What Does It Mean to Have “Safe Sex” in the PrEP Era?
There’s no questioning that PrEP is a huge innovative leap in safe sex practices amongst gay men and the fight against HIV/AIDS. What began as a “gay plague” first reported in 1981, followed by years of protesting government inaction, eventually led to scientific breakthroughs and HIV no longer being an automatic death sentence. We have yet to find a cure, but the 99% effective protection rate of PrEP seems to be a step in the right direction. The question remains however, after years of safe sex advocacy in the gay community and for the most part accepting a common notion of what having “safe sex” means, how are our ideas of safe sex changing with the invention of PrEP? How much do we need to rely on old safe sex practices after making the decision to go on PrEP?
Pre-exposure Prophylaxis, better known as PrEP, is a relatively new strategy for HIV prevention in which the HIV-negative individual takes a pill everyday (although there have been questions on exactly how necessary it is to take it every day) in order to reduce their risk of contracting HIV. Currently, the only drug approved for PrEP use is Truvada, which was approved for such use in 2012. It has been shown to reduce the risk for gay and bisexual men, transgender women, heterosexual men and women, and intravenous drug users.
Now in the PrEP era, we see reconsideration of what safe sex entails. While the collective memory amongst younger gay and bisexual men of the AIDS crisis of the 80’s and early 90’s arguably seems foggy or barely there, there is no doubt that the stigmatizing feeling of fear of infection lingers on. In a culture that both takes the manageability of an HIV diagnosis for granted at times, yet still bears the cultural norm of fear around sex in its psyche, PrEP is both liberating and a reason to reflect.
In the wake of the AIDS crisis, when the exact cause was still yet to be confirmed, with the knowledge that exposure to sperm and CMV were most likely key factors in the development of AIDS, many began to think harder about how one should have sex in an uncertain and fearful time. Some gay men- some of whom were open about being promiscuous before the crisis themselves- began to advocate for refraining from sex. This caused a rift in the community with people arguing over just how much they believed the other was policing individuals, and whether or not they had the right to do so. While some did stress celibacy, many also advocated for an individual responsibility to educate/get educated, then make choices calculating both the risk they are willing to take on themselves and the risk their partners are willing to take.
This second option was the one that has had a lasting effect on the way we conceptualize safe sex. In “How to Have Sex in an Epidemic,” Richard Berkowitz and Michael Callen advocated for condom usage, different ways of having sex to reduce coming into contact with semen/bodily fluids, and making responsible sexual decisions. They stressed that, “what’s over isn’t sex- just sex without responsibility.”
Looking to the present, there has been rising concerns about condom use amongst those who take PrEP. There is a general idea that people who are on PrEP will use condoms less than those who are not on PrEP. While PrEP is still really new, one study of users revealed that 41% of those on PrEP used condoms less frequently after beginning to take PrEP, while 56% reported using them at the same rate.
While there is a reduced risk in contracting HIV, there seems to be the notion that PrEP is the end all be all to safe sex. However, it needs to be reinforced that while PrEP reduces someone’s risk of contracting HIV, it isn’t a safeguard against STD’s. The same study found a 30% increase in STD’s amongst PrEP users after 6 months. Luckily, STD’s are treatable, but it is important that we keep in mind that they still come with complications and the more often one has to take antibiotics the greater the risk of the infection gaining a higher resistance to them.
The worries and warnings of lower condom usage, and the remaining risk of STD’s shouldn’t lead us to automatically believe that taking PrEP leads to users engaging in riskier sexual practices or being more likely to contract a STD than before. This would be without taking for account important factors such as the follow-up protocol PrEP calls for. When someone begins taking PrEP, they must visit their provider every three months to discuss their sexual practices, undergo screening for other STD’s, and get tested for HIV. Because of this follow-up protocol, it’s more than possible that STD’s are being diagnosed more because people are getting tested more often.
PrEP is a revolutionary new tool for practicing safe sex and reducing risk. It can allow gay and bisexual men to have sex with less fear and that is truly liberating. The conversation around PrEP shouldn’t turn into a polarizing “for” or “against” PrEP. That decision is for everyone to make on their own and it is everyone’s right to have the proper knowledge in order to make those decisions. Some on PrEP may want to continue to wear condoms, while others may not. Some may want to stay away from coming into contact with semen, others may not. The important part is that we need to continue talking to one another. Discussing risks, personal rules, and regulations may not seem sexy, but the comfort and security one can gain is worth the brief slow down. As Callen put it in the 80’s, “Our challenge is to figure out how we can have gay, life-affirming sex, satisfy our emotional needs, and stay alive!”
References:
“The Basics.” San Francisco AIDS Foundation. 2015. https://men.prepfacts.org/the-basics/
Altman, Lawrence. “Rare Cancer Seen in 41 Homosexuals.” The New York Times, 1981. https://www.nytimes.com/1981/07/03/us/rare-cancer-seen-in-41-homosexuals.html
Berkowitz, Richard. “How to Have Sex in an Epidemic.” June 29, 2010. https://richardberkowitz.com/category/4-how-to-have-sex-in-an-epidemic/
Konstantinovsky, Michelle. “Why Safe Sex Still Matters, Even If You’re On PrEP.” One Medical, May 18, 2016. https://www.onemedical.com/blog/live-well/safe-sex-prep/
Summers, Daniel. “Some Gay Men on PrEP May Stop Using Condoms. Does It Matter?” SLATE, March 29, 2017. http://www.slate.com/blogs/outward/2017/03/29/do_some_gay_men_on_prep_stop_using_condoms.html
