My Life On PrEP

The Time For Debate is Over. The Time to Implement PrEP is Now.

Jake Sobo — Tue, 30 Apr 2013 22:34:00 GMT

So much has changed since when I began writing this column last October. When I started “My Life on PrEP,” most people were wholly unfamiliar with the concept and its implications for HIV prevention. Apart from the spiteful attempts of AIDS Healthcare Foundation director Michael Weinstein to do everything in his power to kill it, there was a deadening silence that seemed poised to strand PrEP on the island of misfit prevention toys alongside the female condom and post-exposure prophylaxis.

I began writing “My Life on PrEP” to break the silence and shatter the Pollyanna narrative that PrEP was only for good gays who used condoms or had poz boyfriends. Like most of the guys that PrEP is going to help keep negative, I’m not a good gay. I’m a Truvada whore. And I’m proud of it.

I am thrilled to say that this column has reached mission fulfillment. The national – perhaps even the international – conversation on PrEP has changed. Community forums abound. Guys on PrEP are starting to come out of the woodwork and talk about their experiences, and those curious about it are better able to find reliable, sex-positive information. I’m not the only troublemaker to credit for this sea change, of course – folks like the glorious and charming Len Tooley up in Toronto have helped to crack open Pandora ’s big, pink, furry Box. (Len’s got some serious charisma, uniqueness, nerve, and talent to come out as a PrEP-user without a pen name to hide behind. I wish I had his courage.)

The word is out, and the time for engaging in contentious theoretical debates is over. It’s time to roll up our sleeves and get our hands dirty. The question cannot any longer be if we implement PrEP, but how. Gay men – especially black gay men – continue to get infected by the tens of thousands. We have the tools to keep some, indeed many, of these men negative. Public health, ASOs, and clinicians have an ethical duty to act. Continuing to live in a condom fantasyland isn’t just willfully ignorant, it’s immoral. To the powers that be: consider the gauntlet thrown.

I’m not naïve, of course. There are serious challenges to making PrEP a reality. Our primary care infrastructure in the US is woefully ill-equipped to handle an intervention like PrEP that requires regular follow-up and providers who are knowledgeable and willing. While Obamacare is poised to help address some of these serious gaps in access, many questions remain about how those without private health insurance will get access to PrEP. Perhaps the most tragic outcome possible will be if PrEP simply becomes a niche intervention available only to privileged few with the knowledge and resources to get their hands on it. I’ll give you one guess as to what those people will look like (if you guessed they will look like Jake Sobo, you’re right!).

There are creative solutions arising that suggest these obstacles are not insurmountable. Take the work of Seattle-based Dr. Joanne Stekler, who is working with Gay City to set up something of an ad-hoc PrEP clinic to get folks without health insurance access to Truvada through Gilead’s Medication Assistance Program. Dr. Stekler and Gay City deserve serious kudos for this innovative work. As I have written before, providers can be a barrier to getting access to PrEP. But as Dr. Stekler is proving, that need not be true. They can also be leaders in expanding access and ensuring equity. I hope that every single healthcare provider in the US reading these words who is committed to gay men’s health is considering what they can do in their own communities to ensure equity in access to PrEP. Seattle-based readers without health insurance who are interested in PrEP should get in touch with Dr. Stekler.

Of course, innovation should extend beyond access to include designing novel products that help guys on PrEP not miss a dose. We know PrEP works when you take it, and it doesn’t when you don’t. Rather than simply ending the discussion there, why not enlist creative teams to design the PrEP equivalent of the birth control carousel as my former editor, Alex Garner, has suggested? What about an interactive app that creatively engages PrEP users to remind them to pop their pill? PrEP shouldn’t just have to begin and end as merely a biomedical intervention; creative design can help maximize its impact at an individual and community level.

Finally, we’re going to have to educate communities about PrEP in ways that are frank, engaging, and informative. This isn’t easy when you’re talking about a concept as complicated as PrEP, but there are creative design solutions here too that can help. Take, for example, the website of the Rolling Jubilee. Talk about a complicated concept: buying and abolishing debt off secondary markets for pennies on the dollar as a form of social justice. But if you look through their site, they have come up with engaging infographics that clearly explain the social problem they aim to address. PrEP is a beast of a different color, but the communication strategies nonetheless might be similar.

The time has come for me to pass the torch on to those with the skills and knowledge to do the kind of practical implementation work that is now needed. It’s emotional for me to say goodbye, but like all good things, MLOP must come to an end. I am extremely proud of this body of work, but the truth is that I could not have done it without such a tremendously engaged community of readers – including heroes of mine like Jim Pickett, Gus Cairns, Jeff McConnell, Bob Grant, Mark Hubbard, and countless others – who have given me strength, love, and courage in the face of considerable hostility. This experience has given me a renewed inspiration and commitment to working on advancing gay men’s health – a spark that I sorely needed. And when reader Magpie Suddenly sent me this sexy, provocative MLOP tribute-slash-PrEP-promotion music video, I knew I had done something right:

The good news, however, is that Jake Sobo will live on. I’m thrilled to announce that in mid-May I will begin penning a new, once-a-month column for the San Francisco AIDS Foundation’s BETA Blog. The title is still TBD, but the concept will be essentially tackling gay men’s health issues in a context of 21^st century biomedical interventions and prevention science. I am extremely excited to be partnering with the only organization in the US (perhaps the world?) doing powerful advocacy work around pre-exposure prophylaxis, and I’m thrilled that they believe in me and my no-holds-barred approach enough to bring me on-board their team. I won’t be focusing exclusively on PrEP, but have no fear: PrEP will always be on my mind and in my message.

