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May 17 2014
Bitter Pill, But Swallow: Truvada Facts & Fantasies + The Bottom Line Comments (0)

WTF is PrEP?


I can't tell you how many times I have read about what a huge issue this drug is in the gay community, how men using Truvada for pre-exposure prophylaxis (PrEP) are being called “Truvada
whores” and being slut-shamed, how Truvada is virtually 100% effective in keeping people HIV-negative, how using it will simply cause syphillis and other diseases to explode...

...and yet I can't tell you how many times in the past year I have mentioned Truvada to a gay man and received an utterly blank expression. They simply do not believe me when I state that there is a pill you can take that is remarkably effective in combatting HIV. I feel like Dionne Warwick offering them a Psychic Friends membership. Whether it be a 27-year-old co-worker or a middle-aged gay man on my Facebook page (while I was finished this essay, one of my smartest, most opinionated FB friends wrote me to ask what I thought of PrEP, about which he was just hearing), I have had a hell of a time finding a gay man who has actually heard of and understands what PrEP is, let alone has a grasp of the pros and cons.

Now that the CDC has officially endorsed PrEP for sexually active gay men (as opposed to suggesting that only sex workers and HIV-negative people in serodiscordant relationships take it), it's likely to become a lot more commonly discussed, known, taken or refused.

When I first heard of it, I had a bit of a knee-jerk negative response for two reasons, reasons I believe represent the reasoning of a lot of anti-PrEP voices, and reasons I think PrEP advocates should not belittle but should respect and attempt to assuage:

#1 HIV is a BFD

First, as a guy who is (as of this writing, hopefully) HIV-negative and who never had unsafe sex from his early twenties (after three or four WTF-was-I-thinking adventures when I was first burying my virginity) through my early forties (I've had lapses another three or four times in the past two years, whether as part of a mid-life crisis or a belief I was making an educated risk), as someone who grew up with the fear of AIDS, visiting the AIDS Quilt and seeing men waste away and die, it is only prudent to think twice about dropping condom use the moment a possible new strategy presents itself.

This is a thought pro-PrEP advocates should be able to understand.

Also, one of the main arguments of the raw crew, prior to PrEP, was that HIV was no big deal, just another manageable disease like diabetes, and not a good enough reason to curtail condomless sex.

AIDSI've had some friends with HIV tell me they're doing well, which is wonderful, but that they wouldn't tell anyone it was no biggie. But I've had others with HIV tell me they aren't doing nearly as well. A book like Perry N. Halkitis's The AIDS Generation (Oxford) is filled with stories that underscore why I will not accept that HIV is now a non-issue, and why people of a certain age would be more likely to be reluctant to embrace Truvada:

“It's difficult, um, and I struggle with it. Um, and I think I've come to terms with the fact that I have to be happy that I'm just here. I still take 26 pills a day. And I—I don't have the energy. And I have—my—my memory's affected by—and, um, it's—it's disheartening in later  life in a different way because your family understands—your family and friends understand the immediacy of it in the '80s and the '90s when you're going through med changes and things. But as soon as things kind of level off, they don't realize the repercussions all that has for much later on.”

More personally, prior to the existence of PrEP, I was morbidly fascinted by the contingent of gay men who made condomless sex into a sort of metaphor for personal freedom. They called safe-sex advocates “Nazis,” demanded that condomless porn become the norm (which it has, which it will continue to be) in spite of any risks to the performers or the audience and seemed proud to fetishize not only condomless sex (something anyone would want to have, duh) but the risk of HIV itself. This group grossed me out. A lot. I was always understanding of the desire to have sex with no barriers, but it seemed to me there was a huge difference between that and eroticizing sickness and risk. “Poz guy seeking to be re-charged” read one personal ad. This kind of thing was presented as pride and independence and blank-determination in a way that, looking back, is reminiscent of the Tea Party—it was all very “Don't tread on my raw sex!”

