Box Turtle Bulletin

If you meet the CDC guidelines, then get on the drug.

However, lets make it clear.

1) The CDC did NOT say that PrEP is a replacement for condom use. It said that if you are getting STI’s, if you frequently have sex with partners that are HIV positive or partners about whom you don’t know their status, if you inject drugs, or if you won’t use condoms consistently, then the drug is recommended. The study specifically states on Page 47 that condom use is recommended.

2) Its is never “PrEP or Condoms”. It is never “Now we have two tools to combat the disease”, which implies PrEP or condoms. It is always condoms, plus PrEP if you fit other criteria. PrEP is not to be equated with condoms.

3) Bareback sex between casual partners constitutes a serious and an increasingly dangerous public health risk to our community. Risks that cannot be mitigated by PrEP, such as Hepititis syphillis, gonnarhea, and other STI’s, as well as Multi-drug resistant variants of those diseases. We must be vigilant against those that will seek to ‘sell’ or validate barebacking.

I don’t see how you can fight the scourge of bareback advocacy without stating clearly that barebacking is wrong. And that might cause some ‘stigma’. Many of the groups active on this issue appear to be more concerned with ‘no judgements’ than ‘public health’. Obviously, there’s a balance to be taken. But I’m not seeing any balance.

PrEP isn’t the problem. The barebacking is.

I think what should be doing is taking elements of both sides in the debate. Encourage people fitting the guidelines of the CDC circular to get on the drug, but also strongly and consistently educating people that barebacking is never the recommendation and strongly criticizing those that advocate or validate that practice.

Todd

This seems a lot more complicated to me than just ‘Party Drug’ vs. ‘HIV Shield’.

$13,000 a year? That seems to me to be a lot of money that might be better used by insurance companies paying for actual injuries and hosptializations.

At this point in the drug’s development cycle isn’t that money just going to profits for the drug company? If the demand spikes to 500,000 per year, how long until economies of scale in production bring down the price? Are we just going to rely on the kind heart of the drug maker to bring the price down?

How does $13K compare to the yearly price of an HIV+ drug regime?

If 10,000 gay guys in the BCBS insurance system suddenly sign up, there’s now 130 million dollars that that insurance company has to pay out. it’s not going to take long before this drug suddenly isn’t covered anymore. if there are 500K people covered that’s 6.5 BILLION dollars! I’m not defending insurance company profits but aren’t there more effective ways in public health to spend 6.5 billion dollars?

I don’t have any answers, but I think the issue is too complicated for most of the sound-byte/twitter-limit debate that seems to be going on.

Priya Lynn

At 13000 a year I can’t imagine too many people are going to have this drug covered under insurance plans so its probably not going to have a significant impact.

As Tom said, this is not an “either/or” situation, just because you support people using this drug doesn’t mean you can’t encourage condom use and shame those having unprotected sex.

Lucrece

It couldn’t possibly be that the pharmaceutical industry has a corporate muscle that dwarfs even that of the insurance industry?

They already are buying med school deans and curricula. Towleroad is probably getting paid to write for them as well.

I hope this site won’t buy into the expensive( profitable for them) trend of medicating your problems away.

Jack

@Todd

During the last round of BTB breast-beating over Truvada and bareback “shaming”, I made the same point you did: It’s immoral to take $13,000 of insurance benefit in order simply to have condom-free sex.

I was immediately attacked by various commenters who engaged in a reductio ad absurdum whereby if insurers don’t want to subsidize Truvada whoring, then they should stop paying for Lipitor for those who eat too many steaks.

I am totally with you (as well as Tom in Lazybrook) on this issue. Barebacking is crazy.

Merv

If you do the math, 500k users translates to $6.5 billion per year. If we’re going to spend an additional $6.5 billion on HIV prevention, is the this the best use we could put it to?

Eric Payne

Tom in Lazybrook said:

I donâ€™t see how you can fight the scourge of bareback advocacy without stating clearly that barebacking is wrong. And that might cause some â€˜stigmaâ€™. Many of the groups active on this issue appear to be more concerned with â€˜no judgementsâ€™ than â€˜public healthâ€™. Obviously, thereâ€™s a balance to be taken. But Iâ€™m not seeing any balance.

“Geez, Tom, you’re such a downer!” I said, sarcastically.

In many ways, Tom, I’m reminded of the early days — before the CDC began looking for a causative agent… before Kimberly Bergalis and crazed dentists… before the first confirmed heterosexual transmission of the antivirus… when GRIDS was the Religious Right fundraising rally cry — and the fight to keep the bathhouses operating, even as the clientele of the bathhouses was, literally, dying.

It’s been a fight since day one, and the same stupid shit being said and done for the sake of “sexual freedom” thirty years ago is being repeated today.

But just as marriage-equality opponents are learning, repetition of “stupid shit” doesn’t make that shit stink less, all it does is muddy the waters as it loses coherence, until someone comes along and flushes it.

In the case of marriage equality, the flusher is the justice system and the US Constitution.

In the instance do those who see PrEP as the go-ahead to abandon condom use and remain sexually active in a non monogamous setting, the flusher will certainly be a dramatic rise in new infections, a probable mutation of the HIV virus to a stronger, more treatment-resistant strain and, possibly, a return to pre-cocktail death tolls.

