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September 25, 2009

The End of Condoms? Not so much.
FILED UNDER: "Fucked Up Bullshit"
TAGS: Daily BeastDavid KaufmanElizabeth PisaniPre-Exposure ProphylaxisPrEP
By Daniel Reeders

It's Friday night, the rain has eased, I've just got back from an enjoyable session at a sauna (that's Aussie for bathhouse) and cracked the top off a Beez Neez -- a Western Australian malt beer brewed with honey. It's been a rough week but right now, life is pretty good.

And then I notice an article about PrEP in The Daily Beast. Danger, Will Robinson, mainstream media coverage of HIV prevention! And sure enough, it's a shocker.

I'm mellowed-out enough to admit there are flashes of insight in the piece. It has all the right pieces of the puzzle, but author David Kaufman has jammed them together trying to make an altogether less optimistic picture of PrEP than their proper placement depicts.

And that's a shame, because there's enough genuine uncertainty to write a balanced piece without leaving any gay boys itching to rush out and score themselves some tenofovir.

A big part of the problem is Kaufman's deathly purple prose. AIDS, he writes, is "caught in a 30-year swirl of sex and morality" -- and he's stirring away furiously. In his article, PrEP is a "necessary evil" but "downright dangerous", "game changers", elation and alarm, and cringing PrEP proponents -- holy asslicking assonance, Batman!

HIV prevention is a big field, and there's an ongoing dialogue about PrEP -- as well as the whole complex of related issues like safe sex, versus serosorting, versus barebacking, versus social network interventions, versus combination prevention.

So when journalists like David Kaufman and before him (but even more problematically) Margaret Wente collapse all that discourse into a single dichotomy of opinion, the results are not pretty. Wente's article attacked a nameless, faceless "AIDS establishment", while Kaufman gives us "AIDS world" -- now that sounds like my kind of fun park!

According to Kaufman, "AIDS world" still tells gay men "Always use a condom". Seriously? Was he living under a rock when we fought the battles over negotiated safety, barebacking, and serosorting? When a journalist doesn't source material like this, it looks to the reader like accepted wisdom -- something so obvious it doesn't need attribution.

In fact, it's more likely just the author's personal opinion -- and every gay man thinks he's an expert on HIV prevention and HIV prevention workers are all idiots.

So it functions as a straw man. Easy to knock down in your article, but not doing your audience any favours either. It's a missed opportunity to help them understand the complexities of our task in trying to reach them with relevant prevention messages.

But in my lightly-buzzed, post-coital state, I remember Paul Kidd's message at our HIV and the Media forum last month in Melbourne: journalists have limited time and space, and stereotypes are shorthand. So I'm willing to cut Kaufman some slack... until I read this:

Long-time San Diego HIV educator Daniel Uhler reports, "We've seen quite a few drug dealers include (PrEP) meds with meth and Viagra to help better market to clients on the gay party scene."

Stereotype shorthand is one thing; reprinting dumbest of the dumb rumours is another. Kaufman had already found a doctor willing to go on record about prescribing anti-retroviral drugs to "high risk" HIV-negative men as PrEP. That's a coup! So why did he need to print such an obviously questionable rumour?

It's a variation on the "MTV" myth about a "cocktail", "party pack" or "disco dose" combining meth, tenofovir, and Viagra.

There's one simple question neither Kaufman nor his editors apparently thought to ask: how do you know that?

Has Daniel Uhlers been sending illicit drug samples for testing? I doubt it. Most likely it's a rumour he heard from a friend, who heard it from a friend, who maybe once did actually hear it from a dealer -- but seriously, who believes the drug dealer? (That's the guy who says of talcum powder, "This is gonna blow your head off!")

It took me half a second to find an article on The Body which dispelled the rumour about MTV with results from a CDC study of gay men at Circuit parties in 2005, where only 1 out of 397 neg men had ever taken PrEP. The persistence of rumours despite facts to the contrary is good evidence that their primary value is ideological, not explanatory.

What Kaufman misses about the rumour is what it says about gay men as innovators, anticipating (most likely outright inspiring) scientific research and experimenting on themselves to find ways of enjoying pleasure while minimising risk.

