Not every gay man in Australia is having more sex than you or me, but it’s a fair bet that Scott is. Scott, who wants to be known by his first name only, lives in Sydney, where he works as an accountant. He is 52 years old, single and travels a lot. Recently he went to Berlin for the Folsom leather festival, an annual street fair that has become the biggest gay fetish event in Europe. The festival features leather bars and fetish clubs and plenty of sex parties, where, as Scott says, “everyone is up and ready for it. It’s just really relaxed and casual, and quite collegiate.”
Despite having between 12 and 15 sexual encounters in Berlin over five days, Scott only used condoms “on and off”. “You make a value judgment based on the person and the situation, just like you would here,” he says. Yet he wasn’t worried about getting HIV, thanks to a little blue pill called Truvada, which he took every day. “It was great,” he says. “It just took away some of the fear that you always have about sex if you’re a gay man, that spectre of HIV that is always in the back of your mind.”
Truvada is the world’s first oral HIV pre-exposure prophylaxis. Just as the contraceptive pill stops women getting pregnant, Truvada stops you getting HIV. Clinical trials have shown that it reduces the chance of contracting the virus by up to 97 per cent. A combination of two drugs, emtricitabine and tenofovir, Truvada has been around since 2004, when it was released by US manufacturer Gilead Sciences as a treatment for people already infected with HIV. Used in combination with other anti-retrovirals, Truvada can lower an HIV-positive person’s viral load (the amount of virus in their blood stream) to undetectable levels, making them, for all intents and purposes, non-infectious.
In 2010, however, a clinical trial funded by the US National Institutes of Health found that, taken as a daily dose, Truvada prevented healthy people from contracting the virus in the first place. Subsequent trials confirmed the results across a range of user groups, including heterosexual men and injecting drug users. Researchers called the treatment “pre-exposure prophylaxis”, or PrEP. Others have called it “a lifesaver”. Scott calls it “a get-out-of-jail-free card”.
In 2012, the US Food and Drug Administration approved Truvada to be used as PrEP by HIV-negative people who are at high risk of acquiring the virus. In Australia, however, the Therapeutic Goods Administration has only approved Truvada as a treatment for those already infected: for these people, the medication is subsidised by the federal government through the Pharmaceutical Benefits Scheme (PBS), and costs $36.90 for 60 tablets. Doctors here can and do prescribe Truvada as PrEP, but this is not covered by the PBS, meaning that their patients have to pay full market price, or $800 a month. In practice, most people using PrEP buy it online, from websites based in India or Canada, where it costs between $100 and $200 a month. Or they make like Scott, and cadge pills off an HIV-positive friend who has some spare.
You may think the emergence of a drug that offers almost complete immunity from HIV would be greeted warmly by the gay community, but this hasn’t been the case. In the US, where there are 50,000 new HIV infections every year, uptake of the drug has been low, thanks to a reluctance of doctors to prescribe pills to healthy people, concerns over possible side effects (nausea, fatigue, headaches) and the failure of PrEP to prevent others sexually transmissible infections (STIs).
There’s also been a campaign against the medication by several powerful players in the HIV and gay communities, who insist gay men will see PrEP as an alternative to condoms. Earlier this year, the president of the US AIDS Healthcare Foundation, Michael Weinstein, described PrEP as a “party drug” whose main supporters have “all been associated with bareback [condomless] porn”. Others have called it a “profit-driven sex-toy for rich Westerners”.
Studies have found little evidence that taking PrEP increases the rate of unsafe sex, either by encouraging gay men to have more partners or abandon condoms. Yet the drug has unleashed a moral panic almost identical to that which accompanied the advent of the contraceptive pill for women. In an article for The Huffington Post in 2012, journalist David Duran wrote that most of the men “running to get” PrEP simply wanted to continue having risky, condomless sex. Duran called them “Truvada whores”, a term that has since been co-opted by the drug’s proponents in an effort to de-stigmatise it. (There are now “Truvada whore” T-shirts available, in baby blue – the colour of the pill.)
The debate in Australia has so far been more cool-headed, despite a resurgence of HIV. According to the Kirby Institute’s Annual HIV Surveillance Report, the HIV diagnosis rate in Australia is now the highest in 20 years, with 1235 new cases reported in 2013. This represents a 70 per cent jump since 1999, when diagnoses were at their lowest. The Kirby Institute also found that unprotected anal intercourse was a key driver of transmission among gay men, who have become increasingly reluctant to wear condoms. More than 35 per cent of men with casual sex partners practise unprotected sex; in men who are HIV-positive, the rate is close to 60 per cent.
