“For me, like, I never felt comfortable with someone coming in me. The idea of that prior was, ‘That’s too risky.’ But it’s hot,” says Trevor, a 44-year-old NYU professor. He says his feelings changed once he began taking PrEP, a medication for those that are HIV negative that is highly effective at preventing the transmission of HIV.
“It’s like, why not? Something is very different. My mindset is changing.”
After being on PrEP, Trevor* no longer sorts out HIV positive people when dating and hooking up. Before, even when practicing safe sex with condoms, he would shy away from hooking up with any guy who was HIV positive. But because PrEP has proven to be so effective at preventing HIV, he's now much more comfortable being intimate with an HIV positive guy.
“When you're my age, and you came out in the '80s, there was such a stigma about behavior and how it equals death, so you do everything you can to protect yourself against it. I absolutely consider being on PrEP to be practicing safe sex.”
For many gay men, the fear of contracting HIV imbued virtually every sexual encounter. Now, PrEP is providing the opportunity to experience sex without the same level of anxiety. But, for gay men on PrEP eschewing the condom, there is the heightened risk of contracting Sexually Transmitted Infections [STIs] other than HIV and of being branded a “slut” or “Truvada whore” by friends and some in the LGBTQ community.
Interviews with gay men across in NYC suggest that gay men on PrEP are having more condomless sex than before and enjoying it. Some men on PrEP revealed a feeling of freedom from the inherent dread that consumed prior sexual experiences. One doctor interviewed reports seeing patients on PrEP using condoms less frequently and some who are more inclined to bottom during sex when, before PrEP, they would exclusively top because the risk of contracting HIV was lower. Since the advent of PrEP, profiles seeking to find bareback sex are more commonly found on gay hook up sites like Grindr, Scruff, Growlr and BBRT (BareBack RealTime).
But this resurgence in bareback gay sex has others in the community worried that a “new” HIV could develop—a super-strain of some kind—or that the community will see an alarming rise in STI rates.
PrEP, an acronym for pre-exposure prophylaxis, is a once-daily, oral pill called Truvada that combines two medications: Emtriva and Viread. Truvada was approved for preventative use by the FDA in 2012. The drug works by blocking an enzyme that the HIV virus requires to multiply.
Clinical trials have shown that with strict adherence to a daily PrEP regimen, it is nearly impossible to contract HIV. While a gay man who had methodically adhered to his PrEP regimen recently contracted a strain of HIV that was resistant to both of the drugs that make up Truvada, the consensus is that this type of transmission will likely remain exceedingly rare.
Brad, a 27-year-old grad student, began taking PrEP after watching several of his friends having a positive experience on the medication.
“I saw it as an extra layer of protection and had religiously used condoms and would freak out if one broke. I did it out of that. My friends were doing it. I thought it was a solid thing to do.”
Brad had not intended to stop using condoms when he began PrEP. However, his condom use did decrease over time but “the guilt of it hasn’t,” he said. “I would say, like, out of every 10 sexual encounters, I use a condom once. And I still feel guilty about it. It’s weird. I have a weird relationship around it. I have a guilt talking to my doctor when I say I don’t use condoms sometimes.”
Dr. Edward Goldberg, a physician in private practice who has been treating HIV/AIDS patients since 1993, doesn't “find the use of PrEP in any way controversial” and he regularly prescribes it to his patients having anal sex, explaining that, "for people who tell me that they have protected sex 90% of the time, maybe once every two years they slip, I still recommend it. I just absolutely think it's a hugely preventative, safe treatment."
But still, Brad feels the stigma of not adhering to heterosexual norms. “We as gay men are stigmatized not only for being gay but also for engaging in freedom of gay sex, because we have super normative people who kind of demonize that as abnormal behavior. So, I think there’s a cultural thing where you shouldn’t be having this much sex without consequences. And I think that’s where a lot of my guilt stems from,” Brad continued. “I think as a culture, it’s been really drilled in that the worst thing that can happen to you as a gay man, is that you get AIDS and die. It’s part fear for myself but mostly a fear of hurting my parents.”
But asked about the heightened risk of contracting an STI by having bareback sex, Brad said, “I don’t know if it’s worth it but it’s the tradeoff we make when we decide to do that. And luckily, the majority of them are very treatable. It was strange or disconcerting how easy it was to stop using condoms.”
(Sai Mokhtari / Gothamist)
Sex advice columnist Dan Savage, on his Savage Love podcast, recently reported on an increase in STI rates among gay men and implied that it was a result of the increase in PrEP use among gay men. He later recorded an interview with Peter Staley, an AIDS activist who challenged many of Savage’s assumptions. Staley explained that the number of men currently on PrEP (estimated to be between 20,000-30,000 people nationally) is way too low, as of yet, to have such a significant effect on national STI rates and, consequently, too insignificant a number to attribute to the lower HIV transmission rates that are being reported.
