Michael Weinstein remembers popping penicillin to protect against STDs before a night on the town, but PrEP is another story.
By: David Heitz – Follow @davidheitz
Inevitably, when people talk about PrEP they also talk about condoms.
For some, the idea of gay sex without condoms — which have proven highly effective against the transmission of HIV when used properly – is blasphemy.
For others, who point to rising infections rates among gay men in the U.S., the idea of continuing to count solely on an old-fashioned prevention measure seems insane. Between 2008 and 2010, more than 50,000 people in the U.S. became infected with HIV, with more than half occurring among men who have sex with men. Among gay men ages 13 to 24, it was a 22 percent spike during that time. Among all gay men, infections shot up 12 percent.
Even government web sites have acknowledged that condoms, when used for anal sex, can break. Meanwhile, people on PrEP who do not use condoms still get substantial protection against HIV if they take the drug correctly, said Dr. Joel Gallant, president of the HIV Medicine Association.
Where does that leave us?
“Obviously, there are lots of gay men who are not using condoms,” Gallant said. “Condoms reduce sexual pleasure. Not everybody is willing to do that.”
Michael Weinstein, 61, heads AIDS Healthcare Foundation, which offers treatment to more than 279,000 people in 28 countries worldwide. It is the largest provider of the HIV/AIDS medical care in the U.S.
What began as a group of friends helping others die with dignity has turned into an enormous organization which has been at the forefront of HIV treatment and prevention. Today, Weinstein oversees a $750 million budget.
He has built the empire, which has improved the lives of hundreds of thousands of gay men with and without HIV through the years, advocating a safe-sex message of condom use. It has been a low-cost prevention method that has worked while AHF has led the charge against the disease.
“There are known ways to avoid contracting HIV, and they are condom use, abstinence and monogamy,” Weinstein said. “We don’t expect people to be abstinent or monogamous, so we promote condom use.”
‘A moralist view?’
Gallant said insisting on condom use for everyone is “a moralist view that leads to infections.”
According to the CDC, the number of men who have sex with men who reported having anal sex at least once in a 12-month period increased from 48 percent in 2005 to 57 percent in 2011.
Still, Weinstein does not buy the argument that gay men are not using condoms as often as they once did. “You can do harm by telling a big lie that people don’t use condoms,” he said.
He believes infection numbers would be much higher if people who know they have HIV, in particular, were not using condoms. Still, he noted that half of all of infections occur among those who do not know they have the virus.
The CDC promotes condom use even for people on PrEP. “The CDC, in their language, say the politically correct thing, which is total nonsense of course,” Gallant said. “If you were giving it to people who are using condoms, why would you need it? Unfortunately, that PC language has had way too much pull. I’ve had providers say ‘I’ll only give this to you if you use condoms. That’s not the kind of doctor-patient relationship we want to foster.”
Concerns about adherence
“For every sex act where a condom is used there’s virtually total protection,” Weinstein said. “For every act on Truvada for people not taking it, they are 100 percent exposed.”
Adherence levels have been low in the studies. In one study of gay men, the number of those with detectable Truvada in their blood sharply declined from 63 percent the first month to 20 percent by the sixth month on the regimen. Of the 68 men in the trial, 93 percent were black or Latino.
Some PrEP advocates have noted that study participants did not know whether they were receiving a true prevention pill or a placebo, which could have influenced their desire to take the medication.
“You’ve got to be paranoid about your pants falling down to wear a belt and suspenders,” Weinstein said. He noted that young gay men in particular sometimes stay out all night and crash at a friend’s house, thereby not being home to take their Truvada.
Jeremy Dykes of Nashville, Tenn., says adherence is not difficult. “I feel like any methodology that can reduce infection should be encouraged, not panned because of potential adherence problems,” he said. “If the situation is that PrEP is effective but adherence is an issue, then the problem isn’t with PrEP itself, it’s with adherence and that’s the thing that should be studied and addressed. If someone just absolutely can’t take their pill consistently, then their doctor should point them in another direction.”
In the month he has been on PrEP, Dykes said he has not forgotten any doses. He uses his Walgreens app on his phone to remind him to take his pill every morning. >> Click to download Walgreens Mobile App via
Condoms only for ‘reckless’ gay men?
So far, there has been no evidence published that supports the idea that men on Truvada have unsafe sex. In fact, there have been reports to the contrary.
Weinstein believes condoms are the best choice for preventing HIV. Period. “At the end of the day, this is not ideological, it’s about the data,” Weinstein said. “The data does not support this as a successful strategy.”
He said he recently had someone tell him he sounds like a mother telling their child to wear a raincoat. He took it as a badge of honor. “What happens when fogys like me stop talking? There’s an element in the gay community that’s really reckless.”
Although an entire generation of gay men have chosen to never have bareback sex due to HIV, Weinstein admits he hails from a pre-condom era.“If every gay man took (Truvada), it would be a huge windfall for (Gilead), but the changes in culture would be catastrophic. I’m old enough to remember when people popped penicillin before a night on the town.”