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The debate: Condoms vs PrEP

Fri 30 May 2014 In: Health and HIV View at Wayback View at NDHA

Gay Auckland man Paul Kramer thinks the NZAF needs to “end its conservative assault” on HIV prevention drugs, saying condomless sex is happening anyway. The NZAF’s Shaun Robinson says PrEP just won’t work in the fight against HIV, while our condom culture does work. Here are both sides of the argument... Paul Gordon Kramer: The End of Latex-Love They’re uncomfortable. They’re awkward to use. I’m not sure they’re great for the environment. But I must love them. Conflicting studies show anywhere between 70 per cent to the high 90s in terms of efficacy in preventing disease transmission for anal sex. But yet billboards around town awash with JCrew models (because only beautiful people fuck) demand that you literally love tiny pieces of latex, as twinks love straight acting daddies and tops love being withholding. Can you love something out of fear? Can you think of any other advertisement campaigns that so completely confine your intimacy? But condomless sex, no matter how taboo, no matter the prohibition, happens! Most of the porn I watch features men barebacking. Logging onto The Grindr nets profile after profile demanding the prospective courter to leave the condom in the drawer – BBtop4BBbottom, one gent’s handle. No one in the world ever has ever even one single time used a condom for oral sex. If at least these groups of people might be doing it sans rubber, I wonder who else has denied the ham-fisted advances of Condom, Inc. New Zealand AIDS Foundation’s Director, Shaun Robinson, recently emphasised his organisation’s stance on Truvada – a pre-exposure prophylactic which, if taken regularly, grinds HIV transmission to a halt. Regular usage of the drug is more effective in stopping HIV, an unprecedented advancement in the War on AIDS, which has to-date been about as effective as the War on Drugs. Robinson believes men will have great difficulty keeping up with the drug regimen, foreseeing that any disturbance in the current “condom culture” will have devastating consequences. Citation sorely needed. I found the NZAF’s stance on this remarkable weapon in the arsenal against HIV/AIDS disturbing. Imagine, my fellow queers, a society in which pharmacists did not dispense drugs based on whether or not people could be trusted to take them regularly. As someone who has experience taking a pill every day, I feel confident that it isn’t a condom distribution network’s (NZAF’s) prerogative to tell me I can’t be trusted with Truvada. Robinson’s other attempts at fear-mongering are also easily dismissed: He asks, “If you are having sex with a guy how will you really know if he has taken PrEP properly whether by injection or pills?” My answer: Because I’m also taking PrEP and I can handle putting a pill in my mouth every day! He asks, “How many straight guys do you know how have become fathers unwittingly thinking their girlfriend was ‘on the pill’?” My answer: None. But I also don’t associate with many breeder couples, as I find the whole notion rather unsettling, so who knows. Will anyone of my generation ever be permitted to have condomless sex? It’s seemingly asking too much to gain knowledge of our lover’s flesh unto our own. Instead of becoming complacent with the status quo, let us utilize this new tool and get us one step closer to touching one another once more. NZAF needs to end its conservative assault on this miracle drug, and embrace the possibility that this is the future in the assault on HIV/AIDS. It needs to pressure the relevant bodies to make Truvada/PrEP accessible and affordable in New Zealand. It needs to educate its population about correct usage, just like it did with condoms. To be satisfied with the current rate of infection is a slap in the face to all the lives that might have been spared if they were only on Truvada. (Paul Kramer is a PhD Candidate at Auckland University’s Department of Political Studies) The New Zealand AIDS Foundation’s Shaun Robinson: Love Your Condom and don’t mess with success “Ending latex love”, which I guess means stopping the condom culture, would mean a lot more Kiwi gay and bisexual men will get HIV. Good on Paul Kramer for expressing his opinion; there are things to like about what he says. He wants there to be less HIV, fantastic; he wants intimacy between men, that’s great. However his ideas about how to achieve those things won’t work and would put the whole community at risk. The author of “Ending latex love” is promoting PrEP, the use of HIV medication by guys who don’t have the virus as a prevention drug – take it regularly and you reduce the risk of getting HIV. In America the CDC (Centre for Disease Control) has just recommended the drug Truvada as a major prevention approach for gay men. So why not do that in New Zealand? 