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When People with HIV Became Suicide Bombers

| 3 Comments
Maybe we should blame the criminal prosecutions of people with HIV on the mythical legend of Gaetan Dugas, also known by his slanderous nickname, Patient Zero. Dugas was a gay flight attendant from Canada who, according to Randy Shilts' 1987 book And the Band Played On, was among the first people with HIV in the United States.

As the story goes, energetic Dugas (right) spent lots of time in the very early 1980′s getting laid in practically every city with an airport, even after learning he had the mysterious new "gay cancer." He wanted to go out with a bang, the book claimed, and he didn't particularly care who he might infect in the process. The book repeated rumors that after sex with bath house tricks Dugas would point out his skin lesions and then announce, "now you have it."

Except the story isn't true. Two years ago, Shilts' former editor admitted the book needed a "literary device" and had encouraged Shilts to create the epidemic's first "AIDS monster." The scandalous sex life of Gaetan Dugas fit the bill nicely. Dugas died in 1984, never having the opportunity to answer his accusers regarding his alleged behaviors.

Instead of placing responsibility with everyone having sex, the book painted people with HIV as suicide bombers. The damage, to the truth and to the public image of people with AIDS, still reverberates today.

Laws exist in more than 30 States that criminalize people with HIV for not disclosing their status to sexual partners. Even where there are no HIV-specific laws, charges range from assault to attempted murder to bioterrorism. It should be noted that the vast majority of prosecutions do not involve the transmission of HIV. Often, the person charged used a condom, had an undetectable viral load, or engaged in sexual behavior that could not have infected their partner.

Anyone with HIV and a pissed off ex-lover should feel worried, since these cases often become a matter of whom you believe. Prosecutors and unfriendly juries are often shocked that people with HIV are having sex at all. They could care less about condoms or undetectable viral loads. They just want people who don't disclose their status to face serious charges.

A lot of people see this as righteous and are taking the bait. Many of us know someone infected by a sex partner who lied about their status, and we want that jerk to pay for it. This sense of vengeance plays into the hands of a conservative legal system that is more than happy to send some diseased fags to jail. For a really long time. Regardless of the actual harm inflicted.

This issue is a real mine field of emotion, justice, science, and payback. Fortunately, an upcoming event will bring together advocates, legal experts and people living with HIV to discuss criminalization and map out a strategy to address it.

"HIV is Not a Crime" is the first national conference on HIV criminalization.  It will be held on June 2-5, 2014, in Grinnell, Iowa.  Yes, Iowa. Some of the most effective activism around this issue is happening there, where State legislators are actually re-thinking their own laws and health policies as a result of smart advocacy and education. I urge you to alert your local HIV advocates about this important event.

Regardless of your views on criminalization, we can all agree that anyone who intentionally seeks to harm another person should be held accountable for it. That's why we have laws against hurting other people.

But why are there laws on the books specific to HIV non-disclosure? HIV has its very own laws ordering people to disclose if they have it. The same cannot be said for other infectious viruses such as Human Papillomavirus (HPV) or Hepatitis C, which actually kill more people each year. The reason, in the mind of many advocates, is because those viral conditions are not as closely associated with gay sexuality. Or race. Or the disenfranchised. I hope you're getting the picture.

Criminalization is not limited to whether or not someone discloses, even if those scenarios capture our imagination the most. Laws have other ways to punish those with HIV. 

Charges for an unrelated crime can be elevated if the defendant is HIV positive. Prostitution, or spitting at a cop, or punching somebody in the face in a bar, can carry more severe sentences based on the fact the accused is HIV positive.

In other words, defendants are guilty of living with HIV. That should give you real pause.

Surveys conducted by The SERO Project indicate that knowing about the risk of being charged with non-disclosure is an impediment to HIV testing. After witnessing how people with HIV are being treated by the judicial system, getting tested might feel like exposing yourself to potential prosecution.

These prosecutions do not rely upon the context of HIV disclosure, either. "The moral obligation to disclose increases with the degree of risk present," said Sean Strub, founder of The SERO Project and one of the organizers of the Iowa conference, "but the context of the sexual encounter is also a factor.  In the context of a committed relationships, the disclosure obligation is much greater than in a sex club, for example."