Those who don’t remember the past are doomed to repeat it. Those who weren’t around for the past of HIV need to read And the Band Played On.

Hue-Man

“HIV infection should be assessed at least every 3 months while patients are taking PrEP so that those with incident infection do not continue taking it. The
2-drug regimen of TDF/FTC is inadequate therapy for established HIV infection,
and its use may engender resistance to
either or both drugs.”

I was going to rant about PrEP advocacy when there are thousands of undiagnosed HIV cases not being treated – and spreading the infection – because people refuse to or choose not to be tested for HIV.

The CDC quote above says get tested before you start, then get tested AT LEAST every 3 months. If you don’t and take PrEP while being HIV+, those drugs may not be effective treatment for you in the future. (!)

Are doctors giving this warning? Are their patients who are taking PrEP aware and following this advice?

Ray

There are some confusing messages here.

Don’t take PrEP if you become infected? That’s confusing because I read a study that said those who are HIV-pos and whose viral load was undetectable because they were taking PrEP were **NOT** transmitting the disease. The focus group in this study were couples in which one was Pos and the other wasn’t and the second person was not taking PrEP while the Pos pattern did. The study said NO one became infected. 100% of the partners remained HIV-negative because their HIV-postive partner was on PrEP. Some used condoms and some never used condoms.

I read about the study either on JMG or Sullivan, can’t remember which. I have to say, a zero transmission rate is pretty appealing. It’s that like, you know, a cure?

enough already

These discussions are always fraught with danger.
Personally, I welcome any and all allies in the fight against this epidemic.
I firmly believe, had this virus first been found in straight, white, affluent, poly-cotton blend wearing business men, we would have long since found a cure.

It wasn’t and the political baggage of the early 1980s colors our discourse on every aspect of prevention, treatment and cure to this day.

I love barebacking. I’m also in a 35+ year monogamous relationship and we’re both negative. So perhaps my opinions aren’t worth much on the topic, but here goes:
Any attempt to limit safe-sex to condoms is going to have a very high failure rate.
Oh, right…30 odd years on and it does.

Men love to bareback. It’s what we do. Early successes in getting people to use condoms were the result of the there’snocurewe’reallgoingtodieoh’sno’hs!!! situation, not a true change in behavior.

If I were single again, I’d definitely be on this preventative regime.

Now, are the pharmaceutical makers ripping us all off? Of course. Does the US Government do 0.0000000000001 as much as it should and could do?
No.
Does that change reality?
Hell.No.

L. C. Burgundy

I like the possibility of this helping to reduce HIV transmission. I think it’s a no-brainer for some subgroups.

I dislike the possibility of this helping to fuel the anonymous barebacking culture that has simply moved from bathhouses to grindr. Yeah, I said it. HIV is the kingpin; there are many unpleasant minions that are somewhat less fatal but are becoming increasingly incurable.

I dislike the notion that this is going to fuel that even HIV- gay men need expensive pharmaceutical cocktails to stay healthy.

Lord_Byron

“How does $13K compare to the yearly price of an HIV+ drug regime?”

Quite cheap actually. Right now most HIV meds are around $2,600 a month. That means $31,000 a year. Insurance companies now have to spend 80% of the money they receive on actual treatment for their clients. Plus don’t act like it is only insurance companies that are paying for the drugs. Most insurance companies pay, after deductible, between 60 to 80% of the cost of the drugs. So that is still a 520 to 1040 out of pocket monthly expense. At least now thanks to the affordable care act you can’t be denied for pre-existing conditions any longer.

There are other treatments right now in different trial stages and there is one in particular that looks promising. It’s a shot given every three months.

Lord_Byron

Also just to note, but truvada is going to generic next year which will drop the price

Tom in Lazybrook

To Enough Already.

Just because some people bareback, doesn’t mean that people should advocate it or validate it as something acceptable.

It also doesn’t mean that we should tolerate commercial enterprises that glorify barebacking for profit in our community.

It doesn’t mean that we should assign credibility to persons and or groups who advocate or glorify barebacking either.

In the 1990s and early 2000’s, most people used condoms at least most of the time. What we are seeing now is that vast numbers of people are using them never. That represents a change in our community. One that has tremendous negative health consequences for the public health of the community. Why did people use condoms more back then and less now? I think that it is because there are too many bareback enablers/glorifiers/advocators running around. None are medical doctors. We have been so busy saying ‘no judgement’ and ‘no stigma’ that we’ve let those who seek to increase the pool of barebackers for their own selfish purposes to hold 100 percent of the space. No one is concentrating on condoms. No one.

There are things that we can do. First, go back to the campaigns of the 90’s that worked on condom advocacy. Challenge those that will attack that advocacy of being ‘stigma’ creating. Use existing laws such as OSHA and public health laws to put pressure on commercial enterprises that seek to profit from barebacking. Tie PrEP to condoms. Sure, people will still bareback, but at least there will be other voices out there.

We’ve already seen skyrocketing rates of STI’s resulting from the new barebacking world.

And while we’re at it, can we please have some enforcement attention when it comes to crystal meth? I’m tired of the parTiers ruining everything.