Dr. Demetre Daskalakis, NYC Assistant Health Commissioner in charge of the Bureau of H.I.V./AIDS Prevention and Control, says it is difficult to say how PrEP use has contributed to the current national increase in STIs. But Dr. Daskalakis implores that “PrEP is a harm reduction intervention. It does not eliminate risk, so STI transmission may and will still occur. We do not shun seat belts because they do not prevent cancer. We should not discourage PrEP because it does not prevent STI. PrEP, in fact, brings people closer to sexual health services and allows access to STI screening and treatment.”
Dr. Asa Radix is the Senior Director of Research and Education at Callen Lorde Community Health Center. The center provides health care related services targeted to the LGBTQ community in NYC. Dr. Raddix believes that the focused screening work that is done with patients on PrEP is likely to find asymptomatic STIs that would "probably not have been detected if [the patient] wasn't enrolled in the PrEP program" and explained that the "uptick in STIs was occurring before PrEP was implemented. One of the benefits of PrEP is increasing screening for STIs, also notification, testing and treatment of sexual contacts."
Dr. Radix reasoned that "people are on PrEP mainly because they are at risk for STIs and HIV, and it isn't surprising that people continue to have STIs while on PrEP. This means we are identifying people who are most likely to benefit from PrEP.”
Sean, 34, works in TV production and believes the benefits of being on PrEP outweigh the risks of higher STI rates. “It’s totally worth it. The outside benefit is that you are required to get tested more frequently. You have to. I think that is part of the reason the numbers are going up. I know someone who had no idea that he had an STI and then he wanted to get on PrEP and he found out he had one.”
Sean feels that being on PrEP has removed the anxiety from his sex.
“What’s nice about being on PrEP; the weight, the burden, the fear, of, ‘oh, if I want to have bareback sex, I’m going to be worrying about it for the next few months until I get an HIV test,’ that feeling is gone.”
Sean, just out of a long term relationship, has found it more common that men on dating and hook-up apps are looking for bareback sex and he didn’t want to limit the men with whom he was interacting.
“I knew that when I would want to have sex with guys the topic of sex without a condom would come up and I didn’t want condomed sex to be a hindrance in who I was meeting,” he said.
Felix and David are in their early forties and are both HIV positive and have been since before the advent of Truvada as PrEP. Both are on anti-viral medications and have undetectable viral loads, meaning that it is virtually impossible for them to transmit HIV.
Felix, who contracted HIV in 2009, wishes PrEP was available at the time. “There was a period of 6 months to a year, where I know I was edging towards doing things that I knew I shouldn’t be doing. And I put my toe in the water and I was trying to get back into therapy, and if PrEP was around, I would have gone on it instantly. But I found out people close to me who were positive and they were living their lives and I was, for 25 years, not having a lot of butt-sex, I had just shaped my sexuality around not having butt-sex, and when I finally sero-converted, it wasn’t a surprise really, I had known I wasn't being safe.”
(Sai Mokhtari / Gothamist)
Felix and David are in, what Dan Savage calls, a “monogamish’’relationship. They have threesomes from time to time and they have noticed a change in the way HIV negative men interact with them on hook-up apps.
“It's interesting now because the safest people for HIV negative people to play with are the people on PrEP and the people who are positive and undetectable,” Felix says. “And now, on Scruff, you see ‘condoms only’ and you’re like, ‘nope, nope. Haha. I hear about guys in San Francisco who like, sero-sort, and I just don’t want to spend energy on that. Sometimes I guess we have done that, but if people are uncomfortable now, it's like, ‘bye-bye.’”
Marco, 45, a single media professional who has been HIV-positive for many years, has noticed an abrupt shift in the way HIV-negative men interact with him online.
“There was this guy that hit me up and he was really cute, he wanted to fuck around, and my status came up and he was like, ‘I can’t, I’m just too scared of that,’ blah, blah, blah. You know, he wasn’t a jerk about it, but whatever. And then a year later, he hits me up, ‘now I’m on PrEP and my perspective has changed.’ Fast forward, he wanted to get bare backed and take a load in his ass. I wouldn’t say it's 100%, but a lot of people have changed,” Marco explained.
Dr. Goldberg has noticed a change in behaviors among his patients on PrEP. “It may be that someone who wouldn't bottom before will bottom now because they're on PrEP. That has expanded and I think that's a good thing because it's an enhancement of sexual expression. I think the risk and fear of getting AIDS from getting fucked brings another layer of shame and that's not a good thing. In my opinion."