The key point here is morality. Disclosing your status is a moral issue, not a criminal one. Even in the worst years of AIDS, when the virus reliably killed you, we called our doctors to start treatment when we got infected. We didn't call the cops. Blaming someone for our own risk behaviors seemed ludicrous. It still does.

You wouldn't know it from news reports, which often feature race-driven cases of predatory men lurking around the countryside infecting the populous. Suicide bombers continue to titillate the media.

Look closely at the stories and you will find that "not disclosing" is usually equated with "intentionally infecting." It's as if sex of any kind on the part of someone with HIV is malicious. One side effect of HIV infection, it would seem, is a pathological bloodlust.

Never forget that these juicy legal stories represent the lives of real people. Sentences amounting to decades are being wielded. The convicted are having to register as sex offenders. In the often confusing landscape of sexual risk and negotiation, the person with HIV is facing grave consequences for decisions often made in the heat of the moment, or simply because they chose to protect their privacy when no risk to their partner existed.

HIV criminalization does nothing to reduce the impact of a new HIV infection.  It doubles it.

Mark

Will HIV Ever Be Safe Enough for You?

| 11 Comments
There is a classic episode of Oprah from 1987 that can still raise my blood pressure. That year, the tiny town of Williamson, West Virginia, became part of a national discussion about AIDS when Mike Sisco, who had returned to his home town to die of the disease, dared to step into a public pool.

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The community freakout was immediate. Sisco was quickly labeled a psychopath (rumors emerged accusing him of spitting into food at the grocery store), and the town pool was closed the next day to begin a Silkwood-style pressurized cleaning.

Soon thereafter, Oprah Winfrey arrived with cameras for a town hall forum about the incident.  Fear was the order of the day. "If there's just one chance in a million that somebody could catch that virus from a swimming pool," the town's mayor told Winfrey's worldwide audience, "I think I did the right thing."

Sure. Why not react in the most extreme way possible, if there is a chance in a million?

Williamson citizens were not swayed by health officials who calmly explained the established routes of HIV transmission and the impossibility of infection from a pool. "The doctors can say you can't get it this way," a woman countered, "but what if they come back someday and say, 'We were wrong?'"

Indeed. What if? If there's a chance in a million...?

That broadcast might have remained a sad footnote in HIV/AIDS history, an instructive example of people ignoring scientific fact to protect a satisfying fear, if history didn't enjoy repeating itself so much. Today, though, the willful ignorance isn't coming from uneducated residents of a southern town you can barely find on a map.

It's coming from gay men. And they are just as threatened, frightened, and dismissive of science as the townsfolk of Williamson were thirty years ago.

Recently, research known as The PARTNER Study was presented at the prestigious Conference on Retroviruses and Opportunistic Infections (CROI). PARTNER proved something HIV advocates have long suspected: people with HIV with an undetectable viral load are not transmitting the virus to their partners. The study included nearly 800 couples, all involved in an HIV positive/negative relationship, gay and straight, with the positive partner maintaining an undetectable viral load. Over the course of two years, more than 30,000 sex acts were reported and documented (couples were chosen based on their tendency to have sex without condoms).

Not a single HIV transmission occurred during the study from someone with an undetectable viral load. If PARTNER had been researching a new medication, they would have stopped the trial and dispensed the drug immediately.

The PARTNER results bolster the prevention strategy known as "Treatment as Prevention" (TasP), meaning, a positive person on successful treatment prevents new infections. To date, there is not a single confirmed report of someone with an undetectable viral load infecting someone else, in studies or in real life.

Just don't tell that to a sizable contingent of skeptical gay men, many of whom took to their keyboards to dismiss the PARTNER findings. Phrases like "false sense of security," "positive guys lie," "junk science," and "if there's even a small risk" appeared on Facebook postings and in web site comment sections. The people of Williamson must be slowly nodding their heads.

Resistance to the PARTNER study corresponds with stubborn doubts about PrEP (pre-exposure prophylaxis, or HIV negative people taking the drug Truvada to prevent infection). Although virtually every nervous argument against PrEP has been overruled by the facts, naysayers continue to either reject the evidence outright or make moral judgments about the sex lives of HIV negative gay men on PrEP.

