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A Pill to Prevent HIV: A Conversation Gay Men Need to Have

January/February 2013

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Caveat Emptor (Let the Buyer Beware)

I have never known a world without HIV. I came to sexual maturity in the late '80s, at a time when HIV, sex, and gay identity were smashed into one. For me, the concept of sexual freedom without the fear and shame associated with HIV is both liberating -- and scary.

The epidemic has traumatized us through loss of our loved ones and in our shame around the disease. It has traumatized us in our prejudices against our HIV-positive brothers and sisters. And I wonder if the trauma of HIV, fears for our own safety and the safety of our community, and our own shame are holding us back from being able to objectively consider this new prevention method.

PrEP has the potential to liberate us because it gives gay men who have managed to stay negative an opportunity to sever the cord between sex and HIV, perhaps for the first time. To understand the scars that HIV has made, consider that HIV fear is present among many of us even when we are 100% safe, regardless of status. If PrEP can help positive and negative people feel safer and protected, then PrEP will have made a profound contribution to our emotional and physical well-being.

As anyone who has lived through the AIDS epidemic knows -- when it comes to HIV there have been few "home runs." Only a series of singles, doubles, and more than our fair share of foul balls. Truvada is not the one ring to rule them all. And yet it might still be a game-changer for some of us -- if we understand that PrEP is not a replacement for common sense.


Side Effects

Truvada has been around for over a decade, used along with other drugs by HIV-positive people to reduce their virus to undetectable levels. When used alone and not as part of a cocktail by HIV-negative men to prevent HIV transmission, side effects are rare and often go away in weeks. Most common side effects are an upset stomach or nausea. In rare cases, there are significant kidney issues, but these side effects are reversible for people who simply stop taking the drug.


Drug resistance to antiretrovirals like Truvada is an important issue. In fact, it is the reason HIV-positive people are given a combination of drugs in order to prevent HIV from developing resistance and escaping the meds.

However, if you are negative, and stay negative, according to the scientific findings reviewed by the FDA, drug resistance is not a significant issue. You must have HIV in order to have drug resistance to HIV (the virus becomes resistant, not the people). Translation: An HIV-negative person can go on or off Truvada during periods of their life when they are more or less sexually active. However, if someone is taking too little Truvada (less than recommended) and becomes infected, or is HIV-positive but does not know it when he begins taking PrEP, the virus could theoretically develop resistance to one or both of the drugs in Truvada.

In the clinical trial data reviewed by the FDA there was no evidence that an HIV-negative person developed resistance to both of the drugs in Truvada after taking it for prevention. It seems that resistance is not as serious an issue as people seem to think. At least not yet.

Mr. McConnell suggested that someone could even take a daily dose once a day for at least a week prior to a potential exposure (e.g., a "party" weekend) and continue daily dosing throughout the month to get good protection against the virus. "As long as you stay negative," he told me, "there is little problem going on or off the drug. You just need to test negative again before going back on."

A Tipping Point

Price and access issues have yet to be resolved. Most insurance companies appear to be covering Truvada and drug companies may not want to risk the potential negative publicity associated with denying a breakthrough drug to at-risk populations. But there is also the issue of those most vulnerable in our community who do not have insurance and are unable to get access through another avenue. [Editor's note: Gilead, the maker of Truvada, has a patient assistance program for those who don't have insurance and meet eligibility requirements.]

Truvada appears to be a powerful new weapon in our fight against HIV. You may still be skeptical of this strategy. You may still have fears around resistance, side effects, abuse, misuse and access. There is much we still need to learn about PrEP. And yet, how many more 24 year-olds need to get HIV before we are willing to consider that PrEP could be a viable part of a larger safer sex movement? I am optimistic that if we are willing to look at this new strategy without prejudice and judgment we may be able to radically change the trajectory of new transmissions, as our queer brothers and sisters historically did in the 1980s. Perhaps with PrEP we can better protect the young men in their late teens and 20s (like my friend) and minority gay men who represent the largest and fastest growing segment of new HIV infections in the U.S. We could make history once again. 

Additional Links

What is PrEP?

