With last week’s announcement from the CDC there has been a huge uptick in opinion pieces and mixed reactions relating to the prophylactic drug Truvada (or PrEP). In my own life it has become quite the robust conversation topic over social media, dinner parties and happy hour with friends. My broader feelings have been oddly ambiguous, so until now I’ve only commented on smaller, side-issues because I’ve felt so strangely conflicted and underwhelmed by what is surely scientific good news.
As much as I like to think of myself as someone who can just read the medical literature and data (10 years of working for Public Health researchers and epidemiologists has rubbed off on me a little, at least I hope!) I have to confess there are personal, illogical gut-reactions involved too. Either way, this year is establishing itself as the tipping point for the gay community to grapple with several, interlocked issues around this little blue pill.
Way back in distant history–when Bill Clinton was president and web-surfing was something squeezed in at the office–I worked as an administrative temp in downtown Seattle. There was an office manager named Maureen who in so many ways was the prototypical one of that era. Close to retirement and a bit of mother hen to us “kids” (twentysomethings slumming it until we found the proverbial “real job”), she told me a fascinating story that I really hadn’t revisited until lately. She said when she was attending University of Washington, sometime in the early 1960s, she put herself though this peculiar rigmarole to obtain the birth control pill. A Seattle native, she didn’t go to her family doctor who’d treated her since childhood, nor the student health clinic on UW campus. Rather, she made an appointment with yet another, new physician located in Seattle’s Rainier Valley. Not only that, she borrowed a ring from a girlfriend so that she could claim she was engaged at her visit. Fifty years later, Maureen–part of the final slice of the Silent Generation–was laughing with us at how elaborate her performance was. Pretending to be married would have been a more assured way to obtain The Pill with less hassle, but somehow she STILL feared this might get back to her parents via some secret slut-shaming physicians’ network. So Maureen created a back-up plan in case she needed to do later damage control–she could quickly claim she and her boyfriend were secretly engaged (they weren’t and the relationship ended before graduation). Fear of judgement plus some good old-fashioned embarrassment were putting up extra burdens to wise medical prevention. Fear her (male) family doctor would tell her parents she was having sex. Shame that she was having sex and not *really* engaged, much less married. She wasn’t Catholic or against birth control, and probably neither was her family physician, but there was this sense of caution and fear that while The Pill might be a modern science godsend to the *right* sort of girl (married ones who want to responsibly space their children) we must not allow it to be an easy option for the *wrong* sort of girl (unmarried promiscuous ones).
Today Truvada seems to be having some of the same reactions. Some physicians and social commentators are quick to praise it for the *right* sort of gay (HIV discordant monogamous couples) but are very leery of widespread use for the *wrong* sort of gay (unmarried promiscuous ones). In an effective patient/doctor relationship all facts should be on the table, but this is always so much easier said than done. Who doesn’t round-down when even just self-reporting their alcohol consumption, for instance? Talking about Truvada requires being upfront about having condomless sex and taking whatever judgement or awkwardness comes along with that. Because this drug is so new, and is for a narrow niche of the market, it may take a little time–and patients switching physicians–for the awkward cloud to lift. Yet it’s not just the “talking about sex can be uncomfortable” factor that I think is keeping a lot of gay men from embracing this new prevention tool. For the last couple of weeks I’ve been trying to sort out my own feelings. Had the CDC just approved and recommended a vaccine I have no doubt my feelings would have been overwhelmingly positive. Why was I conflicted about a little blue pill that–if taken daily–does the same? My brain has gone through as many justifications and half-truths and second-guesses as Maureen’s did circa 1962: It’s because it won’t protect against OTHER STI’s! Neither would a vaccine, neither does The Pill. It’s because this won’t be affordable for the masses of HIV positive men and women in sub-saharan Africa! Perhaps, but that’s a bigger issue about global health and wealth in general. Sorry, Straw Man. It’s because there could be side-effects we don’t know about yet! Again, that’s true with many drugs. Even if some small portion of people experience side-effects and need to halt usage, surely the greater good (fewer HIV infections, fewer AIDS-related deaths) outweighs that. Those reasons were thin attempts at justifying my lukewarm response to Truvada. I think the real reason the response was so muted in comparison to what a vaccine is something much less
admirable. I was underwhelmed by the idea of long-term adherence to a daily drug precisely because that is the reality of healthy, happy people who are HIV positive. A petulant little voice in the back of head was not pleased that the end result was the same: Daily pharmaceutical intake. Awkward conversations with physicians. Potential battles with insurance plans. “So what was the point of trying so hard to be good (caution & condoms) all these years if we are all ending up in the same boat anyway?“was the niggling voice. Somehow I felt because I played by the safer-rules 95% of the time (okay, 85% of the time) I should get some sort of cosmic credit over the cavalier barebacker. This mindset isn’t logical or pretty. But it was there and I’m over it now. Maureen probably went through irrational justifications of why she, an “almost engaged” college girl wasn’t in the same boat as a promiscuous, picking-up-men-in-bars type. People like to rank and categorize. They also like to engage in magical thinking about “what’s fair” on some imaginary cosmic scorecard (ask anyone who has experienced death or divorce about that one).
I still haven’t decided if PrEP is right for me, and I don’t want to shut down–or merely dismiss as alarmist prudes–those who have sincere concerns about what the future could look like for my community post-Truvada. However, I think it’s worth remembering that people take time to sort through their own phobias and embarrassments whenever the topic is sex. Maybe when I am near retirement, having a doughnut in the office, I’ll be able to have a chuckle with a bunch of 21 year olds about my silly justification-gymnastics around a medical breakthrough that ultimately changed the lives of countless people for the better.