“Safe Gay Sex” Is Still Happening
There was an op-ed posted in the New York Times yesterday called “The End of Safe Gay Sex?,” which turned out to be an egregious and detrimental waste of space. The piece elects fear over education in regards to sexual health and HIV in gay and bisexual men. This is the exact opposite of what we need to be doing to fight HIV in the United States (and globally).
Yes, there is a decline in condom use amongst gay and bisexual men on PrEP, but many men who are on PrEP were not using condoms consistently or at all in the first place, or had always intended to abandon them. This comes anecdotally from working in a sexual health clinic, but I would venture to say many of my colleagues would say the same thing.
The lack of condom use is not necessarily a direct cause of the rise in STI rates. For one thing, those on PrEP are being tested for STIs (at least) every three months; this means more people are getting tested with a frequency they were not before, and therefore, we are capturing more of what was already there but undetected. Furthermore, mathematical modeling has demonstrated that PrEP use may actually decrease STI rates. In a 10-year period, PrEP may prevent about 42% of gonorrhea cases and 40% of chlamydia cases, given 40% risk compensation according to a study published in Clinical Infectious Diseases.
The reason STIs are stigmatized is because they are tied to sex in the first place. We treat both strep throat and chlamydia with a Z-Pak but we don’t castigate someone for acquiring the former. It is time we remove the stigma from STIs, a barrier that keeps many people from getting tested in the first place. Sex is fun. Sex is liberating. Sex should be enjoyed without fear. That is what PrEP (and effective HIV treatment) allows.
Additionally, the idea of equating “safe sex” to solely condom use is an antiquated notion in the era of PrEP and antiretroviral treatment for those living with HIV. We know that PrEP is up to 99% efficacious and that someone who is taking their HIV medicine as prescribed is unable to pass HIV to their seronegative partners, known more popularly as being “undetectable.” While there are strains of HIV that are resistant to Truvada (the only drug FDA-approved as PrEP), it is incredibly rare; a study of Kings County in Seattle, WA, found that only “.03% of local HIV-positive population had viral loads over 10,000 copies/ml, and also had high-level resistance to [Truvada],” as discussed in aidsmap, and there have only been about four cases of primary Truvada resistant HIV transmissions to those adhering to their PrEP regimens in a decade.
Kelly’s op-ed is also harmful in that it assumes all individuals are in the place where they can access or use condoms safely, including the ability to go to locations where condoms are available for free. In domestic violence situations, “victims are often unable to negotiate the use of safer sex practices with coercive partners” and “abusers may prevent victims from receiving medical care.”
To say AIDS in the era of PrEP is “no longer a crisis, at least in the United States,” as Kelly puts it, overlooks the HIV rates of epidemic proportions in Black and Latino gay/bisexual men. According to the CDC, one in two black men who have sex with men (MSM) and one in four Latino MSM will seroconvert (become HIV-positive) within their lifetime. Kelly cursorily alludes to this later in his op-ed, but the initial diction downplays just how alarming these rates are. This HIV epidemic is one rooted in institutionalized racism, classism, homophobia, and capitalist greed. It is informative to look at HIV from a person-to-person standpoint but a monumental disservice to ignore the larger driving forces behind the epidemic. (It should also be noted that the rhetoric in Kelly’s op-ed and other publications continue to suggest that PrEP is a pill for gay and bisexual men only. HIV also continues to disproportionately affect transgender women and Black cisgender women.) If anything, Kelly’s piece demonstrates the privileged bubble in which he lives, removed from the reality of landscape of HIV and sexual health today.
Finally, to say that “the fading memory of the AIDS crisis that once defined what it is to be gay” is a huge slap in the face to gay men everywhere. AIDS never defined gay men. Historically, it disproportionately affected gay men but was never a gay disease in the first place. It should be celebrated that we need not worry about AIDS anymore as young gay men come into their own as sexual beings. We have documentaries, books, and other media and storytelling formats that pass down the stories of the AIDS crisis of the ’80s and ’90s that are easily accessible in the digital age. As Dr. Perry Halkitis, a leading public health researcher and long-term HIV survivor, explains:
“[it’s] shortsighted of us to expect a new generation of gay men to worry about HIV the way my generation did. While it’s still a problem, it’s not a death sentence.”
We need to get information about sexual health and preventative tools — including both condoms and PrEP — into the hands of those who need it the most, free from judgment, finger-pointing, and moral or ahistorical standpoints, while removing structural barriers to preventing HIV in the first place. That is how we end the HIV epidemic. That is how we promote safe sex.