What an HIV Prevention Pill Means for the Future of Gay Sex

The science, at this point, is ironclad: If taken daily, pre-exposure prophylaxis (better known by the acronym PrEP, or the brand name Truvada) is 92 percent effective at preventing the transmission of HIV.

Although only a small sliver of the population is currently on PrEP—a 2014 study drawing on data from about half of all American pharmacies found fewer than 4,000 prescribed users—it is a key component in New York Gov. Andrew Cuomo’s plan to end AIDS in his state by 2020. The Centers for Disease Control and Prevention have recommended that any gay man who has had sex without a condom in the last six months go on PrEP, while the World Health Organization has gone one step further, suggesting that all men who have sex with men should at least “consider” going on PrEP.

If these groups are able to marshal the resources to back their rhetoric, it seems likely that within a few years, a majority of America’s gay and bisexual men will be on some form of preventative HIV treatment. That means we may be standing on the verge of a major drop in new HIV infections—the first since 1990. This begs the question: Who are we without the AIDS crisis? Even if all new infections stopped today, AIDS would be a constant throughout our lifetime. But the crisis—the cavalcade of deaths and new infections that has for so long seemed unstoppable—can be ended.

Thanks to PrEP, “we have an unprecedented opportunity to fully live life politically, socially, and sexually empowered” for the first time ever, said Damon L. Jacobs, founder of the highly active Facebook group PrEP Facts: Rethinking HIV Prevention and Sex. Offline, Jacobs is a licensed psychotherapist and a PrEP user himself. He believes that PrEP is moving us into a post-fear moment in which gay men can focus on broader issues, such as general mental health and well-being.

For the first time in 30 years, Jacobs said, gay men have a chance to break the association between sex and death that was created by the AIDS crisis. He hopes this comes with a reduction in stress. Without this fear and pain, “you open up the floodgates for opportunities for people to relate and have intimate connections,” he said.

PrEP is the wave of the future, Jacobs believes, because it works, and nothing else has—though he is quick to emphasize that he sees it as one tool in the arsenal. When asked how he can be so sure that gay men will embrace PrEP, Jacobs recounted his time working on HIV vaccine trials, and how excited people were by a 30 percent drop in infection rates reported by a Thai study in 2008. “And now we don’t have to settle for that!” he said.

As for people who suggest we’ll see a drop in condom usage thanks to PrEP? “They got the order reversed: People already stopped using condoms,” Jacobs told TakePart, pointing to a 2014 CDC study that found only 16 percent of gay men reported using condoms consistently over the previous few years.

Peter Staley, the longtime HIV activist who was one of the protagonists of the 2012 documentary How to Survive a Plague, sees it somewhat differently. “Will there be people who are wearing condoms 100 percent of the time who go on PrEP and stop wearing them? Yes,” he said, point blank. If studies aren’t showing this yet, that’s because they’re recruiting men who are already unlikely to use condoms.

To get PrEP, an individual must visit a health care professional quarterly to be screened for sexually transmitted infections. Jacobs sees this as a good way to get more gay men connected to preventative health care. But Staley thinks this requirement will keep PrEP from ever being widely effective. He’s particularly concerned that the most vulnerable members of the gay community—young people, people of color, those who are low-income, transgender gay men, those who are not out—are the ones least likely to be able to go on, or stay on, treatment.

Jacobs believes these issues highlight the work that remains to be done, but he doesn’t agree that PrEP won’t work because of them. “We’ve never done this before,” he argued, and he’s concerned that there’s a thin line between worrying about these issues and turning PrEP into a self-fulfilling prophecy of failure.

But Staley’s big hope for PrEP lies in exactly these discussions, not in the drug itself. “It’s the first issue I’ve seen in decades that has gotten gay men talking about HIV again,” he said. Thanks to the level of nuance it requires to understand PrEP, these conversations are including things such as viral loads, undetectable status, treatment access, and other issues that go way beyond the usual warning to just “wear a condom.”

Not only could these discussions help prevent new infections, but Staley hopes they might make the lives of men who are HIV-positive easier as well. “You hear these [HIV-negative] men proudly stating their willingness to sleep with men regardless of their status,” he said, describing online and real-life gatherings of men on PrEP. “It can’t help but start breaking down that stigma, allowing positive guys to start becoming public about their status.”

For Ian Bradley-Perrin, an HIV activist, these discussions are part of the problem. “It’s bringing HIV and AIDS back into the conversation,” he said. The real boom in PrEP usage will come, Bradley-Perrin believes, with the next wave of PrEP drugs—ones that act more like a quarterly shot than a daily pill. And he believes anyone who wants these treatments should have access to them.

Bradley-Perrin is worried that PrEP is a powerful drug overlaid atop a broken health care system, and that the people it will help the most are those who already have access to the best kinds of treatment and the most support—namely, HIV-negative, white, upper-middle-class American gay men in liberal urban areas. He points out that Truvada is also a drug taken by people who are HIV-positive to control their viral load, and wouldn’t it make more sense to focus on getting this treatment to them?

“There are fewer people living with HIV than there are men who have sex with men in the world,” he said. By helping these people get access to treatment, he argued, we would still see a drop in new infections while simultaneously helping those who are the most affected by the crisis. As someone who studies the intersection of HIV/AIDS and health care policy, Bradley-Perrin also worries about how PrEP will be implemented. He predicts that some states (like New York) will try to provide it cheaply, while other (poorer) states won’t. Distribution and access will mimic—and exacerbate—existing inequalities in our country.

Maybe, some PrEP advocates say. But even so, isn’t more people getting treatment a good thing?

For now, these conversations are not going away, and they’re likely to get even louder as PrEP becomes better known in the mainstream straight world. PrEP is and will remain the current face of the AIDS crisis—at least until a cure comes along.