1) New Zealand has a condom culture that works, America doesn’t. The Americans are only doing this because their condom culture has failed. The CDC is promoting PrEP for men who refuse to wear condoms, not instead of condoms. The CDC talk about their frustration that American gay men have not listened to the advice to use condoms, and as a result 50,000 people catch HIV every year. San Francisco has 25 per cent HIV prevalence - 1 in 4 gay men have HIV! They are desperate to find anything that will make this better. Compare that to New Zealand where over 80 per cent of gay and bisexual men use condoms most of the time. This has kept everyone safe, because it has kept HIV levels almost at the lowest in the world. My guess is that if America had these results they would not support PrEP – why would you mess with success? 2) You have to take the pills regularly – not just one person, the whole community would have to take PrEP regularly for it to be effective. There are big questions about whether this could happen. In the iPrEx trial which tested PrEP with gay men they found that a large number of the participants didn’t take the pills and lied about it (they could tell by blood tests). If they had all taken PrEP it would have been about 92 per cent effective, but in fact it was only 44 per cent effective. Imagine that in the real world in Auckland – we could go from the very high protection of a community that uses condoms to something that could be well under 50 per cent effective. Not good odds. Since PrEP has been available in America there has been a lot of controversy about people not taking it. Why don’t people take it? Well this is a serious drug designed to combat HIV in the body. It was not developed as a prevention drug. Doctors in America have been reluctant to prescribe it to people who are not sick. The drugs can have considerable side effects including, feeling nauseous, diarrhoea, dizziness, depression, sleep problems, itchy skin. The fact that men in a clinical trial lied about taking them implies that they didn’t like the effect. 3) Cost – Who would pay for PrEP? In 2012 the cost of HIV medications in New Zealand per person was $14,255 a year. Condoms cost well under $100 per person per year. In America PrEP is paid for by people’s health insurance (if they have it). It will be interesting to see what happens to gay men’s premiums now PrEP is being promoted. What is it that PrEP supporters are promoting in New Zealand … going from less than 6.5 per cent of gay and bisexual men being on medications to 100 per cent and the government (every tax payer) is going to pay the extra billion dollars or more! The Kirby Centre in Australia just calculated that using PrEP for just 30 per cent of gay men in New South Wales would cost an extra AU$95 million a year (they also said it would not be effective). Why would any government pay that when they already have one of the most effective prevention programmes in the world for a fraction of the cost? Of course drug companies love PrEP. Selling drugs to people who aren’t sick has got to be good for business. Perhaps the PrEP supporters are willing to pay the extra NZ$280 per week themselves out of their own pocket? I said that everyone would have to take PrEP for it to be effective, because preventing HIV is not just about stopping your next lover or you getting the virus, it’s about stopping the spread in the whole community. The gay community has spent 30 years building up a culture of condom use, and it has worked. There are people who just don’t like condoms. In New Zealand I would think they feel quite a bit of pressure because most gay and bisexual men support condom use. So people are looking for excuses or reasons to feel okay about not wearing them. There aren’t any. It’s a community thing. Keeping everyone safe is everyone’s responsibility. The less HIV there is in New Zealand the less risk there is for everybody. The New Zealand gay community has never said “wear a condom only if you think you are infectious.” The deal has been “wear a condom because you cannot tell who is infectious and who isn’t”. One in five guys who have HIV don’t know it; last week’s test may be history if you’ve had unprotected anal sex since then and even people with undetectable viral load do not know how infectious they are at any point in time. If someone says they have taken PrEP, how do you know and how do you know how regularly they have done it? There are too many variables and too many risks to “guess”. If one person guesses it encourages others to guess as well, the condom culture breaks down, there is more HIV in the community and everyone is at greater risk. Around the world HIV rates are still going up for gay and bisexual men, except in a small number of countries; New Zealand is one of them. So yes, Love Your Condom and don’t mess with success. (Shaun Robinson is Executive Director of the New Zealand AIDS Foundation)  Paul Kramer and Shaun Robinson - 30th May 2014

Credit: Paul Kramer and Shaun Robinson

First published: Friday, 30th May 2014 - 9:25am

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