Just one month away from my 30th birthday, after six years of dating men, I had unsafe sex for the first time. It happened with a man I'll never know, save for a few details. He was a blond tourist with a charmingly crooked smile, visiting from Fort Lauderdale. I met him at g, a bar in Chelsea, where we enjoyed a few martinis and some conversation. Eventually, we made our way to my apartment nearby and, soon after, to my bed. I fished a condom from a bedside drawer. My guest brushed it away and coaxed me to proceed. I indulged us both, and he left shortly after.
I came of age when AIDS was already in full swing; I was an expert on safe sex long before I was having any. Cautious by nature, and slightly uncomfortable about being gay, I followed the rules to the letter once I became sexually active.
Until that night. Even now, it's hard to come to terms with exactly why. I certainly didn't intend to hurt myself or anyone else. I didn't want to get infected. I wanted to have fun, to blow off steam, to have sex without fear or caution. I wanted, for just a moment, to free myself from the reality of a time that equates naked passion among gay men with death.
I slept soundly after the tourist kissed me good-bye. But the next day I was racked with anxiety and guilt about having possibly exposed myself to HIV. What did it matter that I had never done it before, if I had done myself in with one incautious slip? I called the GMHC hot line and nervously described the events of the previous night. The main reason I was calling was to find out about a medical intervention I had recently learned of, one that might prevent me from contracting the virus if indeed I had been exposed.
HIV post-exposure prophylaxis, or PEP -- better known as the HIV morning-after pill, uses anti-HIV drugs to treat people who have had a high risk of exposure to the virus within the past 72 hours. It has been used principally for health-care professionals, police officers, and firefighters who accidentally come in contact with infected bodily fluids or, most commonly, are stuck by needles that have come in contact with infected blood. A well-regarded study found that a regimen of AZT reduces the risk of contracting HIV by about 80 percent after needle-stick accidents. While there's been very little data to support PEP's effectiveness for nonoccupational exposures, meaning through sex or drug use, doctors are encouraged. In 1997, the first PEP program for non-work-related exposures was established by the San Francisco Department of Public Health. Since then, more than 1,000 people have been prescribed PEP after unsafe sex, and none seroconverted within six months of the treatment. A much smaller pilot program for PEP was initiated in New York City by the Bentley-Salick Medical Practice in November 1999. By the end of the six-month trial, 28 people had gone through the regimen. Again, none had seroconverted.
Having received the approval of Beth Israel Medical Center's investigation-review board, the Bentley-Salick physicians plan to resume the New York PEP program as soon as funding is secured. Of course, a formalized PEP program for sexual and intravenous-drug exposures is controversial. Critics fear that widespread preventive HIV medication could create resistant strains of the virus, that it would subject a great number of people to unnecessary drugs (most people exposed to the virus will not contract it even without treatment), and that it would stretch already strained health-care budgets (the drugs can cost upwards of $1,300).
But the most pervasive concern is whether people (read: gay men) will act less responsibly if they think they can just take the HIV morning-after pill (in actuality, it's a month of more than 200 pills). Only time will tell, but I can attest that a month on the AIDS drugs is a far more chilling prospect than wearing a condom.
When I called the PEP hot line, a recorded message informed me that the program had been discontinued. Fortunately, the announcement also included the number of two doctors I could call for more information. And just minutes after I left a message, Dr. Brian Saltzman, of Bentley-Salick, called me at home. He fired off a series of questions, establishing that I was within not only the acceptable 72-hour range but also the much-preferable 36-; that I had never had unprotected sex before; and that I was HIV-negative. Dr. Saltzman concluded that my partner sounded high-risk (since he'd encouraged unprotected sex with a stranger) and that I was a reasonable candidate for the drug therapy.