Lets be clear. We can increase condom usage. It was higher previously. Much higher. It can be again.

The only question is…do we continue with ‘no stigma’ and ‘no judgement’ at all costs until we end up with a new public health disaster in our community, or do we start to consistently and strongly endorse condom use for all casual sexual acts in our community?

Timothy Kincaid

Byron

Also just to note, but truvada is going to generic next year which will drop the price

I didn’t know that. If like other generics, this could HUGELY impact cost. Do you happen to have a link/source?

Timothy Kincaid

Tom

First, go back to the campaigns of the 90â€²s that worked on condom advocacy.

The only successful campaigns were based in the premise that you were going to die. Death is a pretty effective deterrent. And once you’d lost a few friends, “you must wear a condom” held some sway.

But that is no longer the case. And “you might get gonorrhea and have to get a shot” is no where near as effective in getting people to agree to significantly diminish sensation during sex. And the notion that you must have less enjoyable sex so as to avoid the possibility that someone else somewhere sometime might get some undefined thing has virtually no impact whatsoever.

The campaigns of the 90s will not work because the reality is not the same as the 90’s.

Lucrece

First world problems.

“I can’t feel it as much as I would like to!”

The bucketloads of people in Africa who die with no real access to condom must love the idea of Americans flippantly contracting the disease because they expect insurance companies to pay out for their lifestyle choices.

Lord_Byron

Well, apparently there is already a generic version available outside the united states.
http://www.aidsmeds.com/articles/generic_truvada_1667_24320.shtml

I was incorrect about the date for truvada. The patent on that does not expire until 2021.
“Teva will be permitted to begin sales of a generic tenofovir on 15 December 2017. Patent expiry for both Emtriva (emtricitabine) and Truvada are not until 2021.”

However there is good news

The first patents for the active ingredients in the medication are set to expire in July 2017. As soon as these patents expire (unless circumstances arise to extend the exclusivity period beyond this time), other companies can begin manufacturing a generic Truvada drug.

So, it looks like Truvada, generic form in the US, will be replicable come 2017.
Basically if you want a cheap version now you would have to travel outside the United States.

Lord_Byron

Lucrece, it’s not the lack of condoms. It’s the religious shaming over the use of condoms.

Lord_Byron

Thankfully the reality is not the same as the 90s. People in my age group didn’t go through the beginning of the crisis and so it is true that we don’t know the fear of everyone around us dropping like flies. However I also think one thing that might help is to highlight the real danger of STIs like gonorrhea that are now becoming antibiotic resistant. In general we are living with a ticking time bomb where we are not only due for a pandemic, but it most likely will be a super bug that will decimates millions because it is resistant to current treatments. I realize I could have condensed all three of these posts into one.

Randy Potts

On barebacking – it’s a very loaded term and we need something better. Is sex between a monogamous couple “barebacking?” What about sex between two people who have been recently tested and are both either poz or neg, ie, taking sero-sorting into account? “Barebacking” has a finger-wagging aspect to it – perhaps there is still a use for some degree of disapproval regarding certain sexual behaviors but I’d argue that the term “barebacking” doesn’t fit the bill here – as Timothy noted, without the imminent fear of death, this finger wagging has been shown to have very little effect. “Natural” sex between two human beings is not sex with a condom because condoms, of course, don’t exactly exist in nature, but the term “barebacking” seems to imply that there is something unnatural to sex between two men without the use of the condom. Sex without a condom in certain situations is irresponsible for both gay and straight people – I think we can all agree to that. How we turn that into a public policy that actually affects behavior and reduces infection is another thing entirely. The term “barebacking,” in my opinion, has not been shown to be very useful.

@Todd- I agree, the “Party Drug” vs. “HIV Shield” does not reflect the complexities of the debate, and Weinstein is an extreme outlier here. Re Weinstein, it’s often constructive to look at the general attitudes betrayed by outliers and ask if those attitudes are generally shared by that side of the debate. It does seem, from many of the comments here, that his view is shared by many. As to the potential 6 billion figure, this debate would be helpful to have – if such a price tag came with the promise of eliminating or seriously diminishing the spread of the disease, would it be worth it? I don’t know, but thanks for pointing out something that needs more discussion.

The debate here, to me, does seem to boil down to what Eric Payne pointed out – a longstanding divide even within the gay community about sexual freedom and what that means in re behavior, shaming, and public policy. This divide seems to correlate to the liberal/conservative divide in the general public rather than being a specifically gay debate.

Brian

The thing about “stigma” for me is not that it suppresses “sexual freedom,” but that for the “rewards” we may or may not get in calling a particular actions wrong, there are severe drawbacks. Namely, stigma promotes illusions and incentivizes dishonesty and hypocrisy.

First, the illusion: I think there is this common idea that only certain, highly irresponsible people with low self esteem “bareback,” for example. People call barebacking a “culture”. It is not a culture; it is a sexual practice that is done by a variety of people in a variety of contexts. Some in a monogamous relationship, some with a small circle of people, others with their boyfriends in their “serial monogamous relationships,” some with random strangers, others on a one night “slip-up.” Sure some might try to dress it up in some pseudo-spiritual rationalizations, but I do not believe they are the majority.

