Scott Artley was shocked when his regular doctor advised him not to take Truvada, an anti-retroviral drug that has reduced HIV infection risk by 92 percent among men having sex with men.
One reason why Artley suspects his doctor may have steered him away from the drug: “slut-shaming,” the perception that somehow a Truvada user is more promiscuous, rather than simply taking extra precautions. It’s a dilemma that straight women who use birth control know well. Just Google “truvadawhore.”
But men who have sex with men (a more comprehensive term than “gay men”) face a second, bigger problem when it comes to Truvada: the perception they are HIV carriers and use it in place of condoms, spreading the AIDS-causing virus.
HIV infections in Minnesota: low but rising
There’s ample reason to worry about anything that might increase so-called “bareback” condom-less sex among men. Men having anal sex with men without condoms rose 20 percent between 2005 and 2011 — even though one in six HIV-positive Americans don’t know they are infected.
While Minnesota is a low-prevalence HIV state, new infections among men 13 to 24 quadrupled from 18 in 2001 to 78 in 2009. These young Minnesotans account for 1 in 4 new cases.
That dynamic fuels the search for biochemical alternatives, according to Prof. Simon Rosser, who directs the University of Minnesota’s HIV/STI Intervention and Prevention Studies Program.
Truvada has an impressive success rate when used as part of an HIV prevention approach called Pre-Exposure Prophylaxis, or PrEP. Men who have sex with men were 44 percent less likely to contract HIV if given Truvada daily, and 92 percent less likely if they had detectible levels in their blood, according to the National Institutes of Health (NIH).
Those stats are a big reason the federal Food and Drug Administration approved Truvada in 2012, and the Centers for Disease Control issued clinical guidelines this May.
To Rosser, the CDC’s guidelines seem like an idealized but challenging decision tree: “Today, we’re asking [men] when they see a hot guy and [have a] chance for sex, to first discuss their HIV status, then discuss if they are on PrEP, then discuss using condoms, and then still to use condoms. I suspect there’s a cascade of decreasing response, and while most men may be willing to do one or some of these things at least some of the time, few are willing to do them all, all of the time.”
But is Truvada a devil’s bargain, inducing more and higher-risk sex? Perhaps not. At least one December 2013 NIH study shows PrEP does not reduce condom use or encourage “sexual risk compensation.” (One of the study’s co-authors did receive an unrestricted research grant from Gilead Pharmaceuticals, which makes Truvada.)
After the negative experience with his regular doctor, Artley, a curator at Patrick’s Cabaret, talked with community health workers at Hennepin County’s Red Door Services program and made the decision to go on PrEP. He uses condoms, as the Centers for Disease encourages in new clinical guidelines, and gets tested every three months when he renews his Truvada prescription, which is almost entirely covered by his state-supported health insurance.
Mary Jo Meuleners, Red Door’s Community Health Program Supervisor, said state PrEP funding pays for staff time and subsidizes lower fees for patients without insurance. She said that PrEP can help where other measures fail.
The clinic emphasizes condom use — but does not to stigmatize clients who engage in risky behaviors. “It’s important to have other messages,” Meuleners said, which include using PrEP and getting tested every three months, which the clinic requires for clients on the drug.
One reason Artley’s doctor may have recommended against Truvada is that it is not without side effects. According the manufacturer, they can include “serious liver problems,” “worsening of Hepititis B infection” and “too much lactic acid in your blood.” The CDC says in studies, side effects “were mild and usually resolved in the first month.”
Dr. Frank Rhame, who works at the Allina Health Uptown Clinic, is eager to get higher-risk people using PrEP. In his experience, those asking for it are low risk. Often, gay couples ask for PrEP when one is HIV-positive. If the HIV-positive person takes antiviral drugs, there’s not a high risk for their partner to contract the disease.
Men taking the most risks need it most, Rhame says: “How do you reach the guy in denial about the risks he’s taking?”
San Francisco’s example
One way might be seen in San Francisco, which has higher rates of HIV cases. There, PrEP seems more mainstream. David Schmidt, a Minnesotan who recently moved to that city, said there are PrEP advertisements everywhere, including at bus stops and billboards. When he learned that a man he was dating who worked in the pornography industry was on PrEP, he started taking it, too — to protect himself in a city where “lots of HIV positive men who are undetectable,” he said.
PrEP has allowed Schmidt to talk more openly about sex with his partners, changing the question from whether the person was HIV positive to whether they were on PrEP. His first couple of months on the drug were rough, causing nausea and weight loss. After about four months, he seemed to even out, though he still gets his kidneys tested regularly to make things are OK.
Schmidt got married last month, so he’s not as concerned about contracting HIV, but he still takes PrEP, just in case. “You have this population of gay men who will not use condoms regardless of accessibility of safer sex accessibility or condoms,” especially younger men who unlike himself, didn’t see how the AIDS epidemic affected the world. Gay men who are 18-22 seem to be “terribly trusting,” he said.
Schmidt doesn’t understand the reluctance to take PrEP. “I don’t care who you are — the majority partners I have had have had a lot of condomless sex. If you take that extra precaution to not transmit, why would you even take that risk?”