Interim guidance on PrEP for your doctor

Truvada website

HuffPost Live segment "A Pill to Save Lives," hosted by Alicia Menendez. Guests: Carl Sandler; Damon Jacobs, licensed marriage and family therapist at Private Practice Psychotherapy; Jeff McConnell, sociologist and iPrEx investigator; Robert Grant, iPrEx protocol chair; Tom Myers, chief of public affairs and general counsel for the AIDS Healthcare Foundation

The iPrEx Primary Report

"Emtricitabine-Tenofovir Concentrations and Pre-Exposure Prophylaxis Efficacy in Men Who Have Sex with Men," Science Translational Medicine

"Preexposure chemoprophylaxis for HIV prevention in men who have sex with men," New England Journal of Medicine

Carl Sandler has a degree in economics from Stanford University. He has spent the last 15 years designing, building, and using technology that helps gay men meet, first at (later Planet Out Partners); then as Founder of, a site for older guys; and most recently with the MISTER dating app. A version of this article originally appeared in the "Gay Voices" section of the Huffington Post.

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More From This Resource Center

Undetectable Viral Load and HIV Prevention: What Do Gay and Bi Men Need to Know?

Do HIV-Negative Gay Men Need Condoms if They're on PrEP? Here's What I Tell My Patients

This article was provided by Positively Aware. It is a part of the publication Positively Aware. Visit Positively Aware's website to find out more about the publication.
See Also
More News and Research on HIV Medications for HIV Prevention

Reader Comments:

Comment by: Abe Wed., Jan. 30, 2013 at 11:51 am UTC
Actual sentence pronounced to me upon testing positive after thinking I had always used a condom = "You need to own up to your recklessness and stupidity. What were you thinking?". Actual discourse with most poz gay men who choose to bareback = "Oh my gosh, don't you know that Hep C is sexually transmitted? And Super gonorrhea? And Drug resistant strains of HIV? Are you INSANE?" Actual quote defending the promotion of this marginally effective recreational drug = "A person taking Truvada daily can no longer be considered to be having unprotected sex for HIV. Why isn't a more expansive public conversation happening?" Maybe because everything about this PrEP is ludicrous, not least of all that it makes clear the double standard we afford people depending on their test results. Perhaps if the organization that authored this spent more time trying to help people with HIV, and a little less time hocking a recreational sex drug for Big Pharma, the answer to this question would be obvious.
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Comment by: PozinMaine (Maine) Wed., Jan. 30, 2013 at 6:54 am UTC
Prep is just a very expensive sex toy. People wait on lists for medications that they need while so-called prevention experts tout the need for biomedical interventions for those who can't or just won't exercise self-control. Shame on those trying to sell us this load of crap.
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Comment by: Tim (Cathedral City, CA) Wed., Jan. 30, 2013 at 11:11 am UTC
There were nearly 10,000 people on ADAP waitlists when news first broke of this stuff, and we only resolved that crisis by throwing most of those people off assistance and leaving them to fend for themselves. Even this website, which argues against prematurely starting treatment as part of a holistic understanding of the emotional and financial impact of lifetime chemotherapy, advocates this dangerous and insulting sex drug. The company that manufactures this drug responded to the prospect of a market expansion and lack of funding for those in need by announcing yet more price hikes. Their response to concerns that the precious barebackers might not be able to afford the sex pill Truvada? "Oh, you don't feel like wearing a rubber for random sex? Ok dude, here's your free medicine and labs. LOL". This is a total "F U" to anyone who actually has to live (and die) with this disease, if for no other reason than the exorbitant costs we pay are now directly and indirectly supporting an ineffective "prevention" drug aimed at getting Truvada into the hands of reckless people who don't need it over those who do. Shame on everyone who promotes this!

Comment by: Chuck Anziulewicz (Charleston, WV) Tue., Jan. 15, 2013 at 2:55 pm UTC
As an HIV Prevention Specialist for the West Virginia Bureau for public health, I think pre-exposure prophylaxis can be an important part of the overall fight against HIV/AIDS. But it's also an EXPENSIVE strategy: If you take Truvada every day (as recommended), it will likely cost in the neighborhood of $14,000 per year. That's over $38 per day. If insurance companies consider this to be a purely elective therapy and are unwilling to cover it, it will be a bit too expensive for many people.

And even if someone was willing to pick up the price of Truvada on their own, there is still the possibility of becoming infected with a strain of HIV that is already Truvada-resistant.

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