Reconsidering PrEP

After my mini-meltdown last entry, I did some additional looking into PrEP in general and weekend PrEP in particular. I also reread the thread that freaked me out.

It turns out that Weekend PrEP is a thing. In the literature it is refered to as “intermittent PrEP”. You take two pills before hitting Grindr, then a single pill 24- and 48-hours after. According to two studies (which go by the acronyms PROUD and IPERGAY) this reduces transmission rates significantly (by 85% or so). Furthermore most of the gays in the study were able to adhere to the regimen. So I guess the world is safe for barebacking, if you can afford the drug costs. These are only two studies, and the Centre for Disease Control does not advocate Weekend PrEP, but there is evidence that it works.

Those advocating bareback sex with PrEP (or, as I like to call them, the PrEPers) bring up a number of other points that have merit:

• Assume PrEP works. Then it does not matter whether other people are lying or not. You can’t say the same for condoms (you may not want to click that link at work. Or ever). Taking PrEP prevents you from getting HIV and prevents you from transmitting it regardless of who your partners are.

• Old trolls like us might worry about another epidemic, but there is no actual reason to expect that one will occur. If you think that, then you probably also believe that we deserved AIDS because we were promiscuous.

• It is true that PrEP does not prevent any infection other than HIV, but we prehistoric Marys have no reason to be smug, because nearly all of the other STIs that matter (syphilis, chlamydia, gonorrhea, herpes, HPV) are transmissible via oral sex, and exactly nobody uses condoms for oral sex.

• In order to get a Truvada prescription you supposedly need to be tested for STIs every three months. That keeps the population safer than a bunch of gays who live in denial about their statuses.

• Taking PrEP intermittently helps people tolerate the side effects better.

• If we ancient queens are so worried about drug resistance for Weekend PrEP why aren’t we similarly worried about regular PrEP? Regular PrEP is a pre-emptive drug, the same way that antibiotic dish soaps are. And we all know what the overuse of antibiotics has led to.

• PrEP is expensive. Intermittant PrEP is presumably safer, so more people might adhere to it, so maybe the community as a whole will be safer. (Fun fact: without insurance, a daily Truvada prescription would cost me more than my average monthly income in 2018.)

It should surprise nobody that I still feel anxious about this:

• We are putting a lot of trust that Truvada will continue to work. One of the big problems with HIV is that it mutates so quickly. A condom will stop a new strain of HIV that mutates. Can we say the same for Truvada? (Fun fact: on paper, the reason gays are not permitted to donate blood is because in 1996 there was a strain of HIV (HIV-1 Type O) which was not detectable by testing at the time.)

• No, there probably won’t be another plague. But if there is, then sex (particularly unprotected sex) with multiple concurrent partners is the best way for that infection to spread. This is why AIDS hit gay men so hard in the 1980s, and why it hit certain countries in Africa so hard later on.

• It is probably true that if you are the one on PrEP then you are safer than if you are not. But you must be very very careful about trusting that somebody else is on PrEP to keep you safe. If that person is actually on PrEP, then hooray. If not, you are at greater risk than you would be using condoms.

Maybe none of these are my real concern. My real concern is TRUST. There is something that feels deeply untrustworthy about hookup culture, and I have to presume that anybody who would be willing to sleep with me is also sleeping with other people. Can I trust that person? How does that trust level change when the norm in gay culture shifts from using condoms to routine barebacking?

Personally I am too much of a hypochondriac nellie to trust anybody. (Honestly, I suspect that there are so many of us in the gay-o-sphere that I wonder how anybody has sex at all.) But hookup culture makes me super-anxious, and the way we have collectively decided that barebacking is okay now increases that anxiety even more. A lifetime of unhappy celibacy it is, then.