Pre exposure prophylaxis (PrEP) is touted by many as a revolutionary new strategy for HIV prevention. In the face of rising rates of HIV among gay, bisexual and other men who have sex with men, PrEP might have the potential to confront the number of new infections annually. After decades of believing that condoms are the best way to protect against HIV, however, challenges to the safer sex paradigm are both political and personal. As sex is irrevocably linked to HIV transmission among gay men, we therefore must ask: how will PrEP change sex?
Navigating the complex terrain of sex, desire and safety can sometimes produce situations where HIV risk is increased.
To put it simply, PrEP is the use of existing HIV treatments to prevent transmission of the virus. It’s a combination of two medications (tenofovir and emtricitabine) known commonly by their trademarked name, Truvada. As an antiretroviral drug, Truvada has been used for years to treat people with HIV by suppressing replication of the HIV virus in their body. More recently, Truvada has been used as post-exposure prophylaxis (PEP), which means it’s given to people potentially exposed to HIV in an effort to prevent infection. When administered within 72 hours of possible exposure, PEP can decrease the risk of HIV infections. In spite of its effectiveness, PEP is mainly only available in Canada in response to occupational hazards, such as needle stick injuries, and not widely provided for sexual risk exposure.
Because of PEP’s success, researchers questioned if a similar treatment prior to exposure could also prevent infection. A number of clinical trials have been conducted and are underway. In one widely cited study from the United States (U.S.), PrEP reduced HIV incidence by 100 per cent. Although other trials have found varying levels of effectiveness, there is growing evidence that when taken regularly, PrEP can seriously diminish the risk of acquiring HIV.
Only the U.S. has approved Truvada’s preventative use. Similar approval in Canada would require Truvada’s creators to launch a costly and lengthy submission to Health Canada. As a licensed drug, however, Canadian doctors can (and do) prescribe Truvada to their patients as PrEP, a practice known as prescribing “off label.” A month’s dose of PrEP, however, costs between $700 and $1,000 per month. Although in some cases public or private coverage for PrEP is available, some gay men in Canada have reported turning to the Internet to order Truvada at a fraction of the cost.
As PrEP was introduced, social scientists theorized that gay men would display what is known as risk compensation. It was thought that some men would respond to the perceived protection of PrEP by engaging in higher-risk sexual behaviours, which would offset any gains in public health. Commentators in gay and mainstream media have referred to men who would take PrEP to bareback as “Truvada whores,” and iconic activist Larry Kramer controversially suggested that only cowards would take PrEP. Advocates for PrEP have fired back at the implied slut- shaming from within gay communities. The debate around PrEP continues at a sometimes fever pitch.
Despite concerns of risk compensation, research data suggest that this effect has not materialized. In trials of gay men on PrEP in the U.S., sexual risk-taking remained more or less consistent. It is unclear, however, how men’s behaviour will change in the real world, which is to say outside the structure of a clinical trial.
Intimacy is also of interest when we think about sex and PrEP because we know that bareback sex is sometimes motivated by the desire for intimacy. Indeed, it is easy to imagine how a desire for closeness could lead some men to forego condoms. Men in relationships often negotiate condomless sex by agreeing to only bareback with their regular partner and to wear condoms with others, which is known as “negotiated safety.” It seems likely that PrEP will become a new factor in these negotiations as it becomes more widely available.
Men in serodiscordant relationships (i.e. when one partner is HIV-negative and the other is HIV-positive) have also shown a keen interest in PrEP. Several studies from the U.S. have found that a majority of men in these relationships would like to or are planning to take PrEP and are often motivated by the desire for intimacy and condomless sex. Another key motivator for these men is to reduce stress and anxiety associated with fears of HIV transmission.
It is also necessary to confront the reality that some men are engaging in condomless sex either regularly or sporadically. Navigating the complex terrain of sex, desire and safety can sometimes produce situations where HIV risk is increased. From a health perspective, if PrEP can offer protection in those moments, then it has great potential value. As such, proponents
of PrEP, including men already on the regimen, have highlighted its ability to help men take greater control over their safer sex behaviours.
In spite of its potential, PrEP is not a magic bullet. Many complicated questions remain. PrEP’s efficacy decreases significantly if the pill is not taken at least four times per week, so do we run the risk of creating a drug-resistant strain of the virus among non-adherent men? Pragmatically, how does the number of infections that could be avoided if men were on PrEP compare to the costs of its provision? Philosophically, what differences are there between a regimen of medication to prevent infection and a nearly identical regimen of medication to manage infection? And morally, is it defensible to provide these treatments to healthy men in wealthy countries when treatment coverage for those actually living with HIV is, in many parts of the world, rather poor?
As we move into what promises to be a new era of HIV prevention, we must continue to ask these questions. What PrEP might mean for gay sex is, for the moment, mostly speculative. As more gay men around the world start to use PrEP, its impact on behaviour, sex and HIV infection rates will become clearer. In the meantime, talk to a doctor you trust if you have questions about PrEP, PEP or other forms of HIV prevention.
How to have safer sex
Being educated about safer sex can help you feel more comfortable with sex in general.
- Syphilis among gay/bi men is on the rise in Canada. It can be transmitted by skin- to-skin contact, and without treatment could cause major organ damage. If you are HIV-positive getting syphilis can have serious implications. Get tested.
- HIV is in pre-cum and bottoms can pass HIV to unprotected tops.
- Scissoring/tribbing is a risk for spreading herpes, syphilis, HPV and gonorrhea. Putting some non-microwaveable plastic wrap with lube in between your genitals reduces risk.
- Unprotected oral sex puts you at risk for gonorrhea and herpes. Mouth sores/ cuts, sore throats, recent dental work and vigorous brushing/flossing before and after oral sex all increase your risk. Wait at least 30 minutes after brushing/flossing before you have oral sex. Reduce your risk by using a condom or dam. Deepthroating can create tiny tears and inflammation that make you more susceptible to HIV and STIs.
- Being fisted can increase your risk of getting and spreading STIs during other sex for up to two weeks afterward because it creates small tears. Using gloves, lots of lube and clipping nails short makes it safer.
- Rimming is high-risk for gonorrhoea, chlamydia, syphilis, HPV, hepatitis A & B and parasites like worms. Using a dental dam, a flavoured condom cut lengthwise or non- microwaveable plastic wrap lowers risk.
- It is illegal not to disclose an HIV-positive status in Canada before having sex.
- Negotiating safer sex can be about more than STIs and HIV. Self-worth, pleasure, boundaries, homophobia and transphobia can all be wrapped up in our decisions about what kinds of sex we’re having and how safe we make it. If your partner wants to use condoms, gloves or dental dams, respect that. Conversely, be as clear and firm as possible in stating your wish to use barriers. If a partner is concerned about loss of sensation with condoms, try polyurethane—it’s non-latex and thinner.
- Nobody has to cum for HIV and other STIs to be transmitted. No matter what your gender or orientation, if you’re exposed to, or exposing others to bodily fluids including semen, pre-cum, vaginal fluid, blood, breast milk or in some cases saliva, there is a risk of STIs. Get tested regularly. Many people spread STIs and HIV without knowing.
With information from Scarleteen.com, CATIE and the AIDS committee of Toronto.
–Denton Callander (www.dentoncallander.com) is a Sydney-based research scientist in epidemiology at the Kirby Institute of Infection and Immunity in Society. His work focuses on sex, sexualities and sexual health.