There’s a new way to protect yourself from HIV.
PrEP stands for "pre-exposure prophylaxis". It’s a pill-a-day to keep HIV away. The pill, Truvada, is actually not new. It has been around for ten years as part of the ‘cocktail’ to treat HIV infection, helping bring viral loads down to undetectable levels. Studies have shown that poz guys with undetectable viral loads are highly unlikely to transmit the virus. This is called "treatment as prevention" (TasP), and it’s big news in itself. However, since about 2012, Truvada has also been used by HIV-negative guys, mainly in the US, to keep from getting infected in the first place. This is PrEP.
Does it work? Fear of HIV is high, but the per-act risk of getting HIV is actually pretty low, even without any protection. Simon Fraser University professor Cindy Patton expresses the risk qualitatively, without statistics. You have to be "a little un-careful, and very unlucky," she says. Of course if you’re a little un-careful repeatedly, then the cumulative risk rises. Daily PrEP reduces the already low per-act risk by over 90 per cent.
How much lower, exactly, is debated by scientists. This can drive non-scientists crazy. There’s something about the idea that you could quantify risk and thereby manage it that can turn ordinary people into control freaks. But as the University of California at San Francisco’s Dr. Robert Grant, the world’s top PrEP researcher, puts it simply, "PrEP works if you take it." And as the British HIV/AIDS journalist and editor Gus Cairns echoes and amplifies, "stop arguing about percentages and repeat after me: IT WORKS IF YOU TAKE IT."
Here’s another way to look at it. We contacted Alan McCord of Project Inform, a leading HIV/AIDS advocacy organization in San Francisco, and asked him if anyone in any scientific study, or in the real world, taking the blue pill every day had become infected with HIV.
"No," he wrote.
Stunned, I had to read his email over again. You mean, there really is a pill to prevent HIV infection?
No one on PrEP, in any scientific study or in the real world, taking it daily, has become infected with HIV, as far as anyone knows (you can exhale now).
In May, 2014, the U.S. Centers for Disease Control (CDC) issued clinical guidelines for healthcare providers on the use of PrEP and recommended that at least half a million Americans go on it. "On average," said a spokesperson for the CDC, "it takes a decade for a scientific breakthrough to be adopted. We hope to shorten that time frame and increase people’s survival."
Over 100 U.S. HIV/AIDS organizations signed an open letter in support. The story made the front page of the New York Times. The World Health Organization (WHO) also chimed in, recommending that gay men around the world consider PrEP as an option – one more tool, along with condoms, in their prevention toolbox. But Canada, and especially Alberta, have lagged behind.
While all gay men should heed the WHO’s recommendation and at least think about PrEP, the WHO doesn’t recommend that all of us should actually take it. If you use condoms consistently and correctly (they don’t slip off; they don’t break; you don’t forget sometimes or get caught up in the heat of the moment; you don’t lose your erection; you’re not allergic to them; you don’t just plain hate them) then PrEP is not for you. But studies in both Canada and the U.S. show that most of us don’t use condoms all the time – actually, only 16 per cent of us do, according to the CDC – and, anecdotally, we know that this is true.
The popular hookup site Squirt asks users to report how often they practice "safer sex", where safer sex (in Squirt’s outdated understanding) means just one thing: condoms. Most guys – way more than the CDC’s 16 per cent – say "always". But the savvy squirter knows that this probably isn’t true, not because he has read the studies, but because he has looked in the mirror. He suspects that "always" really means "usually"; "usually" really means "sometimes"; "sometimes" really means "never"; and "never" really does mean "never". (Squirt’s drop-down menu doesn’t let you say you "sometimes" practice safer sex. That’s Recon. But you catch my drift.) Many guys over-report their condom use because of the shame and stigma of not using condoms.
This shame and stigma are preventing us from being completely honest with our partners, and even ourselves, about our actual sexual practices and, additionally, fueling the epidemic. Where did this shame and stigma come from? They are a bad consequence of a good thing: promoting condoms. Condoms prevent HIV infection, of course. But as long as promoting condoms relies on stigmatizing their non-use, dividing us into ‘good gays’ and ‘bad gays’, it just leads to denial and rationalization and pushes so-called bare-backing underground. We should certainly keep promoting condoms, but instead of finger wagging we should offer guys who struggle with condoms a scientifically proven alternative. As a recent op-ed in the U.S. gay magazine The Advocate expressed it, "Put Away the Pitchforks and Let’s Talk about PrEP."