Second, and more dangerously, moralism creates an environment for people to say one thing and do another. It is a breeding ground for people to SAY that they “use a condom every time” but slip into cognitive dissonance and denial about what they actually do. Because barebacking is “bad” and I’m not a “bad person” the mind can jettison or compartmentalize that one-night stand (or two or three) when I slipped up. You can say, “well they shouldn’t do that!” And my response is you can put “shouldn’t!” in one hand and spit in the other and see which one gets filled first. Human psychology is a complex thing.

I think one major problem is a lack of mindfulness. It is not that people are not dying; it is that the “presence” of STIs is no longer hovering over us because HIV is now out of sight, out of mind. The people who are HIV+ are for the most part being effectively treated and living normal lives and even have a lower chance of spreading it when being treated. When you get an STD, the matter is privately treated by your PCP. It’s all back behind closed doors and the public presence of HIV and other STDs is no longer present. That does need to change. Science-based, scare-tactic free but frank and serious awareness about STDs is needed. Including diseases we don’t think about like the bacterial infections that are becoming resistant and the increase in throat cancer among people.

Tom in Lazybrook

Tim,

I would hope that you would not feel that condom advocacy is pointless until massive numbers of people start dying. I get that people sometimes fail in doing the right thing medically, but people aren’t even trying. I would think that we are a bit smarter than that. Apparently we aren’t.

I’m even more disappointed that you would (perhaps unintentionally) ‘sell’ not using condoms as ‘much less enjoyable sex’. I would hope that you wouldn’t diminish the medically sound practice (sex with a condom) with language such as that. I assume its unintentional.

If you go unwrapped, especially in casual relationships, you’re risking a lot more than a simple shot.

——-

Randy

I know the term ‘barebacker’ is loaded. That’s my point. I know words matter. I took Tim to task for his choice of words and I’m about to do the same for you. I’m aware that there is a stigma attached to the word. A stigma that is missing. No stigma means no judgement. And no judgement can be dangerous when we are talking about public health. Condomless sex is bad for the community. Unequivocably. I don’t think that there needs to be another term that normalizes condomless sex. That’s the last thing we need right now.

Even if both partners are poz, barebacking, especially in casual relationships is wrong and not medically supported. Even if both partners tested neg a few months ago, it doesn’t mean that casual sex without condoms is medically supported.

Barebacking might be natural. But so are Syphillis and Meningitis. Barebacking is unsafe, its not medically supported and it shouldn’t be sold as holistic by using terms like ‘natural’ or being compared to the sex your parents have. Trying to sell barebacking as ‘natural’ is kind of like telling people to smoke American Spirit cigarettes because they don’t have chemical additives. The term ‘natural’ implies ‘healthy’. Not applicable to bareback sex.

We all know why people bareback. There’s no need to reinforce it.

Now if someone is in a monogamous relationship, I’d be less harsh. But lets be clear, the next public health emergency in our community isn’t going to come from them.

Again, the term for condomless sex needs to have a negative connotation. If it doesn’t then it implies acceptance of barebacking as a practice.

How would you combat condomless sex without making a judgement call on those that are participating in condomless sex? I dont think you can.

enough already

Tom in Lazybrook,
I really appreciate that you – and everyone else here – is making an effort at not letting this go off track.
Not that ‘I’ have ever used strong language here, of course.
(This being the Internet, I’d better mention right now that that was a joke.)

So please don’t see this as piling on.

Barebacking is wonderful. It’s tremendous. It’s as much better than sex with a condom as the best Swiss chocolate is compared to a 20 year old filling-station vending machine chocolate bar.
Barebacking is also absolutely, totally safe in and of itself – in fact, there is some good work showing that having your lover’s semen in your ass conveys the same great benefits to men as it does to women.
‘Barebacking’ like so many terms (‘bottom’ and ‘top’and ‘queer’ come to mind) is on the officially disapproved list of the PC academic elitists. Fine for them, but it’s a wonderful term (as are the others) and you’re wasting time and energy trying to get the rest of us to come live in the Ivory Tower.

I am absolutely not going to stop having bareback sex with my husband. Nor am I going to abandon my (hysterically attacked here a few years back) position that both sex partners have an obligation to each other to discuss their health before barebacking.

I’m in my mid-50s. I went through the early deaths. I went to so many funerals and shed so many tears that it hurts even today.
Hell, I was one of the louder voices in ACT UP!.
I take the backseat to no-one in my desire to see this horrid disease reigned in. Vanquished.
But – perhaps because I’m in my mid-50s – I know that your lectures on the evils of barebacking and your demands that everyone use condoms, regardless of need are just not going to work with teen-age boys in 2014. Nor with 20 and 30 year olds in 2014.

Let’s look at what can be done to end this horrid epidemic. Thirty-plus years on, the ‘cover the hump before your stump’ arguments just aren’t working. The raised pointy-finger never did.

Tom in Lazybrook

Enough already,

You illustrate perfectly my point as to why our public health professionals need to be placing an emphasis on condoms in casual sex. Even if that means that the ‘sexual liberationists at all cost’ crowd isn’t happy with it.