As always, send me a note to say hello at mylifeonprep@gmail.com! Or leave a comment. Talk amongst yourselves!

Syphilis, Gonorrhea, and Chlamydia, Oh My!

Jake Sobo — Thu, 04 Apr 2013 21:00:00 GMT

One of the most consistent criticisms of this column over the past six months has been that some perceive me to be taking STIs other than HIV for granted. Like the birth control pill for women, Truvada doesn’t protect against anything but HIV. So if PrEP promotion is correlated with condomless sex, wouldn’t it necessarily lead to a rise in STIs?

There are some hefty assumptions implied in this argument – namely, that PrEP promotion is correlated with condomless sex. While the clinical trial found that guys on PrEP were more likely to use condoms, critics suggest that guys on PrEP in the “real world” and not in a trial won’t be as motivated to use condoms. But, perhaps by focusing purely on behavior, this question may be framed entirely wrong. Could there be implications for STIs with PrEP, even if you’re not using condoms more or less often?

I haven’t written about this topic yet, in large part because I’ve been mulling it over. My initial reaction was to write it off completely, but that seems reactionary and not particularly fruitful. Needless to say, when I was diagnosed with syphilis a couple of weeks ago, my mind immediately wondered back to this line of argument.

But before you get in an “I told you so!” tizzy, let me first say that I believe I was infected through oral sex rather than fucking. When you’re infected with syphilis, the first symptom tends to be a chancre or sore that appears at the site of infection. Ironically, perhaps, I distinctly remember a chancre in my mouth a week or two before I was diagnosed. Results from my preliminary test for syphilis (called a “titer”) indicated a recent infection, so this may well have been evidence that I was infected through oral sex rather than anal sex. Sure, a chancer in my ass could have gone unnoticed. But it’s perfectly plausible that I got it from giving head, and there’s actual evidence to support that point.

That’s the thing about STIs: you can get them through oral sex. I sincerely doubt that many of the people who launch the anti-PrEP STI argument my way are using condoms every time for oral sex. Let’s face it: just about nobody uses a condom for oral sex. What a distasteful proposition! I actually have a hard time imagining it without gagging – and given the state of my gag reflex, that’s saying something!

But that’s not the end of the story. My sexual practices haven’t changed greatly since I started PrEP. I’m still having lots of sex with lots of people, and most of it (but not all) tends to be condomless. But who I’m having that sex with, and through what venues, has changed. While before PrEP I almost never fucked guys who disclosed they were HIV-positive, I do now. Whereas before I tended to meet guys on sites like Adam4Adam or Manhunt, now I’m meeting a sizeable number of them on BarebackRT. So while my sexual practices haven’t’ changed, my sexual networks have.

What’s a sexual network, you ask? Think of it like a fishbowl. One of the reasons that an infected fish in a small tank can pose such a problem is that diseases can travel very quickly in a small, enclosed space. It’s just sheer probability: the odds of coming into contact with that lil’ guy are much greater in a 10 gallon tank versus a 10,000 gallon tank. A sexual network can be big or small, depending on who you are, where you live, and who you fuck. Before PrEP, my sexual network was fairly sizeable, both geographically and in terms of the range of players. But by more actively identifying myself as someone interested in condomless sex, I may have inadvertently selected myself into a smaller, more high-risk sexual network. Indeed, public health scientists have tracked syphilis outbreaks in the past to small clicks of highly sexually active gay men.

This might be tough for folks who only think of risk in behavioral terms to get their heads around, I imagine. But the science behind it is robust. It’s one of the leading explanations for why young black MSM are at a greater risk for HIV infection. Studies consistently find that black MSM are not engaging in higher risk behaviors than their white counterparts, and yet their rates of HIV infection are dramatically higher. But risk is not synonymous with behavior. It’s also the context in which those behaviors take place. Many black MSM are excluded from larger gay sexual networks, in part due to self-selection and in part due to racism. The number of profiles from white gay men saying “no black men” is astounding and is almost certainly contributing to the increased rates of HIV infection among black gay men (that seems to be the unspoken truth in public health circles, but let’s cut the clinical talk and call a spade a spade).

Of course, while sexual networks might help to explain these trends, it’s perhaps a bit frustrating because it’s the kind of thing that’s difficult to imagine changing. In my case, what would be the solution? Return to playing the game of pretending like I always use condoms? That’s the rule of engagement for the larger sexual network. I don’t mean to sound dismissive – believe me, as easy as it is to treat early syphilis, I’d like to avoid having another shot in my ass of an antibiotic whose viscosity the nurse likened to “cake frosting.”

The fact that I’ve been having gay sex for 15 years and only now managed to contract syphilis is unlikely to be just a coincidence. But, from where I sit, it feels a bit like a cultural conundrum. If I want to play with most gay guys, I’ve got to deny the sex that I have and play the shame game. “Oh, no, I always use a condom… but okay, if you say you’re clean, I guess I can make an exception!” I almost cannot stop myself from laughing at guys when they pull that charade – it’s such a farce.

But on the other hand, if I want to be open and honest about that sex, I might be inadvertently at a greater risk of infection – both for HIV, and for other STIs. Guys regularly reject me for being so frank about the sex that I have and want, even though many of them have and want the same kind of sex. It’s downright maddening. What’s a gay boy to do?

What’s your guys’ experience? As always, leave a comment or shoot me a note at mylifeonprep@gmail.com!

Stop and Go PrEP: Will it Work?

