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Sex Without Fear

Left: “PrEP for me isn’t about being whore-y. I still use condoms. But for me, as a Jew, to be able to eliminate at least one source of anxiety over my health situation—hello!” —Adam
Right: “I’ve been sexually active in New York City for 29 years, with only nine months of monogamy, and I’ve stayed HIV-negative. I seem to be doing something right. I don’t want to put chemicals into my body when the alternative is just to put a condom on.” —Michael Wakefield   

But some HIV activists feel that Gilead is quietly funding a surge in HIV-negative takers of Truvada—whose list price is about $1,300 a month—while not having to take flak from PrEP opponents for implicitly promoting condomless sex. “If they came out advertising it, they would’ve been attacked,” says Sean Strub, the 56-year-old HIV-positive founder of Poz, the magazine for people affected by HIV and AIDS.

Gilead’s approach seems to be working. At the end of June, during Pride weekend, Governor Cuomo, who has made gay rights a strategic part of his platform, said he wanted to make wider access to the drug part of a new effort to eradicate the AIDS epidemic in the state by 2020. Daniel O’Connell, the state’s HIV-initiatives czar, told me New York expects to put out a public-information campaign about it by year’s end, which will be the first of its kind for PrEP.

Most insurers—both private and public, such as Medicaid—have covered the cost of Truvada-for-PrEP (as they generally do once drugs are FDA-approved for specific uses), and the potentially controversial issue has flown under the public radar. Some bloggers have wondered if the Supreme Court’s Hobby Lobby ruling, which says that private employers can block contraceptive coverage for workers on the grounds of religious belief, might lead some bosses to block Truvada reimbursement on their plans.

Truvada is for everyone at risk of getting HIV, both men and women. But PrEP has been studied in and discussed largely among gay men because the highest HIV rates remain stubbornly within that group, especially among young gay men of color. In 2010, the Centers for Disease Control reported that 20 percent of U.S. gay men had HIV, compared with about .3 percent of the total population. Nearly half didn’t know it—an ignorance that rendered them highly infectious. In 2012, the agency reported that HIV rates in gay men between ages 13 and 24 rose 22 percent in recent years. In an independent analysis of that data, a top researcher projected that if HIV infections continue at current rates, half of young gay men will have HIV by age 50. Cuomo’s stated goal, then, is very ambitious.

Truvada doesn’t, of course, protect against other STDs. Especially for those who were around at the dawn of AIDS, when a mystery microbe appeared out of nowhere, there’s a fear that reverting to pre-condom habits might be tempting fate again. “Mother Nature’s a bitch,” Dr. Martin Markowitz, a veteran of the Aaron Diamond AIDS Research Center, told me. “Don’t underestimate her.”

The idea of prep can be especially fraught for older gay men, particularly HIV-positive ones. Larry Kramer, now 79, in poor health and HIV-positive since the 1980s, has been the most prominent voice projecting contempt and bafflement. In a May New York Times article about the HBO version of his 1985 play The Normal Heart, he was quoted as saying, “Anybody who voluntarily takes an antiviral every day has got to have rocks in their heads. There’s something to me cowardly about taking Truvada instead of using a condom. You’re taking a drug that is poison to you, and it has lessened your energy to fight, to get involved, to do anything.”

PrEP advocates exploded, saying, in part, that Kramer was grossly exaggerating the toxicity of Truvada. (Side effects in HIV-negative takers seem limited so far. Most often, that can mean an initial few weeks of mild nausea and diarrhea—though, as with any new treatment, only time will tell if preventive Truvada has long-term effects.) Andrew Sullivan, who is HIV-positive, wrote on his blog in response: “Imagine a scene [in the play] when someone rushes into a [Gay Men’s Health Crisis, which Kramer helped found in 1981] meeting and declares that there’s now a pill that will make you immune to HIV if you take it once a day. Would Larry seriously have said that anyone who then took it had ‘rocks in their heads’? I think of how it might have saved me.” Michael Lucas, the gay-porn mogul who recently switched from being an ardent condom advocate to a PrEP-taker who now allows bareback sex in his films, wrote on the Out-magazine blog: “Larry Kramer is a hero in many ways, but this time he’s fighting on the wrong side of history.”

Less cantankerous HIV-positive veterans than Kramer also seem to have their misgivings. In a talk this winter at the Strand bookstore to promote his new memoir, Body Counts, Strub, the Poz founder, said of PrEP, “Rather than giving [HIV-negative people] the life skills teaching them how to be healthy about their sexuality … the idea [is unbelievable] that we are going to put tens of millions of gay men on PrEP and bankrupt the economy to spray people with Raid.” (He later clarified that he supports it as an available individual choice.)