Monday, June 9, 2014

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 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? 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 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 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 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 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...


  1. P.S..for those who may be wondering about the pictures I chose for this blog....I am not trying to steer people toward condoms over Truvada or vice versa...I was merely trying to point out how ubiquitous that message has been in my lifetime.

  2. This was awesome. Well said. I wanted to make a video about this topic so badly and tried several times but I could not find the words. I am so happy to see someone I respect and admire discussing this issue in such a meaningful way.

  3. Bryan I agree with you about the use of PreP drugs need to be use as same caution as unprotected sex but like you said that what if HIV mutated live a cold virus which constantly changing from person to person what if HIV become like a cold once again but it becomes air born to fight the PreP drugs effects everyone would be in trouble and that who be impossible to stop then so what if PreP drugs are the change that it needs to happened that is why I will only use condoms to be 99% protected from a STD/STI's.

    1. The fear is understandable but thats not how it works. The drugs that are out today keeps HIV from mutating and reproducing. Even without PrEP I can't transmit HIV to anyone I'm with unless I stop taking my meds. HIV anti-bodies are present in my system but the virus isn't.
      The biggest danger with Truvada is people NOT taking it correctly and theres less danger of mutation than there is resistance to medications, which could result in people not taking it properly. Some fears are justified and well founded others are left over relics from the early days of HIV/AIDS.
      HIV becoming airborne? Thats not how it works, thats one of the unfounded fears and myths from the past that should be left on the trash heap of history

  4. When I first heard of Truvada as PrEP, I had just had my prescription for it changed to something else. You see, one of the two drugs in Truvada is hard on the kidney, and I was showing signs of kidney failure. My reaction was "Yeah, right. Kill your kidneys to avoid condoms!" That was a bit over the top, and I don't really know the cause my CKD, but is food for thought while I prepare for dialysis.

  5. Great blog, it is a debate that for the most part I have kept on the outside of. I know that personally think that condoms are the better answer. I personally find it stupid to not use safe sex practices espicaly if you are outside of a closed long term relationship.

    I also have a personal feeling that Sex Sex (any thing that includes any kind of penetration as sex sex) outside of a relationship is wrong. And that is something that I hold myself to. And I also feel that even inside of a relationship it is important to have safe sex.

    I don't know maybe it is a combination of the safe sex, sex ed that I got in school. But I also know that in many ways it is based on my own values/views on sex that in many ways people would say is old fashioned. (I know that I am old fashioned in many of my other social views/values)

    I guess that Truvada is a good development as it is a tool that those that don't practice safe sex can use, although I doubt that they will use it anyway, but I also fear that it will open up the door to more unsafe and promiscuity. (not just in the gay community but in the straight community, however having the most affect on the gay community)

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  7. Thanks for your thoughtful blog post about the Truvada controversy. I share similar life experiences, having watched vibrant wonderful people in the 1990's die well before their time, which is something that people today can't even fathom. That was such a difficult and heartbreaking time to come out, and yet that’s what many of us did, and we lived in fear because we never could be sure if we would be next.

    In my opinion, the debate over Truvada should be a non-starter. Why are people arguing about this? Why are their factions lining up on opposite sides? If you look at the demographics, most of the people opposed to Truvada and prep are older. They are understandably filled with anger and resentment for so many things that we couldn't possibly appreciate. Though I haven’t heard an intelligent argument from the anti-Truvada faction that makes any sense.

    Larry Kramer is close to 80 years old. He is a brilliant academic, a great writer, and a brilliant activist. History will certainly remember him. I'd hate to see his legacy sullied by this Truvada debate. At the same time, I can understand why an 80 year old survivor would be pissed off enough to want to deny a 25 year old a healthy sex life!

    Before a patient begins the prep program, they are counselled and told to engage in safe sex. They are told that Truvada is not a guarantee of good health, and that risky behavior can still lead to a positive diagnosis.

    Remember that Truvada is for prevention. The HIV infection rate among gay men has been static for years, and this is an experiment to see if the infection rate can be reduced. Bravo to that!

    I’ve resisted writing about this issue on my blog, because I have tunnel vision. Anything we can do to reduce HIV infection rates among gay men, is worth trying. Anyone opposed to it be damned.

    Roy Steele

  8. To me, the controversy over Truvada reminds me of the firestorm over birth control pills. Women who used them were considered when they first came on the market whores. And to many conservatives today the mentality is alive and evergreen that women who use birth control are whores. Remember the horrid comments on the Hill from Rush Limbaugh and others when the debate over having birth control pills be free for Affordable Care Act?

    Its sex shaming for a whole new group of people, gay men. Not sure if these Truvada haters are jealous that other men are free to sew "wild oats" or what, but this fake debate over a true wonder drug is shameful. It. Saves. Lives! End of debate!

    Condoms do save lives, so what is the difference between buying condoms in bulk and using Truvada? Nothing to my mind. A condom and Truvada is kinda like a belt and suspenders but that would provide total protection from not only HIV but a whole host of other nasty STI infections.