Jake Sobo — Fri, 22 Mar 2013 21:59:00 GMT

A couple of months ago, I wrote about the question of when somebody taking PrEP might consider discontinuing its use. A few readers e-mailed me to ask a related but different question: what if you stopped taking Truvada when you weren’t having sex, and started taking it again later? Scientists call such an approach “intermittent” use of PrEP.

The idea makes some amount of sense – especially to someone like me who rarely has sex in the town in which I live, in the middle of effing nowhere, in the frozen tundra of the Midwest. The bulk of my sex happens when I’m on the road, either for business or just simply for sexual tourism. Could it make sense for guys like me to only start taking PrEP before their next vacation, and stop taking it a few weeks after you get home?

Whatever you want to call this approach – intermittent, stop and go, on demand – the first thing to know is that we don’t have clear answers yet. The biggest PrEP studies were intended to test whether it was effective to take the drug every single day. There is a French clinical trial aimed at testing whether this idea would work, but it’s only recruiting in Paris and Lyon. This trial is particularly controversial because some of the people in the study are getting placebos rather than the real deal. Generally, once a trial has shown an intervention to be effective, it’s deemed unethical to continue giving some people a placebo. In this case, the argument from researchers was that it is not yet known whether on demand PrEP is effective and thus it is ethical to assign some people a sugar pill. To say the least, I’ve got mixed feelings about that argument (and from the gossip I hear, so do French gay guys – little birds tell me they’re having trouble finding guys to sign up).

Luckily, a clinical trial isn’t the only way to address these questions. At the 20^th Conference on Retroviruses and Opportunistic Infections (CROI) in Atlanta two weeks ago, Bob Grant – the man behind the iPrEX study – presented preliminary data that grappled with these questions based on his ongoing study of the guys in iPrEX. Grant reports that some guys in the study moved through “seasons of risk,” or periods in their life when they were at greater risk of sexually acquiring HIV than others. This is a little different than planning a weekend of debauchery, of course, but the idea is similar: risk for HIV is not a constant throughout one’s life. If that’s the case, then it may make sense that PrEP might not also need to be a constant.

Indeed, he reports that at any given moment, about 30% of iPrEX participants had zero sexual partners in the last three months. Not surprisingly, these participants were often the same ones who weren’t taking Truvada every day. It doesn’t take a nuclear physicist to figure out that taking a pill every day to prevent HIV when you haven’t had sex in months is overkill – it’d be a bit like wearing a condom when you went shopping with your grandma!

But exactly how long before you plan to get laid, and how long after, should you take Truvada? While we don’t have perfect data to show that starting and stopping PrEP is as effective as daily use, Dr. Grant’s team informs his iPrEX participants that you should start taking Truvada seven days before you think you might have sex. This gives ample time for the drug to get into your system. As for afterwards, Dr. Grant recommends taking Truvada for four weeks after your last potential exposure. It might be that future research shows you only need three days before and two weeks after – but for now, it makes sense to err on the side of caution.

As for myself, while I almost never get laid here in the Midwest, it does happen from time to time. And when opportunity knocks, I jump on it like a starved, feral cat. There’s no way for me to plan a week in advance when I have sex. Alas, for now, I plan to stick to once a day PrEP.

What about you? Might PrEP on demand make sense in your life? As always, leave a comment or shoot me an email at mylifeonprep@gmail.com.

Putting the Nail in the Coffin of Condom-Only HIV Prevention

Jake Sobo — Thu, 07 Mar 2013 22:30:00 GMT

Dearly beloved, we gather here to say our goodbyes. For over thirty years, condoms have been our only lifesavers in the face of HIV. Gay men invented their promotion at a time when death was the only seeming alternative. When treatment did not exist. When Kaposi’s sarcoma was a visible reminder of the epidemic. It was a different world. To quote Mr. Kushner, “You can never make that crossing that she made, for such great voyages in this world do not any more exist.”

Weep not, dear friends, for the passing of our friend. For a new era is dawning in HIV prevention.

If we needed any additional evidence of the need to turn the page, it came in the form of a seemingly banal conference presentation this week in Atlanta at the 20th Conference on Retroviruses and Opportunistic Infections. While CDC staff scientist’s Dawn Smith analysis of data from two previous HIV clinical trials seems at first glance to be of little import, its findings scream a different truth. (You can watch her presentation here – it’s the last paper in the session.)

The study’s aim may seem modest to many readers: to estimate how effective condoms are at reducing the risk of HIV transmission among men who have sex with men. But you may be surprised to learn that we have surprisingly little evidence to support the promotion of condoms to gay men for HIV prevention.

Don’t get me wrong. I’m no denialist. We have good reason to believe they work – all the evidence strongly suggests that they do. But how effective are they precisely? And in what context? Well, for many years, your guess was as good as mine. The last time a major study attempted to tackle this question, the year was 1989 – nearly a quarter-century ago. When Ronald Reagan was President.

But while the aim of the CDC’s study itself makes it important, it is what they found that should have every condom-thumping prevention activist in the country questioning their strategies. While most condom studies just look at whether guys have used them in the past six months, this analysis based on two independent, large studies employs data collected over a three to four year period. And rather than just asking guys once how often they used a rubber, researchers asked them every six months.

Since I began writing this column, I have said more than once that the condom use of most gay men I knew could only be said to be “inconsistent” – at best. But this study puts a more precise figure to my anecdotal evidence. Let’s start with the basic question: How many guys said they used a condom every time during every single six-month check-in? While over two-thirds of participants said they used a condom every time during at least one of the six month intervals, just 16.4% said they used a condom every time every single time they were interviewed. Not 50%. Not even 25%. 16.4%.