Such stats reflect a significant shift in gay culture and a slap in the face for activists who’ve worked for decades to make safe sex the norm. “Condom use among gay men has been one of the most effective behavioural modifications in public health history,” says University of NSW faculty of social sciences Associate Professor Kane Race. “Uptake was widely effective at the beginning of the crisis, which helped keep HIV infection rates under control.”
But with HIV no longer a death sentence, young gay men are becoming complacent. “So many young guys choose to be oblivious about HIV,” a 26-year-old gay man told me. “They just think, ‘Out of sight, out of mind.’?”
For sexual-health specialist Dr Robert Finlayson, “the ignorance of these guys is astounding. It’s hard for older gay men to comprehend it. They’ll be in sexual situations with these younger men who will say, ‘Oh, HIV, do you take a pill for that?’ Or, ‘I saw on the bus that HIV will be cured soon’.?”
It’s in this group that most new infections are occurring, says Finlayson. “The reality is that after 30 years of condom messaging we have increased rates of HIV infection, particularly in young men. And so PrEP may be the extra preventative tool we need.”
But there are risks. Finlayson works in Taylor Square, the traditional epicentre of Sydney’s gay community, where he has written about 30 prescriptions for PrEP. “The studies say that PrEP doesn’t cause more risky behaviour, but that’s not what doctors at the coalface are seeing. Guys come in here and they want it so they can practise unsafe sex without condoms and feel bulletproof. I tell them that PrEP doesn’t make them bulletproof, that it doesn’t protect against other STIs like herpes, syphilis, gonorrhoea and chlamydia, which are already at very high rates among men who have sex with men and which increase your risk of HIV infection.”
Finlayson is concerned that PrEP “might feed into the general social milieu where condomless sex becomes the norm”. And so, he says, the challenge is twofold: “To let young people know about the undesirability of getting HIV without stigmatising people who are already living with it. And to factor in PrEP without encouraging further risky behaviour.”
But many of those on PrEP aren’t seeking thrills, they’re seeking security. Shaun is a 34-year-old curator who lives in Melbourne. He is HIV-negative, but his long-term partner is positive. (Epidemiologists call this a serodiscordant relationship.) Shaun has been taking PrEP for four months, as part of a behavioural study, called VicPrEP, being funded by the Victorian government. (A similar study is starting soon in NSW.) The study provides PrEP to 100 “at risk” individuals to see how consumption of the medication plays out. “We want to know how the men use it,” says study co-ordinator Professor Edwina Wright. “How they tolerate the side effects, if there’s any stigma to taking it and if they take it regularly.”
As far as Shaun is concerned, PrEP is not “a get-out-of-jail-free card” or a licence for sexual mayhem. “It’s just an extra safety barrier.”
Indeed, in serodiscordant relationships, PrEP’s effect is as psychological as it is physiological. “For us, PrEP has almost been an anti-anxiety drug,” says Stephan, a 26-year-old Sydney man who has been taking the medication for five months. (He sources it privately.) Stephan’s partner, whom he has been with for two years, is positive, but has, through treatment, reduced his viral load to undetectable levels. Even so, their sex life before PrEP was severely circumscribed. “You have a much higher risk of contracting the virus if you are ‘receiving’,?” Stephan says, “which has forced us into certain roles in bed. We have always wanted to mix it up, and PrEP now gives us the freedom to do that without risking transmission.” There were other issues, too. “Like if I was giving him oral sex … There was just so much drama and fear, which PrEP has taken away.”
Both Shaun and Stephan believe that PrEP should be made more widely available, preferably by having it put on the PBS. This is also the position of groups such as the AIDS Council of NSW (ACON) and National Association of People With HIV Australia (NAPWHA). But there are big problems with this, the first being cost. At $10,000 a year, PrEP does not satisfy the PBS’s cost-effectiveness criteria. A study by the Kirby Institute found that PrEP would only be a cost-effective strategy among men who are at very high risk of infection, such as those in serodiscordant relationships, but that providing the drug to 30 per cent of NSW’s most sexually active gay men would cost an additional $952 million over 10 years. Which is to say, not so cost-effective.
