Why Are Gay Men Resisting PrEP?

Truvada

Despite the proven effectiveness of taking a daily Truvada regimen as a form of pre-exposure prophylaxis, or PrEP, there is a slow uptake of the drug in the gay community, and even a hostile resistance from some segments. The reasons for this seem to come from multiple fronts:

  • Some gay men are met with negative reactions from others, including their own healthcare providers as well as other members of the gay community who throw around the term "Truvada whore" as a form of slut-shaming
  • A general lack of awareness of what the drug does, or even that it exists as a preventative measure
  • The rare but serious side effects of kidney damage and bone density loss
  • The cost, which can top $1000 per month without medical insurance

In the meantime, HIV infections are on the rise in the U.S. with approximately 50,000 new infections annually and over 57% of gay men reporting having unprotected sex, quite likely as a result of "condom fatigue." Incidentally, during trial studies there was no noticeable difference in the level of risky activity engaged in between men who believed they were on Truvada vs. those who believed they were on the placebo.

Plus, there is a generational shift in attitudes as younger gay men are coming to know HIV as a manageable disease, having not experienced the utter devastation it wreaked in the 80s and 90s.

Still, doctors remain hopeful and the drug regimen itself is likely to undergo drastic changes in the coming years, including changing the administration method to something like gels or injectibles as well as a less-frequent dosing. Said Dr. Mayer of Fenway Health. “It’s going to take time. It’s really early days.”

Comments

  1. MIke says

    Who believes someone would resist taking this for fear of being called a “Travuda Whore” rather than the most obvious explanation (welcome to the real world) that insurance companies and Medicaid are NOT going to gladly cover it unless pre-authorization is required (a partner with HIV, for example) and that “being tired of condoms” isn’t going to get you free medication at the expense of your insurance company or the public.

  2. qj201 says

    “I’m on the pill”

    How many daddy’s have heard that one?

    Yes you are a Truvada whore if you are taking PrEP explicitly so you can run around have unprotected sex with complete strangers

  3. Gregory In Seattle says

    As an HIV educator, I’ve asked why Truvada has not come into wide use. A great many people would LIKE to get it, for a variety of reasons, but very few can get it because of the cost. The cost must come way down, and be covered as a prescription by insurance plans, before people will be able to use it.

  4. J says

    My insurance (blue cross) covers Truvada for PrEP, my monthly cost is only $15. I’ve had no side effects. I practice safe sex, but condoms aren’t 100% safe, can break, or there could be other problems, and so I feel like having this extra level of protection is worth it.

  5. Joe says

    I think it’s highly disrespectful to the countless gay men who fought and who died in the 1980s and 1990s to even just have a pill that would SAVE THEIR LIVES. Why isn’t their a cure yet? HIV researchers have failed at their job. They should all be fired and never receive another drop of federal research money. They should not be hailed as hero but as failures. PREP is a cop out by the researchers who failed to come up with an effective vaccine and/or cure.

  6. mEis says

    Maybe because truvada does NOT protect from syphilis, ghonorrea, herpes, HPV and such other amenities? So it still might be quite better wrap oneself up before casual sex?

  7. Graphicjack says

    I think it mainly comes down to the cost, but here’s another reason why I think PreP is not for me or many others. Why take a daily pill which you may forget to take from time to time when you aren’t necessarily sexually active on a daily basis and even if you are, you may not always be having penetrative sex. I’d rather use a condom for the times I need them, which as others said protect me from other STIs, than have to take a damn pill, with serious side effects, every day.

  8. Anonymous says

    Some of us aren’t taking it because when we mentioned it to our doctor, they looked horrified and gave a safe sex speech and talked about the “danger” of taking a pill daily… and said they woudn’t prescribe it

  9. Sean Maloney says

    Um, I dunno? Condoms are cheaper? Um, who knows what a drug will do to your liver and kidneys after having taken it for more than 10 years? I’m not sick so why would I take a drug, anyway? The drug manufacturer is not rich enough? It’s just more profitable to keep people on the precipice of catastrophic illness, than to find a cure, actually? Etc., etc., etc.

  10. Gerry says

    I also checked my insurance cost. The drug is in the formulary, and no pre-authorization is required. The cost would be $400 / year. The insurance companies would rather pay for Truvada than incur the cost of an AIDS patient. I think it is great that this option is available. I can’t imagine anyone using the term Truvada whore or whore for that matter, and if they did that would just reflect back on them as being an ignorant fool with sexual hangups. Regarding the comment about the doctor looking horrified… time to get another doctor for obvious reasons. That is highly unprofessional behavior. Doctors are suppose to heal, not to judge. For the comments about people without health insurance… according to the law now, you’re suppose to get it. Logon to healthcare.gov and sign up. Oy vey!