"Are there any drawbacks?" I asked. The side effects I was most likely to experience were stomach distress, numbness in my hands and feet, drowsiness, and weird and vivid dreams. In rare cases, however, the side effects could be life-threatening, and I was told to look out for a rash, which could indicate a serious drug reaction. Since I had been on the giving end only (rather than the receiving end), I ran a 3-in-10,000 risk of contracting HIV if my sexual partner was positive, the doctor told me. Had I been the passive participant, the risk would be far greater, as high as 3 in 1,000. (Oral sex is generally not considered risky enough for PEP.) If I embarked on this month of drugs, I could conceivably reduce my risk of developing the virus by approximately 80 percent, at least according to studies of occupational exposures. But, of course, if the Floridian was negative, there would be a zero chance of contracting HIV and I would be needlessly subjecting my body to powerful drugs with possibly serious side effects.
One thing was certain: If I was going to do it, I needed to get started right away. And so my decision came down to this: If I became positive from this single experience, how could I ever forgive myself for passing up the only chance I had to prevent it?
Fifteen minutes later, I was picking up the medication Dr. Saltzman had called in to a nearby drugstore. To my relief, my health insurance covered the cost. "Is this your first time on this medication?" the pharmacist asked. I was aware that these were the same drugs someone with HIV might be prescribed and in the same dosages, but the question startled me. "Yes," I answered, self-consciously adding, "but I'm just taking it for a month."
There were three bottles of pills. I was to take one Epivir and one Zerit every twelve hours, plus three horse-pill-size Sustivas at bedtime. As soon as I got home, I collected the five pills in my hand and, one by one, swallowed my first dose.
The next day, I saw Dr. Saltzman at his office. He tested me for HIV, to be certain that I was indeed starting out uninfected. He also tested for a multitude of other STDs. When I got the all clear on these tests, I was relieved, not so much because I was healthy but because I hoped that the results confirmed that I was still a good person.
On the third night of the regimen, I decided to meet some old co-workers at a nearby pub. I took five pills before I left. When I arrived I limited myself to ginger ale, and at first, everything seemed to be going fine. But by the time my friends were ready for the next round, the room was spinning as if I'd had five martinis. I managed to say some quick good-byes and barely made it into the cab home. For the rest of the month, I didn't stay out past ten. The experience jarred me enough to make me want to share what was going on with my good friends, at least the gay ones. As I made my one-on-one confessions, some of my friends reacted with their own precarious tales; all offered support. However, the one I was most hesitant to tell -- I'll call him Bill -- was the friend I needed the most: the one who is HIV-positive.
I felt guilty. I had done the same thing he did to get himself in his predicament, but through a quirk of timing had a chance to escape his fate. It was not his support I was looking for as much as his experience. I needed to discuss what the drugs were doing to my body, and how they were making me feel. He warned me about the diarrhea, which on a number of occasions caused me to leave work in the middle of the day. And I spent one miserable night vomiting (and cursing myself). But this was just one horrible night of sickness during a mostly tolerable month of medication.
More disturbing than these physical side effects were the dreams. At first, they were mostly strange and unpleasant nightmares about work. But days before the end of my regimen, I dreamed about my mother, who died when I was 16 after suffering from a painful and aggressive cancer. In the dream, I sat beside her while she talked on the phone. I was physically an adult, but with the feelings of a child, and I desperately wanted her to hang up and talk to me. I could feel how fragile her life was, how soon we'd be apart. But she casually chatted the time away, giggling, talking about nothing of importance. I just sat there. And then she was gone.
The next day, I couldn't focus on anything but the pain this dream had awakened. When had I learned to be such a good boy, to sit quietly and not even speak of my desires, let alone act on them? When my mother told me at the kitchen table that she was dying? When I told myself, sitting alone at night in my family's living room, that I loved men?
On the morning of August 19, I took my last three pills, and that evening, I celebrated my 30th birthday with my friends and family. Six months later, I would test negative for HIV. It was, of course, my wish before I blew out the candles on my cake. As the guests applauded, Bill held me tight in his arms and whispered, "Now you're all grown up."