There are also issues of perception. Some in the health community, not to mention the wider public, are uncomfortable with the notion that taxpayers should subsidise gay men’s desire not to wear a condom. “The health budget is finite,” one doctor told me. “The money doesn’t come from thin air: if you give it to one area, you have to take it away from another. And so there are those who think, frankly, ‘How dare these guys demand we take money away from some woman who is dying of diabetes so that a bunch of poofters in Darlinghurst can fulfil what they consider their inalienable right to unrestricted sexual pleasure.’?”
One of the interesting aspects of the prep debate is the window it opens onto gay culture, or rather, cultures, the politics of which can both compliment and contradict one another. When Shaun from Melbourne tells people he is on PrEP, reactions are mostly positive, with the occasional exception of older gay men. “That older generation was the first to deal with AIDS,” Shaun says. “They worked so hard at the condom message and safe sex. So they feel that PrEP, in a way, disqualifies the journey they had to go on, which I can understand. There is also envy there, potentially. They had friends die, and now there is this quick fix.”
Scott, the Sydney accountant, is 52 – old enough to remember the peak of the epidemic and all the gaunt men with late-stage AIDS ghosting down Oxford Street. “Maybe for younger people who are now just coming onto the scene, they will never know that fear. It might be like the Berlin Wall coming down; people will never know it was there.”
With its whispered promise of unbridled promiscuity, PrEP also threatens the push by more conservative elements in the gay community to “respectabilise” gay sex. “You see that especially from the gay marriage movement,” says Nic Holas, an HIV-positive activist and writer. “There is this unspoken idea that because gays have been invited to sit at the table and talk about issues like marriage equality, then we should all behave ourselves and keep it in our pants.”
Holas is tall and slim, with a deep voice and fetching Rhett Butler moustache. I caught up with him at a PrEP forum organised by ACON in Sydney, where he was wearing a “Truvada whore” T-shirt. “The fear is PrEP will give the green light for gays to f… the way they wanna f…, and that this is somehow ‘unsafe sex’. But PrEP protects you against HIV, so how is it unsafe?”
For too long, he tells me, HIV-positive people have been demonised, not least in gay culture, where hook-up sites like Grindr and Scruff often feature profile descriptions like “DDF” (drug- and disease-free). “PrEP is exciting because it puts the responsibility for slowing HIV transmission rates on negative people as well.”
Holas believes PrEP should be on the PBS. It might be expensive, he says, but not as expensive as having lots more people contract HIV. (The federal government spends $300 million a year on anti-retroviral medications alone.) Besides, “It’s not like a guy would be on PrEP for life. Women don’t stay on the pill until after menopause; they let it go after a while.”
Holas is a champion of “sex positivity” – he really, really likes sex. He is a sex worker and also appears in gay porn; his latest performance is in a bareback movie called Breeding Marcus Isaacs. (“Breeding” is a gay term for ejaculating inside another man’s rectum, an activity made transgressive by the advent of HIV.) I mention there seems to be a disconnect between his porn work and his HIV activism – a certain schizophrenia in the messaging. “It’s only a perceived disconnect,” he says. “The reality is that sex workers have been at the forefront of HIV activism since the start of the campaign.” He also points out he does not work in health promotion, and is not employed by any of the AIDS councils. “I advocate for HIV-positive people, and I most certainly can’t claim to represent them all. My platform is about what it means to be HIV-positive in 2014, which is a reality of undetectable viral loads, PrEP, condoms, sero sorting and a host of other ways and means by which I get to f…. That’s a complicated message, one that is more often than not lost on the general public.”
One morning, I speak again to Scott, who is still readjusting to life after Berlin. It had been a quiet weekend: on Friday he went to “Bears’ night” at Kinselas nightclub (“bears” are chubbier, hairier gay men who reject the “body fascism” inherent in gay and straight culture). On Saturday he had dinner with his parents.
He’s not anticipating going on PrEP again any time soon. “It’s pretty quiet for me at the moment,” he says, “though I do have several irons in some internet fires.”
His “ultimate goal” is to find a long-term partner: someone he can spend time with, someone he can trust; someone he can fall in love with. “You’re always looking for Mr Right,” he says. “But hey, in the meantime, Mr Right Now and several of his friends will do.”