Jeremy Dykes does not feel bad about enjoying sex without a condom, and those who think he should may be doing more harm than good
By: David Heitz – Follow @davidheitz
Even proponents of PrEP as a prevention strategy stress that the drug is not suitable for everyone. “For PrEP to be cost effective, you have to use it in people at high risk,” Gallant said. “It needs to be used in ways where you can get the best bang for the buck.”
Jeremy Dykes of Nashville, Tenn., who began taking PrEP last month, fits the bill as high-risk. He attended the Folsom Street Fair in San Francisco in September. While there, he noted that a majority of guys on Scruff, a gay sex app, noted they were on PrEP in their profiles.
“I’ve always felt like every gay man has to come to their decisions about what precautions they are or are not willing to take to reduce their risk for HIV exposure,” he said. “For some it’s just condoms, for others it’s sero-sorting, still others use PrEP, for most it’s some combination of all of the above.”
Before PrEP, Dykes considered condoms a “necessary evil.” Now? “I don’t feel so bound to ‘em,” he said.
As a sexually active man, he sees nothing wrong with using an HIV prevention method that does not require “real-time thought” in the heat of the moment, like rolling on a rubber.
Still, some gay men in large cities nationwide have labeled guys like Dykes “Truvada whores.”
Gallant finds that reprehensible. “That sounds so much like what people used to say in the 1960s about birth control pills, that women who took them would become promiscuous sluts, and maybe some of them did,” he said. “ But it was an important medical advancement that changed society in a good way.”
Dykes said he doesn’t worry much about the stigma some have attached to PrEP. “It makes me feel safer, that’s all I’m really worried about.” Such a stigma could be preventing some folks who could benefit from PrEP from discussing it with their doctor, however.
“Why is this such a big deal?” said Michael Weinstein, president of AIDS Healthcare Foundation. “Why are we fetishizing unprotected sex?”
A solution for minority infections?
HIV infections among young, gay minorities remain one of the highest in the nation. To that end, Moises Agosto, director of treatment education, adherence and mobilization at National Minority AIDS Council, said there needs to be more discussion about PrEP. “While PrEP may not be right for everyone, and should only be used in close consultation with a medical provider, the HIV/AIDS community and the public health establishment should be doing everything we can to educate people about this exciting new option.”
Gallant noted that the problem among many minority groups becoming infected is that they don’t identify as gay or at risk, so they don’t adhere to prevention methods. He said a similar phenomenon has been found in heterosexual, unmarried women.
“Risk perception plays a significant role in the utilization of prevention strategies in all communities, and certainly we should continue to educate individuals so that they can better determine their own vulnerability to infection,” Agosto said. “At the same time, we know that the majority of infections occur – at least among black gay and bisexual men – in individuals who are out and open about their sexuality. Our focus should be on how to educate these populations about PrEP and other prevention strategies, rather than focusing on a hypothetical debate about whether it would be widely utilized or not.”
STDs and PrEP
One such place where PrEP should be advocated is STD clinics, Gallant said. In those cases, money would be saved over the treatment of HIV, he argued.
He said he has diagnosed patients with HIV and later learned they had been treated for an STD resulting from unprotected anal sex, yet never had been counseled abut PrEP. “If you make an STD diagnosis and not discuss PrEP, you may become partly responsible for an unnecessary infection.”
In some PrEP videos that exist online, there is an implication that PrEP can be used only when needed. This is the sort of thinking that causes Weinstein to fear the emergence of a dangerous new strain among sexually active gay men who don’t properly adhere to PrEP.
“We know that you need to have a few doses in you before you have sex,” Gallant said. “We really haven’t studied that.”
He said he did prescribe short-term use of PrEP to a patient who planned unsafe sex aboard a cruise and at a sex party. “In that person, I thought it made sense. But most people’s sexual activity is not this organized.”
Weinstein pointed out that many gay men are married and monogamous or just plain low-key sexually. “Not every gay man lives life in the fast lane, or lives in Chelsea or West Hollywood. A lot of gay men lead relatively boring lives.”
Although not many people seem to be talking about PrEP, numerous trials nationwide are underway in Los Angeles, Chicago and around the country.
AVAC: Global Advocacy for HIV Prevention, operates a Web site at PrEPWatch.org which offers detailed information about PrEP. Educational campaigns about PrEP have been launched in Atlanta, Boston, Chicago, Dallas, Los Angeles, San Francisco and New York.
“There is considerable buzz around PrEP within some communities, but it is a relatively new development, so we should expect that it will take time to catch on widely,” Agosto said. “At the same time, some of the controversy surrounding PrEP has no doubt had an impact on the willingness of some health care professionals and organizations to engage heavily around the issue and that’s a shame.”
Agosto noted that all prevention strategies – with the exception of abstinence – are really risk reduction strategies. “None provide absolute protection,” he said. “But when used in combination with traditional prevention modalities, PrEP has been shown highly effective. Our job is to educate our constituents about all options available to them so that they can make the best decision for themselves.”
Weinstein said he feels the same way, and that is how he has formed his thoughts about PrEP thus far. “My responsibility is to tell the truth as I know it. AHF gets bigger and bigger based on more people becoming infected. I have a responsibility to do all I can to prevent people from becoming infected.”
Although antiretroviral therapy significantly reduces the risk of HIV transmission, there’s a need for PrEP, too, Gallant said.
“There is a lot of tension between the idea of treatment as prevention and PrEP,” Gallant said. “Treatment as prevention means treating people who are positive so they don’t infect others. We need modalities for both positives and negatives for prevention. If you’re a negative person and you have multiple partners, you don’t know if someone is on (antiretroviral therapy) with an undetectable viral load.”
A negative person who is a bottom has to trust the person on top to be wearing a condom, Gallant said. “PrEP puts a person in control as a bottom. An analogy can be made with heterosexual women.”