PrEP (Truvada): An HIV Mental Health Specialist Therapist Weighs In on One of the Hottest Topics for Gay Men Today

Closeup photo of handsome shirtless manAt GayTherapyLA.com, (which can also be accessed via www.PozTherapist.com, to coincide with my identity as a psychotherapist with over 22 years experience providing gay-affirmative therapy to gay men and couples, as well as my 24 years being HIV-positive, and an HIV mental health expert and advocate in Los Angeles), my staff of clinical associates and I pride (pun intended, at this current Pride Season) ourselves on offering frank, personalized, gay-affirmative, and sex-positive counseling and coaching services for gay men.

Among these services has been always keeping myself up-to-date on the latest topics, issues, and even controversies that are discussed in forums, online, at bars, and in bedrooms all over the country. The current “hot issue” of PrEP, or “pre-exposure prophylaxis”, which is using a medication (Truvada, by Gilead Sciences, a pharmaceutical company) for use by HIV-negative men for the prevention of sexual HIV transmission, is one of these.

I recently had the following exchange on my personal Facebook page, after I posted an article from a Facebook fan page devoted to PrEP information and facts, which can be found here, called “PrEP Facts: Rethinking HIV Prevention and Sex”, founded by another licensed psychotherapist, based in New York City, named Damon L. Jacobs, a brave and heroic pioneer in promoting PrEP education, awareness, and community dialogue about what PrEP is, and what it is not.

The exchange on Facebook went like this:
Q: “George”:  I really don’t know the answer, so please correct any misconceptions I may have. Are people taking Truvada so that they can have unprotected sex?

A: Hi George. That’s a good question, but it’s sort of a misleading one. HIV of course used to lead to AIDS and often horrible illness and death, and it still can, if left untreated. After living with HIV myself for 24 years, I’m not sick or dead, but I would say it’s a royal pain in the ass, to say the least. So, of course, it’s desirable that acquiring HIV is to be prevented, at great effort, if necessary. For a long time, abstinence and condoms were the leading prevention strategies in behavioral terms. But asking humans (or just about any organism) not to have sex is impractical because it’s a powerful natural drive.

So, that left condoms. And, condoms have disadvantages, so they have always been used sporadically and inconsistently; research shows almost no gay men (or let’s face it, straight people either) have used them 100 percent consistently. Since that time, research has shown that treating HIV with a combination of antiretroviral drugs will not only slow the replication (copying of itself) of the virus in the poz person, much to our global collective relief in about 1995, leading to sustained health and life itself, but more recent research has shown that poz people on treatment are not infectious — and while this is a fairly new notion that has been played out in the research, most recent research supports this. This is known as “treatment as prevention”. This is why it has been said that an HIV-negative gay man having sex with a known HIV-positive man is quite possibly safer than sex with a man who claims (or even believes) himself to be negative, when he’s actually newly-infected and quite infectious due to a high initial viral load after exposure and seroconversion (which is HIV “establishing itself” in the body).  As crazily counter-intuitive as this might sound, especially when we see “Neg – UB2” in online profiles of gay men’s websites and smartphone apps, it makes a lot of sense.  For example, other research has shown that many straight couples, where one partner is poz and one is neg, they can successfully have sex and make babies, without the neg partner becoming poz, if the poz partner is on treatment and has an undetectable viral load.

We also have learned that when a negative person takes Truvada, for example, which is a combination of two antiretroviral drugs, they are given a sort of “immunity” against the virus taking hold of their system if they should be exposed to HIV. While condoms are a physical latex/silicone barrier to broad HIV infection in the host, Truvada is in essence a “chemical condom” that also provides a barrier to full infection throughout the bloodstream. Some people might use Truvada as the “chemical condom” in place of the latex barrier, and some people might use it in conjunction with a latex barrier. Truvada is seen as an adjunct, or as an alternative, method of preventing HIV infection, when condoms are known to not be used consistently. For many people, it’s easier to take a pill than it is to use a condom (just ask straight people; many women might use birth control pills to prevent unwanted pregnancy, instead of asking their male partners to use a condom to prevent unwanted pregnancy, because both straight and gay men often have the same general complaints about condoms impeding sexual pleasure, being inconvenient, etc.).

So, is Truvada a “license to have unprotected sex”? Not really, because using Truvada IS a form of “protected sex”, it’s just sometimes condom-less sex. Recently, the U.S. CDC announced that condomless sex is not really “unprotected” sex, if another method of prevention (such as Truvada) is used. So, the nomenclature, while annoyingly complex, is very important. Advocates of Truvada as PrEP focus on one thing: reducing HIV transmission, to save the patient the hassle (if not risk to health and life) of living with chronic HIV infection, and to save the medical and public health systems from a lifetime (so far) of treatment for HIV and its complications. So far, the numbers are effective in doing that.

