Is This the New Condom?

9.9.2013

By Tim Murphy

Taken once daily, the pill Truvada can prevent HIV. It’s safe, effective, FDA -approved, and usually covered by health plans. So why are so few gay men taking it?

Photography by Greg Broom

The gay 40-something well-known New York City doctor with many gay patients — let’s call him Dr. John — can barely talk freely about what he’s doing. “It’s telling, how reluctant I am to talk about this, even anonymously,” he says. “This isn’t being talked about in our community at all.”

The subject causing such anxiety for Dr. John is an oval blue pill called Truvada. He takes it once a day — not to treat HIV, but to keep him from getting it. It’s even covered by his insurance, thanks to a decision by the FDA last year to approve it as a prophylactic against HIV. That approval followed a groundbreaking study in 2010, called iPrEx, that found that HIV-negative gay men who faithfully adhered to a one-a-day regimen of Truvada reduced their risk of getting HIV by more than 99%.

Those findings, which HIV specialists had been keenly awaiting for several years, were enough to make Dr. John talk to his own doctor and start the regimen himself. “I don’t want to become HIV-positive,” he says. “But I don’t love using condoms.” Sexually active with multiple partners, Dr. John admits he avoided condoms about 20% of the time. He was tired of stressing constantly over whether he’d gotten HIV. “Even if my sex was relatively safe, I would have long periods where I’d be freaked out that something had happened.”

Since he started taking daily Truvada, or PrEP (pre-exposure prophylaxis), as the regimen is called, Dr. John has remained HIV-negative and has experienced no side effects from the drug. “My sex life has been much less anxiety-provoking,” he says. “Now if I don’t use a condom, I feel like there’s a safety net.”

So why isn’t he shouting about PrEP from the rooftops? Partly, he says, because he doesn’t want people to think that because he’s a doctor, he’s endorsing PrEP for everyone: “There’s a difference between giving medical advice and making individual choices.”

But his reluctance is deeper than that. He also doesn’t want to be judged for eschewing condoms from time to time. “Gay men talking about not using condoms is really stigmatized,” he says. “Most of us have never known sex without condoms or without threat of a ‘deadly disease.’ ” But he adds passionately, “I think it’s a lot to ask an entire generation of gay men to use condoms forever.”

Slow to Catch On
Dr. John is not alone in his reluctance to say that he doesn’t always use condoms, or that he’s on PrEP. I talked to dozens of LGBT health workers in the United States, as well as HIV-negative men on PrEP, and a clear picture emerged: Even though PrEP is the first proven new HIV prevention tool since the condom, and even though it’s FDA-approved and is widely covered by health plans, few gay men appear to be on it.

“The uptake has been extraordinarily slow,” says Dr. Bill Valenti, who works at an HIV-positive and LGBT-serving health care center in Rochester, N.Y. He says that of their 75 HIV-negative patients, three had started PrEP. At D.C.’s LGBT-serving Whitman-Walker Health, staff said that about 90 of their 3,000 HIV-negative patients had started PrEP. The clinic’s patient population is made up primarily of African-American gay or bisexual men, the group at highest risk for HIV in the United States, along with transgender women.

It is difficult to know exactly how many guys in the U.S. are taking PrEP. Cara Miller, a rep for Gilead, the company that makes Truvada, said she couldn’t pinpoint such numbers because the company doesn’t know who is being prescribed Truvada in combination with other HIV drugs — which is necessary for treating HIV — and who is getting Truvada alone for PrEP purposes.

But Jim Pickett, who heads prevention advocacy at AIDS Foundation of Chicago, says that he has heard through inside sources that one of the country’s largest insurers has, to date, covered only 300 prescriptions for Truvada alone, presumably for PrEP. That is a tiny number considering that Truvada, approved for use against HIV infection in 2004, has become a multibillion-dollar seller for Gilead. (The two drugs that comprise Truvada are sold separately or as part of the No. 1–selling HIV med, Atripla.)

Despite its slow uptake, PrEP comes along at a moment when it could potentially help reverse a 22% rise in HIV rates in young gay men in recent years, with young gay and bi men of color most affected. The CDC recently calculated that, if HIV infections continue to rise at current rates, half of young gay men will have HIV by age 50.

At the same time, the longstanding admonition to “use a condom every time,” an approach pioneered in the ’80s and ’90s with posters and ads making condoms look sexy and fun, does not seem to be working. True, condoms are highly effective at protecting against HIV, as well as other STDs, including syphilis, herpes, and gonorrhea. They also sometimes break.

Moreover, studies since the 1980s have consistently shown that gay men forego condoms up to half the time, depending on the situation, for reasons ranging from “the heat of the moment” to alcohol and drug use to a plain old dislike of how condoms feel.

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