Prevention

05.16.14

Will This Pill Kill ‘Safe Sex’?

I’m ambivalent about one side effect of the CDC touting an HIV-prevention drug. Will today’s young gay men never know the painful lessons learned during the AIDS crisis?

I remember when AIDS was something I was afraid of.

I came out of the closet as a gay man in the mid-1990s. After years of unconvincingly pretending to be something other than what I was, I let my friends and family know the truth. It was the most liberating experience of my life. And once the secret was out, I went about getting a life. I started going out, making friends with other young gay men, and trying to find a decent boyfriend.

Those days, the safe-sex gospel was everywhere. The club where I would go to dance and hang out with friends had a poster I’d seen in a news magazine years before showing two men wrapped in an American flag, one of them holding a condom. The drag queens who emceed the nightly entertainment would end their shows with an exhortation “If you’re gonna tap it, wrap it.” There was a weekly fundraiser for amfAR.

The message was clear: Take care of yourselves. Respect yourself enough to be safe. You owed it not only to yourself, but to the community.

Because of course, the AIDS crisis was still raw and real. Though I was just young enough to have missed the years when people lost friend after friend or lover after lover, there were many people I knew who’d lived that experience firsthand. And it felt almost like an act of disrespect to the memory of people they’d so recently lost to be irresponsible.

It was a message I received, internalized, and believed. The idea of having sex without a condom was almost literally unthinkable.

I was in medical school while all of this was taking place. I had several HIV-positive patients, and remember standing quietly outside a hospital room while a mother cried at the bedside of her son who had died of AIDS. Though there were many antiretroviral (ARV) medications by that time, it was still pretty much inevitable that patients infected with HIV would go on to develop AIDS, the only question being when.

And then came the advent of highly active antiretroviral therapy, or HAART. This combination treatment, usually comprising three medications from two different classes of ARVs, seemed almost like a miracle. HIV went from an eventual death sentence to a chronic but manageable illness. When, more than a decade after I entered medical school, I had to tell two different young men they were HIV-positive, I could do so realistically hoping we could keep the virus undetectable in their bloodstreams.

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Justin Sullivan

But I still remembered the message I’d internalized years ago: Practicing safe sex was not only the right choice for personal health, it was a sine qua non of responsible membership in the gay community. Even with HAART at hand, I recommend nothing more strongly than consistent condom use for all of my adolescent patients, and to this day nothing is more likely to provoke a heartfelt plea to change behavior than when a young gay man admits to me he’s spotty about doing so.

This week, the Centers for Disease Control and Prevention issued new recommendations for the prevention of HIV. It recommends that members of high-risk groups take an ARV called Truvada (actually a combination of two different ARVs) every day to prevent infection, a measure that confers 99 percent protection. Among those groups are gay men who don’t use condoms consistently.

I find myself riven with ambivalence.

While I understand that there is a difference in enjoyment between sex with a condom and without, I still expect gay men to use them. I still conflate safer sex with respect for the gay community and the lessons we learned from the AIDS crisis. And I wonder how such a horrible tragedy could seem so distant to young people scarcely a generation removed from it.

And then I wonder if I would be such a scold with my patients about any other issue. If the question at hand was more removed from how I came to understand my own identity, would I have the same expectations?

After all, I prescribe birth-control pills readily and vociferously support a woman’s right to use them, and to have them covered by her insurance as a routine part of her medical care. While I still recommend a barrier method of contraception as backup, if a young woman and her boyfriend aren’t using them 100 percent of the time it doesn’t trigger the same internal disappointment as it does when it’s a young gay man behaving similarly.

My misgivings are more about wanting my patients’ experience to conform to my own, and their identities to look like mine. And that’s not medical care, it’s moralism.

Rest assured, if a vaccine for HIV were approved I’d be administering it with unalloyed zeal. How is Truvada different? How can I justify qualms about Truvada when I don’t have them about Ortho Tri-Cyclen?

In truth, I can’t. If I’m going to be honest, I will admit that my misgivings are more about wanting my patients’ experience to conform to my own, and their identities to look like mine. And that’s not medical care, it’s moralism.

My job is to prevent HIV infections when I can. As the nation’s top AIDS doctor is quoted as saying, I cannot let the perfect be the enemy of the good. My personal feelings about the AIDS crisis are not a valid factor in my medical decision-making, and for patients who would benefit from a preventive prescription for Truvada I will start providing them.