Yes, there are unknowns. There always are when scientific studies meet the real world. And every strategy will not work for every person. But the vehement rejection of such profound breakthroughs suggests there is something more, something deeper, going on in the minds of gay men. What is it?

Our collective memories of AIDS horror are hard to shake, and that's a good place to start. On a gut level, any study suggesting that HIV could be neutralized is met with a weary doubt. Good news is no match for the enduring grief that has shadowed us for 30 years.

The PARTNER study also threatens the view that positive men are nothing more than risks that must be managed. The study kills the HIV positive boogeyman. It means positive gay men who know their status might actually care enough about their health to seek out care, get on treatment, and become undetectable. And, once the positive partner is no longer a particular danger, both partners would bear responsibility for their actions. What an enormous psychic change that would require in our community.

It's tough to do that when fear creeps in and "what if?" fantasy scenarios take hold. What if my partner missed a dose yesterday and, even though HIV meds stay in the bloodstream for extended periods, his viral load has inexplicably shot up? What if he isn't being truthful about his viral load? What if he doesn't know?

The greater threat, folks, isn't positive guys who think they are undetectable but are not. It's men who think they are HIV negative but are not. But we'd rather stay focused on the positive person being at fault, because, well, people with HIV lie a lot. We miss doses constantly because we have a death wish or we're too busy finding our next victim.

I have some "what if?" questions of my own. What if these unrealistic fears were meant to stigmatize and isolate HIV positive people? What if I am undetectable and feel no responsibility to discuss my status with a sex partner because I don't care to engage in a science lesson? What if everyone availed themselves to prevention options that worked best for them? What if my HIV status were none of your damn business?

These risks could be alleviated, of course, if everyone simply protected their own bodies when having sex with people they don't know or trust. But that would place an equal burden on negative men, and what a bother that is.  Better to leave that discomfort to those with HIV, vectors of disease that we are. Just consider us criminals, lying to you about our viral loads and spitting in the food in Williamson, just waiting to infect you when we get the chance.
 
As long as we're giving undue attention to fantasy scenarios we're not focused on the real threats. The rates of STD's are up. Young gay black men in the United States don't have proper access to healthcare and have infection rates worse than any developed country. Our community is plagued by  alcoholism, addiction, and mental illness. Do we want to debate established science or should we devote that energy to other challenges to gay men's health?

If you still have the arrogance to believe you could win the HIV Powerball Lottery and be the one person who gets infected in ways science has disproven, you're perfectly entitled to that point of view.

Here are some helpful instructions, however. Carefully step away from your computer and don't touch the cords because 50 people die of product related electrocutions each year. Walk slowly to your bedroom, being mindful of debris in your path because slip-and-falls kill 55 people every single day. Once there, refuse food or water because, well, you never know. Now slip into your bed of willful ignorance and try to make yourself comfortable.

The good people of Williamson are keeping a spot warm just for you.

Mark

p.s. In the time it took you to read this article, the number of people who were infected by someone with HIV who had no viral load was zero.

Our Problem with Being 'CURED' of HIV

| 2 Comments
In the late 1980′s, I let this odd, fussy man into my office at LA Shanti, my first AIDS agency job. He seemed earnest and harmless and he just wanted a few minutes of my time. 

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"I have the cure for AIDS," he politely announced. Sadly, he wasn't the first person to say that to me, but we practiced more suspension of disbelief during that wretched decade so making such a statement wasn't immediate cause for removal from my office. 

He set a wooden box on my desk, the size of a breadbox and with unfinished wood, like something you had just started building in shop class. He opened it to reveal a jumble of wires and what appeared to be a very large battery of some kind. It looked like a bomb. 

"Electromagnetics," he said, with his index finger up, like a teacher. I was so entranced by the device that I didn't notice him attaching one of the wires to my finger with a clip. I felt it softly bite my skin and looked down, horrified. His scholarly tone didn't change at all. "When I attach this to your other hand," he said, reaching for it, "the magnetic field will purge your body and your blood." I saw him taking my other hand. "This is science," he added proudly. He was smiling. 

