HEALTH DECEMBER 15, 2013
Two weeks ago, when the Centers for Disease Control and Prevention issued its Mortality and Morbidity Weekly report, many outlets were quick to jump on one specific statistic: that unprotected anal sex among men is up nearly 20 percent from 2005 to 2011. In the New York Times, Donald McNeil said that the statistic was “spurring HIV fears” and was “heightening concerns among health officials worldwide.” In Slate, Mark Joseph Stern argued that the “case against barebacking with a non-monogamous partner remains as strong as ever,” and cited monogamy as "clearly the gold standard of sexual health.” And in The New Yorker, Michael Specter wrote, “If unprotected anal intercourse is rising among gay men, the rates of HIV infection will surely follow.” He concluded the piece by quoting Larry Kramer’s landmark 1983 New York Native article, “1112 and Counting”: “Our continued existence depends on just how angry you can get… Unless we fight for our lives we shall die.”
Reading these and other reactions to the report, one has to wonder if the mainstream media has developed an almost Pavlovian response to gay men's sexual habits. Certainly a rise in unprotected sex among men is cause for concern. But as the face of HIV and the AIDS epidemic changes, our responses to these statistics need to change as well, demonstrating the nuance and complexity necessary to reflect the current landscape. The conclusions above read much like they would have two decades ago: HIV infections are certain to rise. Young gay men don't get it, or don't care. Monogamy is the solution. People need to be scared into using condoms again.
And yet, not a single one of those articles mentions another aspect of the CDC report: PrEP, or Pre-Exposure Prophylaxis, arguably the biggest breakthrough in HIV prevention medication to come out in the last two years. Truvada, the first PrEP drug, was approved by the FDA last summer. When taken daily, it can prevent transmission of HIV 99 percent of the time if taken every day. Even if taken only four times a week, its effectiveness remains as high as 96 percent. One would think that a statistic like that would be widely reported and celebrated, and yet there are few people outside of the LGBT community who have even heard of PrEP.
It's easy to understand why PrEP hasn't been heavily publicized by certain institutions involved in HIV prevention. Thirty years into the epidemic, the CDC still says oral sex can result in the transmission of HIV, despite enough evidence showing that the risk is “extremely low.” The agencies play it safe, and PrEP opens them to another kind of risk. There is also the issue of adherence: People are not always good at sticking to a daily regimen of pills, and doctors worry that using Truvada on occasion, rather than as directed, might lead to the emergence of drug resistant strains.
But the lack of reporting about PrEP may stem from something else altogether: a lingering controversy about its use within the gay community itself, and how PrEP has contributed to a growing generational divide between old-guard condom true-believers, many of whom survived the epidemic of the '80s and '90s, and a new generation of HIV activists for whom condom use is seen as just one tool in a growing arsenal of prevention methods.
The case for the use of condoms is clear. PrEP doesn't protect against any of the numerous (and more easily transmitted) STIs. Condoms are affordable, readily available in drugstores, often freely distributed at gay bars and social centers. “It is fashionable in some quarters to attack condom education, but it cannot be sufficiently emphasized that most gay men have got through the epidemic without getting infected because they have indeed been diligent in their use,” Simon Watney, and AIDS activist since 1983, writes at CNN. “Whatever else may be in the pipeline by way of chemical prophylaxis, it remains every bit as important today as it was 30 years ago...that any gay man getting fucked who is not 100% confident about his partner's HIV status should insist on their using a condom.”
Despite these ostensibly sensible pleas, condom usage has slipped by 20 percent, according to the CDC report, likely reflecting shifting perspectives about how useful and necessary they are. This is particularly true among younger gay men living with HIV, several of whom, like bloggers Aaron Laxton and Josh Kruger, have spoken skeptically about an over-reliance on condom messaging. Laxton wrote in The Advocate that it's "time to wake up and recognize that beating people, let alone addicts, over the head with the “condom” message isn’t cutting it,” while Kruger argues that if condom campaigns "were effective, then I would not be writing this right now. Rather, I would have been protected against HIV infection. We must recognize that condom campaigns have failed miserably to be relevant to the world in 2013.