This mentality has been documented in countless porn films, and it's no surprise that the porn industry is leading the charge when it comes to PrEP; Michael Lucas, formerly adamantly pro-condom, now has condomless sex himself and demands it of his performers, frequently hyping famous stars' first bareback scenes. I don't think a porn mogul is the predominant voice we should be listening to on this issue, considering it directly affects his living. I'm also pretty disgusted that most of the gay community thinks that porn is just fantasy and refuses to accept that the behaviors we see in porn have any impact on how we act in real life. I mean, record what you say during your next sex act and it's likely to be something you heard a pornstar say at some point in your youth. As much as we'd like to think we are immune to the power of suggestion, studies on celebrity endorsements in advertising are a good parallel to how influential gay porn probably is on us—namely, a lot.

In summary, I do not believe I'm judgey to feel that if your main goal in life is to collect loads, you need a new hobby.

But as turned off as I am (and not from a standpoint of sexual morality so much as from a standpoint of personal and community responsibility) by the men for whom semen was a spirit animal even when HIV was all but guaranteed in the absence of condoms, that will not stop me from keeping an open mind on alternatives to condoms.

I also can't hold it against them when spermaholics trot out the tired argument that everybody's parents barebacked, so why shouldn't we? As if there is any comparison to our parents, who had a LOT less sex than we do, got married and had sex only with each other in the '40s, '50s, '60 or '70s (barring any cheating here and there), and us, sexually active gay men having multiple sex encounters with partners/dates/strangers in an age where HIV exists.

#2 Too Good to Be True

Along with my lifelong relationship with how undesirable it is to acquire HIV, another reason I was, at first, reluctant to embrace Truvada was believing the numbers sounded hard to swallow. Some advocates of PrEP want you to believe that the pill makes you impervious to HIV (I have been told by some of its boosters that it's 99% effective), but studies I've read stop well short of that. The CDC says, of PrEP's effectiveness:

“In several studies of PrEP, the risk of getting HIV infection was much lower—up to 92% lower—for those who took the medicines consistently than for those who didn’t take the medicines consistently.”

Too often, advocates of PrEP will take that 92% figure and misread it, claiming PrEP has a 92% effectiveness rate. It's a very different proposition for a drug to give you a 92% chance of not becoming infected with HIV over a period of time than it is for a drug to make it 92% more likely that you'd not become infected than if you'd not taken it at all.

Is that distinction simply lost on PrEP's loudest advocates? Perhaps their own personal experience and things they've heard from others are leading them to deduce that PrEP alone is actually far more effective than the CDC is presently ready to acknowledge. They may be right—gay men figured out that bareback topping was less risky than bareback bottoming (and that oral sex was very, very low risk) on their own before these became commonly accepted medical facts.

By the way, when I asked my doctor about PrEP and talked about the 92% figure, before I even clarified that it was not a 92% guarantee of remaining HIV-negative, he pointed out that a 92% success rate is not that high. Having an 8% chance of becoming infected is substantial, and the percentage would shoot up the more often someone on PrEP had sex with someone whose HIV status is unknown. 

On top of what seems to be a misreading of the numbers, the CDC is clear that PrEP should not be used without condoms:

“No, you should not stop using condoms because you are taking PrEP. If PrEP is taken daily, it offers a lot of protection against HIV infection, but not 100%. Condoms also offer a lot of protection against HIV infection if they are used correctly every time you have sex, but not 100%. PrEP medicines don’t give you any protection from other infections you can get during sex (like gonorrhea, chlamydia, and hepatitis), but condoms do.”

So you will get the most protection from HIV and other sexually transmitted diseases if you consistently take PrEP medicine and consistently use condoms during, condoms, if used correctly and every time, are almost guaranteed to keep you HIV-free as long as any breakages are noted and are followed by a trip to the ER.

Where I Stand Today

Putting aside my initial reaction to PrEP, and even taking into consideration the fact that PrEP is not 100% effective, I have come to think Michael Weinstein of AIDS Healthcare Foundation and others who are adamantly opposed to it are not thinking rationally. This is not to say that those advocating for PrEP are always thinking rationally, either, but I do believe PrEP is very promising and should be explored by sexually active gay men who believe they are likely to put themselves at risk for HIV on a regular basis.

In order to come to this conclusion, a few of both sides' arguments need to be dismissed.

For those who are against PrEP, one commonly used argument is that adult gay men can not be trusted to take the pill as directed—once a day. This is ludicrous. Yes, there will be cases of men on PrEP who forget to take pills and endanger their health. However, men are already foregoing the use of condoms in the heat of the moment, so why not have a little backup? More comparatively, are we not in favor of The Pill even though women have to take it very scrupulously in order to avoid pregnancy?

