I attended the PrEP panel hosted by the Impulse Group in Los Angeles on a truly beautiful Saturday afternoon. As many of us know, November in Los Angeles can be a lovely time of year, and the 9th was no exception. Pristine weather, the obligations of a sick puppy dog (a real one) and a grumpy husband almost stopped me from attending. That and the relatively realistic fear that I would be saddened by the lack of interest, lack of education, or both at such an event. I was happily surprised at the turnout, the knowledge, and the passion presented by the panelists and the attendees. PrEP, to the uninitiated, is the use of HIV meds (anti-retrovirals such as Truvada) in a once a day dose by HIV-negative men to reduce the chance of contracting HIV should they be exposed. Studies show that used in conjunction with condoms, using PrEP results in a 96% reduction in sero-conversion. It’s controversial on several levels: 1) will men on PrEP stop using condoms? 2) How effective is it really unless adhered to on a strict regimen and close medical supervision and monitoring and 3) Why can’t gay men just stick to condoms instead of taking the pill that they would have to take if they were HIV-positive? Isn’t it just precluding the event or building resistance should it ever “really” be needed should they convert?
The Impulse Group is funded in large part by AHF and at first blush runs relatively counter to what AHF is known for: militant condoms only, no excuses, no exceptions education. Knowing several of the participants and volunteers that work with Impulse, I can say that they do work diligently to spread a more reasonable, approachable take on safer sex education. It is indeed counter to the AHF mantra but it seems that at the minimum the Impulse Group is making inroads into discussions within our community about safer sex education.
Arriving at the event at noon, per the facebook timeline, I watched as the boys of LA slowly trickled in. They were affable, affluent, diverse, and interested. The party finally got started around 1pm and the panel consisted of Aaron Laxton, an outspoken HIV-positive youtube speaker, Dr. Hardy, and Dr. Wohlfeiler, both whom specialize in HIV prevention and research, and Michael Weinstein, head of AHF. A moderator did his best to wrangle the strong, disparate personalities and divert the conversation back to questions that were being posed by the audience via text and email, but right from the start it was a challenge.
When asked their stance on PrEP, three out of the four individuals said that they think PrEP is beneficial when used in conjunction with condoms and is a safer sex method that’s time has come. Dr. Hardy started the responses and spun into studies, definition of PrEP, how he prescribes it and so on. Aaron was undoubtedly pro-PrEP and received a round of applause from the crowd following his eloquent evaluation. Dr. Wohlfeiler was agreeable, but used a very specific set of circumstances in which he prescribed PrEP. When later asked another question, he referenced the same scenario and patients, which gave the impression he had a tunnel vision approach to how and who should receive the treatment. And of course Michael was dead-set against it and appeared antiquated in his contrarian views. And for good reason. He cited several studies in which the participants simply didn’t adhere to the regimen of a daily pill, the cost associated with it, and the perceived tendency of those taking PrEP to forgo condom usage altogether. Michael made some good points, but the reality is: it doesn’t matter.
Why doesn’t it matter? It doesn’t matter because we are in a new era of HIV prevention, and like abstinence only education, not talking about it doesn’t stop them from doing it. And by them I mean men fucking other men and foregoing condoms on a regular basis. I did a quick qualitative analysis study for a class last semester where I asked 10 friends and strangers about their perception of safer sex, HIV, and how condoms are being used today. It turns out, they aren’t. We, MSM, are a victim of our own success. HIV is no big deal. You get HIV, you take a pill, you qualify for steroids because of “wasting” and you look better than when you were negative. Oh, and don’t forget the bonus of being able to now do the kinkiest, funnest, barebacking-est sex you ever dreamed of. Positive guys simply do not use condoms today. And many negative guys don’t either because they don’t see their friends and fellow gays affected by HIV. The concept of “undetectable” has rendered HIV mentally innocuous.
I am on the cusp of generation X/Y. I was raised that if you fuck someone, or get fucked, you put on a condom and that is just how it is. AIDS education and the condoms only for everything messages were everywhere. If you didn’t use condoms, you caught the HIV and you got sick. You might not die, but it would suck, and you would have a hard time dating, and your insurance would go up, and the pills would cause lipodystrophy, and one good cold could spell the end. I was borne of the era and mentality that putting on a condom makes sex better because I don’t freak out about catching something. I still get the chills waiting for my result regardless of how safe I’ve been, but unfortunately that mentality is virtually non-existent now within the Millennial generation. And that’s okay, if men choose to fuck without condoms, it’s not my job to shame them, or guilt them, or tell them they’re bad people. It is my job to provide them with education and options, like PrEP.
Will gay men go on PrEP and stop using condoms? Most likely. Why not? They’re not using them now, so why would they put on a condom when they have a biological barrier in their body? Will gay men have “riskier” sex while on PrEP? Well, not to tangent, but risky versus kinky are not interchangeable. I can fist someone and be safer than someone barebacking. I can go to the Slammer every night and make a BDSM daddy blush and walk away HIV negative. What someone is really saying when they pose this question is: will someone make choices putting them at higher risk for HIV infection by being on PrEP? That equates to, “will guys bareback more” and again, most likely yes. But if they’re already doing it (and the increase in HIV infection rates bear that out) then it doesn’t really matter. Michael made it very clear that the studies he read showed that MSM simply did not adhere to the protocol’s set up to effectively gauge if PrEP was effective. Meaning: they said they used condoms, but their blood tests showed a small percentage of the drug in the bloodstream: they weren’t taking the meds. So if they weren’t taking the meds, then one may surmise they weren’t telling the truth about their high rate of condom usage either. Double trouble.
Weinstein and Hardy saw their own interpretation of the study; I saw two vastly different takes on social norms and cultural awareness. Dr. Hardy realized that gay men were going to take these risks and wanted to provide another tool in the toolbox to supplement an already relaxed baseline of condom usage. The difference lies in political spin versus empirical evidence. Empirically, PrEP works and has been approved by the FDA and is ready and able to be prescribed by those that have it to those that want it. In my personal opinion, one key component in the fight against HIV and the inclusion of PrEP in our arsenal, is that if someone willingly, consciously, and with education asks for PrEP, they are more likely to adhere to the protocols and requirements needed to render it as effective as it can be. In short: just because some guys in a study didn’t use it properly 100% of the time, does not give one man the ammunition to throw out the entire argument based on a perceived lack of efficacy. Frankly, what I heard Michael say was, “Gay men can’t handle the responsibility and rigors of PrEP, and so condoms are the only logical choice for HIV prevention.”
One of the most important things that I felt was missing, or not really articulated throughout this ongoing discussion of PrEP is the specter of “choice”. If a person wants PrEP, that is their choice. It is no one’s sole responsibility to inhibit the access to a potentially life-saving device. The discussion on Saturday, sponsored by Impulse with a shadow of AHF behind the curtains, really illustrated the passionate responses to a prevention method in its infancy. We, as gay men, must nurture, respect, and raise this new prevention method carefully. We must provide it with education and grow along with it, like a good parent. And we must respect it and the other families affected by our choices. With that being said, it is ultimately up to the individual choosing to utilize PrEP whose opinion matters. I don’t get to say if it works for you. I only get to cite empirical evidence, encourage you to do your own research, and make the best choices you can. PrEP certainly has its flaws, as do the men that will take it, but PrEP is yet another tool in our toolbox and should be treated as such. Exploring it should be encouraged, studying it further should be encouraged, and using it to inhibit the negatives of becoming positive should be encouraged.