Let’s Talk About PrEP: The Silence Of Gay Men On Truvada

Truvada

In a lengthy piece at Out.com, Tim Murphy dives into the controversy and silence that pervades gay male culture about taking the HIV medication Truvada as a pre-exposure prophylaxis, or "PrEP." One of the people Tim interviewed, a doctor who is referred to anonymously as "Dr. John", said of the attitudes around the medication:

Gay men talking about not using condoms is really stigmatized. Most of us have never known sex without condoms or without threat of a ‘deadly disease.’ [But] I think it’s a lot to ask an entire generation of gay men to use condoms forever.

Despite being FDA-approved, 99% effective when taken as directed, and covered widely by health plans, comparatively few gay men are on the drug. Even though condoms are lauded as the ideal, studies have been taken since the 1980s that show that gay men as a whole consistently only use condoms about half the time, and the HIV transmission rates have increased by 22% in recent years. Jim Pickett of the AIDS Foundation of Chicago notes:

If condoms were so wonderful and a part of human nature, we wouldn’t have a problem with rising infections.

The biggest concerns seem to be that PrEP would provide a false sense of security and invite reckless barebacking, which is the stance of Los Angeles' AIDS Healthcare Foundation. A valid concern since though PrEP would dramatically reduce the likelihood of HIV transmission, it would do nothing against other forms of STDs such as Hep A-C, syphilis, and gonorrhea, the latter of which has started showing up in drug-resistant strains. 

What PrEP advocates and activists want men to understand is that the use of the drug is another tool in HIV prevention, not a panacea that will flawlessly protect people from everything. Said Darius Mooring, a 34-year-old bookkeeper in Pennsylvania:

If I go on PrEP, will I be condomless in all my sexual encounters? I don’t think so. But I’m not going to live in fairy tale where I tell myself I use condoms all the time. PrEP will be adding another strategy to my HIV prevention.

Previous Towleroad coverage of PrEP can be found here, here, here, and here

Comments

  1. kennedy says

    “I’m not going to live in fairy tale where I tell myself I use condoms all the time. PrEP will be adding another strategy to my HIV prevention.”

    What is so freaking hard about using a condom?! I’m 23 and I despair of the example that older gay men – who witnessed the horrors of the AIDS crisis firsthand – set for my generation. Use a condom AND take the damn pill.

  2. David says

    Judging from all of the comments on that article, it seems that, some of us at least, are not ready or willing to talk about PrEP.

  3. Rich says

    I echo Kennedy’s comment. When I was single, I had ZERO problem using a condom 100% of the time. No exceptions. I don’t understand what’s so hard about it (no pun intended). It’s always a bit shocking every time I’m reminded that I seem to be in the minority on this.

  4. JMC says

    How many people who can’t be bothered to use a condom for across the board STD protection would really be willing to keep up with a daily pill regimine?

  5. Douglas says

    Below is a link to a far more thoughtful article by Sean Strub, founder of POZ Magazine and now executive director of The SERO Project, which questions, in many respects, the advisability of PrEP. Some key quotes from this article:

    “I think it’s the wrong way to address HIV prevention. It’s a topic of discussion and debate whether the message is being driven by a drug company pushing to expand its markets, and public health officials whose traditional HIV prevention tools–sex education, community-based HIV prevention, highly-targeted prevention messaging, etc.–have been gutted. They’re desperate to find whatever way they can to reduce HIV transmission, even if it is a short-term strategy with unknown or risky long-term consequences or that puts other priorities in jeopardy.”

    “PrEP risks ruining a very effective anti-retroviral by facilitating development of resistant virus, making the epidemic more complicated and more difficult to end.”

    “I question the morality of spending scarce government resources providing treatment for those who don’t have an immediate medical need while others are dying for lack of treatment.”

    http://blogs.poz.com/sean/archives/2012/11/treatment_as_prevention.html

  6. says

    Truvada really begs the question: Why would a healthy person bother to take a drug that we don’t even know what it’s going to do to your body over the long-term?

