When I first meet Mario* he’s wearing a bullet-shaped pill holder on the buckle of his belt. He’s just come back from a check -up with his HIV doctor, and he shows me the three-months’ supply of pills he’s just collected from the sexual health clinic. “It’s important not to miss a dose. If I’m out at the weekend and have sex, I know I’ll always have the pills with me” he says, pointing to the pill holder at his waist.
The importance of taking HIV medication at the right time has been drummed into gay men with HIV for the past two decades. But Mario doesn’t have HIV. He, like an increasing number of gay men, especially in the US, is taking a daily dose of Truvada (a one-pill combination of two HIV drugs more commonly used to treat HIV in those already infected), to prevent getting HIV.
Pre-exposure HIV prophylaxis – or PrEP – hit the headlines in 2010 when the findings of the international iPREX (Pre-exposure Prophylaxis Initiative) study were released. The study found that men taking a daily pill of Truvada almost halved their risk of getting HIV, compared with men in the trial who received a placebo pill. Men who took their pills regularly and consistently reduced that risk by over 90 per cent.
PrEP isn’t currently available on the NHS but over 500 gay men in England have been taking part in a PrEP study called PROUD. Men in the trial were either prescribed PrEP immediately for two years, or randomised into a deferred arm that gave them PrEP in their second year of the trial. The early closure of the deferred arm last month, following interim data analysis by the trial’s Independent Data Monitoring Committee (with all men being offered PrEP by the end of this year), fast-tracked an emerging debate as to whether PrEP should be prescribed on the NHS to those most at-risk of acquiring HIV.
The figures speak for themselves: when PrEP is used as prescribed it is highly effective at reducing HIV and, at a time when HIV diagnoses in the UK have never been higher, HIV activists are calling for PrEP to be made available on the NHS with immediate effect.
Yet, PrEP isn’t without controversy. Just as when the contraceptive pill was introduced in the 1960s, concerns are being voiced that PrEP use will result in condoms being ditched all together, with a spiralling rate of other sexually transmitted infections. Last month, the actor Zachary Quinto voiced his concerns about the new medication, “I have heard too many stories of young people taking PrEP as an insurance policy against their tendency toward unprotected non-monogamous sex”. HIV prevention activists responded: isn’t that exactly how and by whom PrEP should be used?
I’ve spent the past three years interviewing and talking to dozens of gay men about their PrEP use or the circumstances in which they would consider taking PrEP. Contrary to some of the media reports, I’ve found that men are thoughtful, considered and resourceful in how they navigate sexual risk. It’s often complex, and PrEP makes it more so. Yet, one thing is for sure: simply saying that PrEP will lead to men ditching condoms undermines the complexity of how men think about and negotiate sex and risk. For the men I’ve interviewed, PrEP offers more than protection against HIV: it reduces anxiety or stress when men don’t stick to the safer sex rules they’ve set themselves; it allows for intimacy and closeness between partners when one of them has HIV; and, especially for older men, it offers a potential way of addressing erectile dysfunction when men find it hard to stay hard or climax when they use condoms.
For Mario, the criticisms of PrEP are hard to fathom. “Ninety per cent of the sex I was having was unprotected anyway. I would get anxious after. Being on PrEP hasn’t had an impact on the type of sex I have because I rarely used condoms anyway. But it has had an impact on my anxiety levels and psychological well-being”.
His friend Daniel*, who is also taking PrEP, says it doesn’t mean he’s suddenly stopped using condoms. “I struggle between wanting to be safe and an impulse not to be. I recognise that I have a tendency to put myself in a position that’s marginally dangerous. With PrEP I can stop beating myself up when I occasionally don’t use condoms”.
As evidence around the world stacks up in favour of PrEP, the calls for it to be made available on the NHS will only increase. We now have compelling research on the effectiveness and acceptability of PrEP that didn’t exist even a year ago. Now’s the time for thoughtful, well-researched and well-resourced action to be taken to make it available on the NHS.
Will Nutland is a Research Fellow at the London School of Hygiene and Tropical Medicine. His doctoral thesis explores the acceptability of PrEP in gay men in London.
* Names have been changed.