Michael Lucas has been taking Truvada, the HIV prevention pill, for about a year now. And the 42-year-old adult film director and gay porn performer readily admits that the decision wasn't all that hard to make — especially when compared with the alternative. "It just seemed healthier to run the risk of experiencing side effects than to worry about HIV," he says, adding "I come from a generation where people were dying all the time, so I grew up living in fear."
Lucas is part of a small but growing subset of HIV-negative gay and bisexual men who have embraced Truvada, the most widely used incarnation of an HIV preventative drug regimen called PrEP. The little blue pill, which is taken daily and costs $13,000 a year (but is covered by most insurers), helps reduce infection rates by more than 90 percent. But until recently, only a select few were aware of the drug's existence as an HIV preventative. The US government's announcement last week that it was urging physicians to prescribe PrEP to anyone who might be at risk for HIV infection — not just men who have sex with men who might be HIV positive — therefore came as a surprise.
"Soon every gay man will be taking this drug."
"If broadly followed," The New York Times wrote, "the advice could transform AIDS prevention in the United States." Slate took a less nuanced route, referring to the pill as a "miracle drug." But Lucas is even more adamant about the drug's HIV-eradicating potential. "We are there now. This is the breaking point," he says. "Soon every gay man will be taking this drug and we won't have HIV spreading any longer — it'll be over."
These statements are both beautiful and revitalizing — a tone that is, unfortunately, rare in the media's coverage of HIV prevention. But in their rush to embrace a preventative method that is indeed remarkably effective, many missed an opportunity to move the conversation surrounding Truvada forward.
Beyond the guidelines
"We know that the medicine works, it's proven," says Jay Laudato, executive director of the Callen-Lorde Community Health Center, which provides healthcare to New York City's LGBTQ communities. "But what was shockingly missing from the government's announcement was ‘how do we integrate this drug into peoples' lives?' and into HIV prevention plans in general." He thinks the drug is a good fit for some people, but Laudato says it's not right for everyone who might be part of an "at-risk" group.
Where will homeless kids keep a bottle of pills?
People who take injection drugs, for example, might not be able to take the drug every day. "If you're in the throes of substance use, you might not be a reliable person to receive a medication that requires daily adherence." And Laudato wonders where the homeless kids that frequent the center, many of whom partake in sex work, might keep a bottle of Truvada. "If you're someone who has a job, and you understand the risk of side effects, then that's great," he says, but the question that health care providers have to ask themselves is "how do we make the right use of this potent tool and administer it to the people who need it the most?" — meaning to those who dwell the places where HIV is most persistent.
Emma Claire, an HIV harm-reduction counselor and porn performer, voiced a similar opinion. "I think PrEP is a great option, but I don't think it's the solution," she says. "I don't think anything is a solution, short of a vaccine against HIV." Claire thinks that education should remain a priority. People should be aware of all the ways they can protect themselves against HIV infection — including PrEP. "People want options and that's fine," she says, "but you aren't going to see a decrease in transmission rates until people have a lot more knowledge about STD transmission in general."
"People who are taking truvada are the most responsible."
But Lucas, who also believes in HIV education, views things differently. "I recommend that every [gay] man take it, no matter whether they think their relationship is monogamous or not," he says. "I think people who are taking Truvada are the most responsible."
Predictably, a statement made by the US government in favor of a drug that has been shown to prevent HIV infection, even without the use of a condom, also elicited plenty of controversy.
Notably, the AIDS Healthcare Foundation issued a statement in which CEO Michael Weinstein was quoted as saying that he feared the CDC would "come to regret" its decision because a "government-sanctioned widespread deployment of PrEP will be accompanied with a shift to condom-less sex." These comments were perhaps meant to underscore the need for people to continue using condoms to protect themselves against other STIs, such as syphilis and the increasingly antibiotic-resistant gonorrhea. But to some, they came off as condescending and faithless instead.
women have fought against that same kind of moralizing
"I'm infuriated by intimations that prevention drugs lead to people engaging in riskier behavior," said Lorelei Lee, a porn performer, film director, and sex worker advocate, in an email to The Verge. Women, she wrote, have fought that same kind of moralizing in trying to get insurance coverage for birth control pills. It's demoralizing to see it happen all over again to people who are taking steps to protect themselves against a disease that is still widely considered deadly. Moreover, studies have shown that PrEP drugs do not increase risk-taking, Lee said, "so to insist otherwise — especially if you are someone with a large media platform, like AHF's Michael Weinstein — is the height of irresponsibility."
The nature of Weinstein's comments echo a 2012 Huffington Post article in which writer David Duran coined the term "Truvada whores." Duran used the name when referencing the gay men that he feared might view the drug as a license to have unsafe, condom-less sex, but has since apologized and revised his position on the matter. Yet Lucas explains that men — especially those too young to remember the terrible toll that HIV took on the gay community — are already having sex without condoms, so Truvada might finally provide them with a preventative method that they are willing to use.
"The new generation didn't see people dying," says Lucas, who is currently in a relationship with Tyler Helms, an activist who has written about living with HIV. "They didn't see the epidemic, so they aren't using condoms."
The shaming is real, and it's dangerous
Despite the media's fixation on the term Truvada whore, Lucas says he hasn't heard anyone in the gay community use it. Yet the shaming sentiments that lurk behind the term are real, he says — and they're dangerous. "Weinstein can say ‘use a condom' as much as he wants, but condoms fail and there are 50,000 new cases of HIV every year in the US," he says. "So I think it's criminal when gay people like him tell others not to take a drug that could save so many lives."
Weinstein also attacked the drug's effectiveness, stating that PrEP has a "limited preventive effect at best." But a recent study found that men who take Truvada seven days a week are 99 percent protected against HIV (meaning that none of the study participants who took the drug every day developed the virus). The drug is also widely considered a low-side-effect medication. "About 1 in 10 people will have some discomfort like nausea and cramping for about four weeks," says Robert Grant, an AIDS researcher at the Gladstone Institutes and a spokesperson for the San Francisco AIDS Foundation. The drug is also accompanied by a 1 in 200 chance of altered kidney function, so patients need to get routine blood tests, Grant says. "But the vast majority of people don't experience side-effects at all."
Considering the mounting evidence surrounding PrEP's effectiveness, and evidence that condom use among teens and young adults is declining, it's hard to argue with that PrEP represents a remarkable asset in the fight against HIV. But the path forward, one that's been uphill since the beginning, isn't exactly clear. HIV is still laden with stigma, Laudato says. And considering the controversy already building around PrEP, it might be time for people to consider what the government's announcement could one day represent — and how to make the most of it. "It's absolutely worth the money for people not to get infected with HIV," Laudato says, but "we still need to figure out how to get the most out of this tool."