The decision to use the controversial HIV prevention pill, Truvada, should be based on facts and not on shame and moral judgments
JUST THE FACTS | Since Gilead Sciences Inc. released a medication that reduces the risks for HIV-negative men to contract the virus, the debate for and against the pill has raged. (Illustration by Kevin Thomas/Dallas Voice)
Tyler Curry | Contributing Writer
Editor’s Note: This is the first of a two-part series on PrEP.
Regardless of your position on Gilead Sciences Inc.’s HIV medication, Truvada, it has been proven to effectively prevent the transmission of HIV more than 90 percent of the time, according to the Centers for Disease Control. This pre-exposure prophylaxis, now widely known as PrEP, hasn’t just been recognized as a medical breakthrough in HIV research, it also has been reveled and reviled by opposite sides of the HIV advocacy community.
However, despite the banging of war drums from the opposite ends of the battlefield, many people are still unaware of this new form of prevention. So for the average sexually active gay man looking to find out more about the specifics of PrEP, how do you get the facts without trudging through all the moral muck?
As with anything involving HIV, the national conversation of PrEP quickly moved from a rational discussion of facts to a moral debate over sexuality, promiscuity and greed. Unlike the beneficiaries of other medical breakthroughs, those who benefit from HIV research experience a type of judgment we call HIV stigma. Now, PrEP has proven that stigma isn’t just reserved for those carrying the virus; it now affects those who seek to prevent it sans condom.
Instead of heralding the discovery as a new method of prevention outside of condoms and abstinence, PrEP has received an onslaught of criticism from skeptics who held strong stereotypes of gay sexual behavior and pharmaceutical interest.
With the tendency for both sides of the debate to overstate their case while glossing over their critics, a dust cloud of misinformation has been stirred up around the topic. This has led to confusion around the effectiveness of PrEP and a multitude of judgments and assumptions made about the people who may choose to take it.
Michael Weinstein, president of the AIDS Healthcare Foundation, has taken a hardline approach against the prevention drug. AHF released a visceral campaign against Gilead Sciences Inc. with such brow-raising slogans such as “Giving Up on Gay Men,” “There is no Magic Pill” and “Gilead’s Greed Gamble.” Weinstein has continuously lambasted the promotion of PrEP and has gone so far as to suggest the effectiveness ratio of the PrEP clinical studies were manipulated to trick gay men into taking costly medication.
Many others who are against this new prevention method claim the drug is risky for a number of other reasons. Some critics assert that the likelihood to comply with the instructions to take the pill daily in a clinical trial is much higher than in a real world scenario. Therefore, the results cannot be taken seriously and will lead to a false sense of protection that only condoms can ensure. Others have stated the drug will promote unsafe sex among gay men and create the opposite of the intended effect. Instead of a decrease in HIV transmission, rates will increase along with a slew of other STDs.
A crowd of employees from AHF lobbied the Food and Drug Administration in opposition to the release, claiming the pill would lead gay men to abandon condoms and ultimately increase the transmission rate. Calling it the “profit-driven sex toy for rich Westerners,” the former editor-in-chief of POZ magazine, Regan Hoffman, prominently reinserted the language of shame into the science of HIV prevention.
Proponents of PrEP are equally as assertive in convictions as to why sexually active HIV-negative gay men should all be popping PrEP along with their daily vitamins. A slew of activists released multiple articles, blogs and advertisements sanctioning Truvada as the new condom and the messiah of the gay community. Online groups intent on disseminating information on the antiretroviral pill have developed quite the strategy for using viral messaging to spread the word. But many supporters of PrEP are still outraged by just how little recognition the drug has received as a prevention tool in the gay community.
Slate magazine contributor, Mark Joseph Stern released an article titled, “There is a Daily Pill That Prevents HIV. Gay Men Should Take It.” In addition to a title that suggests all gay men “should” do anything in regards to their sexual health, Stern makes a claim that Truvada has virtually no side effects.
The truth is, Truvada does have side effects. What is also true, though, is that these side effects are minimal and comparable to many other prescription pills such as birth control. But the yearning to exclude this seemingly innocuous fact just goes to discredit this otherwise insightful and factual piece.
The recognition of the side effects, however inconsequential, would have made the piece bullet proof. Additionally, recognizing that the long-term effects are unknown would allow for the consumer to more accurately discern whether PrEP is right for him or her. But these glaring omissions create a blind spot for opponents to attack the piece and contribute to the confusion surrounding the drug.
So what is the take away from this somewhat sidetracked argument? Lets break it down.
PrEP works just like condoms. When you don’t put a condom on, your chances of contracting HIV increase. When you don’t take your PrEP as prescribed, the exact same phenomenon happens.
According to the Center for Disease Control, condom use has dropped by 20 percent among gay men despite the efforts of safe-sex campaigns. Since Truvada has been approved for HIV-negative prevention, an estimated 150,000 people have been diagnosed with HIV. If we are measuring the efficacy of condoms based on compliance like we do with PrEP, our little rubber friends have an alarmingly dismal rate.
Regardless of the arguments for or against PrEP, the battle inevitably boils down to two schools of thought: The old school believes using condoms is the optimal way of preventing HIV and other STDs. Since wagging fists at those who forgo condom use isn’t working as well these days, well … they just aren’t wagging hard enough.
The new school recognizes that condom use continues to decline among men who have sex with men. This group embraces PrEP as an additional tool to combat the rates of transmission instead of working against the grain by trying to alter unprotected behavior.
Obviously, the old guard of safe-sex advocacy is failing to resonate with gay men who weren’t a part of the first and second decades of the HIV epidemic. The source of contention for all parties in the debate lies in making assumptions and the use of the word “should.” Phrases such as “all gay men should take PrEP,” or “gay men should always wear a condom” are about as effective as praying to Jesus to stay HIV negative.
We need to focus on the facts and leave the recommendations to the doctors. PrEP does work in helping prevent HIV transmission, but it isn’t perfect. No, it doesn’t work like a condom, and it doesn’t protect against any other STD . But even though it’s not news that condoms do offer protection, people still continue to practice unprotected sex.
The reality is that some people just don’t like to wear condoms. No matter how much we chastise those who prefer unprotected sex, the diminishing efficacy of using fear and judgment regarding condom will continue. If delivering information about PrEP is an alternative that some people would rather consider, then let’s sound the alarm.
PrEP is simply a new tool in the fight against HIV that offers an additional method of protection to condoms or abstinence. We need to circulate the facts without any moral pretense and leave the question of “should” to a gay man and his doctor.
Inevitably, there will be those who think everyone should take it and those who think no one should take it. Then there are the medical facts of an HIV-prevention method you can evaluate to decide whether or not it is right for you, regardless of what anyone thinks.
This article appeared in the Dallas Voice print edition January 31, 2014.
