Dissents Of The Day

A reader writes:

You surprised me when you wrote, “Every doctor who treats a sexually active gay man should put him on a daily retroviral in the Tenofovirsame way you might prescribe a daily anti-cholesterol drug for someone with high cholesterol.” Aside from the cost, prophylactic HIV medications do have side effects, don’t they? In light of the cost and the side effects, do prophylactic HIV medications make sense for gay men who are in monogamous relationships, who always use condoms, or who never have anal sex?

If my doctor recommended that I take prophylactic HIV medications based solely on the fact that I’m a sexually active gay man, and without knowing anything more specific about my sexual practices, my first thought would be, “This doctor is a bigot. I need to find another doctor, pronto.”

A doctor is not a bigot in recommending a preventive pill just in case for an at-risk population (and gay men remain disproportionately at risk for HIV infection). The costs are minor compared with those of combination therapy in perpetuity. And the side effects of just one Tenofovir or Truvada pill a day are also usually not a big deal – but I probably went too far in thinking this should be over the counter. A doctor should monitor your blood for any reactions or toxicity. But no more so than for countless other prescription drugs.

Of course, it’s your call. I’m not arguing for mandatory prophylaxis, for Pete’s sake. But trusting another man’s monogamy is not a great HIV prevention tool, and condoms fail. Anal sex is also not the only way to contract HIV, even if it is overwhelmingly the most risky behavior. I know that from personal experience. Another reader is more blunt than the first:

You are not seriously suggesting that every gay man take anti-retrovirals in perpetuity?

Not just sex workers, not just the extremely promiscuous, not just intravenous drug users – every single gay man? For his whole sexually active life? And to make them available over-the-counter and unmonitored by doctors? That sounds shockingly irresponsible, and besides being unmanageable and hugely expensive, these are toxic drugs with serious side effects.

And besides the practical considerations, what better way to connect gay sex to terror and and disease than to suggest that everyone having it take medicine every day?

One Truvada a day is not hugely expensive or unmanageable. And the rhetoric my reader uses – segregating HIV risk for only the “extremely promiscuous” or sex workers – is far more stigmatizing than a simple preventive medicine. Yes, more sexual partners will increase your risk of contracting HIV; but just one partner can give it to you; and we’re all human. I’m no more connecting gay sex to terror when used to lower the chances of infection than I would be recommending an anti-cholesterol drug to ward against a heart attack. Another reader:

I was put on PEP for a month after a potential exposure, and while I remain HIV negative, just four weeks of drugs knocked me on my ass. Taking those drugs daily is not an option, and while I have managed to remain negative for decades (I’m 47), my behavior in taking care of myself required neither “fear” nor “shaming” in keeping me HIV-free.

That’s a different case: after possible infection, my reader was probably treated with a powerful combination therapy to knock the virus silly. But this could be avoided with one pill that drastically lowers the chance of being infected in the first place. One more reader:

Just one tiny correction on the Plan B analogy: Plan B doesn’t work if you are already pregnant; it prevents ovulation and thus pregnancy.  So PrEP is not like Plan B for pregnant women, but rather like Plan B for a woman who recently had unprotected sex and is at risk.  Perhaps a small thing, but correcting the idea that Plan B can end a pregnancy/cause an abortion has been a long (and continuing) struggle for those of us working to increase access.