  11. MD says

    All drugs have side-effects. Why would you be insinuating that we all should be taking this? How about always wearing a condom (a lot of the young ones are into some sort of bareback craze), not doing drugs that kill your common sense, and not having to sleep with a different guy every week? Much more sensible options but no, let’s pop a pill for horniness.

  12. anon says

    Outside of being in a relationship with someone you know is HIV+ and also know doesn’t have any one of a multitude of other STDs, using this pill does NOT eliminate the need for using a condom.

  13. florida says

    My doctor actually brought the topic up. I have given it a lot of thought and have decided to decline. While my health insurance will cover it with a small co-pay, I have always practiced safe sex and know myself well enough to realize that it might cause me to let my guard down. (Truvada whore?)

    Of course if I had a positive partner, I would probably go this route.

    I also asked the doctor a question that he didn’t have an answer for…and that was, “If I use Truvada for a number of years, will this affect the options for future treadment should I seroconvert?”

  14. says

    And the side effects from using a condom every time are…

    I think I’d choose the option without side effects, thank you.

    But I have no problem if others in different situations choose to go this route.

  15. JoshG says

    “Plus, there is a generational shift in attitudes as younger gay men are coming to know HIV as a manageable disease, having not experienced the utter devastation it wreaked in the 80s and 90s.”

    Then we’ve failed to educate them properly.

    This is the same sort of attitude which existed before the epidemic.

    Got an STD? Just run over to the clinic to get a shot or a prescription.

    Just another time bomb ticking away.

    But, hey, everyone has the right to choose how they live.

    Candidly at this point if another epidemic broke out, I’d probably sit this one out. Men can make their own choices and engage in whatever activity they like.

    But if a new HIV/AIDS appears, my basic attitude would be “clean up your own mess”.

    I would probably turn my back. Already gave at the office.

    That would be my choice.

    And people are crazy to think that risky sexual activity won’t lead to more trouble. It is just a matter of time.

  16. Douglas says

    Within the gay community itself, this risky and unnecessary drug is mostly being pushed by the bareback brigade–among them so-called HIV prevention activists–the majority of whom couldn’t even keep themselves negative. Take a wild guess why that might be the case.

  17. NY2.0 says

    Is it really that hard for them to figure out why gay people aren’t rushing to get Truvada? Are they that dense?

    No way and I mean, no way am I ever going to fork over $1000 a month for a drug when I don’t need it. I rarely engage in anal sex and when I do it’s always with a condom.

    To each there own, but I’m still relatively young. The thought of popping a pill everyday for the rest of my life while potentially doing damage to vital organs is not quite appealing. I’m sure the pharmaceutical companies will do just fine without my $1000 a month.

  18. andy says

    Enough with this BS! I’ve never heard the term “truvada whore”. It’s completely made up to drum up sympathy for PrEP proponents and discredit opposition. Then there’s this constant narrative of the ole geezers who just don’t get it when people bring up valid concerns. Like 90% of people aren’t adherent, doesn’t protect against other STIs, can cause a drug resistant strain of HIV, that the FDA approval was the result of collusion with Gilead..

  19. says

    The comments do a better job of explaining the obvious reasons why gay men would resist such a drug than the post does. For some people, taking an expensive drug with unknown long-term side effects may make sense, depending on their personal risk levels and comfort zones, but for many of us, there are better ways to stay safe than popping an unnecessary pill. The better question would be: Why would someone choose to take this?

  20. andy says

    Why was this exact article supposedly written by David Tuller in the NYT but here it’s by Christian Walters? In fact, these stories come out in spurts and hit all the publications with nearly identical wording, just like a … press release. That’s all this is isn’t it? How much did Gilead pay Towleroad for you to run it?

  21. shibby says

    The comments do a good job of explaining why gay men are resistant to it in addition to exemplifying the hostility towards those who would choose to take this option. It faces the same stigmatization women face when taking the birth control pill. That they were even surprised women were more willing to take it (in the original article) speaks to their lack of understanding of the population they are targeting.

    I applaud them for trying to get another method of HIV prevention out there – more options are always a good thing. But it’s hardly a viable option for many people. The cost alone makes it incredibly prohibitive. When they’re able to make it more easily accessible and affordable, then we can celebrate.

  22. Sam says

    People seem to be missing the point here, which is that 57% of gay men are NOT using condoms even without Truvada. So why wouldn’t you take it if you are not going to use a condom anyway to try to prevent HIV infection? This is not really for people using condoms on the regular, so stop yelling, WHY NOT JUST USE CONDOMS? Obviously some people just don’t – whether you think that is sensible or not.

