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Throwback Thursday: Does a Pill Make You a Slut?

Posted by Mikola De Roo , April 24, 2014

Throwback Thursday: Does a Pill Make You a Slut?

The statements above aren’t about PrEP, the daily dose of the HIV medication Truvada that can be used by those who are HIV-negative to reduce greatly their risk of becoming infected. Both quotations above refer to oral contraception for women. The first came from a 1966 U.S. News and World Report feature on The Pill and morality; the second was from a 1968 Reader’s Digest article. The only revision made was to change “The Pill” to “the pill.” But the fact that these comments could be easily slipped into any of the many recent, opinionated articles popping up on PrEP as an HIV prevention tool without changing a word says a great deal. Irrespective of the health issue at hand, the genders, or the sexual orientations, when it comes to sex, sexuality, sexual freedom, reproductive rights, and sexual safety and responsibility, human beings continue to struggle with withholding judgment—in any era.

In the wake of the most recent condemnations of PrEP by AIDS Healthcare Foundation President Michael Weinstein, one thing is crystal clear: Stigma and judgment about sex—who’s having it, how, how often, with how many partners, and with or without what types of protection—are alive and well in the 21st century, even and perhaps especially within the gay community and within all communities affected by HIV/AIDS.

truvada pillWeinstein denigrated PrEP in a now well-circulated April 7 interview with the Associated Press, calling it a “party drug.” Without explicitly saying so, this assertion makes the daily Truvada pill sound like a recreational drug people take to get high and feel good from the drug itself, when in point of fact, it’s one more HIV prevention tool to add to the arsenal. (Think of it this way: How ridiculous would it sound to call a condom a party drug? But that’s an extension of the same logic: Having a condom implies you’re having sex or are on the prowl and planning to do so, which makes you a slut, right?) The Weinstein statement equates the prevention tool with the sex and goes on to make a lot of assumptions and judgments about the sexual behavior being engaged in if Truvada is being used for HIV prevention. In other public comments Wenstein has repeatedly asserted his belief that the availability and increased use of PrEP will result in a big decrease in condom use, causing a “catastrophe” for the gay male community in particular.

Weinstein cannot be credited or blamed for being the first or only community member to equate Truvada use with sexually irresponsible behavior and promiscuity. He didn’t personally coin or popularize the provocative, stigmatizing epithet “Truvada whore,” which reduces anyone taking PrEP to someone using the meds as an excuse to sleep around and/or engage in unsafe sex without a condom. That said, when the leader of one of the most prominent HIV/AIDS medical care providers in the U.S. insinuates the only real PrEP defenders are tramps and those working in pornography, as he did in follow-up comments published on Buzzfeed, it lends that stigmatization credibility. (Weinstein’s exact comments: “In the last few days in terms of the people who have been yelling the loudest about this, they’ve all been associated with bareback porn. They’re all associated with bareback porn, which kind of makes my point that it’s a party drug.”)

The notion of HIV meds as a pre-emptive prevention tool for HIV-negative people—especially those in high-risk groups—is a relatively new one. Given that, it’s no surprise that Gilead, the company that manufactures Truvada, has not invested heavily in promoting it for its HIV-risk-reduction properties. (Truvada is already a massive commercial success as an HIV treatment drug, in combination with other HIV meds.) For the moment, the stats reveal that estimated usage of the drug for HIV prevention is very low, a mere several thousand people, half of whom are women, according to Gilead.

ecard pill2Interestingly, the larger pattern and the stigma at work are an echo of how oral birth control was rolled out over 50 years ago. The first version of what’s now known as The Pill was approved by the FDA in 1957. The research proved it to be an effective contraceptive, but it was released and promoted for only the treatment of severe menstrual disorders rather than for its birth-control properties, largely due to the same morality-based arguments that made condom access and use controversial in the 1980s and that make PrEP a point of contention today: that it promotes promiscuous, irresponsible behavior. However, because word that The Pill worked as birth control had leaked to the public through the media as early as 1956, by 1959, even without explicit promotion of The Pill as a contraceptive, usage skyrocketed, with a dramatic spike in the number of women requesting prescriptions from their physicians, allegedly to treat severe menstrual disorders.

The point here is a basic one. If the history of human sexual practices and our discomfort with talking about any of it are any indication, the personal judgments of Weinstein, public health officials, politicians, or anyone else about the sexual behavior of those who may be the most likely candidates for PrEP, and therefore its strongest proponents in the general public, are irrelevant.

If we remain neutral about why people may opt to use PrEP, in practice, it means we have one more way to help prevent HIV transmission than we did three to five years ago. Nothing more, nothing less. The other biomedical HIV prevention and risk reduction methods have been around for longer and are mostly comparatively less controversial: condoms and dental dams, PEP (Post-Exposure Prophylaxis, or medications taken as soon as possible following possible HIV exposure to reduce the risk of transmission), and even male circumcision. Some people will use the biomedical tools in combination with one another, others may only rely on PrEP or PEP and forgo a condom. Naturally, relying on multiple prevention tools and using them correctly reduces HIV transmission risk further.