Another common anti-PrEP argument is that as soon as it becomes widespread, we will experience an explosion of syphillis and other non-HIV STIs among gay men. I agree this is probably true and pro-PrEP advocates should admit it. However, better to deal with those mostly curable or far more manageable illnesses than with HIV. The idea that HIV will adapt to be PrEP-resistant, or that a new virus will emerge are possibilities that could happen anyway. Viruses mutate, new viruses emerge, diseases become resistant to treatment—these things need to be monitored and taken seriously, but this is not a good enough reason, in my opinion, to blow off a very effective way to stave off HIV. (Sidebar: The only friend I have who admits to being on PrEP—he's in a study—tells me he fears that PrEP might indeed lead to big-picture problems with other diseases, but he is selfishly taking it to protect himself in his slutty 20s.)

One anti-PrEP argument is really just moral judgment, and it's not usually voiced but is instead usually hidden behind other arguments. Morality is personal. If you think people having serial one-night stands are sluts, that's your right, but it shouldn't color your desire to keep them disease-free while doing it. If you take pleasure from someone getting what they deserve, you're no better than the religious nuts who felt AIDS was God's revenge.

That said, one thing consistently brought up by Team PrEP is that we need to stop labeling users as “Truvada whores.” I'm sorry, but I do not believe for one second that this is a widespread issue. I know I just talked about how morality is behind some of the anti-PrEP arguments, but I do not believe PrEP is widespread enough for huge numbers of its users to be getting bullied on a regular basis. Honestly I think it's being trumped up for political reasons. Gay men are not amoral, but are less likely to condemn other gay men for their sexual practices, so it feels to me like the PrEP pep squad is trumping this up for sympathy. Apologies to anyone on PrEP who feels judged or who has been blasted publicly for using it, but I don't believe it's as overwhelming an issue as it's been made out to be. (A great example of how I feel about this is how proudly that guy wore his Truvada Whore T-shirt to help raise money for AIDS; that guy seemed to enjoy his alleged outcast status. It came off as flippant to me, not as reclaiming a negative word.)

I also do not buy the condom argument used by pro-PrEP forces, namely that men will not be less likely to use condoms once they're on PrEP. It's true that early data showed that PrEP users were also using condoms, but I believe that rate will plummet once PrEP goes from being gay sex's best-kept secret to being something many, if not most, gay men are on as a matter of course. The problem with this is that the CDC flatly states that condoms should be used with PrEP, whereas PrEP advocates like Damon L. Jacobs, a therapist quoted in just about every article on the topic (and a nice guy whom I've met and chatted with, and who I am not attacking personally), advocates vociferously for PrEP but also admits he uses PrEP because he doesn't want to use condoms—and skips condoms even when having anal sex with men who are HIV-positive (presumably, from statements he's made, only with those who have undetectable viral loads, which should further reduce the risk of transmission...possibly to 0%).

As PrEP advocates point out (and as stats support), it is human nature that gay men are not going to use condoms forever, every time. Condom fatigue is something most gay men I know have either experienced in themselves or have witnessed in others. If they haven't had full-fledged penetration with condoms on one or more occasions with a partner whose status was not known for certain, how many gay men haven't teased anal penetration to the point where some insertion has occurred? So this desire to be rid of condoms is real. Therefore, when advocates of PrEP are on blogs quoting stats that say PrEP hasn't led to men abandoning condoms and having riskier sex, they are being just as dishonest as anti-PrEP voices are when they say that PrEP should be ignored in favor of condoms 24/7.

Both sides have to realize that while condoms should be promoted, they will not be embraced by 100% of men having anal sex, and this is demonstrable by the fact that they have not been embraced by 100% of men having anal sex up to this point.

That actually supports the use of PrEP. Are men more likely to remember to take a pill every day or to use an uncomfortable device every time or both? The answer is: Some will do both, many more will stick with the condom and many, many more will at least use the pill.

And that combination of three alternatives will lead to fewer new cases of HIV, which should be everybody's goal.

I think PrEP is very promising, I'm more comfortable with the CDC's endorsement than I am with any condemnation of the drug, and I think if I were someone who felt the need to be topped on a regular basis, I would make a point of getting a prescription.



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