    The Truvada whore thing is a bit strange. Who would know you are even taking it? Are you running around saying, I’m on Truvada? I don’t talk about my general medications to many people on a daily basis.

    I imagine the cost is the issue. And once again, we live in a healthcare system that mostly ignores preventative care. You can be assure health insurers are running the math to try to figure out if it is cost effective to provide this drug cheaply.

    That said, I agree with the sentiment that I prefer to not take a drug for preventative purposes. And will continue to use protection to avoid other STDs. But I also recognize I am not the target audience here.

  23. BrianChicago says

    A better question is why is the a NY Times acting as a shill for the drug companies?

    Noting that studies prove that PrEP is not failsafe; depending on the study it may be as low as 67% effective.

    As sometime in my early 30’s when I was a kid it was all about condoms; whose effective rate is in the 90’s percentiles.

    Also growing up the ideas of personal sexual responsibility was instilled in us. We also knew that if you want to bareback and are in a monogamous, trusting relationship after 90 days you go get tested together and, if your both hiv- and std-free, as long as the trust and monogamy continues you can safely bareback.

    So many of my friends, and I’d argue the community in general,don’t understand the period that an HIV test covers and the time it takes for the virus to mutate to show up on the test. When you get your results it doesn’t mean you’re free and clear if you had unprotected sex in the weeks leading up to getting tested.

    Getting tested used to be an imperative and today getting tested seems to have become the exception not the rule.

    I’m not opposed to bareback sex. I am uncomfortable with the idea of taking a medication that is not completely effective (especially if one doesn’t take their pill every day, miss some doses and the effectiveness drops significantly.

    Frankly, in a country where in 2012, the pharmaceutical industry spent more than $27 billion on drug promotion, one must wonder does putting toxic drugs in your system when you don’t need to are you really benefiting long term or are the pharmaceutical companies benefiting with a medically unnecessary drug that adds countless millions to their bottom line if their marketing convinces you to become a customer?

    Instead of promoting a drug with widely varying results it would be more beneficial to the community to educate people on what it means when you get tested and are hiv- and most importantly make getting tested an imperative in people’s minds.

  24. Paul R says

    I’m fairly ambivalent about Truvada, but some commenters need to remember that every drug has the potential for side effects. Some people will die if given ibuprofen. So yes, there are risks with every drug, but they’re usual minimal.

    What I find far more disturbing is that a huge number of Americans take psychiatic medications (usually for depression) given that drug companies admit they have no idea how they really work, why they work on some people and not others, and why some of the side effects are so severe. Doctors hand out scripts for them like candy, and people really don’t know what they’re getting into by taking them.

  25. The Milkman says

    I took Truvada for a while after an occupational (health-care) exposure. I never had such horrible diarrhea. It was truly terrible. And the fear of developing resistance if I missed only one dose, plus the enormous cost… I can understand why many don’t take it prophylactically.

  26. ORWELLISDEAD says

    If I have to see this xeroxed press release masquerading as original editorial in one more publication I’m going to scream. I have read it at least ten times now – with more or less the same title and tellingly similar content, tone and phrasing – when it has run in the New Yorker, the New York Times, the New Republic, Huffington Post, Out.com, The Advocate, HIVPlus Mag and others over the past three months. It’s common for press releases to be reshaped into editorial, but editorial staff usually try a bit harder to disguise the original material. Maybe it’s the busy-ness of the holiday period. Interns?

    In any case, to answer the question raised in the reused title this time around, I would say much of what my peers have said already in the comment thread above, but add that asking HIV-Negative gay men who are happily using condoms if they need to and staying negative without too much worry just as we have done for decades now in some cases is quite bemusing. We don’t not *want* the medication as much as we simply don’t *need* it. Bear in mind that gay men have shown throughout the epidemic that if they need or want something – new medication, various other related changes – they’ve asserted their need for it and pursued it most aggressively, risking arrest in some cases. Why isn’t that happening this time around, with Truvada as PrEP?

    If gay men wanted this, they would go after it with enthusiasm. Instead, a thorough lack of interest is apparent. Maybe one of the team of rewriters of this press release can disingenuously ask that question next.

  27. ORWELLISDEAD says

    And, I’m with Andy: Who has ever seen the term “Truvada Whore”? I have never seen that phrase, not once. At least get it right, if you’re going to reprint it 500 times in multiple publications.