I sprang from his grasp and shook the clip from my finger. I suddenly remembered I had a staff meeting. An extremely important staff meeting. I thanked him and excused myself to get to my very important, life saving staff meeting. 

It's tricky in the HIV community, using the "C" word. Long term survivors like me have had our hopes raised so many times, only for the rug to be pulled out from under us, again and again.  The list of miracles-in-waiting goes as far back as the dawn of the AIDS crisis itself. Herbal remedies. Rare fish guts. Tribal potions from exotic locales. 

And so picking up a new book with that word right in the title, well, you can imagine the skepticism. 

CURED: How the Berlin Patients Defeated HIV and Forever Changed Medical Science is exactly as advertised and a little more. Nathalia Holt's (below) engaging new book is quite a pleasant surprise, taking a user-friendly approach to its complicated subject. Not only does it provide the timeline of the advancements to date in HIV cure research, it gives us juicy, humanizing details about all of the players involved. 

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Much of Holt's book has the characterizations and forward motion of a good novel. We meet "Christian" (not his real name), the first Berlin patient who has achieved a functional cure to date. We find out exactly what happened in that Berlin clinic when he received his HIV tests results, what he was feeling, how it affected his relationships. We learn that it was Christian, not doctors or scientists, who elected to end treatment after several months (beginning very soon after his infection), leading to the discovery that his virus was under control and has not flared up since. 

The same goes for Timothy Brown, who achieved even more notoriety as the later "Berlin Patient" because of the drama of his curative process (he had two bone marrow transplants and nearly died more than once) and because he has been willing to be public about it. Timothy is the real heart of CURED. His humility and spirit are evident everywhere, as the book follows everything from his medical journey to his love life to his surprisingly modest existence today.

(In both Christian and Timothy, minute amounts of HIV virus have been located in their bodies since their treatment, but these reservoirs have not caused health problems. This is known as a "functional cure.") 

All the principle players evidently cooperated with Holt, an HIV researcher herself, and the level of access shows. We not only learn who each of the major researchers are, but what brought them here, what their families are like, and what personal sacrifices they faced along the way. Particularly juicy are the stories of egos and competition among the scientists -- and how people who made no contribution at all to various studies scrambled to get their names attached because of the cutthroat world known as academic publications. 

Science has never been my thing. I'm not confident writing about it, and intimidated by reading about it. But, except in its last chapters when Holt hurriedly catches us up on the latest research, CURED is easy to follow and has engaging insight into the very real people behind the headlines. 

And hey, how cool is it that no one was electrocuted as part of this research? 

Mark 

The Fog of a Thousand Years

| 2 Comments
"Remember when Billy Perry gave you a black eye?" David asked me. He stood on a ladder with a screwdriver in his hand.  I was holding up Mom's new light fixture while David attached it to the ceiling. We took on the project during a visit I made back home a few weeks ago. 

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"Of course I remember, David." My response had the weary, patronizing tone I reserve for my older brother. 

I've been speaking to him that way since  we were kids, I suppose. The strategy is to act like I'm completely bored with him so, if he tries to make fun of me, it will look like I don't care. I always thought I needed the mechanism, since I came of age as a pimply-faced pansy who was an easy target. That, as opposed to David, who was only one year older and a blond, blue-eyed star athlete. No one ever believed we were brothers. 

"So what do you remember, then?" he asked. 

I rolled my eyes. "I was eight or nine," I began. "Billy and I were goofing around in the back yard, and I pissed him off somehow and he punched me right in the eye." My arms were getting tired from holding up the fixture and I shifted my feet. 

"That's all?" he asked, still focused on his work. "Stop moving." 

"Pretty much. I went inside and I was upset -" 

"You were crying, man," he corrected. He laughed under his breath. 

"I was very upset. Mom was getting me ice and stuff. So after a while, Billy rang the bell and Mom made me come to the door so he could give some fake apology. Billy's mom obviously made him do it. I'm sure he loved seeing how bad my black eye looked." 

"And that's all you remember? Seriously?" 

I wasn't enjoying reminiscing about Billy Perry. "Yes, David. That's all that happened." 

