Pre-exposure prophylaxis, or PrEP for shorthand, is a new effort to prevent sexually transmitted AIDS by giving HIV medications to those who don’t have the virus but who are considered high risk for getting it.

The first scientific PrEP study, known as iPREX, tested the drug Truvada on gay men. The results were greeted with sensational enthusiasm by several doctors and researchers who said iPREX was a “game changer,” and a “milestone,” that HIV prevention was “forever altered.”

What came next were jubilant claims by some gay men that condoms could now be replaced by a pill that has limited side effects and won’t harm you; in other words, that you can fuck as much as you want without using condoms and still avoid HIV.

However, as time has passed, it seems that the initial enthusiastic reviews of PrEP probably represented the voices of a small minority. As one critic noted, “The volume with which a view is promoted doesn’t necessarily represent the extent to which a view is held. A few people can make a lot of noise that drowns out everyone else.”

After extensive reading and talking to doctors, here’s what I’ve learned:

PrEP should only be an issue for those who can’t or won’t use condoms.  For them the use of PrEP makes very good sense.

We shouldn’t judge those who are unable or unwilling to use condoms. On the contrary, we should understand that there are many different circumstances and reasons that lead some to that point.  We should be supportive in minimizing their risk for acquiring HIV by using PrEP.  It’s a harm reduction measure, like providing clean needles.

But here’s the first problem: Can a drug that has the potential to reap millions of dollars in profits be marketed only to those who can’t or won’t use condoms?  There are already troubling signs that it can’t be.

Unlike the promotion and sale of anti-HIV drugs, safe sex education has no financial returns.  That’s why there must be a role for government and not-for-profits.  Otherwise, it can seem like the only value people at risk for AIDS have, is as consumers of drugs!

The history of AIDS in America has taught us that getting money for properly targeted safe sex education has rarely had the adequate government or other support it deserves. This is absolutely scandalous.  When people say safe sex education doesn’t work, we have to remember that there hasn’t been much of it, and what little there is, has rarely been properly targeted.

We should also be looking critically at where the promotion of PrEP is coming from.

Many doctors and even advocates have financial arrangements with pharmaceutical companies; they have glaring conflicts of interest, which we should at least consider in evaluating what they have to say about PrEP. They may believe in what they’re doing but you can’t avoid the fact that they receive money from the drug companies that stand to profit from their recommendations.

It’s interesting that the promotion of PrEP appears to be greatest in the U.S.  In these economic times when public health education budgets have been slashed, it seems obvious that health departments can put the responsibility for prevention on entities that pay for drugs, like insurers, whether private or government. That makes it easier for budget cuts and safe sex education cuts because paying for prevention falls on the insurers.

We still don’t know how great the demand for PrEP will be, but when figures become available, it’s likely that most men will keep their trust in condoms — the only prevention intervention that has an established track record.  To reiterate, condoms are the only thing that we know, from many years of experience, work.

This is not the time to further weaken safe sex education. The promotion of PrEP means we have to further strengthen it. Unless the promotion of PrEP goes hand in hand with prevention education, it threatens to undermine support for continued condom use even further.  The term being bandied about now – particularly by activists — is “combination prevention,” but I’m having a hard time figuring out what that means. They say we have to reduce the confusion over the term “combination prevention,” but their attempts to clarify it left me just as confused.  Do they mean you have to use a condom and PrEP?  Well, no they don’t seem to be saying that, so what do they mean?  I still can’t tell.

We have many years of experience to be confident that condoms can work, and maybe in time we’ll be able to say the same about PrEP — but not yet. What’s at stake is your life.

AIDS history has taught us that we should always be wary of enthusiastic recommendations that don’t yet have a track record to back it up.  The early use of high-dose AZT is one example.

As we said in How to Have Sex in an Epidemic, safe sex is about more than preventing AIDS.  The promotion of PrEP seems to conveniently overlook or downplay all the other sexually transmitted disease risks, (gonorrhoea, herpes, primary syphilis, nonspecific urethritis, Chlamydia, CMV, etc.) many of which can be prevented with condoms.  This is especially true for the highly sexually active who may be more likely to use PrEP.

While some argue that condoms are a barrier to intimacy, others actually find that they enable intimacy by freeing people from the risk of a life-changing infection.  By removing the threat of transmitting HIV, condoms can actually enhance intimacy.

It’s a tragedy that HIV still infects 41,000 new people a year, but with 300 million Americans, it seems that lots of people are also doing something right.

Safe sex isn’t always easy.  We need to encourage and support each other to keep on doing it.


February 20, 2013

I want to thank Mark Adnum of for instigating and inspiring me to write about PrEP during our recent interview.

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