My point about PrEP and barebacking is that it should be grounded in medical science.

1) If you fit a profile for PrEP, get on it.
2) Barebacking is not healthy, especially in casual relationships.

Anyone excusing barebacking or glorifying it is not looking out for the public health of the Gay community. Anyone opposing the CDC without reason on PrEP is not looking out for the health of the Gay community. Sure, oppose the CDC, if you’ve got medical doctors and a medical rationale for doing so.

You can’t say “the CDC has spoken” with regards to PrEP credibly while you ignore their pronouncements on condom use.

Barebacking is not endorsed by any medical science. Anal reception of semen is not endorsed by any medical science.

I think we should tell PrEP deniers such as Weinstein AND bareback glorifiers such as yourself to listen to the CDC.

Why should we criticize Weinstein for ignoring the CDC recommendations regarding PrEP while you ignore the CDC recommendations regarding barebacking?

That’s the problem with Mr LA Leather, Andrew Sullivan, and many of those attacking Weinstein. They appear to not be abiding by the CDC guidelines. Why should they be taken seriously when they ask others to put their kidneys and bone density at risk (as well as their wallets) by getting on PrEP?

To be clear, I want people to follow the CDC guidelines. Including PrEP if they fit the profile.

Just my $0.02. I hope you guys are right and we don’t end up with a massive and unmanageable STI outbreak.

Timothy Kincaid

Byron,

thanks for the info. 2017 is not that far off.

Timothy Kincaid

Brian,

Second, and more dangerously, moralism creates an environment for people to say one thing and do another. It is a breeding ground for people to SAY that they â€œuse a condom every timeâ€ but slip into cognitive dissonance and denial about what they actually do. Because barebacking is â€œbadâ€ and Iâ€™m not a â€œbad personâ€ the mind can jettison or compartmentalize that one-night stand (or two or three) when I slipped up. You can say, â€œwell they shouldnâ€™t do that!â€ And my response is you can put â€œshouldnâ€™t!â€ in one hand and spit in the other and see which one gets filled first. Human psychology is a complex thing.

Excellent point.

I was raised in a culture that stigmatized sex outside of wedlock. There was no need for condoms or birth control (or even sex education about STIs) because good people simply didn’t have sex until they were married.

Except that there was also a pattern of what I called “miracle babies”. They were the ones who came about 6 months after a rushed wedding. Conceived – of course – on the wedding night and perfectly healthy though obviously they were premature birth. You know.

Human nature – and human sexuality – is a much more powerful force than social expectation or stigma, especially when “but no one will ever know”. Until they do.

Timothy Kincaid

Tom,

In response to:

Iâ€™m even more disappointed that you would (perhaps unintentionally) â€˜sellâ€™ not using condoms as â€˜much less enjoyable sexâ€™. I would hope that you wouldnâ€™t diminish the medically sound practice (sex with a condom) with language such as that. I assume its unintentional.

One thing about me is that I’m really not the type of guy who ‘sells’ anything. I’m not going to say something just because it is the politically correct or socially acceptable thing. I say what I say because I believe it. (You may be aware of a heaping pile of angry response when I recently took a position that was not acceptable to some readers).

I say that using condoms is much less enjoyable sex because, well, it is. To me. It’s not even a close call.

Perhaps for you it is all the same. Or (and I know this is true for some) more pleasurable with a condom. But based on what I’ve heard over the years, I think most men find condoms to reduce pleasure.

That may not fit into a marketing strategy. But it’s true.

Tom in Lazybrook

Tim,

I get what you are saying, but is it responsible to say it?

I’ll leave my comments with this…do you think that condomless sex in casual relationships is ever acceptable? From a medical perspective?

We are talking about a medical issue here. Not a ‘feeling’ issue. Or do ‘feelings’ take precedence over medical science? It not anti-PC to say what you are saying. Its just not ‘promoting health in the community’.

And if you think that Weinstein is being wrong for ignoring the CDC recommendations regarding PrEP, then why would you hold the CDC guidelines on condom use to a lower standard?

Why should the CDC be listened to on PrEP and completely ignored on barebacking?

And the CDC is being completely ignored on barebacking.

Consistency, please. I’ll leave the thread with that.

Timothy Kincaid

Tom,

I think we will have to agree to disagree on this.

Lord_Byron

You’re welcome, Tim. It also looks like other HIV meds by the same company that make Truvada will also have their patents expire around 2018.

enough already

Tom in Lazybrook,
There’s no point attempting a discussion with you based on either the hard or the social sciences – you’re not interested.

I’m going to focus on the points on which we agree:
1) Aids is awful.
2) We should do our best to help people avoid getting Aids.

My argument is, quite basically, that safe-sex propaganda up until now has been next-to-useless.
We need to approach this disease from a rational viewpoint – that is, we need to look at what works with real people and not bother with propaganda which does not.

Your approach is unclear to me. It seems to be one of forbidding people like my husband and I to have the safest sex of all – that of two monogamous partners of the same HIV-Status.

That just doesn’t strike me as useful.

How do you want to achieve your goals?