"No, it's not," he said, and he stopped his work to look down at me. "You walked in the house. You were crying. I asked who hit you and you said Billy. So I left and found him down the block and I kicked his ass." 
David watched my jaw drop. "Billy's mother didn't tell him to apologize, Mark," he added. "I did." 

"Oh c'mon, no way," I replied, a little weakly, feeling something like frustration. How could I not have known this? And besides, this was my black eye story. I'm the one who got punched. 

"Hold the light up higher," David said, and he tugged on the fixture. "Do you even know how many times you would have been beaten up if it wasn't for me?" 

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Recasting David as my protector seemed ludicrous. He was frustrated all the time when we were growing up, unsure how to handle a brother who wasn't the companion he might have expected. I loved Broadway musical albums. He loved the noisy drum set that dominated our shared bedroom. 

And yet, the most antipathy he could muster was to ridicule me as I made my way through the confusion of gay adolescence. I resented his effortless masculinity and the fact I had to watch this annoyingly handsome straight dude grow up right beside me, reminding me on a daily basis of all I would never be. 

My shoulders ached from holding up the fixture but now I barely noticed, too busy trying to get a handle on a lifelong resentment that suddenly wasn't holding up under close scrutiny. 

Brothers fight. But I only got one black eye in my whole life. And it wasn't from David. 

"What do you mean I would have gotten beaten up?" I asked him, finally. "I was so gay those guys were scared to get near me. I freaked them out too much." I honestly believed that my late 1970′s fashion choices of jumpsuits, platforms and elaborate jewelry kept the straight boys of Bossier City, Louisiana too off balance to bash my face in. 

"Mark, I had guys on my football team who wanted to crush you," David said. "All the time. But they knew I would never let them. That's how you made it out of high school alive." 

He finished with the installation and stepped down. I finally let go of the fixture and shook the numbness from my arms. 

David was changing the narrative of my adolescence and I didn't like it.  I wanted to count him among the high school jocks and hayseeds who taunted me. Those bullies are gone, lost to time or floating around in alumni Facebook groups that I never join. David remains, so he became the default stand-in for the injustices of my youth. 

I was sweeping bits of wire and drywall from the room when David spoke up again. "Did you ever think about what it was like for me, Mark? When we were in high school?" 

I narrowed my eyes at him, amazed the popular varsity quarterback would dare take any childhood sympathy for himself. "Oh, please, David. Really?" He stood there. "Fine. What was it like for you?" I dripped sarcasm. "How did my struggle coming to terms with my gay identity in a hostile environment affect you, pray tell?" 

He considered his words, mentally editing them down to a single remark. "It was just hard, Mark," he said. "That's all." 

And somehow, in that moment, my selfishness abated. I allowed the possibility that it could be tough growing up with a gay pride parade float as a brother. 

Once you change the lens, other things come into view. Like the openness of David's emotions, and his guilelessness when facing our family tragedies. He was the one who said he could never handle it if Dad died, even as our father's fate was sealed, even as the rest of us had the same thoughts but couldn't express them. 
David tells me he loves me, even if I stare back wordlessly. He asks blunt questions. 

"Are you going to die?" David had asked in a crackly long distance phone call nearly thirty years ago, when I told the family I was HIV positive. "Are you sure you're not going to die?" he repeated. It was what everyone in the family wanted to know, of course, only no one dared to pose the question. It never occurred to David not to. If I had been able to peer over the wall I had constructed between us, I might have loved him for asking. 

We are the storytellers of our own lives. We select the bits and pieces to remember, and the truth fades. It becomes lost in the fog of a thousand years. 

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Mom returned home to the sight of her two youngest sons standing beside their afternoon installation. While I displayed the fixture like I was a model from The Price is Right, David explained the details of his electrical prowess. 

"But I vacuumed," I jumped in. I clicked off my contributions as if they were a checklist for Mom's affections. "I took all the parts out of the box. I cleaned up the mess. I held the light fixture!" 

"You didn't need to hold the fixture," David said, and his smile gained wattage. "I just liked seeing you squirm." 

I threw up my arms. "What do you mean? It could have fallen on my head!" 

"Not a chance," David said. "I was actually holding it up at the ceiling." He punched me in the arm. "I had you the whole time, little brother." 

And with casual amusement and affection, David grinned again.

