’s a magical thing.  We don’t pretend that we don’t value our clients.  We know names, we remember all the details. We have this steady and consistent clientele, as well as new people, and we respect them and are psyched that they are with us, and believe they’re special, and try to emanate the fact that they’re a special club.  They spread the word themselves.  Word of mouth is our second or third most common way to find us now.  At the end of the day, I am no different than Hunteur (Promoter of Grab Ass at Paddles) or the staff at the West Side Club or East Side Club or Grab Ass.  In fact, I consider myself staff at those locations now.
JR: I understand that, but it’s also great to have someone like yourself who’s truly an expert in the field: who really knows the medical, scientific facts AND who works directly with the population affected by or at risk for HIV. Too many people today get their health information from anecdotes, or from the internet– not necessarily from a health care professional!
DD: I feel that one of the things with public health that has been a mistake with HIV prevention in New York is that they take an “all or nothing” approach, and they don’t realize that what they need is a champion in each risk environment.   If you’re having problems with women of color, then you need to find someone who will champion the situation.  If you’re having problems with men who have sex with men who are highly sexually active, you have to have someone willing to champion that.  So, rather than saying that there’s one policy for the universe, you have to say: Here are the multiple contexts of risks.  We have to address them.  We can’t do it all as a City.  We need help.  I see myself really as an intermediary, where I know this knowledge and can work with that.  I have this sort of “street cred”, thank God, to be able to work with the other folks.  It’s kind of nice.  It’s all about “street cred” in both directions!

JR: Gotcha!  Now, there has been, no exaggeration, an explosion of bareback sex videos and websites, and in general, a lessening of the “taboo” of barebacking.  To me, it’s mind-boggling. One of my friends who’s involved in the sex biz says that he doesn’t judge whether guys do it, but he feels that they should still get tested anyway…
DD: Totally!
JR: How do you feel about barebacking?  Especially when some adult film companies specialize in bareback videos and aggressively promote them?
DD: The reality is that media images are powerful, but they are more representative of what people are thinking than they are of what necessarily triggers that thought.  So I feel– and this is gonna sound kind of New Agey and Zen I guess– that all of this energy that we’re focusing on HIV prevention is in my opinion. just calling in more risk and more HIV.  I feel like what the emphasis has to be is not on HIV prevention, but on sexual health.  That’s the difference. The difference may be very narrow, but I really believe that you’re calling in more trouble by sort of saying, “You must prevent HIV.” rather than saying “You must have a healthy relationship with your sexuality and with what you do.”  The preponderance of barebacking things going on– videos, parties, and other things– is really a side effect of that “all or none” approach to HIV prevention, and the lack of a really clear understanding that (1) focusing on people’s health, and (2) making sure that they have the resources necessary to keep themselves healthy will likely prevent HIV… not this “You must do this, you must do that, you must wear a condom”.  I mean, it’s important to wear a condom, and I advise that everyone does… but if you don’t, there are other things you can do to keep yourself healthy– and that also includes actually asking yourself why you bareback.  Whenever we meet someone who’s a consistent barebacker, my favorite thing to do is ask them “Why?”  No one ever asks them.  They can say, “Because it’s pleasurable”, and I’m like, “That’s not what I mean.  WHY?”  Like, you are smart, you know the risk, you get what’s goin’ on.  They all know.  I get, “Well, I do it because it makes me feel like more of a man.  It makes me feel like I have better intimacy…”  There’s all these interesting perspectives on why people do it.  The answer may be, “Because I’m on drugs.”… but that’s not the most frequent answer.  The most frequent answer is some deeper thing. So, I feel like it supports my point.  You have to figure out what is a healthy relationship with your sexuality, and promote that relationship, to be able to actually reach the next level– which is declining HIV rates.  Not to say “Prevent it! Prevent it!” and cram it down your throats… because that’s just gonna bring it more.  Period.  I say that from a place of experience, from lots of men that I met.  Lots and lots and lots, and the more I see it, the more I believe it.

JR: For me, it’s still puzzling that after having “safe sex talk” we have had drilled into our heads since the ’80’s, we’ll still meet a lot of guys who say, “I only bareback”.  
DD: But why?  The answer is, it isn’t just pleasure.  People seek pleasure for lots of reasons.  The specific kind of pleasure they seek may just be from a purely primal place, but very often when it’s pleasure that puts them at really high risk for things, there’s something else going on about their relationship with their own health and sexuality.  Again, it sounds very New Agey, but it’s almost like you’re asking for what you don’t want by saying, “I want HIV to stop and that’s by making everyone do exactly what I say.”  It’s like a dictum for prevention.  I really think that the answer is: The side effect of having a healthy sexuality is learning what is appropriate for you to keep yourself healthy.