Note to Squirt: the CDC has quietly stopped referring to condomless sex as ‘unprotected’. Nowadays, it depends. Sex without condoms – or PrEP – is unprotected. But using PrEP – with or without condoms – offers a high level of protection against HIV. Wrap your head around that: bare-backing – on PrEP – is safer sex.
"The HIV prevention landscape has changed considerably in recent years," opens the position statement of the Australian HIV/AIDS organization ACON. Titled "What is Safe Sex?", this question, which seemed settled for 30 years, is one that more and more people and organizations are asking again. Defining safe sex as "sex with a very low likelihood of transmission" of HIV – a better term is safer sex – ACON echoes the CDC by concluding that it is "no longer restricted to binaries of condomless sex or sex with condoms."
But which is better? It’s impossible to answer this question in a general way. In practice, the best method of HIV prevention is the one that you actually use. If you use condoms consistently and correctly, great. But if you don’t, PrEP will give you 100 per cent more protection than the condoms you’re not using.
The trend now is toward more options, not just one, because no one method works for everyone in every situation. Some guys are using condoms and PrEP as a second line of defense. This is the official CDC recommendation. It offers the highest level of protection, not only against HIV, but also against other sexually-transmitted infections (STIs). Remember that PrEP only protects you from HIV; not syphilis, gonorrhea, chlamydia, avian flu, the ebola virus, global warming, nuclear war, or God’s next plague upon homosexuals.
On the other hand, PrEP isn’t just a pill. In order to get a prescription in the first place, and have it refilled, guys on PrEP must undergo testing for HIV and other STIs every three months. By requiring regular STI checkups, and treatment if necessary, taking PrEP might actually reduce the incidence of other STIs too.
Like PrEP, condoms are really good at preventing HIV infection. And condoms are more effective than Truvada alone (ignoring the mandatory STI checkups that are also part of PrEP) at preventing other STIs. But there are three caveats. The first is that guys only wear condoms for anal sex, which limits their effectiveness to anally-transmitted infections. You can still get STIs from oral sex (HIV, by contrast, is rarely transmitted orally), and depending on the STI, even just by rubbing bodies (it sounds kinkier in French: frottage). But unless there’s bleeding or open sores, you can’t get HIV that way. The point is that condoms don’t offer full protection from other STIs. You still need to get regular STI checkups, which brings me to the second caveat: most guys don’t. The third caveat is the biggest one: condoms have a major adherence problem. Most of us don’t use them consistently.
Some guys are using condoms and PrEP with "casual" hookups and relying on PrEP alone for more committed partners, or partners they know better (husbands, fuck buddies, friends with benefits). However they draw the line – maybe only hubby gets it raw? – for guys like these, fucking without condoms, on PrEP, signifies greater intimacy and trust. Fucking without condoms or PrEP signifies ignorance or naivety: committed relationships are, in fact, a major vector of HIV transmission.
Some guys are using condoms and PrEP with HIV-negative partners who are not on PrEP. That’s because neg guys not on PrEP might not be HIV-negative. To repeat, many guys don’t get tested regularly. They could actually be poz without knowing it, and highly infectious. Because of frequent mandatory testing, a guy on PrEP is more likely to be right about his HIV-negative status.
Other guys are relying on PrEP alone for HIV-positive partners who are on meds and undetectable. To repeat, studies have shown that undetectable guys are highly unlikely to transmit the virus even if their partners are not on PrEP. That’s why the activist, and pioneering Canadian PrEP user, Marc-Andre LeBlanc counter-intuitively advises neg guys to "fuck poz guys" if they’re going to fuck raw. This is even more true for neg guys on PrEP. If both guys are on meds, either to suppress the virus or to prevent infection in the first place, then HIV status arguably doesn’t matter. Wrap your head around that!