The Fury of the PrEP Debate and Facts to Win It

| 10 Comments

"We don't know the side effects of this drug. It's too expensive. Insurance won't cover it. It hasn't been studied enough. It will encourage slutty behavior. And why the hell don't people just use condoms?" 


- Objections raised to the oral contraceptive progesterone ("The Pill"), approved by the FDA 54 years ago.

 

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When the drug Truvada achieved FDA approval in July of 2012 as a medication to prevent HIV infection among people who are negative (a strategy known as pre-exposure prophylaxis, or PrEP), it's as if the ghosts of naysayers from the 1960′s rose from their resting places, delighted and re-energized, and began drilling their mid-century objections into the hearts and minds of contemporary society.

 

Maybe proponents of PrEP like myself believed the response to the drug would be more enthusiastic. Surely anyone who lived through the horror of early AIDS would thank God that a new prevention strategy exists that doesn't rely upon condoms alone. The fury of the response has been a little startling to me.

 

Fortunately, Facebook groups and online sites that explain the facts about PrEP are springing up everywhere to address misinformation and to clarify legitimate areas of concern. Here are the most persistent objections to PrEP, and the facts as we know them.

 

People wouldn't need PrEP if they would use condoms. They just want to bareback. Studies show that people on PrEP do not have an increase in high risk sexual behavior, but cynics have visions of wanton orgies ahead worthy of vintage gay porn. Alas, what others do in their sex lives is out of our control, whether that drives people up the wall or not.

 

The facts are these: more than half of gay men do not use condoms or do not use them consistently. This fact has remained true throughout the 30 years condom use has been measured among gay men, including during the darkest years of the AIDS crisis. We can address 50,000 new infections a year or we can have a useless moral debate.

 

The lack of condom use is what makes PrEP so exciting as a prevention method. The very first large study of Prep was the iPrEX Study, an international study of 2,500 people that was comprised mostly of gay men and some transgender women. The study showed that people who use Truvada as PrEP correctly (taking a pill every day) can have their risk reduced by 90% or more, depending on adherence. Some models show an efficacy rate of up to 99% based on near-perfect adherence.

 

PrEP is also not dependent on last minute decisions in the heat of passion. Taking a pill in the morning is calmly detached from having sex that night.

 

PrEP is not necessarily an either/or proposition, because lots of people taking PrEP are also using condoms. But let's be real. Most people seeking out PrEP already don't use condoms or they don't want to use them anymore. Since they are trading one prevention device for something that has a better success rate and is easier to use, what's it to you?

 

We don't know the side effects of Truvada. We have years of data of Truvada side effects on people with HIV (it's been FDA approved to treat HIV since 2004). Truvada was selected for clinical trials as a PrEP drug because of its favorable safety profile.

 

It is true that there are some reports of bone density and kidney problems among people with HIV using Truvada as part of their treatment regimen. These side effects have sometimes been serious. We can't assume the experience of HIV negative people will be the same, and that's why all Truvada patients, positive and negative, are routinely tested for bone density and kidney function.

 

More and more HIV negative writers and bloggers (and even a gay porn star) are sharing their experiences on PrEP but, thus far, side effects haven't been part of their story. Watching them share their progress publicly over time should be quite interesting.

 

Understanding side effects is part of the assumed risk we take with medications, as any television commercial for a pharmaceutical drug will attest. If you don't want to cough up blood, for instance, or have bloody stools or nausea or a ringing in your ears, don't take aspirin. Those side effects are uncommon, and so are the side effects for Truvada.

 

People taking PrEP also have the option of discontinuing Truvada depending on life events and necessity. Maybe you stop dating the HIV positive guy, or take a break from casual sex, or return to condoms for a while. Starting and stopping the drug in this way does not lead to resistance as long as a medical professional verifies you are HIV negative before restarting.

 

If you are wary of Truvada side effects, don't use it. And allow others to make that same determination for themselves.

 

PrEP is too expensive and insurance won't cover it. This argument is losing steam rapidly. The Affordable Care Act in the United States is underway and by all accounts every insurance company as well as Medicaid is covering Truvada -- although it may require pre-authorization from a doctor for use as PrEP (the CDC has produced a handy document available online to help explain PrEP  to your physician).