Now the more complicated question: By how much did reported use of a condom every time reduce the risk of HIV infection? This is sticky. As you know, guys lie left and right about how often they use condoms. Social scientists call this “social desirability bias.”

We tell docs what they wanna hear. So any estimate of condom efficacy based on self-report is bound to skew lower than what it probably is in real life. With that in mind, the CDC found that guys who reported using a condom every time were 70% less likely to contract HIV than guys who never used them, and 68% less likely than guys who said they sometimes used them.

Now here comes the rub: guys who reported using a condom “sometimes” were almost just as likely to contract HIV as guys who said they never used them. In other words, sometimes using condoms is no better than not using them at all.

So what does this study tell us? Over the long haul, the vast majority of gay men aren’t using condoms every time. And if you’re not using a condom every time, your risk of infection is similar to guys who fuck bare every single time.

Of course, these findings do not mean we should throw out condoms entirely from our toolbox. They are a part of the puzzle, and should continue to be. But we can no longer pretend that they are the only tool worthy of our time, energy, and money. These findings are clear evidence that we cannot rely on condoms alone to end the epidemic among gay men.

In the new era of HIV prevention, condoms will be one of many technologies in our arsenal. PrEP and treatment as prevention for HIV-positive people will be recognized as important tools as well, as will serosorting and other harm reduction strategies. These technologies will be understood not as implements that exist apart from sexual behavior, but as integrated within the social landscape in which people navigate, understand, and practice HIV risk.

We have the tools to build a new framework for HIV prevention. What stands between us and a new era is not science, but politics. Sexual shame. HIV stigma. Misinformation. Let us tear down those walls that separate us from a new tomorrow.

The Unexpected Struggle to Make Doctors Allies in PrEP

Jake Sobo — Thu, 28 Feb 2013 22:00:00 GMT

If you had asked me back in September when I started writing this column what I thought the biggest obstacles facing PrEP would be, it would not have immediately occurred to me to add doctors to the list. Of all the various parties that need to be onboard for PrEP to actually do much to mitigate the number of new HIV infections nationally, I would have expected doctors to be an easy sell. I would have thought insurance companies—those paying for private coverage—would be much more difficult to get on board. Doctors love pills, after all. And insurance companies hate paying for them.

Truth be told, the reality is precisely the opposite of what I expected. So far, there have been no reports of private health insurance denying coverage. Meanwhile, stories of doctors stonewalling their patients and denying prescriptions abound.
I was recently visiting Los Angeles and gabbing to my friends about PrEP, as one does, and my friend who has been HIV-positive for years relayed a very telling story to me. During a recent, regular check-in with his HIV specialist at Kaiser Permanente, he told his doctor that he and his HIV-negative partner were curious about PrEP. They’ve been together for years, but they thought PrEP might be at least worth considering.

If you’re not familiar, Kaiser is the largest nonprofit health care provider in the United States, and they’re generally renowned for providing excellent HIV care—it should have been a moment for that HIV specialist in Los Angeles to shine. Los Angeles, after all, trails only New York City in the number of new infections each year among men who have sex with men. One would thus expect the doctors providing HIV care at one of L.A.’s largest healthcare organizations to know a thing or two about PrEP.

One might expect that, but one would be disappointed. My friend’s doctor hastily replied that the data was not convincing and that he suspected PrEP was not particularly effective at all. He went through a litany of arguments as to why he thought this, mostly relating to his suspicion that the reduction in risk demonstrated in the trial was attributable to condoms rather than Truvada.

My friend relayed all this information to me in a way that suggested he was not inclined to disregard the doctor’s arguments. So I rolled up my sleeves and got to work. I went back to the iPrEx data and checked to make sure that there were no differences in reported rates of condom use between study participants who were randomly assigned Truvada and participants randomly assigned the placebo. In order for the doctor to conclude that the risk reduction observed among guys who received Truvada was the result of their using condoms and not due to the Truvada itself, the data would have to indicate that guys assigned Truvada used condoms more frequently than guys who were assigned the sugar pill. If, on the other hand, guys in the Truvada group and guys in the placebo group both reported similar levels of condom use, any reduction in risk observed among guys who got Truvada could not be attributed to condoms because the guys taking the sugar pills were also using condoms at similar rates. That’s the whole reason we do randomized control trials: to make sure that any findings are specifically the result of the intervention being tested.

However dubious I found them to be, I took this doctor’s claims seriously—for my friend’s sake, at the very least. Unlike him, I did my research and dug up the published data on condom use. Lo and behold, there was no such difference to be found between the Truvada group and the placebo group in the iPrEx data (see the graph on page 15 of the supplement published alongside the results in the New England Journal of Medicine).

I know, you’re probably sitting there thinking to yourself, “What a surprise! A doctor who didn’t know what he was talking about.” But what makes his actions so upsetting isn’t that his opinion about PrEP is negative, it’s that he manufactured an argument that had no evidentiary basis. That’s the kind of thing we have come to expect from people on FOX News, but it’s certainly not the kind of thing we expect from doctors—especially HIV specialists in the center of the nation’s second largest fucking epidemic. Maybe he heard some other doctor make this ridiculous claim about the iPrEx study, but that certainly does not give him license to go around repeating it to patients without first making sure it was, you know, factually accurate.

I’ve heard plenty of other horror stories just like this one; stories in which patients seek out PrEP, and their doctors actively discourage them by presenting baseless arguments and/or misrepresenting the available data. My friend is not alone.

