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This PrEP-ed Life: Damon Jacobs on Sex and Dating in a New Era of HIV Prevention

May 13, 2013

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Can you tell us about your PrEP regimen? How do you remember to take your pill, and when do you take it?

I have a pretty consistent routine, and I always have. Well, not always, but as long as I've been health conscious. I take vitamins. I'm not a health food nut; to be honest with you, I hate healthy food. I live off pizza. That's the thing. But, I take multivitamins. I take multivitamins that are rich with all these dried-up vegetables; they come from a special farm in Wisconsin. They're really good for you. So, that's really an important part for me, is to maintain a vitamin regimen and to eat breakfast every single day. Which is another thing we often do, all of us do, to neglect our self-care. It's so important. And I drink coffee. So, I wake up; I have my breakfast; I have my vitamins; I have my coffee. That was already an established routine in my adult life. Those are important things I do to take care of myself and start the day right. PrEP was just one thing to add into that. It wasn't anything that was inconvenient. It hasn't been something I've forgotten. It's just with the vitamins now. It's on the same little thing that the vitamins sit on, so I don't forget.

Did you feel that you had to go through a Truvada "coming-out process" where you had to tell people in your life that you were making a decision to go on PrEP? I mean friends and family, not sexual partners.

"If I'm dating someone who is positive, they will tell me that they're positive, and I will tell them about PrEP, and sometimes the response is 'Phew! Good!' And other times, the response will be, 'Well, we're still using condoms, because never in a million years would I knowingly put someone at risk for HIV. I just won't do that. That's not my principle.'"

Who likes to talk about anal sex with their friends and family? I mean, I kinda do, because that's the field I work in, and those of us who work in the HIV field often do anyway. Nevertheless, it's not always a common conversation that you have at the dinner table with your parents. And before it was approved, honestly, I was concerned about talking about it. I was concerned that my insurance would cease supporting this if I was open about it. The shift in me now telling my friends and family and trying to get the word out there is because the FDA did approve it. It's all on the record with the insurance companies.

So, yes, it was weird. I had to explain this to my parents before talking about this publicly, because I'm friends with my mom on Facebook, and I thought that, quite possibly, she's going to see some of my shenanigans. So, I explained to them, "If I was a woman and I told you I wanted to take birth control pills, would you support me?" And my parents were like, "Yeah, we'd support you on that." Then I said, "Well, if I told you that there was a pill that could actually prevent me from becoming HIV positive by almost 99 percent, would you support me on that?" And they said, "Why would you need that?" Ugh, not what you want to hear. So, basically, I explained to them the idea of oral prophylactics, of prevention, of responsibility, of prioritizing my mind, my body, my spirit. That's consistent with the work I've always done, both personally and professionally. And this was very much in alignment with that. That they got; that they understood.

The other thing with friends is just that people don't believe it -- because there's so little information out there, because this has not really been covered very much. So, the friends I told about this, they didn't disapprove, they were just scared. They didn't really believe that this works. They didn't think this was real. They just thought I was going out and being self-destructive. They don't think that now, but in the beginning when I was starting to talk about this, my friends were concerned that I was on this binge of self-destructive, hedonistic, bug-seeking anarchy. And didn't really understand. So again, I did my best to show them the research, show them the data that were out there. Explain to them that this was being done with a doctor. Time has shown that, OK, we're on the right path here. We know what we're doing.

How do you broach the subject of PrEP with potential sexual partners? Do you feel like you can say, "Oh, it's OK, I'm on a pill." Run us through that whole song and dance.

Well, as I said, dating in 2013 is really different from 2003, and one of the biggest differences is that the condom conversation doesn't happen half of the time. In San Francisco in the 1990s, there was no treatment, and half of the men in San Francisco were positive. So, it was pretty much a given that, if I was going to be sexually active, that 50 percent of the people I was going to meet were going to be positive. So I just assumed everyone was positive, regardless of what they told me, and acted accordingly. But there was often a conversation; there was some acknowledgement that a condom was being used.