For those without insurance or money for a co-pay, Gilead (the maker of Truvada) has a patient assistance program that can provide the drug outright or supply co-pay cards worth up to $200 per month. Even if none of this were true, the potential benefits of a drug should not be assessed solely by its price tag.

 

The people who need it most can't access it anyway so what's the point? It's a good thing we don't have this attitude towards condoms. Access isn't the same as efficacy.

 

But it is certainly true that young gay black men, whom the epidemic is affecting in shocking numbers, have less access to healthcare. This is a systemic problem and it is unfair, frankly, to expect PrEP to solve it. It is also true that PrEP can be an occasion for HIV negative people to seek care, and once on PrEP they are typically required to have medical follow-ups throughout the year, which offers obvious benefits.

 

The biggest hurdle is often physicians themselves. HIV negative people may have a doctor unfamiliar with HIV care, much less PrEP, and those doctors are often intimidated by what they see as the complexities of HIV treatment. Until more professional education is done, potential PrEP users must learn to advocate for themselves and share CDC recommendations with their doctor.

 

People won't adhere to PrEP and that will create resistant strains. It is true that in some early PrEP trials adherence was a problem. Real life behaviors, though, differ from clinical trials in some important ways.

 

Trial participants have no idea if they are taking the actual drug or not, and in trials the efficacy of the drug hasn't even been proven. So, the commitment of trial participants to stay adherent to the drug is less rigorous than users today, who know that the drug works, know they're getting the real thing, and are invested in remaining HIV negative. People taking PrEP today have more skin in the game, as it were.

 

For those who do miss the occasional dose, Truvada is somewhat forgiving. The protective ability of the drug doesn't drop if you miss a single dose because Truvada remains in the blood for up to 72 hours (compare that to missing a condom occasionally, which CDC statistics show to be as risky as never using them at all). That being said, it is optimal and recommended that Truvada be taken consistently each day, and users should take seven daily doses for Truvada to achieve optimal protection.

 

Taking Truvada alone when a PrEP user doesn't know they are already positive can lead to resistance and significantly reduce treatment options. Resistance has not been found with individuals who were verified HIV negative at the time they started Truvada, but it has happened in people who became HIV positive due to low adherence.

 

PrEP is just putting money into the pockets of pharmaceuticals when we have cheaper solutions.  I can't imagine anyone telling HIV positive people not to take their medications because their drugs are making profits for Big Pharma. The argument that HIV negative people aren't worth a fraction of that investment astounds me. I suppose we should wait until negative people get infected before it's okay for them make a profit for the drug companies.

 

And those are the facts as we know them about PrEP. I have no delusions that the debate will calm any time soon, of course. Human nature is far too predictable for that.

 

Just recently, politician Mike Huckabee addressed a gathering of fellow Republicans. Part of his remarks, delivered half a century after The Pill was approved for contraception, was his belief that "smart" women don't need the government "providing them a prescription each month for birth control because they cannot control their libido."

 

Right. Because birth control, as critics have been saying since 1960, would be unnecessary if women only showed some restraint and didn't behave like barebacking sluts.

 

Everything old is new again.

 

Mark

 

My thanks to HIV advocate Jim Pickett of AIDS Foundation Chicago for his expertise on this issue. Jim is active in the development of rectal microbicides (lubes and douches that kill HIV on contact). Damon L. Jacobs, who writes about his personal experience taking PrEP, also served as a resource.

 

Stop Bludgeoning Young Gay Men with Our AIDS Tragedy

| 19 Comments

Lesley was my closest friend to become sick in the 1980′s, and he fought bravely until his death from AIDS. Today, there are little rituals I have to honor his memory, and I often write about him, the first of many friends lost to the epidemic.

 

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But there's something I will not do. I will not dig up Lesley's body and beat young gay men with his corpse. Lesley didn't perish so I could use him as a scare tactic. He wasn't a cautionary tale. He wasn't a martyr. He was a man with the same passions and faults as anyone else, and I won't use his death as a blunt instrument.