  7. GregV says

    There will always be a sub-segment of MSM who choose to take unnecessary risks. It should not surprise the researchers that the same men who could easily choose other safety strategies BUT DON’T are not going to be interested in PrEP.
    There seems to be a naive assumption by the spokespeople that anyone who is not using condoms could be protected by PrEP. One quote says “gay men as a whole consistently use condoms only half the time.”
    Okay, but a very high percentage of the time, there is no risk for which a condom would be needed. If a man is finding strange men in the park to have anal sex behind his wife’s back, then he needs condoms; If a disease-free man is monogamous with his disease-free husband and they are engaging in mutual masturbation, condoms are irrelevant (unless they just enjoy wearing them.).
    Some people don’t wear condoms at all because they are never at risk, and some wear them 50% of the time because that’s how often they are engaging in something that requires them.
    The problem occurs only with those who need them for what they’re doing but won’t use them.

  8. Fenrox says

    @Kennedy, basically it wears on some people. I am 31 and it hasn’t yet on me but who knows? I don’t love condoms but it’s not even in my mind as an option to not use one on a rando.

    I’m a tad confused, when do you use this? If you use condoms you don’t need this, if you use this you don’t need condoms, but you still need condoms if your are doing a rando as they might have syphilis.

    And like, a pill every time you have sex is crazy excessive, it makes sex too dangerous, what if you eat a food and get drunk and it like weakens it. I know that that is fear vs science, a bad fight to have. Im gonna get some from my dr. as a “man this sketch dude is hot, lets have sex” scenario.

  9. GregV says

    “I’m a tad confused, when do you use this? If you use condoms you don’t need this, if you use this you don’t need condoms…”

    No, that’s a dangerous assumption that they are afraid some people may make. The people who take PrEP due to their reckless sex habits still SHOULD be using condoms. The medicine will just help decrease (but will not eliminate) the chance of contracting one type of virus.

  10. Bob says

    How about showing some moral restraint by not engaging in unfettered sexual activity with total strangers? Stop being perverts, basically.

  11. Buckie says

    People using both PrEP AND condoms ?

    Really ?

    Not. Buying. It.

    There’s NO reason to use both.

    PrEP is just another marketing scam to distract us from the goal we should be shooting for. Reduction of HIV infections AND ALL STD’s.

    People using PrEP are not people who are using condoms. People who are NOT using condoms are people who don’t care about STD’s in general.

    Let’s be up-front and honest about this.

    It’s a fact.

  12. Matteo says

    We should be thankful to have PrEP.
    Many docs I know have it on hand in case of needle prick and I have taken it before and the % of not sero-conv is very high.
    I don’t practice unsafe sex but accidents do happen re broken condoms etc.

  13. Franklin Black says

    “PrEP risks ruining a very effective anti-retroviral by facilitating development of resistant virus, making the epidemic more complicated and more difficult to end.”

    THIS ! The INTENTION is to accomplish this, because the drug companies make money with NEW combos, not with old ones that are effective but become generic !

    And then there’s that HUGE elephant in the room, the fact that HIV is far from the only STD. Every STD, and the ensuing treatment you need, impact health negatively. And the more of them you collect, and the more frequently you need to be treated, the less healthy you are over time.

    It complicates HIV treatment; it arguably shortens your life even without HIV; it’s the thing nobody wants to talk about.

    Because we’re a target market and we’re being sold something that is bad, any way that you look at it, it’s a horrible thing to be pushing on the community, and I question the motives and intelligence of anybody that’s pushing PrEP.

    Let’s see some full financial discloser from those writing these articles encouraging PrEP use. These people, they are not our friends and they are NOT to be trusted !

  14. Douglas says

    @FENROX and GREGV: Gilead, the manufacturer of Truvada, specifically instructs that it is to be used as PrEP in combination with the use of condoms.

    As quoted from Truvada’s website: “If you are prescribed Truvada for PrEP…you must always practice safer sex. Use a condom, know your HIV status and that of your partner(s), get tested for other sexually transmitted infections (like syphilis and gonorrhea) and take action to limit your contact with body fluids.”

