Prevention and its discontents
Michael Boudin says “walking a red light can get you killed; it can also get you to a job interview on time.”
In November of 2010, The New York Times wrote, under the headline ‘An AIDS Advance, Hiding in the Open’, about what at first and even second glance appeared to be a major step forward in HIV prevention: Pre-Exposure Prophylaxis, or PrEP.
In the war against AIDS, a new weapon has emerged.
It wasn’t a secret weapon. It was a well-established treatment pill that has only now been shown to be effective as a prevention pill too. Which raises a question: What took so long?
Last week, a clinical trial showed that taking Truvada, a pill combining two drugs, once a day would greatly reduce a gay man’s chances of getting infected with the dangerous virus. Although confirmatory studies are still needed, the practice — called “pre-exposure prophylaxis,” or “prep” — will, in theory, also protect sex workers, needle sharers, wives of infected men, prison inmates and anyone else at risk.
Truvada, along with other drugs, is already in use for post-exposure prophylaxis and in HIV combination therapy, presently the standard treatment for those infected with the virus.
Recently, however, the AIDS Healthcare Foundation has petitioned the U.S. Food and Drug Administration (FDA) to reconsider giving the agency’s approval for the use of the drug in a preventive context. AHF used a rather novel argument:
"Any approach that relies on adherence for people who don't have a disease is going to fail," AHF President Michael Weinstein said at a press conference on Thursday.
‘Relying on adherence’ is precisely what HIV prevention has been doing for three decades. Use protection, every time. Every. Single. Time. Without fail. In other words, we took what is in most cases a voluntary and spontaneous process, intercourse, and added a dimension of required control to it. There is not, however, a single system one can think of engineered by human hands that is entirely fail-safe. A few years ago, the entire electricity grid in the Northeastern United States went dark for several days, causing billions of dollars in damages; that grid, however, is one of the most complex and most stable systems on the planet. It powers hospitals, the money factories of Wall Street, even the nerve centers of another kind of power, the matchless military force of the United States.
So it really shouldn’t surprise anyone that prevention is a bit of a problem, nor that statistics bear that observation out. For many gay men at least, the idea that in our most intimate moments, we would need to have, as an absolute and non-negotiable necessity, the foresight of mind to treat intimacy as a potential threat, was and remains a challenge. It’s not that we don’t know what constitutes risky behavior; it’s that it’s simply not possible to always avoid it, or in a given moment even desirable. Walking a red light can get you killed; it can also get you to a job interview on time.
Sex is really no different. You make choices, some of them well-informed, some less so. The calculations of risk and reward may not always seem as balanced as the rational mind would make them. The phenomenon of condom fatigue is very real.
I’ve had several conversations recently with people in the AIDS activist movement about a perceived shift in that risk-reward calculus. Simply put, they – we – find ourselves needing to communicate two messages that are at odds with one another. On the one hand, externally – that is outside of the HIV community – we need to raise awareness of the risks inherent in unprotected sex and other behaviors, and to unsubtly convey that, as has been said, “HIV is still not a day at the beach.” Because really, it’s not. Chronic or inevitably lethal, a major illness is still just that.
On the other hand, you have, say, people like myself with great skin, gym memberships, families and friends, the whole nine yards of modern gay life. In short, not the picture of devastation those of us of a certain generation remember all too vividly. But this message – that there is a life with HIV, and that it can be a good one – is precisely what we communicate internally, within the HIV community. We’re saying, “fine, you have it, here’s how you can live the full life you want and deserve.”
That’s a classic binary, a contradiction in terms, isn’t it?
I would posit that resolving that binary, squaring that circle, is the biggest challenge we as a community will face in the coming decade. But whatever strategy is developed, however many arrows are in that particular quiver, will need to take into account that the fright factor is no longer the omnipotent answer it was even a decade ago.
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(Image: National Aeronautics and Space Administration)