The Great Truvada Debate

When we talk about gay rights...and how far we have come as a community, I think many people would think first of the tide of marriage equality that has been steadily advancing across the nation. This is what makes the news and has become a defining movement for the community. And indeed, we have come very far in the legal recognition of our lives and loves, thus beginning to stem a tide of injustice that was just an accepted and given part of gay life as I knew it when I came out. It is amazing to be writing this to you as an out, gay, and married man with a family as those things were so far beyond my dreams not too long ago.

But there are other issues and conversations that move us along as a community with equal momentum. Some of those conversations are quite heated and so emotionally laden that they are hard to approach. Today's blog is one of those for me. Living the life that I have, and coming to terms with my sexuality when I did....I understand the debate over Truvada affects me, as it does all of us....but another part of me feels so ill prepared to tackle it with the breadth and understanding I think this topic deserves. However, there are few topics today that can cause such heated division as Truvada...and PreP therapies in general. For something sold as an "advancement in HIV prevention, it has engendered such a divided response, with both sides digging in their heels in their positions...that it leaves anyone looking in from the outside confused as to why this drug that can save lives should get this much controversy.

Is there actually a meta-conversation going on underneath the outward discussion of facts and transmission rates? Are we still grappling with old fears and ingrained self prejudices that is keeping us from see this drug as anything other than another tool in the fight against HIV? As the debate swings from one heated comment to another...what are we saying to ourselves, about ourselves?

For those of you who do not know(and at the risk of exposing what I don't) Truvada is a drug that falls into a class of drugs known as PreP (Pre-exposure Prophylaxis). Truvada, if taken correctly and under a doctors supervision, can drastically reduce HIV transmission rates. The Center For Disease Control estimates that reduction as much as 90%. That is a game changer for a community that has been, for decades, been told that the only way to prevent new infections has been through a combination of condom use and regular testing...or, at worst....abstinence.  And to be clear....Truvada does not offer any protection from other STD's such as Syphilis, Gonorrhea, or Herpes. Those are the facts as I understand them.

But here is where I start to delve into murkier waters..Everyone has big opinions about this. From those who laud it as a new form of sexual empowerment....to still others who view it as an open door to risky sexual behaviors and resulting in a new wave of HIV infections.

 We are not so far away from the worst days of the AIDS crisis that many of us don't have some instinctual fear about the notion of gay men having unprotected sex. Even long time HIV activists are split in their opinions over how this drug changes the landscape of how we fight HIV. For example, founding member of Gay Men's Health Crisis, Larry Kramer, in a recent NY Times piece called the act of taking Truvada "cowardly"....

“Anybody who voluntarily takes an antiviral every day has got to have rocks in their heads,” Mr. Kramer said, describing the side effects of drugs he has taken. “There’s something to me cowardly about taking Truvada instead of using a condom. You’re taking a drug that is poison to you, and it has lessened your energy to fight, to get involved, to do anything.”

And on the Other end of the spectrum is Act Up founder Peter Staley, who in a recent Slate interview, addressed Kramers remarks and offered his own sobering counter opinion...

"...Because we don’t have the death and dying that forced a drastic change in sexual behavior among gay men in the mid-’80s, which was largely sustained until the early ’90s, the safe-sex condom code that we created then has collapsed. And that’s the reality we live in today. Just talking about it, telling people that they’re cowards for not wearing condoms—I don’t think that’s going to create a mass movement of putting condoms on..."

The very people who fought the hardest through the darkest days of AIDS deaths can not even agree on whether or not Truvada is a beneficial development. While it is not uncommon for Larry Kramer to be at odds with...well, the world...the fact that these two men are coming at this from such different perspectives highlights what is going on in a larger sense within the community itself. This rather civil disagreement echoes a much larger and less civil disagreement taking place on the internet, between friends, and in the boardrooms of gay orgs. The landscape has changed, and we are learning to grapple with it.

Yet, one of the first things that stands out when I read articles or see discussions about Truvada is that fear is one of the loudest voices.The legacy of HIV is the awareness of how sex was tied to HIV and the loss of so many. Indeed, anyone who came of age in the late 80's to 90's had, "put a condom on it", drummed into our heads from junior high into adulthood. We learned the facts that HIV does not care what race, gender, or orientation you are, it can get all of us. Sex became dangerous for my generation and that has been such a part of our understanding of the sexual landscape for so long that it doesn't go away easily...not even by magic pill. Regardless of how many facts about reduced transmission rates you put out there, there will always be that specter of doubt within some of us that fears that we could be leaving ourselves open and vulnerable to danger should HIV mutate to overwhelm a drug like Truvada. Is that rational?...no. But there is also nothing to be gained from judging and shaming a person that holds that opinion because it was taught to us as how you survived in the modern world gay or straight. 

Linked with the notion of survival is what we think about sex. No matter what you opinion  to sex might be, we all have opinions about it and sometimes standards that we apply to others that we don't apply to ourselves. Some see sex as a liberating act...others an  act so private that even talking about it is too much. So throw in a drug like Truvada that offers the chance to leave behind a portion of the caution around sex that we have learned to live with...and it blows the lid off everyone's secret judgments. Will gay men(notice no one else mentioned) start having tons of unprotected sex is the question at hand. But is that question focused on HIV...or merely the sex?