When questioned about the decrease in stigma surrounding HIV positive individuals, Dr. Daskalakis responded, “We want to make sure that PrEP users are aware of the limitations of PrEP; PrEP is not a silver bullet but is a very powerful tool to help end the epidemic. A fulfilling sexual life should be enjoyed by all New Yorkers regardless of gender or sexual identity.”
After Marco noticed this shift in behavior among his hook-ups, he asked his doctor if he was prescribing PrEP and his doctor appeared frustrated.
“He was part of ACT UP in the '80s and he was annoyed because, he was like, ‘we fought for all this stuff and now people are behaving irresponsibly and everyone comes in with, like, gonorrhea and this and that,’’ Marco explained.
“Overall, I'm all for it. And what it comes down to, if it's preventing HIV, it's a positive, right?”
Marco’s doctor is not the only gay man to have such a negative reaction to PrEP use and the possibility that it could lead to less condom use among gay men. Larry Kramer, one of the founding members of Gay Men’s Health Crisis and a tireless AIDS activist, at one time bemoaned the use of PrEP, saying anyone who takes PrEP “has got to have rocks in their heads,” and that “there’s something to me cowardly about taking Truvada instead of using a condom.” Henry, 32, is a comedy writer and agrees with many of the criticisms he has heard about gay men on PrEP.
“I’m fine if you’re on it but don’t be preachy about it. I find that most gay men who are on it state it first and foremost. Like, I don’t know your last name, I don’t know where you’re from but I know that you’re on PrEP and that's kind of alarming to me. It raises some red flags in my book.”
Henry also agrees that the “Truvada-whore” label may not be that far off the mark. “There’s a part of this PrEP thing happening where it’s part of the party scene almost and that's what I’m not really into and the whole culture it's created. I’ve heard of terms like, PrEP-train, where people are like, ‘I’m on PrEP and it's a PrEP party and it’s a big orgy!’ It's regressing back to before AIDS because, look, ‘we have this magic pill that prevents it.’ And not that I think that time period was bad, and I want to tread lightly with this, I think people learned an important lesson from that, you have to be more cautious about what you’re doing, and I feel like, just because this pill was created and the CDC says it's good, like, so many people are using it as an excuse to go crazy and throw caution to the wind, when you should still be cautious even if you’re on the pill.”
The stigma surrounding PrEP had a definite impact when Richard, 33, an arts professional, was weighing whether to start taking the medication.
“I, psychologically, felt a little bit ashamed about being on PrEP, like, I think I was a little embarrassed, ya know? I thought in some way, I was saying, ‘Hey world! I’m gonna get fucked!” Richard remembered. “Like, I should just be a normal person and not engage in behavior like that. Don’t engage in dangerous behavior and you won’t have to take a pill everyday to make sure you don’t get HIV, right?”
After deciding to hold off on PrEP, Richard had a close call with a broken condom while having sex with someone who was positive.
“I’m so stupid, because, that's the point of PrEP, sometimes you do go out and get drunk and go home with someone and get more drunk and you’re having fun and you have sex without a condom and they are positive. And then, two days later, I got an appointment with my general practitioner and got the lab work done and he wrote me a prescription for PrEP.”
Richard was fortunate that his insurance covers PrEP and he only pays a $25 co-pay each month.
PrEP is not cheap. It can cost between $8,000 and $14,000 a year and requires several doctor visits and frequent blood work to screen for STIs and organ function.
Clinics geared towards the LGBTQ community like Callen Lorde, APICHA and GMHC assist clients with finding ways to pay for PrEP. Dr. Daskalakis advises that the NYC Health Department has an online PrEP service locator. As of June 2016, there are 86 sites on the PrEP locator.
Dr. Daskalakis added that the city is “in the process of establishing a number of clinical sites that will function as part of a PrEP network, along with HIV testing sites and community based organizations. [They’ll] provide PrEP-related services to help at risk populations access PrEP; including assistance with obtaining medications through the PrEP manufacturer’s assistance programs and reimbursement for the cost of PrEP starter packs.”
Walter, 38, is a professional actor and he feels his union insurance doesn't pay nearly enough of the cost of his PrEP. “I want to lobby my insurance, we have to make this medication more financially accessible.”
“On Truvada, I’m like, super excited to hook up with this friend of a friend on Facebook because I know he’s also on Truvada, so it’s like, no holds barred, like, we get to do all the stuff that always seemed taboo.”
*Names in the article have been changed to prevent slut-shaming.
Joe Gallagher is a sometimes writer living in New York City.