That’s why it’s so important that those of us on PrEP who are knowledgeable and who do care take the initiative here to educate doctors. Tomorrow, Jake Sobo will be making his first public appearance at a nearby medical school to speak during grand rounds about PrEP. I’ll go ahead and admit that I’m a little nervous. My audience usually consists of fags, academics or academic fags. Doctors are a foreign breed to me, and I expect that they’ll have more than a handful of questions to pelt me with after my brief talk.

But let’s face it: if we want doctors to be more informed and thus more powerful allies in promoting PrEP, we’ve got to talk to them on their turf and on their terms. They’re not going to come to us.

What are you doing to educate medical providers about PrEP? As always, leave a comment or shoot me a note at mylifeonprep@gmail.com.

Fucking the Future

Jake Sobo — Wed, 13 Feb 2013 23:11:00 GMT

Every year around the New Year, a friend of mine— we’ll call him Thomas—gives a presentation about the sex he had during the previous 365 days. It’s a geeky-whore mix of PowerPoint slides and statistics, as well as steamy photos and lurid anecdotes. Every year for the past six years Thomas has set aside time to pause and reflect on the dalliances, trysts and fleeting encounters that kept his libido churning during the year—inviting a close group of friends to share in the process.

I received my first invitation to hear Thomas’ annual state of the slut report this year, and I was entranced. Like a modern-day version of Samuel Steward and his “Stud file,” Thomas has a list of everyone he’s ever had sex with and can readily recount details of each of his several hundred partners. He described annual trends in his sexual practices, replete with line-graphs charting the number of partners and detailed descriptions of new and exciting episodes.

I felt like a gauntlet had been thrown. My friends know me for being something of an expert on the topic of sex. I talk a lot about it with my friends. I’ve had a lot of it. I’ve published peer-reviewed articles about it, for pete’s sake! But despite my lifelong mission of analyzing, understanding and politically mobilizing sexuality, I couldn’t tell you with any sort of precision the most basic facts about the 15 years of dick behind me. Had I been with 500 guys, or 2,000? Is it just my memory, or didn’t I used to mostly just suck dick back in the mid-2000s? And when I did get fucked, was it usually without condoms or was that a more recent trend as well? Thomas’ rigorous self-study made me realize just how little I knew about my own sex life.

As I sat listening to his presentation, I thought about how PrEP had been pushing me to be more reflexive about my own sex life. It made me fess up to what I wanted and allowed me to declare my desires with more clarity and confidence. For me, the “pre-exposure” part of PrEP has entailed more than just swallowing pills. Taking a pill once a day has a way of making you reflect on your sexual practices, what turns you on and the lengths to which you’re prepared to go in order to protect yourself when your legs are in the air.

As I’ve noted before, this is precisely the argument made by the Australian academic Kane Race: PrEP is controversial in part because it forces one to anticipate a future sex life that includes the risk of contracting HIV. Quietly, some have even speculated to me that PrEP’s sex/risk re-orientation may have something to do with the small but notable increase in the rate of reported condom use among men in the iPrEX trial.

Not to be nerd/slut outdone, I left Thomas’ apartment, returned home and opened a blank Excel spreadsheet. File, save, “Tricks.xls.” Staring at the endless lines of rows and columns, I was faced with the challenge of defining exactly what it was about the sex that I had that I wanted to record and, ultimately, remember. I suspect that if 20 readers attempted such a feat, they’d each wind up with 20 completely different configurations. Sex means different things to different people.

After a few rounds of revisions, I wound up with a set of 20 discrete variables and a section for comments. The project isn’t just about logging the sex that I have, but about making it better and perhaps even more efficient; I pay $12 a month for a Manhunt membership, but I met only one of the 17 guys I’ve logged so far this year on that site—and that was one of the worst sexual encounters I’ve had so far this year! Perhaps it’s time to cancel my membership.

In all seriousness, though, PrEP was the spark that ignited my newfound sexual reflexivity. Every day before I go to bed, I take a pill. Once a month, I go to the pharmacy to refill my prescription. Every three months, I go to the doctor to have a battery of tests done to confirm my lack of side effects. Every minute, dollar, ounce of blood and emotion I invest in PrEP is always being weighed against what I perceive to be its benefits. For me, those benefits are not just measured by some abstract, statistical reduction in risk—they’re measured in orgasms, blowjobs and mind-blowing sex. For HIV-positive men in relationships with negative guys, it might be measured in terms of alleviating their anxiety that they might infect their loved one.

But while the benefits will vary for every PrEP user, the need for them to outweigh the perceived costs will not. My “Tricks” file gives me the opportunity to reflect on the sex that I’m having and ensure that all the time, money and energy I spend on PrEP is warranted. It’s a kind of sexual accountancy, a way of making sure the books balance. So far, I’m thrilled to report that I’m in the black.

Has PrEP pushed you to be more thoughtful about your sex life? As always, leave a comment here or shoot me a message at mylifeonprep@gmail.com.

That Barebacking Thief-Whore: PrEP and Responsibility

Jake Sobo — Wed, 06 Feb 2013 23:30:00 GMT

I’m fast approaching the four-month anniversary of “My Life on PrEP,” a milestone that I imagine equal parts of you are either thrilled or disgusted to see pass. You've made your views about me and my ideas plain, which I have honestly appreciated. One of the wonders of the internet is that guys who would never dare to do so in public don’t hesitate to leave a comment calling me a whore online.

I think that’s great. It exposes the dirty underbelly that we often brush aside because of politeness or political correctness. Go ahead, call me a whore. It gives me fodder for more columns like this one. Feed me.

