Safer or Stupid? Some Gay Men ’PrEP’ for Sex

by Steve Weinstein

EDGE Media Network Contributor

Tuesday March 10, 2009

More than two decades into the AIDS epidemic, the well-known conundrum of condom burnout among gay men has produced a highly controversial underground practice. "Pre-exposure prophylaxis," or PrEP, involves taking a comprehensive anti-retroviral drug, usually tenofivir, before having sex.

Some men are actually doing this because they take safer sex seriously indeed. One doctor told me of two patients who took the drug before they had protected sex with strangers as an added preventative in case a condom breaks.

But for the vast majority of gay men who practice this esoteric means of disease prevention (and it should be emphasized that it is a tiny, tiny number of all gay men!), PrEP means a key to not using a condom. That's what makes it such a hot-button issue among AIDS researchers, doctors and activists. The theory behind is that the anti-retroviral drug prevents HIV from grafting itself onto healthy cells and replicating. When HIV first enters the human body, there isn't much of it; theoretically, if those few viruses swimming around the bloodstream don't have anywhere to go, they'll die out--just as do millions of germs we come across every day that don't affect us.

One prominent doctor in Boston maintained that PrEP, despite its bad rep, is necessary as one more tool in the arsenal of AIDS fighters. But others see it as an enabler for those men who don't want to bother using protection.

"Disco dosing" has actually been for a few years among the PNP (party-and-play) crowd--that is, men who like to have sex while high on crystal meth or GHB (or both). There is another such cocktail known (especially on the West Coast) as "MTV" -- meth, tenofovir, and Viagra. It's these men who have been begging, borrowing or stealing anti-retrovirals from their HIV-positive friends.

In an era when the AIDS "cocktail" drugs are widely prescribed, it's not hard for such patients to tell physicians or clinics that they lost their prescription or ran out early. "You can get Viread [a branded anti-retroviral] at many gay bars or clubs," says Bob Adams, managing editor of HIV Plus.

"Patients don't get the fifth degree if they say they've run out," says Kenneth Mayer, director of Brown University's AIDS program and medical researcher out of Fenway Community Health in Boston. "It's easy enough to get more."

AIDS physicians argue vociferously that PrEP is a poor substitute for that millimeter of latex. But they also acknowledge that many men are sick of condoms, or that they find themselves flagging while pausing in the heat of passion to "put on the raincoat."

It's difficult to find any doctor who advocates for PrEP among sexually active gay men--and nearly impossible to find any who talk openly to their patients about its possibilities. I did find one Los Angeles doctor who has prescribed anti-retrovirals for at least one patient who has not tested positive for HIV and has unprotected sex, but he would only discuss it on deep background.

Studying PrEP

One study published in a peer-reviewed journal a few years ago looked at black urban men who have sex with men. The researchers, based on both coasts, found a surprisingly high number of men queried at black-oriented Circuit events had heard of PrEP--nearly one-third--and several had tried it or knew someone who did.

The Centers for Disease Control is undertaking research in Thailand, the United States and Africa to try to discover whether PrEP is effective. the CDC joins international organizations in such studies. There are so many studies that one website does nothing but track them.

It should be emphasized that other studies conducted by the CDC, the City of San Francisco and other researchers found a far smaller number of gay men who had heard of PrEP and a much smaller than that of men who had actually practiced it at any time.

While it's easy to pooh-pooh PrEP as fallback among self-indulgent gay men, the researchers point to situations where condoms are not an option, aren't as readily available, or other factors. For example, some women are forced into sex with HIV-positive men as partners or sex workers. Then there are IV drug users--not the most cautious group about disease control.

There are men in serodiscordant relationships. And then there are men who lie about their HIV status to partners.

All of that adds up to a serious look at this contentious issue.

No doctor argues that PrEP is a substitute for safer sex. "Doctors will still recommend people use condoms," says Dr. Albert Liu, researcher in the San Francisco health department. "It would need to be combined with other strategies."

But there are also several indications that something new is needed. Bareback porn is moving from the fringes to the mainstream (recently, a major porn producer announced it would be doing barebacking DVDs). Rates of HIV infection among gay men are rising. So are rates for other STDs, which indicate less condom use.

Clearly, something needs to be done.

PrEP itself evolved from another unproven regimen known as "post-exposure prophylaxis," or PEP. For the past few years, men (or women) who believe they may have exposed themselves to HIV could go to a physician or clinic and receive what's been called a "morning after pill." Actually, it's more like a month-after series of pills, a regimen of retrovirals. The theory works the same as PrEP.

While no one advocates for PrEP, as the studies by CDC and others show, it is beginning to be taken seriously. One New York City physician told me that it was "the talk of Montreal," at the latest retroviral conference. After getting through the issue of why these men won't use a condom, it makes a certain amount of sense. Not only are gay men increasingly weary of navigating safe sex, they're constantly on the lookout for the Next Big Thing in the fight against the disease that has ravaged their community.

"Gay men have traditionally been ahead of scientists in trying to lower their risk," says Bill Stackhouse, who, as director of the Institute for Gay Men's Health at Gay Men's Health Crisis in New York City, sees the issues at the street level. "Unfortunately," he hastens to add, "this [approach] comes with complications."

But as long as gay men keep having sex, some of them will look for ways to enhance the experience. Even that millimeter of latex is one millimeter too thick.

"Clearly, sex is more exciting without a condom," says Rob Garofalo, deputy director of Chicago's Howard Brown Health Center. "They're not very convenient, they're not sexy, they don't feel natural. People are clamoring for a strategy that works."

Steve Weinstein has been a regular correspondent for the International Herald Tribune, the Advocate, the Village Voice and Out. He has been covering the AIDS crisis since the early '80s, when he began his career. He is the author of "The Q Guide to Fire Island" (Alyson, 2007).