Andrew Asks Anything: Rich Juzwiak

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If you ever read Gawker, you know who Rich Juzwiak is. Yesterday he came out with a new piece revealing how he’s not just taking Truvada again; he thinks almost every gay man should be on it too:

In my first piece on Truvada, I said that I thought most sexually active gay men should at least consider going on it. That was not strong enough: All sexually active gay men who are negative should go on it, at least those who are in the highly populated gray area that I find myself in—guys who either have casual condomless sex from time to time or who are “always safe” but still burdened by the fear of HIV.

If you know that you don’t need Truvada, I trust your judgment. If there’s a shred of uncertainty, just take the fucking pill.

I try to be as nonjudgmental as possible when it comes to the behavior of other gay men (though I cannot refrain from judging those who judge). We are all in different places in life; we all enjoy different things. That variety is, in fact, what makes gay culture so vibrant. The choices at the disposal of those who are privileged enough to live in areas where gay is OK and where same-sex marriage is legal—these are part what make being gay so wonderful. But if you cannot deal with taking a single pill every day, you need to get a grip and reevaluate your life. After you do that, then just take the fucking pill.

Rich and I sat down a little while ago to talk about sex and love and gay men’s lives today. The resulting podcast can be a little racy and provocative at times. Hey, it was a real conversation. We actually talk about the sexual adventurism of gay men – a subculture where no women restrain sexual desire – as an often wonderful thing, regardless of the judgment that so many, including gay men, have made about it. There may be a measure of mutual respect, friendship, democracy and brotherhood in a sexually liberated gay male world – that is perhaps unavailable to heterosexuals:

 

The whole conversation is up on Deep Dish now for subscribers only. Check it out. If you haven’t subscribed yet, do so here – you only need to spend $1.99 to download the whole thing. And you’ll also get access to my unfiltered conversations with Dan Savage and Hitchens, among many others.

92 Percent? 99 Percent?

Josh Barro has a useful piece drilling down on quite how effective Truvada is in preventing HIV-truvadainfection. It’s a dense statistical article and worth reading in full. The basic gist is that while a big study found zero HIV infections among those taking Truvada as prescribed, the sample size is too small to declare it 100 percent effective. So they use statistics to come up with the 99 percent figure. One reason to qualify it: there may have been other factors preventing HIV infection in those taking the pill regularly (like having fewer sex partners) than those who didn’t adhere closely to the regimen. If you add in those not taking the medication every day, but almost every day, you can get a statistic of 92 percent effectiveness.

Does this matter? Psychologically, there is a difference between a one percent chance and an eight percent chance of getting infected. But in reality: not so much. Anything well above 90 percent (and indeed, so far as we have actually measured, 100 percent) is a huge deal, especially since regular condom use only seems to lower the chance of HIV transmission by 70 percent. But it’s worth reminding ourselves of the statistical nuances here.

Why Aren’t Gay Men On The Pill? Ctd

The New York Times has produced a “Room for Debate” colloquium on Truvada, the daily pill to prevent HIV infection. They lead with the Michael Weinstein, who writes this sentence:

PrEP has failed to protect the majority of men in every clinical trial (study).

He links to an Indian summary of drug trials from 2011. That ignores the data since then:

A key Truvada study found more than 90 percent effectiveness in preventing HIV infection even among those not fully compliant with the one-pill-a-day regimen. Another study showed that “parti­ci­pants could re­duce their risk of HIV by 76 pe­r­cent tak­ing two doses per week, 96 pe­r­cent by tak­ing four doses per week, and 99 pe­r­cent by tak­ing se­ven doses per week.”

That’s a huge majority in all the most recent studies. Then we have Larry Kramer writing the following:

Truvada is a form of chemotherapy, and we have not faced up to the possible side effects that might come.

truvadaChemotherapy? He sounds like someone’s hysterical grandma from a Roz Chast cartoon. It’s one pill a day whose side effects have been documented as minimal for the vast majority and easily monitored for anyone else. You get your bloodwork every three months. The drug has been used in combination for several years and has no resemblance even slightly to chemotherapy in any form. Of course, with any drug, including aspirin, there are side effects. But they pale in comparison to the side-effects of the full anti-HIV cocktail – which is the real life alternative to this simple pill a day.

So where are these people coming from?

If they were deadly serious about reducing HIV infections, why wouldn’t they want every possible means of prevention? Why, in fact, continue to favor an approach that has already demonstrably failed, rather than try a new one that might work? One clue comes from a sentence like this from Weinstein:

What we do know is that this generation didn’t live through the holocaust of the ’80s and ’90s.

As if that’s a bad thing! It doesn’t seem to occur to him that sex without terror is a good thing, in fact, an extraordinarily good thing for a fully realized life. Or that adjusting your behavior when the cost-benefit analysis decisively shifts is a perfectly rational thing to do. The same blindspot is in Larry’s sentence:

There is already a lot of complacency among gay men that makes the lucky uninfected neglect or reject condom use.

Complacency? It doesn’t seem to occur to Larry that it’s not complacency, but rationality at work here. Adjusting your behavior when the cost-benefit analysis decisively shifts is a perfectly rational thing to do. The only people being complacent with HIV are those “mainly” using condoms, hoping for the best when they lapse from time to time, and not taking Truvada. Why would Kramer not support someone attempting to make his own body as immune to HIV as possible – with a safety net as well as protective gear?

What we’re seeing perhaps is the understandable trauma of an older generation cramping the options of a younger one, in a different time, with different – and much less terrible – problems. The obvious drawback is the possibility that fewer condoms means more other STDs. But the check-ups required for continued use of Truvada can be a warning sign for that; and one study has found no probability of such unintended consequences. Maybe they’ll occur and we can adjust. But right now, we have a lethal weapon in the fight to the most lethal STD there is, and we’re unconscionably failing to use it.

The long-running Dish thread on the male pill is here. Update from a reader:

Thanks for continuing to cover Truvada. I’m a 54-year-old gay man, HIV-negative, lived in San Francisco in the early ’80s (and have lived to tell about it). I don’t have unprotected sex (truth be told, I don’t have much sex, period, but that’s another story). But at my last doctor’s visit, I went on Truvada. My doctor was unfamiliar with it (my gay doctor!), but he was happy to prescribe it. He said it seemed “a bit like overkill, but when the alternative is a life-and-death condition, is there such a thing as overkill?” My health insurance covers it, and so far no side effects that I can tell.

My reasons for going on Truvada are mostly emotional (what a spectre of fear relieved!) and political. As part of the political aspect, I’ve begun telling people that I am taking Truvada. The stigma attached to it needs to be removed, and having more people on the drug will enlarge the medical track record as well as, eventually, bringing the price down.

When I told two women friends about it, and the very high prevention rate some tests show, she said, “Why aren’t they putting it in the drinking water?” The other, in response to the idea that if gay men won’t even always wear a condom, how can they be expected to take a pill daily, pointed out that women on birth control seem to handle taking a pill every day.