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 firstname.lastname@example.org!