I also know that if I were to do every single thing I could possibly do to prevent HIV and STI infection I would not be enjoying sex very much at all. If I were to do only things that were "no risk" or "negligible risk" that would mean, for example, that I would have to use a condom even if I was giving a blowjob to a guy I was on a date with. It's low risk to get HIV from giving oral sex, but when you're having sex in an epidemic, low risk really doesn't mean no risk. I've had to give HIV-positive results to guys who were certain they hadn't had any unprotected anal sex, some of whom could even pinpoint the exact partner and blow job they'd given that had led to seroconversion symptoms shortly after. Their stories have really stuck with me, because they taught me that for guys in my world low risk really doesn't mean no risk. I don't really want to give blowjobs with condoms. So while statistically the risk is low for oral sex, I know that I could still end up with HIV anyway. This really made me re-think my relationship to risk and where I stood on things. And it also makes me aware that even if I'm only giving blowjobs, I still have to be vigilant about HIV because I could be one of those guys -- I've seen it, so I know it isn't impossible. The stress and anxiety that I was living with around getting HIV really impacted my life and it was something that affected every experience I had with other guys I was dating and/or having sex with.
John: One of our regular contributors on PositiveLite.com, Dave R, worries, among other things, about possible resistance to Truvada, one of the most highly prescribed antiretroviral medications, developing down the road due it being used as PrEP**.**
Len: The question of drug resistance is definitely a challenging one. If I ever were to test positive, I would want to be able to take the most tolerable drugs possible, and Truvada is one of those drugs. I decided that this is a consequence that I will have to deal with, and a risk that I will have to take. If anything it gives me all the more incentive to manage my risk for HIV as carefully as possible, to get regular HIV tests done, and to stick to my medication schedule as closely as possible.
I guess the only other thing I would say again (I know I said it before) is that taking an HIV medication every day at the same time without fail is not a simple task. It really takes a commitment. But I'm really motivated to do so, because I do indeed hope to stay HIV-negative. I'm not great with routine, I'll admit, but for me taking a blue pill at the same time every day, while difficult, is much easier than dealing with the anxiety and guilt of not being a perfect condom user. I want to stay HIV-negative, so I make the adjustments necessary to adhere to the prescription as best as possible.
John: That's very helpful, Len, to hear your responses to those who criticize negative guys on PrEP. Yet here in Canada, it's not just community members who have expressed these kinds of concerns. Professionals, too, are undeniably divided about PrEP and treatment as prevention generally, arguing over whether they work or not, even though both were among the major focuses of last year's International AIDS Conference. Why is Canada such a divided country on these things, do you think?
Len: That's a really difficult question to answer, John. I think that, as should be expected, nobody wants to jump the gun and start making decisions based on what they feel is not complete evidence. So scientists, politicians, and healthcare professionals may be worried that implementing a new technology, that we aren't 100% certain of, is a dangerous proposition.
But science will never be perfect. And as a fellow "PrEPer" Jake Sobo noted in his blog, back in the day when gay men took it upon themselves to have "safer" sex (by using condoms) rather than have no sex at all, they were doing so without evidence that condoms were 100% effective. I'm in a situation where I can't be 100% sure I will never get HIV unless I'm abstinent, so I don't have the same standards as scientists, politicians or healthcare professionals might -- since I don't have the luxury to.
I understand that those who are hesitant about PrEP feel they are taking the most conservative, cautious and appropriate actions. But at the same time I feel that for me, the evidence that exists is good enough to be confident that if I do it right, PrEP can have a significant impact on my chances of not getting HIV.
On another note, there are a number of poz guys that have taken Truvada and experienced horrible side effects of the medication. I've spoken to a few of them who had very strong (negative) feelings about the idea that I would take the drug if I don't actually "need" it. I can understand where they're coming from, for sure, but I felt I needed to see for myself if such would be the case. It turns out that for me, there weren't any side effects -- at least there haven't been any so far. The only real effect PrEP has had so far is to allow me to be a little less guilty, feel a little bit less shame, and be a little more confident, about the sex I have.
John: Why did you decide to talk publicly about your decision to go on PrEP?
Len: John, I talk to a lot of gay men both through my work doing HIV testing but also socially. So I know how many of us struggle with being -- or trying to be -- perfect condom users. I also know that the majority of guys simply don't know that PrEP is even a possibility, period. If I had the opportunity and privilege to read and learn about PrEP and decide if it was right for me, I felt that other guys in similar situations should have the ability to make their minds up too. I guess I just felt that it's time we have this discussion.
John: What would you say to other guys who are considering PrEP as part of their strategy to prevent getting HIV?
Len: Firstly, while there are no official Canadian guidelines and even though Truvada has not been "approved" for this use in Canada, it is not illegal for anyone's doctor to prescribe PrEP. Doctors have the freedom to prescribe drugs "off-label" if, through experience or deduction, they feel it to be in the best interests of the patient.
Secondly, I want to make it very clear that I have gone out on a limb by seeking out and taking PrEP. I'm aware that this strategy might not completely insure me against getting HIV, and I keep this in mind with every safer sex decision I make. It's impossible to know exactly how much of a 'risk' I'm taking, but for someone like myself who is having sex in an epidemic, sex without risk is more of a dream than a reality.