The other blue pill

PrEP is short for Pre-Exposure Prophylaxis. It involves the use of prescription medication by people who are HIV negative to reduce their risk of HIV infection. PrEP is recommended by UNAIDS for communities at high risk of contracting HIV, but it remains difficult to obtain in Australia, where much of the debate continues to focus on whether it might encourage condomless sex. HIV prevention researcher Daniel Reeders examines the framing of the heated PrEP debate.

Illustration by Jon Tjhia

Let’s begin with a thought experiment. Imagine your two best friends partner up and have twins: two boys. You babysit and watch them grow up and you would throw yourself in front of a bus to protect either one of them.

The elder is competitive, driven and loves sport. The younger, from an early age, loves people: he’s funny, outgoing and affectionate, openly gay from his early teens onwards and beloved of his classmates.

Both kids are adventurous in different ways: the elder challenges himself at different sports, goes rock-climbing, gets on national teams. He loves learning new skills. If he’s not good at something, he’ll keep at it until he’s got it wrapped. 

As an adult, the younger twin’s passion is for learning about sex and relationships. At uni he focuses on gender studies; pretty soon he’s a peer educator with the Young and Gay program at the AIDS Council and he’s visited the on-campus clinic several times after having sex without a condom.

Australia invests heavily in supporting our national sporting teams and promoting participation in sport from primary school onwards. Encouraging participation in sport is seen to have many public health benefits as well as cultural benefits for our society. But when it comes to our younger twin, and whether he should get access to medication that can prevent him acquiring HIV even before he has sex without a condom, the response from many people is, ‘But should we pay for that?’

I think the state should fund prevention technologies that enable adventurous sexual cultures, because, like sport, they deliver a benefit to our national cultural and social life.

Adventurous personalities

The analogy between sport and sex is not purely metaphorical. In fact, one strand of sociological research suggests an appetite for adventure – sometimes referred to as ‘edgework’ – links various forms of voluntary risk-taking, including illicit drug-use, sex without condoms, rock-climbing, BASE-jumping and other extreme sports.

People attracted to these activities are not necessarily casual or reckless about risk. Rather, they value being in control. They enjoy mastering their own fears and emotions and they crave new challenges and experiences.

Adventurous sexual cultures ... deliver a benefit to our national cultural and social life.

This can apply to people who are sexually adventurous as well as physically adventurous. Someone who is adventurous might take on more risk, but they’re also likely to have more knowledge about and practical skills to manage risk.

In the heated and often vicious debate over HIV prevention in the gay community, sexually adventurous men are often depicted as reckless hedonists, blind to the risks, bent on pleasure and damn the cost to themselves or the health system. 

Research with sexually adventurous men, though, finds evidence they are taking steps (other than condom use) to prevent infection – and the infections that do occur in part reflect the failure rate of these risk reduction strategies.

If gay men really were ‘abandoning condoms’, as many headlines have put it, HIV infection rates would not show the gradual increases we’ve been seeing for a decade. Instead they’d show the kind of structure that rock-climbers and BASE jumpers get excited about. What makes sexually adventurous men different from the armchair commentators on the PrEP debate is in where they draw the line on what kind of costs they are willing to accept in order to reduce the risk of HIV infection. 

Specifically, they are not willing to use condoms every time they have sex.

People often think prevention involves the repetition and reinforcement of simple rules, such as ‘just say no’ or ‘use a condom every time’. For many, it’s easy to take that view because the issues don’t really concern them – they are heterosexual, or monogamous, or wholly untempted by drugs or condomless intercourse. 

Illustration by Jon Tjhia

That’s certainly the case for many of the expert voices weighing in against PrEP. They have argued that condoms are cheaper than HIV medications without acknowledging the most basic fact of social existence: that other people are different from them, and not everyone has the same experience of condoms! 

Instead they evaluate cost-effectiveness only in terms of money and prevention, not in terms of values pertaining to freedom and quality of life: pleasure, intimacy, excitement, closeness, connectedness and freedom from fear of HIV and pressure to use condoms.

Taming the screw

Not long ago, ABC TV aired a British documentary, Secrets of the Gay Sauna, whose narrator made numerous exclamations along these lines: ‘Despite being in a relationship of thirty years, Norville still keeps going to the gay sauna.