    That’s not to say that this instruction is consistent with what those in the bareback brigade have in mind, but it is nonetheless clearly specified by the manufacturer of Truvada.

  15. BABH says

    It only protects against HIV (not other infections) and it only costs $14,000 a year! Clearly a perfect substitute for condoms.

    [Obviously it’s the right choice for some people. High-risk individuals should consider every option they can, and should be using them cumulatively — PrEP *and* condoms, not PrEP *or* condoms.]

  16. Buckie says

    MATTEO :

    Then market it as such, and stop the lying and fake promotional stuff masquerading as real people that actually believe PrEP doesn’t exist purely to do harm to the community.

    I’m sick of the obvious drug company viral marketing fakes conning us. PrEP is NOT for people who use condoms, it’s NOT for “accidents”, it’s being viral marketed to us as a SUBSTITUTE for condoms.

    Fraud and lies are just that, and shame on anyone that’s pushing this.

    If PrEP is just for emergency use, let’s see some indication that there’s any effort to prevent it from being used like Viagra !

  17. Douglas says

    @MATTEO: To be clear, the type of scenario you are describing would require the use of PEP (post-exposure prophylaxis), which is a weeks-long regimen of HIV medications that are prescribed following exposure to the virus in order to prevent, if possible, sero-conversion from occurring. PEP is different from PrEP (or pre-exposure prophylaxis) which is the subject of this article.

  18. Delicious says

    After reading the entire article, I just can’t help wondering, how could anybody look at PrEP, at HIV research, at how some people in the community accept being drugged and being guinea pigs for new “rectal microbicides” (anyone remember what a DISASTER nonoxynol-9 was ? No ? How easily we’re conned into forgetting) and I wonder, what kind of freak show am I missing out on ?

    Is it worth it ?

    I’m seriously asking those with HIV. Was it worth it ? What COULD have been said to you that would have mattered ? Is a life of constant medical intervention what you had in mind ?

    Pushing 50, and not needing any prescription drugs, simply because I made choices based on the facts, I feel like I’ve somehow missed-out !

  19. Bob says

    The problem with gay men is that you have confirmed all the Right Wing’s prejudices about you. You are hedonists looking for a druggie quick-fix. Your holy grail is promiscuity.

  20. Fiveht says

    Some of this comments remind me of what was said of the birth control pill.

    It’s another tool. With birth control, it’s suggested for people to use two methods. This would be a good way of using two methods for HIV prevention if you’re at risk.

  21. MGC says

    “When I was single, I had ZERO problem using a condom 100% of the time. No exceptions.”

    When you were single? Over two thirds of new infections occur when people bareback IN RELATIONSHIPS.

  22. Bob says

    MGC,

    The problem is promiscuity, not bareback. Why don’t straight guys refrain from bareback with women?

  23. Eric says

    I remember back in the 1980s or early 1990s that someone pointed out that we should make peace with the fact that safer-sex was here to stay forever. Even if we cured HIV tomorrow, we have no way of knowing that there isn’t another sexually-transmitted disease here already, or will be here soon, to take it’s place. Or more than one. This whole attitude that “it’s a lot to ask an entire generation of gay men to use condoms forever” sounds like a bunch of entitled whining. Wear the condoms until you’re in a monogamous and absolutely sure you can trust your partner and you’ve both been tested over a period of months.

  24. SAFETY FIRST says

    Herein lies the problem. Too many gay men only concern themselves with “anal” sex and using protection. People seem to forget all of the diseases you can catch from oral sex. This is one reasons why I will never understand why men who are married or partnered with other men, insist on bringing a “third” into the relationship. Or why some men will put their mouths on anything that protrudes. Just as this pill may provide a false sense of security, so does the myth that marriage will make a man monogamous if he’s prone to being a whore. Protection should be used at all times, regardless,

  25. Zlick says

    Seriously, if you’re aiming to prevent all STDs and thus make a damn good habit of using condoms, why take a drug whose side effects are not yet known. Unless you’re aiming only to prevent AIDS, I don’t see any reason to take this pill. (And I don’t see any particular problem with someone aiming only to prevent AIDS, but this breakthrough preventative seems absurd for someone seeking to prevent STDs as well.)

