Opinion : Why PrEP Isn't For Cowards - by Damon Jacobs

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May 23, 2014

Why PrEP Isn't For Cowards

by Damon Jacobs

An HIV-negative gay therapist who takes Truvada as pre-exposure prophylaxis (PrEP) responds to anti-PrEP comments by Larry Kramer.

Damon Jacobs
Damon Jacobs
Larry Kramer, writer of HBO's The Normal Heart, is arguably the most formidable and well known AIDS activist in history. His public record of anger, passion, and ruthless diatribes are legendary, and have garnered the respect of his followers and his detractors. His seminal work Faggots, originally published in 1978, was a scathing critique of what he perceived to be the sex-obsessed and imprudent aspects of flagrant 1970s gay culture.

So it came as no great shock when Kramer singularly dismissed the advances of pre-exposure prophylaxis (PrEP), a daily medication that has proven higher than 90 percent effective in preventing HIV transmission. What was surprisingly is that Kramer, while promoting The Normal Heart film, which he adapted from his original 1985 play, would use such bizarre and fabricated notions to express his opposition.

According to Kramer: "Anybody who voluntarily takes an antiviral every day has got to have rocks in their heads. There's something to me cowardly about taking Truvada instead of using a condom. You're taking a drug that is poison to you, and it has lessened your energy to fight, to get involved, to do anything."

As someone who has been using Truvada for PrEP daily since July 19, 2011, and has been publicly helping others learn about Truvada for PrEP during most of that time, I find Kramer's words to be naive at best, grossly deceptive at worst. But instead of judging or scrutinizing the man, let's just focus on what is erroneous in his words.

"Anybody who voluntarily takes an antiviral every day has got to have rocks in their heads."
This statement would assume that by "rocks," Kramer is referring to someone intellectually dim, judgmentally impaired, with limited decision making skills. But in fact, the consideration to use Truvada as PrEP is extremely complex, and requires one to go through a series of decision making factors in their minds.

This process involves asking, "Am I at risk for HIV? How do I determine what 'risk' is? Is sex that important? Can I adhere every day to a medication? Would I tell my lovers/friends? Would I tell my family? How would I ask my doctor? Would my insurance cover it? Where would I get it from? What if people think I'm HIV positive? How would I remember to take it on vacation? What are the side effects? What happens if I forget? Where can I go to learn more information? What if my doctor judges me? What if people find out without my permission? Will I be denied life insurance? Will I be stigmatized as a 'Truvada Whore'? Do I still use condoms?"

These thoughts are rudimentary in the process of using Truvada, and require one to use higher order thinking skills. They demand that a potential consumer of PrEP learn new information, analyze pros/cons, evaluate benefits/risks, and then implement a new set of behavior skills. These are hardly the actions and reactions of one who has "rocks" in their head, much less someone who would make such a decision based in haste or triviality.

"There's something to me cowardly about taking Truvada instead of using a condom." I'm not sure when condom usage became a sign of bravery or nobility. I can tell you with absolute certainty that using Truvada or PrEP is no cowardly feat. As The Normal Heart illustrates, it can be pretty hard for gay men to be honest with doctors, and trust them with personal details about sexual preferences. In order for someone to talk to their doctor about PrEP, they must be willing to make an explicit or tacit admission that they enjoy condomless anal sex. That, in of itself, has scared many people away from using PrEP.

Then, assuming your doctor doesn't slut-shame you too much and actually writes a prescription, you have the greater joy of taking on your medical insurance company. For some on PrEP, this has been a non-issue at all. But for many HIV-negative people who are not accustomed to dealing with insurance plans, co-pays, deductibles, rude operators in the Member Services department, and arguing for the right to access their medicine coverage, obtaining PrEP can be a daunting and exhausting process. Many then must go through an additional course of paperwork through the Gilead Assistance Co-Pay Assistance program. Not at all recommended for the faint-hearted.

Finally, if you obtain the medicine at a reasonable cost, you then have the added thrill of either dealing with your friends' and community's judgments, or staying completely in the closet. Many on my PrEP Facts Facebook page have lamented the disapproving shame and ignorant rage they have encountered upon disclosing their decision to use PrEP to others. The stigma against those who use PrEP is palpable and present. It is obvious in the name calling of "Truvada Whore" (which has since been taken back as a label of empowerment and solidarity amongst PrEP users). It is less obviously in the disapproving looks, the dismissals as "promiscuous," and the rejection from potential dates that some people receive upon disclosing. These reactions, dear reader, are not for the spineless or thin-skinned.

"You're taking a drug that is poison to you." One generally thinks of "poison" as something that kills, tarnishes, or seriously damages. That certainly has not been the case with use of Truvada as PrEP. Side effects are rare, and have all been reversible. As a matter of fact, on the same morning Kramer's words were publicized, so was a study that demonstrated there has been no irreversible kidney damage from using Truvada as PrEP. Most people who use Truvada as PrEP experience no side effects whatsoever. One could say that you need rocks in your head to dismiss an effective prevention strategy as "poison" when there is no evidence or incident to support that.

"It has lessened your energy to fight, to get involved, to do anything." Clearly Kramer hasn't gotten out lately. My PrEP-O-Licous! event in New York City had over one hundred attendants last February (in a snowstorm, no less!). Two weeks ago, even more people packed into a room at GMHC to attend the first of four "PrEP Rally" events. There are more people getting involved every day in social media and local organizations to help the education and implementation of PrEP.

If anything, using PrEP has reinvigorated my own activism that had become relatively lackadaisical by the 2000s. In reaction to the organizational apathy that typified the gay community's response to PrEP, I created a Facebook Group that would allow anyone anywhere in the world to have access to the science, research, data, and opinions about PrEP. Over 2,700 individuals have joined the group since July 2013. One can look through the recent debates, and read that people's energy is hardly passive, sedentary, or alienated. On the contrary, I see more involvement, engagement, and fiery passion about PrEP than any other medical issue in the past decade.

So clearly, using PrEP doesn't make us dumb, cowardly, or apathetic. PrEP has awakened and electrified a passionate, intelligent, and spirited fight amongst activists, medical professionals, health care providers, and social leaders. It calls upon consumers of PrEP to become educators, advocates, and at times, peacekeepers. Perhaps in time Kramer will find a way to recognize the efforts of those who have become more engaged in our communities because of PrEP, and the thousands who are working to change the minds and "normal hearts" of people like him.

Damon L. Jacobs is a Licensed Marriage and Family Therapist in New York who has helped hundreds of couples and individuals create joyful, peaceful, and pleasurable relationships. He is the author of the books Rational Relating and Absolutely Should-less. His trainings have helped thousands to learn practical skills for living an empowered and fulfilling life. This article was originally published on The Bilerico Project.

Search: Damon Jacobs, PrEP, prevention


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