Many have argued that gay marriage is in fact a conservative political agenda, and this is bolstered by the view that gay marriage will somehow ‘tame’ or at least temper the promiscuous gay lifestyle. 

Recently I watched the HBO production of legendary gay playwright Larry Kramer’s The Normal Heart, about the HIV/AIDS crisis in New York City in the early 1980s. As cultural researcher Dion Kagan has discussed, Kramer views AIDS as a kind of moral corrective to an intensely experimental lifestyle of which he personally disapproved. 

Despite being in a relationship of thirty years, Norville still keeps going to the gay sauna.’

Over the years, many different people have approvingly shared Kramer’s angry screeds with me, and I have found this mystifying. It’s obscene to feel satisfied and vindicated by the losses our community elders lived through. These losses have ongoing effects on the connective tissue of the community, especially on the possibility of friendship and learning between younger and older gay men.

So, coming back to our thought experiment, is the best option – the happiest outcome for our younger twin and for public health – for our younger twin to meet another guy who wants monogamy and will tame him? Should he have to pay $100 per month out of pocket to import generic PrEP from overseas? Or should he live with the life consequence of potentially acquiring HIV – and potentially infecting others - just because he is different from his brother who prefers sports, or from other gay men who prefer just one partner or find condoms easy to use? 

And how did, ‘Should we pay?’ become the question we’re asking about PrEP?

The role of the news media

Earlier this year I participated as ‘guest tweeter’ for an episode of ABC Radio National’s Background Briefing that framed otherwise balanced coverage of PrEP around the question: Should the public pay for gay men to have group sex?

Without that framing, serious media coverage around PrEP would be limited to the kind of five-minute piece Norman Swan presents on RN’s Health Report, where the host’s clinical perspective dominates. With that framing, reporter Hagar Cohen was able to offer a sensitive introduction to the gay men’s sexual cultures that make HIV prevention less simple than ‘just use a condom’.

That report was very much an exception. It’s been hard to tell the story of the HIV treatments revolution, which began in 1996. These stories are almost invariably framed in hand-wringing ways: ‘But doctors worry this may lead to gay men becoming complacent’. This is a framing that preserves a moral perspective and defers reckoning with the policy implications of this momentous shift. We should be using every tool at our disposal – including education, prevention and medication - to stop the spread of an infectious disease, not debating whose fault it is when people become infected. 

They have argued that condoms are cheaper than HIV medications without acknowledging the most basic fact of social existence: that other people are different from them

Recently, a doctor in the UK told the Spectator he would rather get HIV than diabetes. That’s how much the experience of HIV infection has changed since the advent of the combination treatment approach way back in 1996.

Although it has taken two decades, it’s no longer just adventurous men who are reassessing the cost of HIV infection. There have been steady (although gradual) increases in the proportion of gay men reporting occasional unprotected sex in every country where treatment is available.

Sexual adventurism and the mainstream

When journalists and commentators ask, ‘Why should we pay for gay men to have group sex?’, it’s worth thinking about what role cultures of sexual adventurism might play in broader society, including the lives of heterosexual and even married people. There’s a case to be made that players in sexually adventurous cultures are learning lessons and developing practices that have broader relevance for people in more conventional relationships, both gay and straight. 

You might be surprised to learn that certain modern social conventions for sex and dating first emerged as sexual practices among gay men, and only later were they articulated in research and promoted more widely via health promotion campaigns. Like getting tested together by a doctor before having sex without condoms in a relationship. Or getting regular sexual health care so any infections can be treated and future partners are protected

Other aspects of sexual adventurism have social value that isn’t about HIV prevention. One is the way gay culture includes conventions for safely allowing one or both partners in a couple to have sex with partners outside the relationship. As the recent Ashley Madison scandal suggests, society at large has a lot of learning to do around the negotiation of primary and secondary relationships. 

Let’s revisit our thought experiment – only now, let’s think of the twins’ parents: your two best friends. Imagine they fit a common scenario where one partner has a more adventurous approach to life than the other. Over time, within the confines of monogamy and under the pressures of raising kids, it becomes apparent there’s a mismatch in what each partner wants from life. How do they handle that situation? What scripts does society offer them to follow in this scenario? What does research tell us, for once, about the lives of straight people?