  26. American Dreamer says

    Has anyone else seen a gay hookup website called Barebackrt.com?

    It has almost as many men trolling for sex on any night of the week as manhunt.

    Most are positive or “dont care” but many are negative and just dont care either

    There are literally thousands of men hooking up on a bareback hookup site in New York on any night of the week

    And more people are gravitating to that site from manhunt every day

    I honestly think bareback sex is becoming the new norm in the gay world

    And it is pretty darn scary

  27. kodiak says

    How does Truvada impact the liver? Look at a Truvada ad in a gay rag, then turn the page to find 3 more pages of small type about the various types of damage it can do to your organs, etc.

  28. Douglas says

    Although Towleroad has yet to provide any coverage of this, it should be known that last month a U.S. District Court judge–in response to a lawsuit filed against the FDA by AIDS Healthcare Foundation–ruled that Gilead, the manufacturer of Truvada, may have colluded with the FDA to spin what were its unfavorable drug trial results in such a way that the FDA deemed them sufficient to approve Truvada’s use as PrEP. In other words, based on the experience of the drug trial and the insufficient adherence of its participants to taking Truvada on a daily basis–even when specifically counseled to do so–it is questionable as to whether the FDA should have approved the use of Truvada as PrEP in the first place.

    Linked below is an article from a biopharmaceutical news source that reports on this legal ruling. As it states, absent a successful appeal by the FDA, the ruling has potentially enormous implications for the drug approval process going forward, including possibly as relates to other HIV medications.

    http://www.bioworld.com/content/courts-foia-ruling-could-endanger-trade-secrets-0

  29. John says

    I agree with FiveHT that the conversation reminds me of the dialogue around birth control, but I see it as mirroring the discussions around abstinence-only education.

    We at least all agree that abstinence isn’t a viable solution, but neither is using condom every time forever. Studies have repeatedly shown that significant numbers of men do not use condoms everytime. These are not simply recalcitrant men. The condom every single time approach simply is not a viable solution. Yes, it works for some men. But so does abstinence-only until marriage for some straight people. But that’s not a justification for promoting it as the only method of protection. In fact, it’s irresponsible to do so.

    To complicate things, there is such a stigma around HIV and admitting to barebacking that men simply lie to each other about their condom use. As a result, we can no longer make fully informed decisions about our safer sex. Even if one used condoms every time until he were in a long term commited relationship, the stigma around admitting to barebacking may result in his partner lying about using a condom everytime or perhaps using one of the standard “Safe unless it’s someone I know really well” or “I’ve done it before but it was like 6 months ago” lies that I’m sure we’ve all heard before.

    We don’t live in a perfect world, and not a single one of us is perfect. Demanding perfection is unreasonable. We have to meet people where they are at. To deny access to an effective prevention method for the sake of… what? There’s not even a good reason to favor condoms over anything else because even condoms aren’t 100% effective. Only abstinence is. So we all, by virtue of having sex at all, are placing ourselves at risk. We need to purge ourselves of the morality of condoms only and always mindset. That’s the only way we will ever win this fight.

  30. Paul R says

    I’m 41 and have never worn a condom. I haven’t slept around tons, but I’ve done my fair share—though only anal with maybe 3 guys as a bottom, and all but one (my boyfriend of nearly 20 years) wore condoms.

    I’m obviously not endorsing avoidance of condoms. But I would never have anal sex with someone I just met. Condoms hurt me and have killed my erection on the two occasions I’ve tried putting them on. Not being incredibly slutty and knowing who you’re sleeping with are good ways to lower risk.

    I’ve messed around with maybe 50 guys and only had chlymidia and crabs, and those were both bad enough to teach me how to avoid HIV. (And I know who I got those from, and it wasn’t a surprise.) I can’t understand not caring about it, but I know that many people won’t understand my seemingly cavalier attitude. Anal sex is a lot of work, and most guys aren’t worth it. I also seem to only meet guys who are exclusive tops, which is funny for someone living in San Francisco but incompatible with my current tastes.

