This post originally appeared on the Visual AIDS blog as part of a series on the FDA approval of PrEP – the use of HIV medication as a tactic of prevention for HIV negative people

You can see it here

I had lunch with Tony to talk about the possibility of him going on PrEP. For twenty-five years he’s been having mostly protected sex, but with a few fuck ups, which sent him into an anxiety spiral. Now he feels in control: making mathematical calculations, picking partners with undetectable viral loads and having conversations about their mutual medication barriers. Now he is experiencing intentional barebacking, instead of it being a slip-up. This is a slip-up both he and I have had: guiding someone’s raw dick into our holes. It’s that moment where you just want it real bad, or need something to give the sex change meaning. Or you just want them to cum more quickly. But then, afterward comes the month of PEPing and calculating window periods. I understand why PrEP would work for him, feels like a right he should have. After all, other than the prohibitive cost, is it so much different from birth control pills? Is the only reason it feels more complicated because we live in a culture that devalues the worth of queer sex?

There are a couple of ways you can think about PrEP: on an individual level, on a public health level, and in questioning its place in the growing divide of what HIV prevention looks like for those who have insurance, versus those without.

Thirty years into the AIDS epidemic, there needs to be prevention strategies other than condoms. I appreciate PrEP being an option. Simultaneously, the increasing biotechnological approach to HIV prevention feels dangerous to me. After AIDS drug availability was something that was fought for so tirelessly, there seems to be little language to criticize the new single-minded, ART-based approach to HIV prevention. With community viral load suppression, “Test and Treat”, and PrEP as the “Brave New World” we are entering I wonder how this will play out on the ground for the people unable or unwilling to access drugs.

PrEP doesn’t make sense as a widespread prevention tool. For many people who are HIV-positive, getting access to and staying “med compliant”, is a struggle, to jump through the hoops of Medicare, ADAP, or even private health insurance. Not to mention how hard it is to take meds when you are struggling with issues of homelessness, trying to hide your status, drug addiction and/or mental health issues. For low-income HIV-negative people PrEP would be further complicated by the cultural shaming and the “we won’t pay for promiscuity” taxpayer mindset.

There are so many questions about PrEP: Exactly what is its efficacy? What are the long- term side effects of taking Truvada? What are the risks of drug resistance for those who do seroconvert? But the biggest question I have is what effect will PrEP have on the rapidly diminishing programming aimed at marginalized communities. My fear is that programs that provide community building, education, and realistic risk reduction will be replaced with pills for those who can negotiate the system, while those who can’t will be, once again, left with nothing.


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