Randy Potts

@Tom, I’d argue that we need to drop the gay-specific “bareback” and go with “unprotected.” The idea that two gay men can’t in any situation or circumstance have sex without a condom without deserving society’s shame puts gay men in a special category. I think it comes from living as a straight married man for years and learning from that experience that straight people have no concept of barebacking or the idea that unprotected sex is bad or shameful on its face – rather, they pragmatically see that there are situations when condoms are called for and situations when they’re not. The information a gay couple needs to have safe sex is absolutely different than the info a straight couple needs in terms of risk, incidence of disease, etc, but I don’t see a place for an especially shaming word like barebacking for gay men when it’s not used for straight couples.

enough already

Randy,
That’s an interesting take. What information need is different for gays than for straights? I’m curious.
While I’ve never had sex with a woman, I’ve seen films and can’t think of a single, solitary difference in risk.

Of course, I don’t see ‘queer’ and ‘bareback’ as shameful, so perhaps it’s a matter of semantics.

Randy Potts

@enough – I read up a bit this weekend on the history of the term barebacking – seems it originally was a proud declaration in the mid-90s by poz men that they would sero sort and “bareback” when both partners were poz. So, it makes sense that there was a backlash and condemnation of the macho “bareback” term, to the point where now it seems to be mostly used negatively.
As far as diff. in risk, there is a difference in sexual risk for hetero couples vs. MSM couples simply based on the incidence and types of diseases that frequent certain communities, but whether that difference should translate into a difference in focus for public health policy is to me an open question.

A lot of the pushback against PrEP, it seems to me, hinges on what exactly the clinician will discuss with a patient, what kind of testing will be done, how often, etc, all legitimate questions. The CDC guidelines seem fairly intensive and clear but there seems to be doubt among some as to whether or not clinicians will really “toe the line.” Where this skepticism comes from I’m not sure – is there a history of clinicians ignoring CDC guidelines?

Nathaniel

This was a fun debate to read through. Its nice when people are all ranting with each other. I think there is room in this debate for a variety of opinions, all of which are needed to keep decisions balanced and realistic.

That said, my greatest concern is where the actual rise in HIV+ cases is coming from. If I am not mistaken, it is in the youngest age groups of MSM, and makes me concerned that neither condom campaigns nor PrEP recommendations are going to be useful. Specifically, I expect that many of those cases are among individuals who come from backgrounds that stigmatized same-sex sexual relations. We see the same thing among evangelical straight youth, who have some of the highest STD and teen pregnancy rates of any group in the US. I don’t know if the problem comes solely from being uneducated about the dangers of sex and the best ways to circumvent them, or if there is a mentality that believes that as long as one doesn’t use condoms or other preventative methods, one is not sinning (ex: I remember watching a Real World resident go in for an HIV test, and he said that it was a rite of passage for gay men. It is easy for me to imagine a young gay man saying to himself “as long as I don’t get tested, I am not really gay”). If these kids are afraid of, or unknowledgeable about, condom use, would they not be more so about PrEP? If our goal is zero new infections, any plan is going to have to reach this group the most.

enough already

Randy,
Thanks for your reply.
Given that more straights than gays die of Aids in Africa, I suspect your sources are slightly ethnocentric.
Basically, there’s no health risks only benefits when two healthy monogamous lovers (gay or straight) have sex.
As for ‘barebacking’, it’s a bit like ‘queer’ – meanings change over time.
In my experience, the term today simply means natural sex with no barriers and the freedom to ejaculate and exchange fluids.
A great thing, when both partners are healthy. I’ve read so much contradictory (and most of it bullsht) information on the risks of two positive guys barebacking, that I don’t trust it.

At this point, I suspect anything which helps prevent the spread of the disease is a good thing, even if it does mean that the evil corporations profit (that was sarcasm, there are too many on this site lacking even a whiff of a scent of a sense of humour.)

Randy Potts

@Nathaniel, that’s an important point and a big issue – it seems obvious that certain communities require a different approach to be most effective, but how do you make that a part of a national public policy? Louisiana has a high evangelical pop and its HIV problem is beginning to really stand out – it will be interesting to see how the CDC’s new PrEP guidelines are received by clinicians there.

@enough – I was referring to the US population since this thread is about the CDC’s guidelines, not sure if that’s what academics mean by ethnocentrism or not, and yes I’m being snarky and trying to be funny (my jokes usually suck, FYI) ..

enough already

Randy,
Actually, CDC recommendations are taken quite seriously by WHO.
Nevermind, I don’t mind snark and being funny – it’s a relief to have a genuine conversation on this topic. All too frequently, it’s a free-for-all.

chiMaxx

Tom in Lazybrook once again advocating doubling down on policies that never, ever worked. Even when gay neighborhoods were full of people walking around with severe wasting and KS Lesions, public health campaigns were never successful in getting all gay men to use a condom every time. No amount of shaming worked. No amount of scare tactics worked. No amount of stigmatization worked.

But for some reason, Tom is sure that if we just shame and scare and stigmatize more, that somehow we’ll reach a nirvana where every gay man uses a condom every time for the all the decades that he is sexually active.

He asks:

“Tim,

I get what you are saying, but is it responsible to say it?”