  28. Hansel Currywurst says

    @Milkman — You can’t develop resistance to a virus that you don’t have. You can miss all the prophylactic doses you want (go on/off prophylaxis whenever you wish) and it doesn’t matter at all UNLESS you HAVE been exposed — which you might not know — and the exposure hasn’t died-off yet.

    If you’re a serial virgin ask your physician how long you should wait after each exposure incident before you can discontinue the drug.

  29. Bill says

    @Bill (I’m a different person with the same name): the use of a preventative drug and the use of a condom are not mutually exclusive. Some people may choose to do both.

    BTW, one advantage of using the drugs for prevention is that, with a much larger customer base, the cost of the drug should drop substantially – aside from the rumored obscene profit margins, the cost beyond the manufacturing cost includes the R&D to develop the drugs the FDA testing to show that they are safe and effective.

    @Hansel: don’t forget that it not just whether you are a “serial virgin” but whether your boyfriend “grazes in other pastures” (to use a quaint euphemism).

  30. Bryan says

    Why would I want that pill when for the cost of the pill, I could buy like a bajillion condoms, which while not a 100% are still pretty darn good and I’m not one of those people who “just can’t feel anything with condoms on”

  31. Bill says

    @Bryan : the answer to your question, assuming the cost is not a show stopper, is that if condoms are 99% effective and PREP is 99% effective, then both together are 99.99% effective: instead of reducing your risk by a factor of 100, you get a factor of 10,000. You can plug in the actual numbers for the effectiveness of both – I was just illustrating what happens given statistical independence.

    Also, if everyone, or at least a lot of people, cooperate to reduce their risk, the end result is that the chances of finding an infected partner go down as well.

  32. andrew says

    Condoms are inexpensive ( free at many LGBT Centers and Health Clinics etc,). They are even more effective in preventing HIV infection and they also protect against other STDs. They carry no risk of Kidney damage or bone density loss. You can even come up with some creative foreplay in putting on the condom, not so much pill popping.

  33. GregV says

    To say that “57% of gay men reported having unprotected sex” is an oversimplification of the findings.

    7 out of 8 of the HIV-negative gay men reported having no “unprotected discordant anal sex at last sex.” That means 7 out of 8 of the healthy group had either no anal sex at all ( at least on the last occassion they had sex before the question was asked) OR did so only with a condom OR did so without a condom but with a partner whose status they are sure is negative.
    Among those who were unaware that they had turned HIV-positive, on the other hand, 1/3 had had “unprotected discordant anal sex.” This group (those newly turning HIV-positive) was far more likely to have taken this risk than either HIV-negative men OR HIV+ men who knew their status.

    There are very big likely reasons that PrEP is not being widely adopted. There are already inexpensive and even free ways of remaining uninfected that entail no health risks. Why would someone who is not already taking those easy measures spend potentially more than it costs to buy a house for a riskier preventive measure?

  34. Mark says

    How pathetic and sad that the “debate” here is between one group of men that put themselves at high risk of viral infection and want to manage this risk by ingesting a toxic drug and a second group of men who also put themselves at high risk of infection and who want to manage that risk with a rubber contraceptive device.

    Here’s a better solution. Stop living a life structured around decades of loveless sexual encounters with large numbers of partners you don’t know. It doesn’t work and you have to work harder and harder as time goes on to ameliorate its toxic effects.

    No other group the world lives like this. While some heteros sow their wild oats for a time in their teens and 20s, very few do it for decades or a lifetime.

    If you spend your life hooking up with people for whom you don’t care and who care nothing for you, you stand an excellent chance of having a life marked by depression, anxiety, loneliness, substance use or abuse, STIs, suicidality, and a shortened life span. That will be true even if you never acquire HIV. By contrast, if you can structure your life around relationships characterized by stability, commitment, kindness, and love, you will get the opposite results on average. It doesn’t have to be marriage or 1950s conformity. But it has to have these 4 features, which every human being needs.

  35. BrianChicago says

    @Bill you wrote:
    “if condoms are 99% effective and PREP is 99% effective, then both together are 99.99% effective: instead of reducing your risk by a factor of 100, you get a factor of 10,000.”

    Unfortunately if one examines the multiple clinical studies of the effectiveness of PReP it is clear that not one found the drug to be 99% effective, in fact more than one study determined that, if taken properly, it is only 60-70% effective.

    You know what PrEP is effective at doing? Getting the user comfortable taking one pill every day so that if/when he contracts HIV it won’t seem like such a big deal to them.

    I’d encourage folks reading this to search YouTube for the Abilify commercial currently airing nationally because it is a great representation of the fact that the pharmaceutical industry cares more about your money than your health.