  31. Zeta says

    “99% effective when taken as directed”

    Then the next sentence

    “studies have been taken since the 1980s that show that gay men as a whole consistently only use condoms about half the time,”

    Humans are stupid and can’t be trusted. You don’t make them take a pill. You make them get the equivalent of Depo Provera. And when you screw said person, you use a condom anyway because people lie.

  32. Hagatha says

    Great! They have a drug which helps prevent HIV. .Have you all forgotten that certain hepatitis infections kill some people quickly and others slowly?

    Seriously people, when you want people to “be realistic” aren’t you actually saying “Let’s accept that people take unnecessary risks because they aren’t willing to limit the number and quality of their sexual partners? Oh, I can hear Kiwi screaming already, yes I said “quality”. Let me define it for you. A quality person takes care of his health. A quality person doesn’t knowing put someone else’s life at risk. A quality person doesn’t say, “Well l don’t think I have a duty to disclose, it’s everyone’s duty to protect himself.”

    Selfishness, lack of consideration, dangerous behavior, lying, and putting others at risk are not qualities.

  33. will b says

    What’s so difficult about using a condom? I like being alive. And healthy. I’ve definitely kicked people out of my apartment who wanted to bottom without. Half of my friends died between 1988-1998. Did we forget so quickly? And this Dr. John is an idiot – “condemning” people to using condoms for a lifetime? How is that good medical advice? Just don’t get it.

  34. evan_la says

    Will B said it.

    Almost my entire circle of friends died in the 1980s and 1990s too. I was right there with them and I miss them every single day.

    I’ll be treating everyone I have sex with as if they are HIV+, I won’t be using Truvada, and I will be using a condom.

    You all do what you want but there won’t be any bare-backing in my bed.

  35. andrew says

    From other articles and studies that I have read about Travada that 99% effectiveness in preventing the transmission of HIV is not accurate. Check with a study by Dr. Fauci’s Institute. I believe they found that among MSM (men who have sex with men) who take Travada everyday there was a 73% decrease in the rate of infection. That’s great news, but I don’t think it means you should throw away your condoms.

  36. Louis says

    All you need to know about this article about this miracle drug is that it’s star witness is a “gay 40-something well-known New York City doctor with many gay patients” who won’t stand publicly, (as a medical expert with ‘many gay patients’) for what he is advocating. If, as a doctor, he can’t associate his good name with this method of HIV prevention, then one should have serious pause about taking his advice or following his example.

    On the off chance that “Dr. John” is a complete fabrication, which I think he is, that is a whole new level of serious pause to be given to this testimonial which reads like a big pharma print ad.

  37. Delicious says

    LOUIS – you hit the nail right on the head, the article is a propaganda and advertising piece, and we should be freakin’ DEMANDING full freakin’ DISCLOSURE from the publisher of it.

    OUT.COM is unquestionably UNETHICAL, and acting as a PAID MOUTHPIECE for the drug companies.

    Which begs the question – CAN you trust ANY “gay” media outlet to behave in an ethical manner, to fully DISCLOSE their financial interests, and to objectively report on ANYTHING ?

    TW is just a regurgitation site, so Andy is off the hook. Still, I can not help but wonder how the hell he can sleep at night when he presents this stuff as “news aggregation” when some of it is really just pure manipulation and lies presented as journalism.

  38. Woah says

    Douglas posted a link that I think everyone needs to check out : http://www.bioworld.com/content/courts-foia-ruling-could-endanger-trade-secrets-0

    Also, TW has reported this int he past :

    http://www.towleroad.com/2011/04/african-study-of-aids-prevention-drug-truvada-halted.html

    Now, how the hell is it that Truvada went from 44% effective in men to 99%, and so entirely ineffective in black women that the trial had to be aborted early ?

    With sites like Manhunt and OUT pushing this, and non-profits suing the FDA for essentially lying and hiding the proof that it works at all, where IS the outrage ?

    And what about ACTUP and other “AIDS activists” who are pushing this ?

    WHEN ARE WE GOING TO DEMAND FULL FINANCIAL DISCLOSURE FROM ALL THESE PEOPLE ?

