The Best Threads Of 2014: “Why Aren’t Gay Men On The Pill?”

Dozens of readers this year added their very personal perspectives to the breakthrough drug Truvada and the baffling resistance to it by many gay activists. Read the whole discussion thread here. Below are a few previously unaired emails to add to the mix:

Most of the coverage of Truvada has been about the idea of “Truvada whores” who take the drug so that they can have indiscriminate sex with any number of people. I wanted to write truvadayou with a different perspective.  I am a HIV-negative guy in a relationship with an HIV guy. I’m 33 and he’s 30. Unfortunately he made some poor decisions in his very early 20s but he’s been very proactive since. He’s remained at an undetectable viral load for 7 years now and his more recent T-cell count was excellent, as it has been for a while. He was very straightforward with me when we started dating and that has helped a lot too.

Recently I began taking Truvada as an additional step to protect me. It’s very very inexpensive through my insurance and after a few months I’ve had no side effects. Not only does it provide physical aid but it also provides a great deal of emotional assistance. It puts me at better ease and it makes him feel better that there is basically zero chance that he could infect me. It also gives us a daily ritual in which we each take our daily medication, using each other to ensure that we are very strict on taking medication every day. Hopefully, as more news comes out, he’ll one day be free of his decade-old bad choices and we’ll live together totally and completely free.

But another reader cautions:

Your ongoing coverage of Truvada as pre-exposure HIV prophylaxis is fascinating and reaches a large number of gay men. This is why it’s important to correct a error that keeps occurring in Dish pieces on PrEP:

the notion that Truvada “reduces your risk of contracting HIV by 99 percent” (for example). PrEP does not reduce the risk by 99%; it reduces the risk by less than half.

As a young physician, I realize that the medical community does a crappy job of explaining statistics related to treatment. For your readers (a generally sophisticated bunch), here’s a breakdown of the numbers:

In the Truvada study in gay men (found here), 1248 men were given a placebo pill and 1251 men got Truvada. In the placebo group, 64 men subsequently got HIV (rate of infection: 64/1248 = 5.1%). In the Truvada group, 36 men subsequently got HIV (rate of infection: 36/1251 = 2.87%).

So what does Truvada do? With general sex practices, risk of HIV is low. Without Truvada, there’s a 95% chance you won’t be infected and a 5% chance you will be infected. With Truvada, there’s a 97% chance you won’t be infected and a 3% chance you will be infected.

Truvada does reduce HIV infection. And that change is about 2% in absolute terms (5% down to 2.87%) and about 44% in relative terms (5% reduced by 44% is 2.87%).

Saying Truvada “reduces your risk by 99%” mistakenly implies an enormous effect of the drug – one that was not shown by the trial.  Rather, it would be true to say that men taking Truvada had a 97% chance of remaining HIV-negative. But even without the drug, the chance of remaining HIV-negative was 95%. Truvada does make a difference, but it’s not a magic bullet.

Thanks for shining a light on this important issue.

Truvada And Women, Ctd

Arielle Duhaime-Ross observes that “condom use — even female condom use — requires a partner’s acceptance”:

That’s where Truvada comes in: the little blue pill is discreet enough to require no truvadaparticipation from sexual partners who might not be willing to help out. And it’s repeatedly shown to be extremely effective at preventing HIV infections when taken daily.

There’s no shortage of evidence linking intimate partner violence to inconsistent condom use. In a 2011 study of over 500 heterosexual men in New York City, researchers found that men who are physically violent with their partners are half as likely to report consistent condom use compared with men who aren’t. And another study, published in 2013, showed that women who were physically abused by their partners in the three months prior to answering the survey were more likely to have had sex without a condom than women who hadn’t experienced that type of violence. …

Thus, the threat of violence during condom negotiation is an important contributor to “risky sex” in abusive relationships — relationships that one in three women in the US will experience. And going through these experiences won’t just affect a woman once, as surviving intimate partner violence can significantly decrease a woman’s confidence when negotiating condom use with future sexual partners. “It’s not that women are stupid, or that they don’t know that they need to protect themselves from HIV,” [Anna] Forbes [of the US Women and PrEP Working Group] says. Rather, it’s that in some situations “the cost of insisting on condoms use is often greater and more immediate than the risk of HIV, either because of partner violence, stigmatization, the risk of the break up of a relationship, or community ostracism — it’s just really tough.”

Earlier Dish on the subject here. Our thread on PrEP is here.


Andrew Asks Anything: Rich Juzwiak, Ctd

Below is another clip from my conversation with Rich (first sample here). In it, we tackle condoms – why men don’t like them, and why the opportunity to live without fear of HIV and, in some cases, without rubbers is one worth grasping:

A reader writes:

I really enjoyed listening to your insightful conversation with Juzwiak.  Most of my friends, gay or straight, don’t have the patience to read Love Undetectable, but they may be willing to listen to this conversation.  It beautifully distills what it was like to come of age during the plague of the ’90s and of its impact upon our generation’s attitudes towards sexuality, risk, and death.

I deal with a number of grad students/postdocs who are in their thirties, and I am just realizing that their generation has love-undetectablenever experienced anything comparable, and most have never dealt with death.  Recently, one of the grad students died unexpectedly of a rare disease, and it hit some of the other students hard.  I think they were upset that I did not display equal levels of grief.  In response, I told them a bit about my experiences during the height of the AIDS epidemic … about calling a friend in New Orleans to tell him about the death of a mutual friend, and his response was flat and unemotional.  He said, “I’m sorry if I seem cold, but the truth is that I simply don’t have any more tears to shed; I’ve been to thirteen funerals just this month.”

My students simply couldn’t imagine the magnitude of such loss of a social circle, nor realize how it impacted dating, friendships, and having sex.  Now, if they wish to understand, they have something to listen to.

Another dissents:

Perhaps it is a reflection of my sixty plus years, but I had a real visceral negative reaction to your conversation that multiple random sexual hookups constitute a community. In my life I have bed-hopped, bathhouse visited, and anonymously interacted with countless dicks and asses (as well as dick-heads and assholes), but MY Gay community came together when my contemporaries battled the scourge of AIDS, the terrifying unknowns, the constant anxiety of looking for that first red lesion … my history is littered with the names of the fallen, my own personal World War III.

After the terror of HIV subsided just a bit, my community was formed with men and women, of all sexual stripes, who lobbied, battled, organized for equal protections under the law and advanced the reality of same sex marriage and adoption

As a freshman at Georgetown University in 1970, I would tiptoe past the open bar-room door of the first Gay Establishment I had ever known on Wisconsin Avenue. To think in my lifetime I can check into just about any hotel in the world (excluding Russia and Uganda) with a same-sex partner and be shown a room with one bed, is astounding. And that is because we organized to become a political, economic, and religious force that peacefully brought about change

When I think of our Male Gay community, I think of all the brilliant artists, authors, teachers, health care providers, athletes and scientists who excelled in their fields. I don’t think about how many men they hooked up with, furtively or openly, and that is the furthest thing from my mind when I identify with my tribe.

It’s not what I focus on much of the time either. But it’s there and deserves some elucidation given the obloquy directed at it from gays and straights alike. Another adds:

The push for Truvada needs to be tempered with some medical judgment. My doctor took me off it because I had a kidney stone, because he said that if I got another kidney stone and Truvada backed up in my kidneys, it could potentially damage my kidneys. So there needs to be some awareness that Truvada DOES have potential side effects.

Indeed it does, as all drugs do. This blog has addressed the potential side effects many times, namely in our long-running thread, “Why Aren’t Gay Men On The Pill?

Andrew Asks Anything: Rich Juzwiak


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.