Rather than take them personally and cry in a corner about how mean some of y’all can be, I think there is much insight to be gained from these accusations and slanderous, mean-spirited comments. While this verbiage came in a variety of ugly packages, perhaps the most common came in the form of questioning my tendency to fuck without condoms. This column isn't exactly about condoms, or sex without it, per se. I chose to sidestep those debates because gay men spent the past decade or so beating the shit out of each other as if in some kind of perpetual, “Whack-a-Ho” game. What more could be possibly said? How much more anger, shame and frustration could be wasted rehashing such a tired, ridiculous debate?

With that in mind, I began my first column not with a manifesto about the “right” or “natural” way to have sex. I don’t believe any of that hogcock. From where I sit, unless you’re a gay-bashing evangelical, it’s probably not a good idea to put “natural” and “sex” in the same sentence. Instead of making some artificial over-generalization, I began my first column with something I knew readers couldn't argue with: my experience. Those first few words of my first column were, in a sense, strategic: “Over the past three years, I've noticed something about my sex life. For a host of reasons that this column will be exploring, I’d all but stopped using condoms.”

It was my truth. I don’t have to defend that—to you, my lovely reader, or to anybody else for that matter.

Lest anyone think otherwise, my position is clear: If you use condoms regularly, please by all means do not interpret me as judging you or suggesting that the sex that I have is somehow better. I’m sure you have great sex. I hope you have mind-blowing sex. Good for you! Seriously.

I believe that taking precautions against infection is a form of responsibility—not just for yourself, but for your partners and your community. Given recent predictions that over half of gay men will contract HIV by the time they’re 55 (not to mention, over three-quarters of black gay men), every effort to curtail the spread of this virus is a way of caring for your gay/bi/queer brothers.

Guys who herald condom use as the only acceptable prevention strategy often imply that they have the moral upper hand because they’re the real “responsible” ones in the room. But why would this be true? Wouldn't taking a pill that reduced your risk of infection also imply that you, too, cared about yourself, your partners and your community? And that you, too, wanted to do your part to prevent HIV?

This point is not unrelated to last week’s—given the numerous strategies gay men have devised to reduce the risk of transmission, we've got to abandon the notion that anything other than sex with condoms is “unprotected.” Similarly, we've got to give up the notion that anything other than sex with condoms is “irresponsible.”

Beyond condoms, critics have charged that PrEP users are irresponsible for “stealing” resources that they do not deserve. I don’t usually point out specific comments, but this one has stuck with me since it was posted last December:

My work puts me in contact with the reality of HIV/AIDS in Africa, where countries are struggling to pay for ARV treatment to keep people alive. Thousands still die because they can't afford the meds (many can't afford condoms, either, or are women who have no power to demand that their partner use them). Most of these people won't make $1,400—let alone $14,000—in a year of backbreaking labor.

Some 30 million men, women and children have died since the beginning of this pandemic. What an insult to their memory this whole fatuous conversation is. To demand that our healthcare system spend ungodly amounts of money so educated people can *choose* not to use condoms because of their "need" for sexual self-expression would boggle the minds of most inhabitants of this planet.

According to DW, I’m not just an irresponsible barebacker—I’m a thief. And I’m not just stealing from the American health care system, no. I’m stealing right from the hands of an impoverished African woman in order to feed my perverse desire for bareback sex.

Man, that’s pretty low. Who is this Jake Sobo guy?

This argument wasn't unfamiliar to me. Plenty of screeching criticisms of PrEP have come out alleging that it’s going to pilfer the pillboxes of HIV-positive people around the world. This kind of “zero-sum game” talk makes it sound like the number of resources dedicated to HIV are finite and that my prescription paid for by my health insurance company is directly linked to the future denial of care for some poor, destitute HIV-positive person out there. In my mind, I hear the voice of SNL’s Arianna Huffington, “You want other people to pay for your reckless sexual choices? Can you be serious, Jake?”

If this whole conversation sounds familiar to you, it should. It’s exactly the same kind of slut-shaming patented by Rush Limbaugh when he called Sandra Fluke a prostitute. His logic was precisely the same: Why should everyone (e.g., men) have to pay for women to have sex? In effect, Sandra was asking to get paid for sex! She was a slut.

The same logic is now being used to denigrate PrEP users and stonewall its implementation. Let’s set the record straight: PrEP is a way for you to take responsibility for your health—and for your community’s health. Don’t let anybody tell you otherwise.

As always, please feed me! Leave a comment or send a note to me directly at mylifeonprep@gmail.com.

No, Seriously—Quit Saying 'Unprotected Sex'

Jake Sobo — Thu, 31 Jan 2013 22:00:00 GMT

Author’s Note: When this column was written Wednesday, the study’s “Zero Feet Away” report was not publicly available. Jake received a copy of the report Thursday, just as this column was about to go to print. The link is included in the story below.

Last week, The Huffington Post did their usual job of fanning the flames of panic by running a “story” (more like a copy and paste job) on an alleged study that claimed to have found that a bunch of gay men “had engaged in unprotected sex.”

Before I tear that press release a new asshole, let me just relate to you what the study claimed to have found. Allegedly, two New York-based researchers conducted a survey of just over 700 gay men “who meet their sexual partners through the use of geosocial networking apps like Grindr, Scruff, Manhunt and Growlr on their mobile devices.” The big (allegedly shocking) finding was that just under half of the guys who responded say they had sex without condoms.

Eeek! Oh my God! Call the cops! Call the president!

Well, wait a goddamned second here. All we have to go on is a two-page press release from the organization that funded the study. Who are these gay men? Who were they having sex with? Your guess is as good as mine. We don’t know because the researchers did not tell us.