However, like so many sexual issues in the (Puritan-based) United States, the issue of stigma rears its ugly head in almost all discussions of American sexual matters, from birth control pills for “slutty women” (according to Congress), to gay men blasting their peers for being “Truvada Whores” instead of just guessing or selecting partners who “say” they are HIV-negative in order to have condomless sex (see above image, of the t-shirts currently being sold by Adam Zeboski, a PrEP education and awareness advocate for reclaiming the ironic “#Truvada Whore” term from its stigmatizers).

There will always be a battle in the United States between the science/research of public health issues, particularly sexual ones, and the social politics of them, as long as the Religious Right tries to conflate science with a certain brand of misogyny, classism, looks-ism, heterosexism, racism, and particularly anti-sex moralism in the discussions. In order to understand the issues, one must separate the factors that influence the discussion.

From my point of view as a person living with HIV myself for over 24 years, I feel strongly that anything that can help a person prevent contracting HIV in the first place is a good thing.  I don’t mean to play “poor me”, because I realize that I’ve been very lucky to be diagnosed in 1990 and survive and thrive living with HIV for this long, when friends who were diagnosed around that same time did not.  But it hasn’t been easy.  Even if you take out the “early days” of wondering whether, in 1990, at 26, I would outlive my 89-year-old grandfather, and the “plague years” aspects, living with HIV is not much fun.  Even after “the cocktail” and an undetectable viral load in the mid- to late-90s, I’ve still had two hip replacements (right and left), multiple treatments for lipoatrophy (fat loss) in my face and butt (injectable fillers), two eye surgeries (lipodystrophy), skin disorders, osteopenia (bone loss), blood clots (DVT), and countless blood draws, lab tests, and doctor office visits, let alone taking an entire handful of pills twice a day.  So, if someone (an HIV neg guy) taking one pill, once a day, can prevent HIV from the get-go, I say great! What a gift from modern science that is.

From my point of view as a mental health professional, particularly one who has specialized in HIV mental health for so long (I was the Chair of the Los Angeles County HIV Mental Health Task Force for 9 years, and co-coordinated its annual HIV mental health conference), I have seen many major issues emerge, and it’s been my job to help others with them.  Of course, coping with massive and overwhelming illness and death, or threat of illness and death, marked the early years that I was involved.  Then, we had the “Coping with Hope” era, when instead of illness and death, we had hope (that turned out to be, thankfully, quite justified) that HAART (combination therapy, “the cocktail”) would be effective in halting HIV and saving lives.  Then we had the issue of actually increased stigma of HIV, as a new generation of gay men grew up without much education on the issue, thanks to the federal government’s “don’t say gay” gag order on HIV prevention program funding, led by conservative, religious, anti-gay Republicans, and a seemingly widening divide between poz and neg, even within our own gay community.

Now, with PrEP, we have a new sense of hope, collectively as a community, that we have new weapons in our arsenal for HIV prevention, beyond the notoriously unreliable “sero-sorting” or the, let’s face it, unpopular use of condoms.  Just like the early days of HAART, we are seeing the wonders of modern science, and how effective and safe medications can make a difference in our lives — as individuals, and also as a community.  With advances in science, we have more options.  We become more self-empowered.    The challenge, though, is to become educated, understand, and appreciate the scientific advances, while coping with the voices of stigma, hate, mis-information, and of course anti-gay antipathy that plague our community, from outside it, and even sometimes from within it (see gay/HIV activist Larry Kramer’s recent dismissal of PrEP, citing its side-effects, which by many reports have been minimal, and its rebuttal).

So, George, I think it’s great you’re asking questions like this, that keep the community dialogue going and also clarify your feelings. This is a part of what I, and my clinical associate staff, help clients with in our counseling and coaching work at GayTherapyLA.com in Los Angeles and with others who come from phone or Skype connections.  While our many valuable HIV specialist MDs in the community can help patients with the medical information, and even the consultation and services needed to receive a prescription for Truvada as PrEP, our community of gay men is often left without sufficient psychosocial and emotional support resources.  While some of our local AIDS service organizations in Los Angeles, and their respective mental health departments (funded by the federal Ryan White CARE Act and other public funds), help with this a little bit, my associates and I at GayTherapyLA.com offer individual, couple, and group counseling for questions and issues related to PrEP (as well as many other issues) in a private practice office setting (near the Beverly Center).

We will also soon be offering a new Gay Men’s Group on Saturdays devoted to the frank discussion of all kinds of sexual issues, including support and information for the use of PrEP, which will be co-led by staff of GayTherapyLA.com.  Stay tuned for more information on this, or call 310-726-4357 for more information, or email Ken@GayTherapyLA.com.

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