Kaufman's article does nicely illustrate what happens when science and then finally educators catch up. Scientists think "huh, cool" and "why didn't we think of that" because, at heart, they see technological solutions as simpler and more reliable than social ones. The medical and community people start to worry about implementation and informed consent and minimise-versus-eliminate the risk and all the other considerations that arise from our general conservatism about risk/pleasure.

"There is this cultural reluctance to giving people pills that allow them to do things we don't want them to do," says Thomas Coates, Professor of Medicine at UCLA's David Geffen School of Medicine. He's talking about the point at which fears about PrEP cross over from practical to moral-fears of a future in which PrEP, like the Pill before it, becomes as much a vehicle for pleasure as for prevention.

This is (unintentionally) a very revealing quote: pleasure is only moral in a Puritan world. Thinking he's moving on, Kaufman goes on to make the excellent point that the high cost of PrEP roll out introduces the problems that plague every other kind of healthcare in the United States -- inequitable access based on ability to pay.

Maybe I've been living in a socialist utopia for too long, but for me, that's the point when the issue becomes a moral one. Not whether we're using a medical technology to facilitate people enjoying themselves. Sexual pleasure and physical intimacy is not a luxury, like an icecream Sundae at the movies; it's a basic human need.

Kaufman rightly calls bullshit on the latest "menu-based" misunderstanding of "combination prevention", pointing out that gay men will NOT use a combination of PrEP and condoms and partner reduction: the whole point is having sex without condoms.

This highlights the dirty truth underlying all these discussions: gay men HAVEN'T abandoned condoms. In most areas, 70-80% of gay men use condoms all the time for casual sex.

The remainder are probably like the 30% of American voters who continued to think Bush was doing a heckuva job even after Afghanistan, Iraq and Katrina. And even they (the gay men, not the Tea Baggers) use condoms sometimes -- indicating some baseline/remnant adherence to safe sex motivation.

PrEP is an option for people in that tiny minority of gay men who will never use condoms. And Kaufman acknowledges that himself, when he talks about the "high risk" patients to whom Dr Conant is prescribing PrEP. It's a measure of his sexual prejudice that Kaufman automatically assumes "high risk" means all gay men.

Once you factor targeting into the analysis, along with intermittent dosing and slow-release formulations and tenofovir coming out of patent, you get the beginnings of a PrEP strategy that might not be prohibitively expensive, and that's a far cry from "keeping people negative by any means necessary".

As Elizabeth Pisani sensibly points out:

I think we should develop a vaccine even at "modest" effectiveness; for people who do not have any safe behaviour to undo, a 30 per cent reduction in risk is better than none. But I'll be curious to see if the public heath nannies agree.

Hear bloody hear. This concept of "partial effectiveness" is an important one, and we need to communicate it carefully to our community. Combined with careful, thoughtful targeting of high risk men (contrary to public health doxa that's not all gay men) it underpins all the major alternatives-to-condoms, like PrEP, rectal microbicides, treatment as prevention (Swiss Statement), and serosorting. But that's another post. Right now, my arse is numb and I need to sleep.

PERMALINK | Posted at 10:21 AM | Post a Comment (5)

5 Comments

What a wonderfully insightful piece, Daniel. Thank you! I've just sent it 'round to everyone I know.

And, yes, I was just having this conversation about partial effectiveness yesterday in light of the news about the vaccine from Thailand showing a 30% reduction in risk. I was on the verge of making the argument against implementing it, because of the reasons you point out, but I realized that I was just recycling a PH logic that distrusts the populations it works with. Which leads us to the question: Should we be arguing for that vaccine candidate to be implemented as a stop-gap measure?

Author Profile Page Trevor User Profile | September 25, 2009 2:29 PM

Ok, "PrEP is an option for people in that tiny minority of gay men who will never use condoms."

And on what ethical ground do you justify limiting access to PrEP if it is proved efficient? And how do you identify this tiny minority? Will they have to fill up a score-card?

PrEP as a strategty is not that simple and can't be that confined.

PrEP is very appealing in the developped world (and I would even dispute that) but what happens in resources-limited settings? Will PLWHA have to compete with those People not-LWHA to access treatment?