And there’s only one answer: Absolutely. Absolutely it’s responsible to say it, and it must be acknowledged up front in any campaign to get men to use condoms that has any chance of being successful, because it is never responsible to lie or evade telling the truth about something so easily falsified by experience (that condomless sex feels significatly better for nearly all men). Lying about that makes every other claim you make about the subject suspect.

enough already

chiMaxx,
You’ve said something really important. I wish I had your way with words.
Whether safe-sex, pot or buzzed-driving, you’re not going to be taken seriously if you begin by telling blatent lies.
Any man who’s had a condom-free blow-job knows already that barebacking is going to feel enormously better than wearing a condom. Ditto for the guy who’s bottoming. More, actually, because jiz-joy is a real thing for many of us.

Far too many factors played into the spread of this horrid disease in the early years. Most of them had nothing to do with safe-sex – they were the hate-driven response of the Christians who were so delighted to see us dying by the hundreds of thousands.

It’s 2014. Time to see what works today. Time to start fresh and be open to any and all new ideas.
Maybe there is a way to make condoms palatable to gays. I can’t think of one, but if we set aside our petty differences and really focused on it, perhaps we might find a way.
Popping a pill a day or getting a shot every three months strikes me as more likely to succeed. Goodness – how effective have all the hundreds of years of attempts to get straight me to use condoms been?

Eric Payne

Sex is fun.

Sex is great.

Sex is wonderful.

But is the momentary pleasure of someone else’s orgasm worth dying for?

Condoms save lives.

The life you save may be your own.

enough already

Eric,
That just doesn’t cut it.
People’s minds aren’t made that way – if the danger is not truly visible, they don’t judge it’s risk correctly.
Nice sentiments, but they’ve failed across several decades and the entire planet.
Time to rethink.

Eric Payne

Enough already commented:

That just doesnâ€™t cut it.
Peopleâ€™s minds arenâ€™t made that way â€“ if the danger is not truly visible, they donâ€™t judge itâ€™s risk correctly.
Nice sentiments, but theyâ€™ve failed across several decades and the entire planet.
Time to rethink.

Time to rethink? Hmm… give me a minute.

OK.

Sex is fun. Sex is great. Sex is wonderful. But is the momentary pleasure of someone else’s orgasm worth dying for? Those who believe condoms don’t save lives — and that the life they save might be their own — are, as my mother used to put it , “dumber than a sack of hair,” and would probably do something else incredibly stupid that would kill them a lot faster.

chiMaxx

Eric:

This ignores that the 99% protection rate of PrEP changes the likelihood of dying from any given instance of condomless sex.

Hell, effective treatment of HIV affects the equation–both directly (if you do get infected, you are less likely to die) and indirectly (HIV people treated to the point of undetectable serum levels are far less likely to pass on the infection–see the recent partners study “30,000 Sex Acts Between HIV-Mixed Partners Result in Zero New Infections”
http://www.healthline.com/health-news/hiv-no-virus-transmission-in-mixed-hiv-status-couples-031014 ).

Yes, there are other diseases and infections that should be protected against–most notably hep C and syphilis when talking about the life-endangering rather than the simply uncomfortable and embarrassing-but neither of them killed the same numbers of people in as gruesome a way.

PrEP plus condoms is ideal. But individually, PrEP and condoms provide similar rates of protection.

Randy Potts

A point about condoms – the new PrEP guidelines do recommend them; in fact, I have not heard any public official discuss Truvada without referencing the continuing need for pairing the meds with condom use to prevent other STDs.

As far as whether or not we should be truthful about their use and how people feel about them, I would point to the the drug war as an example of the failure of that kind of truthy policy – the govt has been lying about marijuana for years and, as a result, many people when they discover that marijuana’s effects have little in common with the hype go on to distrust all govt information regarding drugs which, of course is a dangerous assumption. Truthiness in public policy is always bound to fail eventually.

Three facts here: most men, straight and gay, prefer sex without a condom; two, PrEP is the most effective method available for preventing the spread of HIV; three, condoms are still the best way to prevent all other STDs.

The trick is designing public policy that both acknowledges these facts and helps to further prevent the spread of STDs including HIV. That’s what I hope a thread like this encourages – discussion about how we can arrive at better ways to stop the spread of HIV and other STDs in the gay community – that’s something we all want.

chiMaxx

Indeed. Gay sex is done for pleasure (and bonding and connecting, and all those other wonderful things). As our opponents are quick to point out, we’re not making babies here (though, frankly, neither are they, most of the time).

If you’re doing something *for* pleasure, it i not irrational to maximize pleasure. As adults, we learn to balance pleasure with safety–to occasionally indulge in not particularly healthy foods we love but not gorge on them til it negatively impacts our health, to drink responsibly (if our constitution allows, etc.).

But everyone draws the line differently on what risks are worthwhile for pleasurable pursuits. Skydiving seems pretty crazily over the line to me, but others find it worthwhile. I used to enjoy the occasional cigar, but have foregone them since the time when hereditary heart disease gave me my first cardiac stent.