Let me just tell you why this is 1) a big fucking, 10-inch-dick-sized problem; and 2) some shady ass behavior. While the press release alleges to be based on a report, “Zero Feet Away,” this report was nowhere to be found when the organization ran the irresponsible press release (it has mysteriously surfaced today, just before this column was about to go to print). It has not been published in an academic journal. And until this morning, it had not been published on the organization’s website.

There is exactly zero information on the press release about the survey’s methodology.

“So what, Jake?” you might ask. “Why does that matter?”

Here’s why it matters. Let’s imagine a different research question. Since gun control has been on our minds, let’s suppose you were interested in measuring opinions about gun control. So you head to the local gun show and ask 500 people coming out of the event what their opinions were about gun control. Well, I’ll be! You find that 95 percent of people who bothered to talk to you opposed stricter gun control laws. You put out a press release claiming that 95 percent of Americans oppose gun control.

Who would take you seriously? Not a single person in their right minds, of course. Social scientists call this sampling bias. The press release about the “Zero Feet Away” study was very sketchy about who they asked. Was it 700 gay men exiting sex parties for HIV-positive people? Was it 700 men who showed up for HIV testing? Was it a random sample of gay men obtained by random-digit-dialing? We don’t know because the researchers did not tell us.

But this is just the tip of the iceberg. Let’s look at the finding that garnered all the media hype. They claim that “almost half of respondents (46.4 percent) admitted to barebacking always, often or sometimes.” This statistic seems scintillating at first glance, but perhaps we should pause to consider the question. What exactly is this question getting at? Were some of these guys referring to sex with their boyfriend? Were some of them HIV-positive, and referring to sex with other HIV-positive guys? Were some guys referring to sex they had six months ago? We don’t know because the researchers did not tell us.

I don’t deny that the researchers found something. But what that is, exactly, is extremely vague. Based on a thinly-detailed press release, the best we can say is that some gay men somewhere are having sex without condoms sometimes.

Doesn’t sound so exciting when I put it that way does it? The fact is that there have been hundreds of well-designed, well-executed studies on condom use among gay men that are published with loads of details about their findings and how they found them. Don’t believe me? Just do a Google Scholar search for “barebacking” and “men who have sex with men.” We already know that a sizable proportion of gay men aren't using condoms every time. We’ve known that for, like, forever.

This all brings me back to the original question at hand: Is sex without condoms always unprotected? Well, it depends doesn’t it? If you’re HIV-positive and only having sex with other poz guys. If you’re having condomless sex with your boyfriend. If you’re on PrEP. Even if you don’t let guys cum in your ass. These scenarios all may well involve some kind of risk for something, but the level of risk (and for what) varies dramatically.

And that, my dear friends, is why we should immediately abandon the term “unprotected sex” when what we really mean is “condomless sex.” The two are not synonymous anymore. In an age of treatment as prevention, of serosorting and of PrEP, it just doesn’t make sense to keep pretending like the game hasn’t changed. It has changed dramatically.

Thankfully, a couple of brave HIV-positive bloggers have stepped up to criticize the hype around the “Zero Feet Away” study. I encourage you to read their posts.

As always, leave a comment below or shoot me an email at mylifeonprep@gmail.com and let me know what you’re thinking.

I Thought PrEP Would Put a Stop to Freaking Out About HIV—I Was Wrong

Jake Sobo — Wed, 23 Jan 2013 22:00:00 GMT

When I first starting taking Truvada last October, I thought that I would finally be done with the incessant freaking out about HIV and self-diagnosing that many HIV-negative gay men go through on a regular basis. If you are (or have ever been) an HIV-negative gay man, you likely know what I’m talking about. You wake up in the morning with chills—or wake up at night feeling feverish. Almost by instinct, your hands fly to your neck to check your lymph nodes. The internal monologue begins. “Are they swollen? They feel lumpy?!? Is that normal?” Suddenly, you’re in the bathroom with a thermometer lodged in your mouth. “Do I have a fever? I feel fucking hot in this sweatshirt. Am I sweating? Jesus Christ, I’m fucking sweating!”

Of course I was sweating. The heat was on in my apartment and I fell asleep in a sweatshirt and under three blankets. But nevermind the facts. The mind is a powerful organ, able to repeatedly convince me that those beads of sweat are signs of something much worse than overheating—it’s gay cancer! Cue the horror music.

By the time I started taking Truvada, I had been fucking guys for 15 years. I can safely estimate that I’d have something just short of a panic attack every 3-6 months during those 15 years. That’s a lot of anxiety to cope with, needless to say. I had hoped that PrEP might finally put a stop to that ridiculous cycle of fear and acne-inducing anxiety. But I was wrong.

Last weekend, I woke up feeling… off. I had the chills. I felt feverish and a bit nauseated. Now, unless you live under a rock, you know that we’re in the middle of a gigantic fucking flu epidemic. I had spent an hour on the elliptical machine just days prior watching CNN reports with bleeding maps of the United States, highlighting the massive epidemic that was sweeping the country. So naturally I concluded that… I had seroconverted.

I spent the entire day trying to figure out my symptoms. Were my lymph nodes swollen? They didn’t feel swollen—but maybe I wasn’t looking in the right place. I felt sick, but only mildly so—like a very weak flu. Ah, of course. It must be the Truvada. I had seroconverted, but the sickness associated with it was lessened because I was on Truvada. Of course! Bing! Genius.