 

Plenty of us are more than happy to rob graves, however, in an attempt to frighten gay men into acceptable behaviors. This kind of horror-by-proxy happens all the time. Concerned but misguided gay men of a certain age hear whatever the latest HIV infection rates are, and they pull the AIDS Crisis Card.

 

"If their friends all died like mine did, maybe they would think twice before having sex without a condom," goes a typical remark, drenched in self pity and tenuous logic.

 

This statement misrepresents our lost friends and oversimplifies the state of HIV today. It projects our grief in the direction of those who bear no responsibility or resemblance to what we experienced. It subtly blames our departed friends for their mistakes, and then tries to equate them with a new generation of gay men who are much too smart to buy into it.

 

So frozen in time is our victimhood, it hardly allows for the facts of the here and now. Young gay men are more aware of HIV than my generation ever was. They simply relate to it differently, having come of age since the advent of successful treatments. Asking them to fear something they have literally grown to accept is as realistic as asking them to perform "duck and cover" drills in case Russia drops the bomb.

 

To view these young men and say, in effect, "if only you saw all the death that I saw..." is a wishful fantasy that disturbs me on all sorts of levels, and it says far more about us than it does about them.

 

I understand these attitudes come from a place of complicated emotions, ranging from grief, primarily, to our own shame or guilt over dodging a bullet -- and it may come from a sincere need to share our experience with others. The punishing tone that often accompanies it, though, isn't going to win the respect or investment of younger men.


I take our community history very seriously. I've written a book about the dawn of AIDS in Hollywood, have read And the Band Played On more than once, cheered on the activists in the documentary How to Survive a Plague, and can't wait for the release of Sean Strub's upcoming AIDS memoir, Body Counts. There is enormous value in preserving our history -- and in recognizing that many of us still carry trauma born of that time.

 

Community advocates have stepped up work to help us process what we went through a generation ago. Post Traumatic Stress Disorder (PTSD) is a very real phenomenon for longtime survivors, and excellent community forums have been mounted to explore these areas by the Medius Working Group in New York City and the Let's Kick (ASS) AIDS Survivor Syndrome" project in San Francisco. Hopefully, other cities and LGBT organizations will follow suit.

 

That important work is quite different, however, from allowing our past to blind us to the present. When we raise our finger and say in a voice filled with foreboding, "people think you only have to take a few pills and that's it," we are denying the actual experience of a lot of people with HIV. For many like me, taking a few pills a day is, in fact, the only impact HIV has on my life. Research suggests I will live a normal lifespan and am more likely to die from cigarettes than HIV. And I'm not going to deny all that in order to advance a fright-show storyline that isn't my experience.

 

There are young voices telling new stories, thankfully. Gay writers living with HIV such as Patrick Ingram, Josh Robbins, Tyler Curry, Aaron Laxton, Robert Breining and the irascible Josh Kruger are peering across the generational divide (I have HIV antibodies older than they are) and they seem bemused. Their blogs suggest a post-AIDS life of full engagement and purpose. I consider this progress. If their lives (and writings) don't include burying friends or serious health concerns, wasn't that our goal all along?

 

Our AIDS tragedy mindset isn't simply an annoying aspect of our social lives. It has actually stood in the way of embracing exciting new developments in HIV prevention.  New understandings of what it means to have an undetectable viral load, or the breathtaking breakthrough of Pre-Exposure Prophylaxis (PrEP), have been unfairly maligned not because the science isn't convincing, but because we're too attached to the mythology of condoms. We idealize their usage and efficacy, when nearly half of gay men are not using them consistently and never have. Gay men who don't use them, if you follow this thinking, are doomed heretics unworthy of new prevention strategies. Let them eat cake.  Just don't waste money on PrEP.

 

Perhaps, in the end, we are simply victims of our own success as advocates. We successfully entrenched the immediate, mortal danger of HIV, the shameless inaction of our government, and the profit-driven, opportunistic role of the pharmaceutical industry. Anything that veers from that narrative, especially for those of us who lived it, feels like betrayal. Yet here we sit, in an age that confounds so much of the horrific truths of decades past.

 

The 1980′s are history. They are not a prevention strategy. The war as we once knew it to be, the one Lesley and so many others fought so valiantly, is over.

 

May they rest in peace.



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