Last Monday, the New York Times ran an excellent piece exploring the curious controversy over Truvada, a daily pill that provides almost absolute protection against HIV infection. By far the most effective PreEP (that is, pre-exposure prophylaxis), Truvada has virtually no side effects and, if taken daily, it is more than 99 percent effective at preventing HIV—and it’s covered by most insurance companies. Basically, Truvada is a miracle drug. It’s also one of the most unpopular HIV medications ever invented.
Why have only 1,774 people—half of whom are women—filled Truvada prescriptions over the last two years? The fault lies squarely in the gay community itself. As the Times notes, Truvada’s most vehement opponents are AIDS activists. The AIDS Healthcare Foundation actually lobbied the FDA to reject the drug, arguing that gay men would stop using condoms, forget to take one pill, and quickly become infected. The former editor-in-chief of Poz, a publication for HIV-positive people, called PrEP a “profit-driven sex toy for rich Westerners.” Dan Savage, a popular sex advice column and sachem of the gay community, had similar fears, infamously describing Truvada users as “self-identified idiots who can only be saved by a vaccine.” What’s more, the phrase “Truvada whore” is becoming pervasive on some gay social networks.
Behind all these anxieties lie two beliefs, one condescending and incorrect, the other unpleasant but accurate. First, the suggestion made by AIDS advocacy groups—that gay men will stop taking other safe sex precautions once on Truvada—is simply untrue. Several studies have effectively debunked this rather patronizing notion, illustrating that a Truvada prescription leads in no way to “sexual risk compensation” (that is, ditching other safe sex practices). In PrEP’s early days, this concern was understandable. But it’s now been discredited, and those still bandying it about are only furthering a refuted paranoia.
The second thorny problem raised by Truvada is the condom conundrum. Those who slam Truvada tend, in the same breath, to praise condoms like it’s 1986. But condoms—despite being a favored solution of the gay old guard—present serious problems of their own. Only 1 in 6 gay men use condoms unfailingly, and sporadic use provides minimal defense against HIV infection. Even more troublingly, condoms don’t work as well during anal sex: With perfect use, they’re only 86 percent effective against HIV during anal intercourse. (With perfect use during vaginal intercourse, they’re 98 percent effective.) Add to this the fact that unprotected bareback sex just feels better, and you’ve got a strong case for combining Truvada with condom usage as an extra protection against infection.
Truvada’s opponents’ last argument is perhaps their most puzzling. Activist groups like the AIDS Healthcare Foundation like to note that missing a single dose of the drug reduces a patient’s protection against HIV—the implication being that because humans are bad at remembering to take pills, Truvada will provide false comfort and little protection. But humans are bad at using condoms, too, and no one cites this as a reason to give them up altogether. Rather than abandoning Truvada because patients might forget it, public-health advocates and AIDS activists should be encouraging patients to remind themselves to take the pill daily. It makes little sense to renounce the whole endeavor merely because human memory sometimes falters.
But a concern about memory isn’t really what’s holding back Truvada from becoming a lifesaver in America. The problem, instead, lies in a generational dispute between older gay men, who lived through the worst of the AIDS crisis, and younger ones, who often see HIV as little more than a chronic but manageable disease. Gay men in the 1980s fought for their lives to get the government to expand access to and education about condoms. It was a noble struggle, but also an insufficient one. Today’s AIDS landscape reveals that an unyielding devotion to condom usage isn’t enough to halt the spread of HIV. It takes a variety of safe-sex practices to shield gay men from infection, and Truvada should be a linchpin of that strategy. Given the seemingly unstoppable drop in condom usage among gay men, this is no time for ideological disputes or intergenerational conflict. Every gay man with multiple sex partners should take Truvada, and AIDS activists should do everything they can to get the drug in the hands of those who want it.