A lot of guys don't use condoms and don't talk about condoms. Now, from an education, from a prevention standpoint, that's terrifying! But it's also for real. But to answer your question, it doesn't always come up. The conversation doesn't always happen.

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When I am with a partner, or if I'm dating someone who is positive, they will tell me that they're positive, and I will tell them about PrEP, and sometimes the response is "Phew! Good!" And other times, the response will be, "Well, we're still using condoms, because never in a million years would I knowingly put someone at risk for HIV. I just won't do that. That's not my principle." And that's a response I often get from the positive community. Here's what I say: "All right, cool, I understand. But here's what I also want you to consider. Daily use of PrEP has been shown consistently in different research studies to be 99 percent effective in preventing HIV. Daily use of antiretrovirals by someone who is positive has been shown to be about 96 percent effective in reducing the transmission of HIV. On my side, I've got 99 percent protection, on your side, you've got 96 percent protection. The likelihood that I will be getting HIV from you at this point in time is pretty miniscule."

But, to be political on another subject, when you look at the escalation of gun violence in this country, and you see that about 30 murders a day are happening in America in which people are being killed by guns, I feel like the likelihood of me getting shot right now is higher than the likelihood of me becoming HIV positive with those odds. So, I put it like that to partners and then I say, "So, what do you think?" Sometimes, they say, "Nope, I still will not have sex without condoms." And there are people who are like, "OK, I see where you're coming from. Let's get busy." And I respect people's right to use condoms. Which is one of the biggest misconceptions about people who take PrEP. We're not the anti-condom police.

They think that you're the "barebacking brigade"?

"We're talking about PrEP as one strategy to prevent HIV, not the strategy to prevent HIV. ... It has been an opportunity for people in serodiscordant relationships, including myself, to experience more intimacy and more pleasure than ever before in the 32 years of this thing called AIDS. And I, honestly, didn't know if I would ever see that in my lifetime."

Radical barebacking brigade! On the streets! We're talking about PrEP as one strategy to prevent HIV, not the strategy to prevent HIV. It is one strategy to prevent HIV. Along with condoms, along with positive people knowing that they're positive and taking antiretrovirals so that they cannot give HIV to another person. It has been an opportunity for people in serodiscordant relationships, including myself, to experience more intimacy and more pleasure than ever before in the 32 years of this thing called AIDS. And I, honestly, didn't know if I would ever see that in my lifetime. I really didn't think I would ever see that in my lifetime, to be honest with you. It's really been a revelation in that way. So, to answer your question, sometimes I talk about it, sometimes I don't.

Does the condom conversation ever come up around STIs (sexually transmitted infections) other than HIV, since PrEP only protects against HIV? Or do people just not talk about it?

I'm telling you from my experience: People are not talking about HIV and they are definitely not talking about STIs. I'm not saying that's good. I'm not saying that's right. I'm not saying that's healthy. I'm just saying that's the reality of many hookups and of many of the conversations, or lack of conversations, out there.

This is why it is so so so important for people to have medical care with a doctor who they trust, who they respect. I always say, "If you can't talk to your doctor about getting fucked up the ass, then you have the wrong doctor!" You need to have a doctor who you trust. If you feel judged or criticized or condemned by your doctor because you have a healthy sex life or a sex drive, find a doctor who you trust. They are out there. In some areas they are easy to find, and in some areas they are not so easy to find.

You are a consumer. Not the patient. You are a consumer. That's a very different paradigm. Because a "patient" is passive, and just has to do what the doctor tells them do. A "consumer" can say, "If you don't treat me with a certain level of respect, and if you don't engage in a sophisticated, adult, respectful conversation with me about anal sex, then I, as a consumer, can go to somebody else who is willing and able to do that with me." That's the reason we have to have really positive relationships with the medical community, because part of taking PrEP is that it's so important to see your doctor consistently, have your blood drawn consistently, and get tested for other STIs, because PrEP does not offer ANY protection against syphilis, gonorrhea, herpes, all that fun stuff. There's no protection there. So, I do get my blood and urine drawn from my doctor every three months to screen for that.

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