There are, of course, objections to PrEP. The biggest one is adherence – the same problem condoms have. But PrEP is more ‘forgiving’ than condoms, which don’t work at all if you don’t use them. One study suggests that taking PrEP even four days a week is highly effective. Still, the recommendation is daily dosing. Fortunately, if you have trouble adhering to condoms, that doesn’t necessarily mean you’ll have trouble adhering to PrEP. It’s completely different. You take your pill every morning, say, with breakfast, and you’re good to go. Taking PrEP is separated from the timing of sexual activity, which allows you to be responsibly irresponsible, as it were: responsible in the morning, when you take your pill with Cheerios, but not so much on Saturday night, when you may have had a few drinks and one thing is leading to another.
Another objection is the risk of developing a strain of HIV that is resistant to Truvada. This could happen if you don’t take your pill every day, or if you’re not HIV-negative before you start PrEP. It’s your doctor’s responsibility to make sure that you test negative before initiating PrEP – and that you go off PrEP and on treatment if you become positive. But you can’t develop viral resistance if you don’t have the virus! The biggest risk of viral resistance comes with being HIV-positive. Then you have the virus for life, even if it’s undetectable, and you have to take antiviral medications for life. Every poz guy represents a lifelong risk of viral resistance. But if you’re on PrEP, it’s highly unlikely that you’ll get HIV in the first place. And PrEP isn’t meant to be taken for life; only during so-called ‘seasons of risk’. You know, like your 20s, or your 40s, as the case may be.
Another objection is side effects. Many guys have no side effects at all. Nada. Others may have minor side effects, like nausea or diarrhea, which go away within the first couple of weeks or months. Anecdotally, I have heard of few cases where someone had to stop PrEP because of side effects. Truvada is considered a safe and well-tolerated drug. The biggest side effect is peace of mind. That’s precious!
Another objection is that if guys go on PrEP, they’ll stop using condoms and get some other STI. Studies haven’t borne this out. Besides, candidates for PrEP already don’t use condoms consistently. PrEP is not the cause of their inconsistent condom use. Condoms are the cause of their inconsistent condom use.
Moreover, the same objection could be made against a vaccine. If an HIV vaccine were ever developed, would some people really clutch their pearls and say, Oh no! What a public health disaster! If you vaccinate gay men against HIV, they’ll stop using condoms and catch chlamydia! (They could catch chlamydia anyway). It makes you wonder why we put resources into developing new biomedical HIV prevention technologies in the first place if they just might work.
Another objection, finally, is the cost, which has nothing to do with the science of PrEP, but it does economics and politics. This is the objection that resonates the most with me. I hate helping to make Big Pharma rich (by the way, they are not paying me to write this essay!). The company that makes Truvada, Gilead Sciences, charges as much as existing patent laws and the market allow. In Alberta, that’s $1000 a month. Even if you have private insurance that covers, say, 80 per cent, you could be left with a hefty co-pay.
Political geography has a lot to do with PrEP affordability and access, making a mockery of universal healthcare in Canada. You could pay a lot less in Ontario, whose Trillium drug coverage helps lower-income people. In Quebec, PrEP is included in the provincial drug plan. And in the U.S., the manufacturer offers financial assistance to lower-income PrEP users, leaving many people with very low co-pays or no co-pays at all.
Pressuring the manufacturer to lower the price of Truvada, not just getting it included in drug plans, should be a major goal of PrEP advocates. It hasn’t been yet, neither in the U.S. or in Canada.
To date, the rollout of PrEP has been largely confined to the U.S. In this country, Truvada isn’t even approved for PrEP yet, although doctors can legally prescribe it "off label". Canadian healthcare providers and community-based HIV/AIDS organizations have generally been tight-lipped about PrEP, and excruciatingly slow to follow the lead of their counterparts south of the border and the WHO. That is why you have likely never even heard of PrEP! But they can’t control the flow of information online, including social media, which is how many of us are learning about it and starting on this journey.
Last June, a small group of us started a PrEP Canada group on Facebook, modeled after the thriving U.S.-based PrEP Facts group. Size matters! The more members we have from across the country, the more we collectively know, and the more we can help each other. PrEP users and allies sharing information and helping would-be PrEP users do the job that healthcare providers and local HIV/AIDS organizations should be doing, but in many parts of the country, are not.
I want to end by putting in a good word for HIV Community Link here in Calgary. They have recently come out in support of PrEP, one of the few Canadian organizations to do so, and started on some much-needed advocacy. I look forward to hearing more from them – and from you – in the future.