Whether it comes from the homophobia of our upbringing...or perhaps some inborn belief that too much sex is a character flaw....we have a new word to shame sexually active gay men who chose to go on Truvada...."Truvada whore". Hell, even the head of AIDS Healthcare Foundation, Michael Weinstein, referred to Truvada as a "party drug" instead of a preventative tool. The thought process here being that anyone who has the intent of using this drug also has the intent to have lots of indiscriminate and unprotected sex. A leap in logic if you ask me. Just the use of the word "whore" tells you all you need to know about the attitudes of the person using it. Not that the gay community is any stranger to throwing shade at ourselves, but you would think that after having gone through so much in our collective history we could get past B.S. like this...but no...

Indeed, the entire conversation is reminiscent of when people like Kramer and Staley were trying to get people to use condoms in the first place. Activists were accused of being homophobic and self-hating for insisting that condom use could save lives. For a gay community coming into it's own in the 70's, sex equalled the freedom to be who we were without judgement. Sexuality was a symbol of that freedom. We had chosen to throw off that judgment...and with it went our inhibitions about sex, so being asked to put on a condom was tantamount to being asked to go back into the closet....and act unthinkable to many. It took many years to get people to see that condom advocates were only trying to save lives and galvanize the community to fight for it's own lives. Though it was literally about life and death then....does anyone not see some similarities of that fight in the conversation over Truvada? A bit of that same intertwining of  sex and identity is at work in both and we are still just as conflicted as a community.

I do not even know if it is fair or appropriate to look at this issue with such a large frame of reference as "community". Though this does affect us all in the same way that condom use and testing also does, the fact of the matter is that our "community" is made up of individuals from so many different walks of life, each coming to their own acceptance of their sexuality and living that out where ever in the world we find ourselves. That's a pretty broad spectrum of viewpoints and levels of self-acceptance to try and integrate into a community opinion over Truvada and where we are now with HIV. We are not just the population of a few cities or even a neighborhood...we are all over the nation, and the world...and all of us have skin in the game....literally.

If asked, we all affirm the rote response that sex is positive and beautiful, but then where to do we take it from there? Do we add conditions to that? Do we add conditions to ourselves that we don't hold to others? What about the guy who lives in a long-term monogamous relationship vs. the single guy dating and sexually active? Are we making silent judgments about both of them? If those two men both decided to take Truvada and posted that status to Facebook, what do you suppose would be the response to each? My guess is the one in relationship would get asked "why?" and the assumption would be that one of them wants to play around. The response to the single man could range from relief to judgement about his choice to be sexually active outside a relationship. We look at both men differently but each through the lens of Promiscuity instead of taking charge of their own sexual health...or that they may be using multiple strategies to accomplish this.

But in closing...as Peter Staley expressed, isn't it our goal to reduce new cases of HIV transmission such that we eventually beat it into non-existence? And if we still hold to the camp that believes that condoms are the only way to be sure...how has that worked out so far? The prevalence of bareback porn shows us that people are more than willing the take the risk of sex without condoms as things are. Can we at least admit that unsafe sex is happening already in both gay and straight bedrooms all over the country and give people a way to prevent HIV that they might actually use? Could this prevent new infections from HIV coming from people who don't even know they have it?..or don't think it could happen to them? Our judgments about sexuality seem to take a backseat to the stark reality that this pill could save a lot of lives even if it doesn't permanently rid the world of HIV.

Conversely, Is it accepting the easy way out to just take a pill like Larry Kramer intimated? Having we given up our will to fight HIV to the extent that we will accept taking a pill everyday...forever? And don't we already do that for other sexually transmitted diseases? That I have no answer for...so many promising treatments pop up in the news never to be heard of again after...and here we are offered a solution that requires us to take a pill everyday. Is and endless supply of money for pharmaceutical companies behind this new "advance"? There are still no easy answers there either.

In the end...I support the use of Truvada because I know dam well that there are already tons of people out there who don't use condoms and this could not only save their life but also the lives of those they sleep with. It could save the lives of people who think HIV will never happen to them. I support it because I have friends in mixed  positive/negative relationships for whom a treatment like this one will be incredibly healing to their relationship. I support it because it can help stop the spread of HIV in countries that don't even acknowledge it's existence. I support it because it may help HIV positive moms keep from passing the disease onto their infants. But mostly, I support it because I want HIV gone forever, and this is one more way to make that happen. If this means I have to confront my own demons over sexuality and how I was taught to deal with it, then so be it.

As medical providers are taking a serious look at Truvada and other PreP drugs being developed as a way to curtail new infections, we also need to take a long hard look(no pun intended) at how the controversy over Truvada is revealing how we feel about sex and the judgments we are putting on each other. We have fought to be "out" and every year we go to "pride"....Our very language points to building our self esteem as human beings and yet, what the conversation about Truvada has revealed is that, not only is our sexuality tied to our feelings about ourselves....we still have a lot of baggage around that. 

I am not a part of the "sexual revolution" generation...but even I can see that the sex=death messages I grew up with are no healthier. The real truth was that silence=death. As we have all fought to obtain our piece of self acceptance...possibly even "pride"...we need to remember that, it is still a work in progress for us as it is for others. To that end, we recognize what we are really talking about when we are having a conversation as heated as one over Truvada has been. If our beef is with the fact that we are afraid HIV will return worse than ever....name it. If our beef is with people who don't have the same inhibitions or values that we do...then be honest enough to own it. We have all come too far to let the same old wounds keep sidelining us. Instead of turning that animus on ourselves. Let's put that anger where it belongs...on fear, shame, and HIV. 

Wouldn't that be progress?

Until next time dear readers...