I’m not a medical doctor. I have no training to come to such an outrageous conclusion (seriously, I have no idea if or how Truvada would affect seroconversion sickness). But by midnight Sunday night, I was downright certain. I sat on my computer, feverishly researching the newly available rapid, at-home HIV test. I was THIS CLOSE to making a midnight run to CVS to shell out $40 for the test, when I finally managed to calm myself down. I reminded myself that there was a national flu epidemic and that I had just had a viral load test for HIV a month prior. And even if I had seroconverted, a rapid test would be unlikely to pick up such a recent infection.

Of course, that didn’t stop me from heading to the clinic the next day to get a free rapid test, which unsurprisingly came back negative. It is possible that I am in fact HIV-positive and that only a viral RNA test could pick up such a recent infection. But I asked myself what was more likely: that I had contracted the flu during a massive flu epidemic in the U.S., or that I had contracted HIV while on Truvada?

In the end, this is one of the things I hate most about being HIV-negative. And before you go on about how it’s because I’m engaging in such risky sex, let me point out that gay friends of mine who have the most boring sex lives in the world report similar experiences—perhaps less frequently, but nonetheless frustrating.

What do you do to help avoid or assuage the self-diagnosis spiral of panic? I’d love to hear your thoughts! Leave a comment, or shoot me a note at mylifeonprep@gmail.com.

Jake Sobo is a pen name used for anonymity. Jake has worked in the world of HIV prevention for nearly a decade, and is eager to share his experiences taking PrEP. Having closely followed the development of PrEP from early trials to FDA approval, he was excited to give it a shot when it was approved for use among MSM for preventing HIV. He has spent the better part of his adult life having as much sex as possible while trying to avoid contracting HIV, and started taking PrEP as a way to help him stay negative. He is well aware that the drug is not 100 percent effective and that he could test positive; while he hopes that does not happen, he knows that he can rely on his numerous HIV-positive friends to deal with that situation should he seroconvert.

Transforming Reluctance Into Action: Getting Positive About PrEP

Jake Sobo — Thu, 17 Jan 2013 19:22:00 GMT

One of the things that I’ve always found somewhat maddening about the public discussion about PrEP is the downright reluctance—nay, pussyfooting—that colors so much of it. It seems nobody is allowed to speak about PrEP without adding a slew of conditions. PrEP “might” be right for you. PrEP “could” be a good option.

I don’t really recall AIDS activists being so hamstrung about condoms back in the '80s. Though it certainly took painstaking hours of fundraising, organizing and troops-rallying, campaigns singing the praises of condoms plastered billboards in gay ghettos from coast to coast. Where are the PrEP campaigns? Where is the excitement about the first new, highly effective HIV-prevention tool in 30 fucking years?

The genius Aussie academic, Kane Race, noticed this about PrEP last spring. In his cultural studies academic-speak, he characterized PrEP as a “reluctant object” that was terrifying for its possible utility as a gateway to “unbridled homosexuality.” While public health researchers love to categorize people as “high risk,” people don’t similarly enjoy thinking of themselves as being “risky.” PrEP, however, demands that you do just that. Every time I pop one of those pills, someone in the back of my brain I’m acknowledging the probability that in the near future I will be exposed to HIV.

It is this anxiety that underlies much of the reluctance about PrEP that we need to work collectively to allay and to transform into action. I’m doing my part to generate interest and excitement about PrEP. My online profiles ask guys to ask me about it. I talk to my friends about it. I write this damn column. But I am only one human being. I can only fuck so many men and reach so many readers.

It’s going to take a more collective response to generate action. We need to stand together to demand that PrEP be made readily accessible beyond just a handful of research studies that are not long-term solutions. PrEP shouldn’t just be for those “in the know” who ask for it. It needs to be presented to the public by respected organizations and leaders in our communities. It needs to be carefully promoted.

If you’re wondering who is doing this kind of work right now, you’d be hard-pressed to find any answers. To my knowledge, nobody is truly doing the job of promoting PrEP. Has your local HIV/AIDS agency had a public forum about PrEP? If not, ask them why. Suggest that you’d be interested in assisting in organizing it. Does your city and/or state health department have any official policy on PrEP? Ask them about it. They are public servants—they work for you. Reach out to them. Do you read other gay blogs that you think could benefit from a discussion about PrEP? E-mail their writers.

On a smaller scale, your sex life is ground zero for PrEP discussions. Put “I’m on PrEP—ask me about it!” in your Adam4Adam or Manhunt profiles. Talk to your gay male friends about it. What do they think about it? Do they know about it? And I’m not afraid of competition—if you’re a writer, write about it!

If you’re wondering what to say, keep it simple. I developed a very basic response for people who ask me about it: PrEP is basically a pill a day to prevent HIV. It’s highly effective, and it’s my way of taking responsibility for my health and the health of my partners.

That’s a conversation starter in and of itself. You don’t need to immediately inundate them with numbers or statistics. For some people, that’s all they want to know. Others might ask how effective is “highly effective.” If they do, you can tell them that it’s estimated to be 99 percent effective for those who take the pill every day. If they inquire about side effects, you can tell them that the vast majority of PrEP users didn’t report negative side effects. If they want to know more, direct them to my column about side effects.

These are the kind of conversations that are necessary and urgently needed to begin to build a foundation for a true public discourse on PrEP—the kind that provokes excitement, energy and ultimately action to transform PrEP from a good idea in theory to a practical reality. Now is the time for proactive, positive action towards promoting PrEP.

I believe that PrEP can change the epidemic for the better, but only if we make it so.

What are you doing to make PrEP a reality? As always, get in touch with me at mylifeonprep@gmail.com! I’d love to hear from you.