April #80 : Editor's Letter - by Walter Armstrong

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April 2002

Editor's Letter

by Walter Armstrong

"Did you get lucky?" gay men ask each other, about coming up a winner or loser in the weekend's sexual lottery. One Friday night last August I got lucky. Drunk, horny, lonely, I closed The Cock, a neighborhood nightspot known for its masturbating go-go boys. At 4 a.m. I lingered outside with the leftovers, eyes darting with desire or desperation before the bouncer lowered the building's metal grate and sent us scurrying like rats. My luck was a dark, handsome stranger. The details blurred a bit: foreign accent, a little formal, young. In bed, as he prepared to enter me, I summoned enough consciousness to say, "I'm HIV negative. Can you use a condom?" "I'm negative, too," he said. "And I've never been fucked. So don't worry." Fade to black.

When I woke up, my luck was gone. I barely had a moment to regret not getting his name and number before I remembered what I truly had to regret. I spent the day trying to coax myself down from panic ("He was telling the truth," "Only one in 120 exposures leads to infection," "Please, God..."), but it was no good: I've had more than my share of unsafe-sex scares, but no one before had ever cum inside me.

So on Sunday I took my sorry ass to the emergency room at St. Vincent's Hospital, filled out my admission slip ("I had unsafe sex two nights ago. I need PEP" -- I carefully spelled out post-exposure prophylaxis -- "as fast as possible") and began to wait. Some 90 minutes and much explaining later, the attending physician gave me my first dose: one white Combivir and five pale-blue Viracepts. "Nobody knows if this works or not," he said, disapprovingly, "and we can only give you enough for three days. Get a prescription from your doctor." I swallowed the pills like manna.

In fact, I would have cleaned the floor of the ER with my tongue to get PEP out of St. Vincent's. Still, the staff's -- how to put it? -- peevishness disturbed me. Well, maybe it was a bad day. But probably it was a clear sign of the murky feelings that this form of prevention provokes in many medical professionals and others. For PEP is, as news reports insistently reiterate, "controversial."

First, there is the controversy over whether or not it works. Contrary to the ER doctor's warning, however, virtually all of the data, starting with the first AZT studies of needle-stick exposures in hospital workers 15 years ago, suggest that PEP very likely does prevent infection. In recent research by UCSF's pioneering Center for AIDS Prevention Studies, PEP was given to 400 people after possible sexual exposures, and of the 78 percent who completed the four-week course, not one seroconverted. While you can't argue with that stat, it's no proof of cause and effect. "PEP should work if you catch the exposure within 36 hours," my doctor told me nonchalantly while drawing blood for my 12th (count 'em) HIV-antibody test. "I've given it to many patients and never had an infection." Then he added, "Of course, there's no way to ever know if it's PEP or luck." In other words, maybe my dark, handsome stranger wasn't lying.

The other controversy has to do, typically, less with us civilians who need more than condoms than with the public health officials who run HIV prevention, from the CDC on down. They are a frightened, fretful lot -- and yet you have to wonder if they know the first thing about real HIV fear. Just as the pros still refuse to certify unprotected oral sex as low risk, so they resist making PEP accessible for sexual exposures. That's why PEP remains poorly publicized (better that we not know about it than mistake it for a "morning-after pill") and requires persistence to obtain even at leading AIDS hospitals.

But if my own experience is at all common, the CDC has little reason to fear that PEP will further undermine condom use. In fact, PEP is, if nothing else, a crash course in the nature of consequences. Twice a day for four weeks I had to stop and take a handful of pills that tasted bad and made me feel worse. But that was the least of it. As the publisher of this magazine said (with a snort) when I complained about the side effects, "Try taking them for the rest of your life!"

That, in a phrase, is the beauty of PEP: It gave me a bitter taste of the reality of "managing" HIV. Although I have had to think long and hard about AIDS ever since I came out in 1987, have had boyfriends with the virus and lost friends to the disease, it wasn't until I found myself hiding in a bathroom stall at the gym to down my meds that I had that too-close understanding that constitutes true knowledge of what living with HIV is like. And I never missed a dose: The choice between try taking them for the rest of your life and swallowing the meds right now (or, for that matter, putting on a condom) is easy.

Last August, the CDC announced that it may deign to "make recommendations" for the future use of PEP for sexual exposures. Don't hold your breath. My own future is more certain: The PCR test I took a week after my last dose detected no virus. Since I may never have been exposed to HIV, this anecdote offers no proof that PEP works to prevent infection. But PEP definitely works in another, wholly unexpected way. And as long as the sexual lottery remains an HIV gamble, even those of us now and then reckless enough to play for the highest stakes deserve all the luck we can get.

-- e-mail: waltera@poz.com




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