  39. Gestly says

    I currently take Truvada, not for Prep, but to suppress hep b (fornwhich it is very effective). A few observations:

    — Truvada is not a “pleasant” drug to take. It causes nightmares and has other psychological effects.

    — Truvada is kidney toxic. Over 3 years, 33% of users have significant kidney damage.

    — Truvada is expensive. It is simply not available to those without great insurance.

    — Truvada is only 50-55% effective at blocking HIV infection. Using Truvada as the only method of HIV prevention is playing Russian roulette.

  40. FakeOutrage says

    God I am so sick of having to listen to gay men go to any lengths to continue the campaing of rampant promiscuity and anonymous sex, barebacking etc. And of course, everyone wants free healthcare to pay for HIV meds that they feed the government owes them, because we should be free to do as we wish without any personal responsibilty…it really is enough to make your turn republican sometimes. Ugh. We NEVER learn….

  41. Duke says

    The CDC has gutted the programs that educate people about the effectiveness of condom use and fast tracked this drug ?

    What is wrong with this picture ?

    Something about this stinks to high heaven.

    Why do so many of us need this ? I mean the whole thing, why do we need to make these stupid mistakes and suffer so much so unnecessarily ?

    WHY ? WHY ?

  42. Jack M says

    Why would somebody take medication if they didn’t need it, even as a preventive measure? So, they can take a pill but they can’t be bothered to put a cap on their dicks? How self-indulgent.

  43. Epic says

    Propaganda or not, no one should be taking Truvada without an active infection that Truvada is effective against. PrEP for the sake of it is dangerous, the side effects are serious and the chance of not working vs. using a condom makes almost no sense…do you understand how expensive this drug is? And you still have to use condoms, it’s not a free pass…having a population of people throwing around antiretrovirals like we did antibiotics will lead to one thing, a Truvada resistant strain…then where do we go? We did it with MRSA, VRSA, C-Diff., Drug Resistant, some our most powerful first line treatments for fighting infections cannot be used like this and there be no consequences. Until there is a vaccine prophylactic use of antiretrovirals is as bad as taking antibiotics to treat a flu…you are going to make it worse for the future plain and simple

  44. Wakefield says

    PrEP is for people who really want another tool in the arsenal of fighting HIV. Follow the science, it is clear on how to use the currently available PrEP meds. The good news is research continues on the best ways to get this to those who need it most and ways to build on the knowledge we have to get us to the next generation of fighting HIV – a virus.
    I for one am glad for a phone that works so much better than the one in the hall of my parents home 50 years ago I have also had the pleasure of sexual encounters with men who care about themselves and each other enough to know their HIV status and do everything they can to keep having fun with a variety of partners.
    Sure I wish there was better condom technology, I am hopeful that science will find a cure. I also know that for today I want to be with people whose desire for freedom and intimacy is fueled by passion and guided by science.

  45. DW says

    It’s awfully convenient for Gilead: a vast new market of men dependent on its expensive drugs long-term. If some of the guys slip up and get infected, so much the better for the bottom line. (So they cover their *ss by printing a warning that you have to use condoms when taking Truvada. Sort of like the liquor ads telling you to drink responsibly. Or poppers bottles that say it’s a video head cleaner).

    Don’t get me wrong — every tool in the fight against HIV is welcome if used correctly, but Big Pharma is not our friend. It has huge influence on the FDA and many of the major AIDS advocacy groups on its payroll. Follow the money.

  46. DoogieDC says

    “I believe they found that among MSM (men who have sex with men) who take Travada everyday there was a 73% decrease in the rate of infection.”

    In the study of positive/negative couples the people taking Truvada were 73% less likely to acquire HIV. Both groups were advised to practice safe sex.

    However they also analyzed blood samples to monitor whether the medication was being taken as directed. If you eliminate the people in the Truvada group who did not take the drug as prescribed, then the improvement is 99%.

  47. Jo says

    Um, hello? How much does this Truvada stuff cost per year? How many of us have $8000 lying around annually we haven’t got a more pressing use for?