A 2014 study of Australian couples found 96% expected sexual exclusivity of themselves and their partner. However, only 48% of men and 64% of women had discussed the matter and explicitly agreed. Only 1% reported mutually nonexclusive (‘open’) relationships. A year later, in follow-up phone calls, 93% of respondents were still in the same relationship, among whom 4% of men and 2% of women had had sex outside the relationship. Most respondents who had sex with someone else were in relationships that were expected to be exclusive.

Players in sexually adventurous cultures are ... developing practices that have broader relevance for people in more conventional relationships

One of the authors of the study, Juliet Richters, has argued that ‘Health promotion advice to engage openly with this question may be fruitless for many people, given Australia’s strong ethic against “two-timing”.’ Instead, she recommends prevention messages ‘should focus on ensuring that new couples do not embark on unprotected sex without prior testing.’

By contrast, the Gay Couples Study of 556 male couples in San Francisco found fifty per cent of men had sex outside their relationship with the consent of their primary partners. Research by Warwick Hosking at Victoria University has outlined the way rules of engagement are more important than monogamy in many gay relationships. Such rules may include an agreement not to bring casual partners into the shared home or limiting the number of times it’s acceptable to see casual partners. His research found that exclusivity did not lead to greater relationship satisfaction: what mattered to couples, both open and closed, was whether the agreement between the partners was kept, or broken.

Key facts about PrEP

  • The iPrEx study found that men who took the pill every day on time experienced a 92% reduction in their HIV infection risk.
  • Off the shelf, a month of brand-name medication for PrEP costs around $800. The patent for tenofovir, the key ingredient in the medication, expires in 2018, and the cost will fall to around a dollar per day.
  • PrEP is not currently available on the PBS. Men using PrEP in Australia are accessing it through limited places on trials and public access programs, or by paying out of pocket to import generic medication.
  • Because condoms don't protect against all STIs, education campaigns for gay men focus on regular testing and treatment rather than behavioural prevention for non-HIV STIs. People taking PrEP are required to attend appointments every three months for monitoring and sexual health care. Such regular testing and treatment for the most sexually active cohort is good news for arresting the spread of other infections.
  • In the initial trials there was no evidence of ‘risk compensation’ – men using condoms less because they were on PrEP. However, early data reported by researchers on the VicPrEP study suggests this may be happening now that gay men know PrEP works.
  • The World Health Organization has recommended PrEP be made available to people at substantial risk of infection.

Another aspect is the exploration of kink and intermediated sexual practices (such as sexting) that broaden our definition of sex and offer possibilities to learn new skills and interests that aren’t as focused on penetrative intercourse. BDSM players are developing concepts and practices for negotiating consent in a context of an explicit power differential. Our present-day societal discussions of violence against women are helping us recognise that power differentials created by our patriarchal society need to be considered in all sexual encounters. But there’s not much discussion of how to negotiate these in practice beyond the absolute ‘no means no’. For a receptive partner who eroticises that power difference, they need to know how to say ‘yes’ in ways that maximise pleasure and minimise the risk of harm.

In an era of contraceptives, antiviral and antibiotic medications, we no longer need to promote ‘just stick to one partner’. People who want to, can do so. But since not everyone wants to, we need to identify and amplify practices for safe and ethical non-monogamy, developed through cultural spaces of sexual and social learning and innovation. That experimentation – and the important social learning that can come from it – should not come at the cost of increased risk of HIV infection. When the Pharmaceutical Benefits Scheme (PBS) pays for the oral contraceptive pill and even Viagra, what motivates the demand that gay men use the cheapest, nastiest form of protection available? A range of different HIV prevention strategies must be funded so that everyone can choose what works for them.

Portrait of Daniel Reeders

Daniel Reeders has worked in HIV prevention since 2004, including roles with the Victorian AIDS Council, Living Positive Victoria, and most recently as a researcher in HIV prevention strategy at the Australian Research Centre in Sex, Health and Society. He writes a blog, Bad Blood, and in 2016 will commence a PhD on the cultural dimensions of public health and HIV prevention. 

Discussion

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