PrEP and the moralization of calamity
I love teaching people in the medical profession things they don’t know.
Friday, I slapped my primary care doctor up the side of his head with my incredible innovation of the “refills per men” ratio. You see, he wanted to know how I was handling PrEP, and I admitted to about one sexual contact per 30-pill refill. My actual ratio is about 40 pills per man. Good-looking and stable gentlemen are encouraged to contact me to see what we can do about fixing that number. It’s not just about myself, mind you - I would also like to help my insurer get the maximum value out of all that money they’re funneling to Gilead. Like a good American, my mind is always on everyone’s Bottom Line.
Recently I was also going through the usual pre-treatment questions at a local hospital, and answered truthfully when asked what medications I was taking. The admitting nurse dutifully went ahead and marked in my patient file that I was HIV+. When I discovered his mistake, I had the opportunity to explain both to him and to the attending doctor that pre-exposure prophylaxis with a commonly-used antiretroviral is now a “thing.”
And boy, is it ever! My Facebook feed lately has been blowing up with two controversies. The first: that a well-known socialite had her picture taken. The second: that a well-known actor, who is gay, expressed a negative opinion about PrEP.
Gosh, what a handsome devil! Rather than link to his words (or the responses to them — or his responses to those responses), I’d just like to address the controversy and try to link it into something larger.
We live in a risky society. One of the salient features of American life is the degree to which our government does not take care of us, compared to the citizens of other developed nations. With the exception of the most indigent among us, we are expected to find a way to pay for our own healthcare, our own food and, increasingly, our own education. With the notable exception of recreational drugs, we are also given more trust to play with more potentially destructive things (cars, firearms, etc.) than any of our other civilized compatriots. I will not pass judgment here on this phenomenon — but I would be remiss in not pointing it out.
Americans have developed a cultural relationship to this risk. We like to tell ourselves that we deserve the calamities that befall us. This has become an almost instinctual reaction to calls to expand the social safety net, or redistribute the balance of wealth and power, or even respond appropriately to a natural disaster (see: Katrina). We believe that the poor are poor because of poor choices. We believe that good fortune flows to those who deserve it. We are committed to this myth of fairness and meritocracy. It comforts us and allows us to feel safe. Swathed in confidence in our own good judgment, we downplay the likelihood of bad things happening — and ponder as to what flaw in another person brought about their misfortune.
What I have observed is that this is also our relationship to HIV. Those gay Americans who survived the epidemic uninfected credit our own good choices. We shame those who are infected, assuming that in a moment of weakness or bad judgment (or “sin”), they made a poor choice that we would not have. Is this necessarily so? Science describes HIV infection as a matter of odds, which implies that many of those not infected engaged in some of the same behaviors we shame, and simply got lucky. Despite this, we persist in the idea that HIV infection is the comeuppance of the promiscuous (even if we subsequently shower that person with pity). We make paeans to monogamy as an ideal preventative, neglecting the inconvenient fact that many infections occur within the context of what is assumed by at least one partner to be a monogamous relationship.
The myth is powerful. The person most likely to infect somebody is the self-declared HIV- who is unaware of his/her real status, yet we continue to strum the canard of sero-sorting (i.e. “don’t sleep with positive individuals and you’ll be fine”). Research, however, tells us that the safest person to sleep with, assuming imperfect knowledge, is the HIV+ individual who is complying with antiretroviral therapy and has an “undetectable” viral load. We are only now starting to learn this deeply ironic statistic. Thankfully, PrEP is providing us with a new class of safe individual — the HIV- person who maintains her/his negative status by adhering to PrEP. If I’m having a pre-sex conversation with you, I now have an additional piece of information which will help me gauge the safety of our encounter. Better yet, I’m on a medication which will dramatically reduce my risk of infection even if you turn out to be infectious.
What PrEP does is put me in control — real control, not the illusion of control that comes from the idea that I am successfully sero-sorting, or can do a perfect job of safer sex practices. When we have medical professionals who are trained in the use of PPE acquiring Ebola from their patients, is it really reasonable to assume that an amateur (and we are all amateurs, except perhaps for experienced sex workers), can do a 100% perfect job of practicing safe sex and protecting him/herself from HIV? Does that person deserve their infection if they fail, or a condom breaks? Does that person deserve an infection if their partner lied to them (or was simply unaware of their status)?
It’s absurd. But as long as we believe calamity is the reward for bad behavior, we will continue to suffer. We may have the opportunity to end the spread of HIV among men who have sex with men. Are we willing to break free from our destructive attitudes and embrace this gift for what it is?