JR: Well, obviously the way things have been done the past few decades have NOT worked!
DD:  It has not worked.  A paradigm shift is needed.  The problem is that the funding stuff all goes with the robotic HIV prevention agenda.  That’s not what the agenda should be.  The agenda should be one focusing on health.  If you’re an HIV positive man in New York City who’s depressed, you will have all of the resources on the planet to bathe in, to be able to deal with that depression.  If you are the highest risk man having sex in New York City, and are depressed, and HIV negative, and have no money or insurance, then you’re plum out of luck.  It’s the way the resources are allocated.  I think it’s important to have resources for prevention and health care for HIV-positives, but you need to look at health before the damage to health has happened as well.
JR: Sort of like “health care” as opposed to “sick care”.
DD: It’s “well care”.  I do care for HIV positive patients.  This is what I do all day long.  When I meet one of these guys, I feel that all these services that I have for my HIV+ patients, I cannot access for you.  But you need exactly what I have.  It’s all about the funding stream and the way the resources are allocated.    Theoretically, some places are doing this.  But the places that were doing it– which I will not name, which are famous in New York City for doing things for HIV and prevention– are focused on HIV positive people, not HIV negative people.  So, I kind of feel that the whole point of M*SHP is to put the focus back on the people at risk, and say, “Look here.  Allocate resources to this.  Make it happen!”  Look at the power that there is this: 4.2% of the people are HIV positive.  But guess what? 95.8% are negative.  If I could enact my vision of what we could do, I could keep many of those 95.85 people negative– many, many, many— by just doing very simple things– like PEP (post-exposure prophylaxis).
JR: We don’t always reward people for creative visions, sadly!   In fact, thinking outside the box is often DIS-couraged!

DD:  The one thing that’s really heartening is that the sex club folks and the City both think I’m cool.  They think that this is a good idea.  At some point, the immobile object and the irresistible force come together to generate something.  So, it’s on its way; it’s just a question of when it comes!
JR: I hope so!  Now, there’s a group of people called “HIV denialists” that believe in and promote a theory that HIV does not cause AIDS.  There’s even this awful documentary (“House of Numbers”) which was out a while back that provides a platform for that theory.  Part of their rational is a conspiracy theory that the drug companies don’t want to find a cure for HIV, because it’s more lucrative to have people be on meds the rest of their life… and that the HIV drugs are poison that actually contribute to sickness a speedier death.  How do you feel about that?

DD: My answer to that, generally, is that there MAY be other factors. But what I know is that when I start HIV medications on people who are dying, I can make them not die.  So, yes, there are toxicities inherent to that.  HIV medication, no matter how you look at it and without a doubt, is chemotherapy.  Chemotherapy has side effects.   Chemotherapy isn’t good for you.  HIV medicines were really bad for you, then they became less bad for you, and now they’re even less bad for you.  As we go along, I expect the toxicity will be better and better.  But remember, we haven’t even had a whole generation of people with this disease yet.  Not even one.  It’s still brand new.  Who knows what’s gonna happen?  That’s one of the reasons I like being in the field.  I gotta say that in the last two years, something very exciting has happened in HIV research.  I’m excited that the conversation of “eradication” is back.  People are looking at the fact that the science has progressed far enough that we’re looking at ways to eradicate HIV– which means “cure”.  We went years and years and years without hearing the “C” word– and now, more and more highfalutin’, high-powered immunologists and geneticists are talkin’ “cure” again.  So, I think that the fact that we’re having this conversation means that the energy is focused again on that the meds are toxic, and that the goal really is not to make more and more meds, but to make meds to make people survive long enough for a cure.  So, I’m pretty excited about that!  M*SHP-wise, I’m excited for two things.  One is research, and I’m happy to say that M*SHP is gonna spin into a deep, deep research mode, which I love.  And so, because we have established a rapport with a lot of the most sexually active men in New York City, we have in effect identified a bunch of people who despite years and years of unprotected anal sex, have not seroconverted.  Amazingly, we’ve just been IRB-approved and have a small amount of funding to collaborate with the best scientists in the U.S to actually look at these men, to see if there’s anything immunologically or genetically different about them that could be a target for a cure, a vaccine, or a drug.  The part that’s cool about that is M*SHP attracted it.  We just did our little clinical thing, and then everyone from the outside said, “Holy shit! There is no other group of people in the country who have this level of potential exposure and are still negative.”  So, we very well may be staring down this little project actually coming up with a drug target, vaccine target, or cure target.  And I gotta say– and it’s all more hocus pocus– that I totally believe that we’ve got something.  I feel that there has to be something that has to be poetic about the fact that the epicenter where HIV starts is going to be the epicenter where HIV ends.  The community that was hit first and hit hardest is going to be the community that will answer the question!

Now, that’s a reason to be optimistic!

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