…about your ill-informed ‘personal opinion’ about PrEP.
In August 2009, I went to the National LGBTI Health Summit in Chicago and took part in a panel on HIV stigma with Erik Libey and Tony Valenzuela, talking through some work I did on behalf of the Australian Federation of AIDS Organisations.
The summit included another great panel on bareback porn, recorded by Feast of Fun at the Center on Halsted. It was great to be there and talk with my North American colleagues about HIV risk reduction strategies, rectal microbicides, the Swiss Statement, and a new application of HIV treatments just entering clinical trials, called PrEP.
I had the great privilege of spending some time in conversation with Tony, subject of the Rolling Stone article “They Shoot Barebackers, Don’t They?”, and Amber Hollibaugh of Queers for Economic Justice.
We talked about the emotional sustainability of working in HIV prevention for AIDS service organisations (ASOs). The puritan, sex-phobic culture of North American public health practice makes too many things unspeakable and leads to a performance of evidence-based practice that chokes off funding to community-building strategies that actually work.
The result is pent-up frustration and, every few years, it is unleashed in a community-, sector-, and nation-wide cataclysm centring on some issue that, by a process of metonymy, is made to stand trial for everything that’s wrong with HIV prevention.
Tony had been the touchpoint for an earlier firestorm around the first public acknowledgment of bareback cultures in the mainstream media and his efforts to single-handedly establish the now-unremarkable category of the HIV-positive porn star.
There was concern at the time that a similar process might start up around non-condom strategies for HIV prevention. Sure enough, five years on, moral entrepreneurs like Michael Weinstein from the AIDS Healthcare Foundation are engaged in a concerted effort to spark off a national panic about PrEP, and there’s an emerging divide among gay men that threatens to crystallise into stigma.
This is staggeringly unhelpful, as the case of barebacking will demonstrate: even as behavioural surveys showed unprotected sex with casual partners increasing, gradually but steadily, in every developed country that collects the data, ASOs struggled to promote messages about how to reduce the risk during non-condom sex, because the moral panic about barebacking in the gay community and mainstream media made even the most cautious messages controversial.
Note that I’m not taking a position on casual non-condom sex: just saying that if it’s happening, ASOs should be able to respond honestly and effectively, and the strongest response is a strategic combination of messages. The drum beat is condom reinforcement (and promoting negotiated safety) for those who only do it occasionally with casual partners (or more regularly in relationships). The melody is a cultural narrative around the changing nature of HIV. The instrumental solo is reliable information about non-condom risk reduction strategies for people who, as a matter of disposition or personal difficulty with condoms, prefer exclusively non-condom sex.
In a short and altogether predictable exchange of views on twitter, I was challenged to engage more fully with the nine reasons given in the article Conner tweeted. So here goes: why I don’t give a damn if one person says he will never, ever use PrEP. (His reasons in bold.)
- Money. Just because your health insurance doesn’t cover it now, Zach, doesn’t meant it never will. If you have trouble using condoms, it’s a lot cheaper to pay for you to take PrEP than for full HIV treatment after you seroconvert. In particular, it will be a lot cheaper in 5 years when the patent monopoly on the key drug Tenofovir expires.
- Trust in pharmaceutical companies. Zach says he’s skeptical because Gilead makes HIV prevention and treatment drugs. There’s a missing premise here, explaining why that’s a problem. But in fact it’s the same drug used for both purposes.
- Zach likes condoms. Good for you, Zach. Not everyone does. The hidden premise here is that Zach thinks gay men are going to be choosing between condoms and PrEP, when in fact PrEP is likely to be used by men who either cannot or choose not to use condoms.
- Zach is forgetful. This is a pretty good reason for Zach not to use PrEP. In the iPrEx study, although 93% of respondents said they took the drug everyday on time, monitoring drug levels in their blood suggested only 51% actually did. [reference] There are now trials underway exploring alternative dosing strategies for PrEP agents, such as monthly injections and slow-release implantables. There is actually a huge amount of knowledge about how to solve this problem, if we only looked at research into hormonal birth control practices among women.
- Side effects. “Everything from joint pain to kidney problems have been reported. Also: Nausea, diarrhea, and skin discoloration.” Truvada has been studied for PrEP because it has the fewest side effects of any combination treatment. Its side effects include bone mineral density loss leading to increased risk of bone fractures, and kidney problems, both of which can be monitored. The other side effects Zach mentions are from different drugs not used in PrEP.
- Truvada makes it harder to find somebody to fuck. A drug most people take in order to have safer bareback sex “limits me to only having sex with men willing to go bareback.” Well, in practice, yes — but there’s no reason someone taking PrEP could not also use a condom.
- The difference between condoms and bareback sex is negligible to Zach. Zach did something rather slimy in this piece: he frames it as “personal reasons why I will never, ever use PrEP”. That’s just a pretext to write a bunch of stuff about how PrEP sucks. Why bother doing that if you’re already determined never to use it? The use of the second person voice in the point gives the game away: this is really about what Zach thinks other gay men should do. He writes: “If wearing a thin layer of latex is that difficult for you, maybe your problem is psychological, not physical.” (Emphasis added.) The question I’d pose in return is: so what if it is psychological? Or cultural? Or emotional? Or even just that you prefer raw sex?
- The science is still out. Zach imagines a scenario where, out of the 2499 gay men who took part in the iPrEx trial, only the half who were not receiving the placebo somehow figured that out and only had sex with negative men, and that’s why they had fewer HIV infections than those who received the placebo. This betrays ignorance about how clinical trials work but also gay men’s sexual cultures. Most of the men in the trial and control group would have sought out self-declared HIV negative men for bareback sex; it’s called serosorting and it’s not new. If serosorting worked as perfectly as Zach imagines, however, we wouldn’t need PrEP. We need it because some proportion of the men who think they’re negative are not — they’ve been recently infected and their viral load is sky high.
- The risk of other STIs. Zach lists a bunch of STIs, including syphilis, herpes and HPV — which are, newsflash, not prevented by condoms, since they can be spread by skin contact with a lesion not covered by a condom. Many people wrongly assume that condoms prevent any STI transmission. In fact, they mainly prevent HIV transmission. Bacterial STIs like chlamydia and gonorrhea can also be passed on via oral-anal contact during rimming and oral sex without a condom. That’s why we recommend testing for HIV and other STIs at least once a year and every 6 or even 3 months if you’re a really busy boy.
Ironically, one of the things Zach counts against ‘the science’ on PrEP (at point 8) is the prevention effect of HIV treatment among known-positive partners, which is another one of the risk reduction strategies we were talking about at that conference in Chicago.
Neither one is new, exactly. We’ve known since the late 90s that HIV treatment in positive people probably reduces transmission efficiency. Negative people have been prescribed a month-long course of HIV treatments as post-exposure prophylaxis (PEP) since the early 90s, and PrEP is just ongoing PEP. So why did it take so long to consider studying and formalising them as HIV prevention strategies?
Two main reasons. The ‘bareback wars’ made non-condom risk reduction strategies unspeakable. The bareback wars were due, in turn, to people, both gay men and public health practitioners, forgetting that the goal of HIV prevention is to prevent HIV infections using all the means available, not to promote a religion of consistent condom use and demonise those who don’t adhere to it.