Back when I was still a young HIV-prevention worker in the long-ago 1990s, I came across a new campaign for gay men that had launched in Australia. It focused on negotiated safety within a committed relationship — basically, what steps a couple should take to stop using condoms. Plenty of my generational cohorts in other organizations were equally taken with the approach, in large part because we knew that plenty of gay men were already quietly using ''the Australian method'' in their relationships and it made sense to encourage and support healthy decision making and behavior change.
Excited by the prospect, I proposed to my organization's leadership that our new prevention campaign focus on exactly that. In turn, I was greeted with the widened eyes and totally crickets silence normally reserved for flatulence at a formal dinner party.
In its own way, the HIV-prevention community is deeply conservative. Not conservative in the sense of the hateful homophobes like Jesse Helms who used every tool they had to block effective prevention programs. I mean conservative in the sense of being extremely resistant to change.
It's easy to forget that even the efficacy of condoms was at one time not universally accepted in the gay community — I have some old campaigns from the '80s in my files that warned gay men that condoms could fail. Mercifully for the lives of many, that perspective fell by the wayside. Home HIV testing, while admittedly burdened with some important limitations when first proposed, incited a wildly vociferous opposition. The institution of rapid testing frightened many with the possibility of people going from the test to the result without a period of counseling in between, a fear only heightened by oral rapid testing.
Expanding post-exposure prophylaxis (PEP) — the administration of highly effective antiviral medications within 24 to 48 hours of a possible infection — from medical personnel who suffered a needle stick to gay men who had unprotected anal sex, caused huge concerns and opposition among many advocates who feared it would be seen as carte blanche for abandoning condoms.
So, while PEP is now standard practice, rapid oral HIV home-testing is scheduled to be available in October of this year, and condoms remain the centerpiece of HIV prevention programs for gay men, it is absolutely no surprise that the approval of Truvada for pre-exposure prophylaxis (PrEP) would cause an uproar in the prevention community.
To cut to the chase, I'm all for it. An expensive pharmaceutical isn't going to replace frontline prevention efforts, especially when our government can't even adequately fund AIDS Drug Assistance Programs (ADAPs) for people with HIV. But it should be welcomed as the first step on a new prevention path, not a miracle pill to solve all prevention problems.
More importantly, I want the availability of PrEP to force gay men to have more honest discussions about sex and HIV and condoms. We know that it's the rare man indeed who uses a condom every time for a lifetime, from first sex act to the last — I know I haven't. We know that many gay men, single or partnered, actively choose not to use condoms — we just don't like to talk about it, aside from shaming or tsk-tsking.
No matter how important or effective condoms are to prevention — and so many gay men, myself included, are alive today because of them — we can't pretend that we have just one path. We're at a point in the history of HIV where we can't avoid these conversations about the complex and independent choices gay men make when they have sex. It's time to start talking.