An activist recently noted on another forum that "If one is aware enough to take prophylaxis for a future exposure, one should just take the necessary precautions to avoid the exposure itself rather than take some drugs in the hope that willful exposure will not lead to sero-conversion. "

I don't know if I agree, but I know it made me think...

Author Profile Page peripheries User Profile | September 26, 2009 2:28 PM

Ummmm, none of this convinces me to license this product. And please, tell me, how would such a product be targeted to only those with unsafe behavior?

I would also love to see the data behind the statement - "In most areas, 70-80% of gay men use condoms all the time for casual sex." That doesn't match with data I am familiar with - which puts the percentage around 50%.

And finally, I think you or someone has "menu based" prevention wrong. I am not sure many of us think a dude is going to use PrEP AND condoms. Or a microbicide AND condoms. Please. Rather naive, eh? My thought is people will be able to choose off that menu, and pick things that work for them.

Many of us who have "risky" sex are not risky all the time. Many of us who have "safe" sex are not safe all the time. We have different needs at different times in our lives. That is where the menu comes in.

Oh, and one more thing. Not all public health people think all gay men are risky. THAT is a stereotype that is at least false as much as it is true. The bashing of public health is tired - unless you have ways to engage and improve it.

Author Profile Page Jim User Profile | October 5, 2009 9:08 AM

Well, notably Jim, Daniel is in Australia -- so perhaps the data issue lies in this geographical difference. But I'll leave it to Daniel to wrangle with that.

I've heard you saying the "The bashing of public health is tired" message for sometime. Obviously, I'm rather mixed on this. I want to approach this issue in a productive manner. But my mindset is also clouded by emotions like anger, resentment, and perhaps a tinge of a desire for revenge. I want to recognize that it is not fair to let this emotions color my analysis, but this is not any easy feat. But I want to acknowledge here that I am not unbiased in my approach, because I do myself feel under attack by PH on a daily basis -- just as you do by these kinds of critique, it seems. This is what I talked about in Chicago.

In any case, I think it is fair to say that Public Health as a set of INSTITUTIONS promotes and reproduces these stereotypes (through funding streams, DEBIs, etc). Though there is great VARIATION among its practitioners. So please, Jim, I'm asking you to hear a critique of PH as institutions. I also encourage you to evidence the variation among its practitioners, to advocate for practitioners who disagree with PH's dominant logics, and to promote change from within its institutions. I think you're already doing some of this, and thank God for folks like you who are. But I need you to hear and understand us, rather than merely dismissing the critique as being "tired." It's just dismissal. So I know that when we throw around critical language about PH, that can feel upsetting to folks within these institutions. But you know, PH hasn't really stepped up to acknowledge how painful and hurtful the way it talks about gay men can be to us. Never, to my knowledge, has that been discussed openly by PH officials. Or the repeated damage inflicted by being constantly called to discuss (and apologize for) the every detail of our sexual lives every time we go in for check-ups or STI screenings. I want to hear some acknowledgment, and some work towards mending these wounds, by PH people, before I feel sorry for hurting their feelings by critiquing the organizations and bureaucracies they answer to.

I want to find a way around this painful dialectic. Because I can easily see that it often is counter-productive. It makes you not want to hear me. And it makes me not want to hear you. PLEASE lets hope that there is someway for meaningful communication here.

Author Profile Page Trevor User Profile | October 5, 2009 11:58 AM

Daniel:
I've been traveling and only now found your response to my Daily Beast article from a few weeks back.

It's great to see the piece got your both thinking and writing -- much as it was intended.

And it's important to learn that you clearly had a problem with my story.

Sadly, between all the talk of bath-houses and bottoming -- we never really learn what exactly that problem is.

You diss my prose, question my reporting and judge...er...my judgement -- without either spelling out why, or offering coherent alternatives.

Like many members of the shrill-o-sphere, you rely on mere contrarianism to hook your reader without providing any meat to back it up.

Dude: You clearly have something to say here about what we would all agree is an incredibly important -- and potentially life-saving -- topic.

Next time, just be a man and say it.


Author Profile Page David Kaufman User Profile | October 25, 2009 4:48 PM


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