Why Aren’t Gay Men On The Pill?

The Associated Press – about as mainstream as you can get – has an article out this week about a very marginalized medication:

It’s the Truvada conundrum: A drug hailed as a lifesaver for many people infected by HIV is at the truvadaheart of a rancorous debate among gay men, AIDS activists and health professionals over its potential for protecting uninfected men who engage in gay sex without using condoms.

Many doctors and activists see immense promise for such preventive use of Truvada, and are campaigning hard to raise awareness of it as a crucial step toward reducing new HIV infections, which now total about 50,000 a year in the U.S. Recent efforts range from think-tank forums and informational websites to a festive event at a New York City bar featuring popular drag queens.

Yet others — despite mounting evidence of Truvada’s effectiveness — say such efforts are reckless, tempting some condom users to abandon that layer of protection and exposing them to an array of other sexually transmitted infections aside from HIV. “If something comes along that’s better than condoms, I’m all for it, but Truvada is not that,” said Michael Weinstein, president of the AIDS Healthcare Foundation. “Let’s be honest: It’s a party drug.”

I have to say I’m aghast by that attempt to stigmatize – yes, stigmatize – a medication that could prevent countless men from being infected with HIV. Think about it: if it were 1990 and the news emerged that – just by taking one pill a day – you could avoid ever getting infected with HIV, do you think there would be any debate at all? There would be lines around the block for it, huge publicity campaigns to get the amazing news out, celebrations in the streets, and huge relief for anyone not infected with the virus. Fast forward a quarter century, and those taking this medication are actually demonized as “Truvada Whores“.

Whore? Why are some now channeling Rush Limbaugh’s sex-phobia? I mean: are women who are on the contraceptive pill “whores” as well? All they’re doing is protecting themselves from the consequences of sex in terms of pregnancy. And all gay men on Truvada are doing is protecting themselves from HIV. Why on earth would we want to prevent or marginalize that? As Peter Staley, one of the true heroes of ACT-UP, has put it:

It breaks my heart that the worst of HIV stigma comes from my own community: gay men.

Mine too. The reason, it appears, is that being free from the fear of HIV infection could lead gay men to have lots of sex again with lots of partners. (One study we have examining this did not bear this out.) But here’s some breaking news: for vast numbers of gay men, lots of sex is already the case. Now that HIV is not a death sentence but a chronic disease like diabetes, the terror is long gone. But the virus isn’t. And rates of infection remain stubbornly high, especially in this demographic. Because, well, men are men. Betting against their testosterone in a sub-population without women is a mug’s game. Add to this that fact that for many men – spoiler alert – condoms make sex less pleasurable, less intimate and less intense, and you have the current high rates of infection. Given where we are, we have a choice, it seems to me. We can either use our medical knowledge to prevent infections, or we can allow them to continue.

Screen Shot 2014-04-09 at 11.29.56 AMWhat about side-effects? Yes, they exist with Truvada, as with any drug. But this pill must be prescribed by a doctor who can monitor quickly for any early adverse reaction in the liver and end the drug if necessary. One possible effect on bone-density takes a very long time to occur and again can be monitored and the drug ended if that’s the case. And compared with the side-effects of getting infected and having to take the full spectrum of anti-HIV drugs? Let’s just say your liver prefers Truvada. What about getting people to take it every day? Yes, that’s vital – just like contraception. If you are not taking it regularly, and you get infected, there’s a chance that the virus could mutate in the presence of Truvada to foil similar drugs in a future cocktail. But since the Truvada regimen requires blood work every three months, the resistance is unlikely to go on for long. And there are, mercifully, plenty of other classes of anti-HIV drugs that can replace it in a cocktail if you go on to get infected. So, yes, it might not be the best option for a tiny minority. But for the vast majority? It’s a complete no-brainer.

Can gay men be relied upon to take a pill once a day? Please. Why would they be regarded as less capable of protecting themselves than millions of women? And the cost we have already incurred by not aggressively promoting this drug as a preventative is huge. I wrote about this option as far back as 2006, when it first appeared on the horizon. 400,000 people have been infected since then. Back in 2010, in a thread called “A Massive HIV Breakthrough“, I noted that the trials concluded that the pill was more than 90 percent effective. Truvada was subsequently approved by the FDA in 2012 and continued to have high rates of success in clinical trials. From another Dish thread last summer:

According to the C.D.C., when study results are adjusted to include only participants who took their pills most of the time, the protective effects are 92 percent for gay men, nearly 90 percent for couples in which only one partner is infected, 84 percent for heterosexual men and women, and about 70 percent for drug injectors.

Think of how that can change the dynamic in a sero-discordant couple where one man is negative and the other positive. Think of how it can also help end the barriers between HIV-positive and HIV-negative gay men, with far, far less chance of infecting one another. But, in a felicitous medical coincidence, it also raises the tantalizing prospect of wiping HIV out of the gay community in our lifetime.

If you’re my age and remember the horror and the trauma and the paralyzing terror of the plague, that is not something you can feel indifferent about.

Here’s why it is now perhaps possible in ways that have never existed before. If all HIV-negative gay men are on Truvada, they cannot get infected with the virus. And if all HIV-positive gay men are on retrovirals, then they cannot effectively transmit the virus. Bingo! Epidemiologically, HIV is facing extinction. But is it true that those of us on anti-retrovirals with undetectable levels of virus in our blood and semen cannot infect others? Well, we just got pretty amazing news on that front. A two-year PARTNER study – with more than a thousand sero-different couples, gay and straight – found that no-one was infected with HIV.  (The results are available on aidsmap here.)

The bottom line: if we can get a critical mass of gay men on either Truvada or retrovirals, we could soon reach a tipping point in which this virus could be wiped out in a generation.

When we are still having 50,000 infections a year – and gay men remain a resiliently vulnerable population – this should be an urgent goal. We have a chance our predecessors long dreamed of: to have great and enjoyable sex lives without this paralyzing fear and this dehumanizing stigma. We owe it to them and to ourselves to do all we can to make this scenario possible.

Why on earth are we hesitating?


Update: This post prompted a thread, which you can read here.