I'm a Gay Man on PrEP: We Need to Have Mature Conversations About HIV and Sexual Health
Back in 2014, I wrote an op-ed endorsing pre-exposure prophylaxis (PrEP) treatment for HIV prevention. PrEP is delivered as a daily pill that prevents HIV infection by blocking an enzyme used by cells infected with HIV to replicate the virus. For residents of the U.S. who have commercial health insurance, PrEP is usually free of cost with the addition of the Gilead co-pay card. All Medicaid programs cover PrEP as well.
I’m a sexually active gay man who takes PrEP every day and is tested every three months. I was not on PrEP when I wrote my endorsement in 2014, but I chose to begin taking it after I asked a partner to do so because of his sexual history. Aside from brief initial nausea, I experienced no sustained side effects and my comprehensive blood work remains excellent.
The World Health Organization recommends that all men who have sex with men be offered once-daily PrEP, distributed in the U.S. as Truvada. The treatment reduces the risk of HIV by at least 92 percent. And that’s the conservative estimate. Some estimates put the efficacy rate of consistent PrEP use at nearly 100 percent.
Common social stigma and lack of education among medical care providers continue to create a barrier between an effective prevention tool and the communities that need it.
For many individuals who lived through the AIDS epidemic of the 1980s, the idea of anything other than condoms being promoted as a preventative measure seems dangerous. Conversely, the success of HIV treatment over the past couple of decades has resulted in a younger generation that doesn’t fear AIDS and is not concerned enough about HIV prevention. Young people see folks living long and happy lives with HIV―a stunning success that was unimaginable during the Reagan administration.
Much in the way abstinence-only education proves ineffective in preventing pregnancy, condoms-only education based on STI scare tactics is ineffective to a generation that isn't afraid of HIV. Many young people are not receiving the message that HIV is a serious health concern, even if it isn't something scary.
While HIV concern is down, the fear of social stigma around sex continues. Many men who have sex with men conceal risky sexual behaviors, avoid testing and don’t want to seek preventative treatment for fear of slut-shaming by their peers or medical professionals.
We need to have a mature conversation about sex, pleasure and risk to ensure we don’t wind up with a generation of people living with expensive, preventable health conditions.
An important part of this conversation is acknowledging that condoms, for a variety of reasons, can be a sexual hindrance. The physical nature of condoms can be perceived as a barrier to intimacy and pleasure, which has practical implications. A person in an open relationship may want to have condomless sex with his primary partner. Or an adult film performer assigned a condomless scene could want an extra layer of protection in case of inaccurate test reporting by a studio or co-star. While condoms are the best way to prevent all STIs, they are not the only answer to HIV prevention—just the most effective one.
The least-discussed component of HIV prevention is treatment as prevention. HIV-positive individuals who adhere to treatment and achieve an undetectable viral load prevent the transmission of HIV to their partners at a hugely successful rate. The single best way to prevent new HIV infections is to ensure that every HIV-positive individual is aware of their status and receiving high-quality medical care. Not only does this protect future sexual partners, it prevents HIV from progressing to ensure HIV doesn’t become an impediment to quality of life.
PrEP is another tool in the HIV prevention kit. A once-daily Truvada pill is an invaluable method of prevention for high-risk communities, including those who do not consistently use condoms or struggle with drug addiction. To reduce stigma, we need to emphasize that PrEP is for everyone—all sexually active adults. WHO recently expanded its own recommendation to “all population groups” who have a substantial risk, which can include some women who have sex with men, men who have sex with women or individuals who do not have any sexual risk but use drugs that are injected.
Condoms continue to be the most effective barrier against STIs, but the effectiveness of condoms is not a reason to downplay the important role other HIV prevention methods play in a modern sexual landscape that sees lower rates of condom usage among the LGBT population.
Using all available strategies can improve and save countless lives, and the best way to fight sexual stigma preventing public health progress is to speak the truth, loudly.
We need to create an environment where every individual feels comfortable speaking honestly about their sexual lives and seeking the best kinds of prevention and treatment for their circumstances. There is no one-size-fits-all answer to sexual health, only a one-size-fits-all stigma that prevents us from saving and improving lives.
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