If someone believes that the pleasure is worth the risk, scare tactics, shaming and stigmatization will not get them to change their mind. Eric Payne: Some people may answer your question (“Is the momentary pleasure of someone elseâ€™s orgasm worth dying for?) with an unequivocal “yes” (though probably after reframing it to include the pleasure and satisfaction THEY get from the exchange). This is especially true now that the risk of actually dying a long, slow, painful death from HIV has been significantly reduced by ARVs. What do you want to offer such people to reduce their chance of getting and passing on the virus?

Thirty years into this disease, with effective treatments meaning that our community newspapers are no longer padded with multiple pages of obituaries, and now with the introduction of PrEP, it is not completely irrational to say “my partner and I agree that the pleasure we get from condomless sex is worth the risk of one of us passing the virus to the other, but if there were a pill I could take to reduce the chances of that happening, I would.”

Yes, some people are going to make that calculation now that PrEP is here. But most of those who adopt PrEP are probably already cautious about their health by nature and will continue to use condoms to protect against other STDs. The best public policy for reducing the spread of HIV and other diseases in the herd is to get people to use the most protection they are willing to use correctly and consistently given their individual risk:reward calculations, and to recognize that those decisions will be made based on the perceived impact of the disease in 2014, not based on what the world was like in 1990.

Eric Payne

ChiMaxx writes:

?.. Eric Payne: Some people may answer your question (â€œIs the momentary pleasure of someone elseâ€™s orgasm worth dying for?) with an unequivocal â€œyesâ€ (though probably after reframing it to include the pleasure and satisfaction THEY get from the exchange). This is especially true now that the risk of actually dying a long, slow, painful death from HIV has been significantly reduced by ARVs. What do you want to offer such people to reduce their chance of getting and passing on the virus?

1. Since it is impossible to be infected by the by-product of one’s own orgasm! those who reframe the question aren’t being honest with themselves. Again, I refer to that person’s level of intelligence.

Look, I’m in a relationship over nineteen years; we are completely monogamous. Infection is simply not one of my worries.

But, due to my long-term, end-stage heart failure, my existence is dependent on 14 different medications taken in a combination of 24 pills each day. And I do mean dependent!, completely. Should I “forget” dosages, my blood chemistry gets thrown out-of-whack; potassium levels can drop to nothing, blood thickens and clots in my veins and arteries — or around the leads and edges of “devices” implanted in my heart and chest; my blood pressure drops to the 60s/40s range from its norm of high-80s/mid-50s; my lungs fill with fluid; my body retains fluid.

It’s so simple, right? And common sense tells me never forget to take medications.

But there are times when I do forget. There’s also a psychological dislike (that borders on a hatred) of being tethered to a twice-daily medication routine. It doesn’t take long for that dislike to manifest itself into a resolve/belief of “I don’t need to take this anymore.” Which leads into…

2. While HIV/AIDS may no longer be the long, slow death sentence it once was, virus mutate as they branch out into hosts. Viruses also become resistant to established treatments as the viral colony grows and expands. It’s not out of the realm of possibility — and, in fact, is a projected reality — as HIV infections spread, a “super” HIV virus will develop that will not be responsive to treatment.

The best pro-active response to the projected mutation(s) of HIV is one of pre-emotion: to halt the spread of the virus in its current form. While PReP currently claims a low-to-zero viral population spread, a sudden mutation (as virus are also known to do) may completely change that statistic.

HIV is still completely preventable. To remain HIV-negative, don’t allow the introduction of another person’s bodily fluids into your body. In sexual situations, that means the sheathing of penii if said penis is inserted (and withdrawn, and quickly reinserted, then withdrawn, then inserted/withdrawn, etc.:-)) or activities in which there is no insertion.

Timothy Kincaid

Eric, to address two of your points:

Itâ€™s not out of the realm of possibility â€” and, in fact, is a projected reality â€” as HIV infections spread, a â€œsuperâ€ HIV virus will develop that will not be responsive to treatment.

No I don’t think that is a projected reality. The only way in which a resistant strain can develop is if there is transmission of such a strain. It appears to me that the increased incidence of undetectable viral loads combined with PrEP would virtually eliminate transmissions. In fact, PrEP may be the only way to avoid the transmission of a supervirus – as it eliminates the transmission component.

Also, when you say “HIV is still completely preventable”, that sounds very familiar to me. I hear it from the anti-gay activists who quote failure rates for condoms and insist that the only way to prevent HIV is to ban gay sex. Your argument is quite similar.

Randy Potts

@Eric – I’d say you really hit a central issue here, that prophylactics should be, as much as possible, pre-emotion. For better or for worse, condoms don’t qualify as it’s impossible to put a condom on a flaccid penis. This doesn’t mean we stop recommending them, but it does push me to lean toward recommending something like PrEP which truly is, as you say, “pre-emotion.”

Eric Payne

Randy,

Once again hoisted by the petard of iOS 7.1 and it’s spell-check.

The word I typed was not “pre-emotion” but “pre-emption.”

Randy Potts

@Eric, ha! My iphone gets me all the time. Well, at least this time around, I like the iOS 7.1 version ;)

chiMaxx

PrEP is also pre-emption.

Eric Payne

@Timothy Kincaid,

Nowhere did I call for celibacy and/or abstinence.

But, then, as some of your pasts posts in “follow up” to my posts have shown, reading comprehension isn’t one of your stronger suits.

chiMaxx