To some, the suggestion that we downplay condom usage reads like heresy, bordering on willful ignorance. It's very often tied up with the idea that young people are misinformed or cavalier about the dangers of HIV, partly because many of them don't know anyone who has died of AIDS. (The Times story cites a hypothesis by two CDC doctors that many young men “never having known anyone dying of AIDS and therefore not fearing it.”) Yet are young people necessarily making risky choices? Isn't it more likely that, in the face of myriad conflicting messages about what it means to contract HIV, they are just making decisions that better reflect the reality of their lives?
Not all of the older guard are taking the younger generation to task. Many of them have spoken out against what they perceive as the good-intentioned but often strident finger-wagging of their fellow AIDS survivors.
“The notion that young men do not fear HIV...is a myth that needs to be dispelled. It undermines the lives and struggles of a new generation of gay men trying to make their places in the world,” writes Perry Halkitis, professor and author of the book The AIDS Generation: Stories of Survival and Resilience. “The truth is that HIV is no longer a death sentence, and to expect a new generation of gay men to perceive it in that manner is unreasonable, unwarranted and unrealistic.” Longtime activist and author of My Fabulous Disease, Mark S. King, seems to agree: “Young gay men are more aware of HIV than my generation ever was. They simply relate to it differently.”
How are younger gay men relating to HIV differently? By engaging in a wide range of prevention practices including sero-sorting (the practice of choosing partners based on HIV status), sero-positioning (choosing sexual position based on same), monogamy, frequent testing, choosing partners with undetectable/non-transmissible viral loads (amount of the virus in the bloodstream), among others. Meanwhile, the mixed messages that younger gay men receive about HIV is complicating their decision making. “This has been a prevention dilemma since the mid '90s,” Ed Wolf, an AIDS activist and educator featured in the acclaimed documentary We Were Here,told me. “On the one hand, we want to tell someone who finds out they're positive today, you're going to be fine...you're not going to die of AIDS... On the other hand, we want to tell uninfected people, don't get this terrible disease.”
Finding the balance between those messages has become the central struggle of HIV prevention, and may be why PrEP remains bitterly controversial. Many in the gay community still perceive it as a license for promiscuity.
David Evans, the director of research advocacy at Project Inform, in October wrote in The Huffington Post that the gay community couldn't afford to lag in embracing PrEP—and was met with a fair amount of vitriol. "I've seen so much of that in the community," he told me. "We demonize people who are having a really hard time making choices not to use condoms.” Doctors, too, are raising moralistic objections, according to Evans: “We get about 2 calls or emails a week from someone trying to get PrEP and are unsuccessful…. The problem has been, every single time, that the provider themselves often either didn't know about PrEP or had very negative opinions about it.”
Many people within and outside the gay community cannot fathom why gay men would have unprotected anal sex, but it's all a matter of perspective. All of us take calculated risks every day, as Ed Wolf points out. “Driving a car is a very deadly serious issue, but because driving a car is so valued in our society, no one is going to say not to do it," he said. "Instead they've come up with a whole cafeteria menu for how to reduce your risk in the car, and this is all we are saying: for some people having ... anal sex is as important to them as is the car that you are driving. And so we need to have a wide menu of options for those people as well. But that behavior is not valued.”
PrEP, then, is a sort of seatbelt for gay men, and it's no more a license for promiscuity than a seatbelt is a license for speed: for some users it may be, but not for most. The aforementioned reports notwithstanding, the fact that PrEP remains little known and poorly understood cannot be blamed on the media entirely. The culture at large, including many gay survivors of the '80s and '90s, need to rethink their biases and assumptions—that, yes, it's possible now to have safe, unprotected gay sex.
The existence of this debate, though, represents staggering progress. How lucky we are to be facing these particular concerns, considering where we were only twenty years ago. The fact that we now have PrEP, and antiretroviral medications making the virus non-transmissible, and that people in the U.S. are mostly living with AIDS rather than dying from it, is something we didn't dare to imagine back then. “Some day we're going to look back at this, and the epidemiologists and the social scientists are going to go, isn't this interesting, a virus came that was transmissible from person to person, and the big global response was to keep these people alive, which is so compassionate,” said Wolf. “We didn't want people with HIV to die, so we created systems to support them and keep them alive, but then it guarantees an ongoing viral pool, because it kept the virus alive as well.”