    Prescription drugs shouldn’t be pitched to people the same way an advertisement/commercial for a car, clothing label or fast food tries to instill a sense of want and need in the viewer. Medication is something that, based on one’s symptoms or test results that your doctor should suggest to you, not the other way around.

    When the patient is the one pushing his doctor to prescribe him medication that is not only medically unnecessary but toxic and unproven to be absolutely effective, then the only person to blame, if while taking PrEP you become infected, is yourself. But in a country that in most States an HIV positive man, who is honest and upfront about his status, can be arrested and go to prison for the decision made by a sexual partner; I think it’s clear that the only people that will be blamed for the ineffectiveness of PReP will be their doctor and the drug company…

  36. Marc Paige says

    There are side effects for gay men using condoms for anal intercourse: you won’t get HIV (unless you share needles); you won’t get anal transmission of gonorrhea or syphilis or chlamydia; if the condom covers the skin where an HPV or herpes lesion is present, you greatly lessen the chance of passing warts or herpes. How about this guys – use condoms when you’re having intercourse with a person of unknown HIV status!

  37. JC says

    After reading what little there was about Truvada I began taking it two months ago. My doctor is supportive and it is covered by my insurance. I am single and don’t have a lot of sex but you can’t always be sure and I wanted to be as close to 100% in control of my health as I could. I took it every day but even as a very structured individual it was not always easy to remember. I did not notice any obvious side effects and my follow up series of blood tests were all in the normal range. That being said last week I decided to discontinue use for now as I am not sure that I want to take a pill every day until there are more studies on the effectiveness, side effects and long term use effects. I am also waiting to see whether other countries approve Truvada for preventive use. I did share my Truvada experience with a few friends and acquaintances and was surprised by the lack of knowledge, misconceptions and judgements.

  38. Mark says

    I am a 43 year old and in the healthcare industry. I have been having safe sex with a condom since I came out at 20 and used to be one of those judgemental gays, who would say well,we should always use a condom, well after 20 years of making very few mistakes I have started to make a few and I am very happy that I have been on Truvada for almost 2 years now. I have not missed one dose yet. I was in one of their first studies.
    These are the facts as outlined by the lead Researcher, Dr. Grant.
    1. You have to test Negative before Starting Prep and then get tested about every 3 months to make sure you are still Negative.
    2. Resistance is highly unlikely if you remain HIV negative while on Truvada.
    3. Dr. Grant has not seen a gay man infected with HIV to date who has taken Truvada daily.(He actually told me this via email)
    As I stated I am 43 and have always been into guys my age or younger and I have a very active sex life and let me tell you that the majority of younger guys I sleep with are not using condoms and when I bring them up, most are not interested in using them. They just did not see what I and peers my age have seen.
    Insurance companies will cover Truvada, it is simply not true that they will not cover it, yes the copayments vary and can be high, but they are covering this drug. My copayment is 175.00 for a 90 day supply which is not bad, that said the manufacturer of Truvada will cover the copayment!
    You just have to call Gilead at 1877-505-6986, tell them that you want to start Prep and they will send you a card and then they pay for your copayment.
    Also for the record I have had no side effects from day one and most side effects if any go away within a month. My kidney function is checked regularly and are doing fine.
    So many misconceptions going around about Prep that it makes me upset.
    I say if we have something else in the battle against HIV that we have the right to choose to use it or not, but with the majority of younger gay men not using condoms regularly, lets give them this option and other older gay men who are sick of using them all the time and lecturing younger people about condom use.
    and Yes I get checked for other STDs regularly, fortunately the majority of them can be cured with a shot.

  39. Buster says

    WOW!!! So many many judgmental people here, even more than I would have supposed.

    Gentlemen: There is nothing wrong with men who decide to have sex with many different partners. It is a natural impulse. It is fun. It can transmit, BUT DID NOT CAUSE AIDS or any other STDs. It is not inherently evil or disgusting as some of you seem to think.

    If you find yourself thinking that such behavior is immoral or “whorish” or dirty, maybe it’s time to revisit your childhood (preferably with a good therapist) to search for what religious or family voices are in your head telling you that something is bad about enjoying your body and exploring your desires with whatever partners you want.

    This is not to say that everyone should have lots of sex, of course. There are lots of reasons, including just one’s own preference, to live a less “wild” sexual life. I myself am married and only rarely have sex with other men than my husband. And it’s fine to advocate strongly in favor of safer sex behavior to help protect all of us.

    But don’t you DARE tell other men that there’s something wrong or bad about them just because they enjoy multiple partners. THAT’S classic internalized homophobia and if you can’t get rid of it, you should at least just keep it to yourself and let it fester away at your own life.

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