For those who are sexually active, every safe-sex tool has its limitations and caveats. PrEP’s high effectiveness as a prevention tool in HIV transmission is evidence-based. (The CDC offers neutral, science-based information about PrEP and HIV advocate and writer Mark S. King uses his thoughtful blog post in POZ to address all the common anti-PrEP arguments being made these days.) The risk reduction percentages vary depending on how closely the individual adheres to the daily drug regimen, but overall, the studies indicate if PrEP is taken correctly, it reduces HIV transmission risk by at least 90% and as much as 96%-99%. By contrast, condoms protect against multiple types of sexually transmitted infections (STIs) as well as pregnancy, but they also break and aren’t always used properly or consistently. That distinction is why condoms have an effectiveness rate of 97% on paper, but their actual effectiveness based on usage and accounting for human error is about 90%.

From a health and safety perspective, would it be better if everyone who used PrEP also used or continued to use a condom? Absolutely. Is it true that PrEP doesn’t protect against other STIs? Sure. (Guess what? Neither does The Pill. Or the diaphragm.) Is it also true that PrEP needs to be taken consistently for it to reduce transmission risk by 96%? Yes, just as it’s true that a condom needs to be used right, for every sex encounter, and throughout the act to make good on its full potential as an STI and pregnancy prevention tool.

No one, Weinstein or anyone else, gets to dictate for other people what prevention tool(s) they will or won’t use and whether they engage in high-risk behavior. That part is the choice of the individual. Like it or not, self-reported condom use decreases dramatically when people are asked repeatedly if they’re using condoms over an extended period of time, presumably because trust between partners is supposed to develop over time and people want to believe they can or believe they should take the health safety aspect on faith. According to CDC data released in November 2013, condom use is also already on the decline among gay men, with unprotected sex between men who have sex with other men increasing by 20% between 2005 and 2011. Some estimates say that more than half of gay men either don’t use a condom or don’t use them consistently.

Let’s also not forget about the big challenges inherent in the data about who has HIV. More than half of Americans have never been tested for HIV in their lifetime. According to surveys with U.S. youth, half of high school students report having had sex, but according to CDC data, only 13% have ever been tested for HIV. And of the 1.1 million Americans living with HIV, 16% do not know their HIV status. That’s 1 out of 6 people. This same number is significantly higher for those aged 13 to 24; 60% of these individuals don’t know they are infected with HIV. An estimated half of the new HIV infections we see in the U.S. each year—that’s 25,000 out of the 50,000 new HIV infections every year—are being transmitted by people who do not know they themselves have HIV.

Public apathy and gaps in data and knowledge are part of how the AIDS epidemic came to be and how HIV continues to spread.

Until a cure and a vaccine for HIV and AIDS are found, the job of those in the medical world and in the world of HIV/AIDS services is to make sure the public, and high-risk groups in particular, know about every prevention tool, are armed with the right information about how they work and how effective they are, and have access to them so they can make their own educated and informed choices. One thing we know for sure. From Nigeria, where simply being gay can lead to a 14-year prison sentence and people are therefore scared to go get tested or treated for HIV for fear of being arrested, to the U.S., where people risk getting labeled a tramp if they use Truvada and are open about it, stigma is a key driver in spreading HIV, not preventing it.

VD pinup boyAs Housing Works President Charles King has noted many times, stigma remains one of the biggest drivers of the AIDS epidemic today because it plays on our shame. Shame of being sexual beings. Shame of being gay. Shame of getting tested for HIV regularly because we might have it—because that might suggest to someone else that we sleep around and/or are unsafe, or simply because we are afraid of what the test will say. Shame of having a frank conversation with a potential sexual partner about HIV status. Shame that we aren’t 100% safe in our “safe sex,” so we’re taking more risks than we want to admit. Shame over asking a new partner to use a condom before anything goes any further because of the fear of everything from sexual rejection to mistrust and hurt feelings. Shame of drug addiction. Shame of being HIV-positive—even if we adhere to the ARV meds and our viral load is undetectable, making it highly unlikely that we’ll transmit the virus to anyone. Shame of asking our doctors about a drug that might keep us from us from getting HIV. The list can go on and on and on.

Shame and shaming aren’t specific to HIV & AIDS. It’s important that we remind ourselves that it takes time and persistence and courage to get past our own individual biases and preferences and withhold judgments in favor of what’s best and most effective for the wider public’s health.

In that spirit, AIDS Update Blog is using this post to launch a new Throwback Thursday series. As the Instagram-esque title suggests, the column will appear periodically on Thursdays and feature “throwback” tidbits from our past—quotations, images, and other media. Some may be specific to HIV and AIDS. Others may go farther back in time and touch upon broader, related issues, such as sex education, contraception, other STIs, stigma, homophobia, racism, and poverty. Some will provide a little levity, others will be sobering in how much they still resonate today, and hopefully, some may do both. The intent is for them all to remind us that ending the AIDS epidemic is biomedically possible—we can end the epidemic as we know it in New York by 2020, in the U.S. by 2025, and globally by 2030—but the road to get there requires money and political will invested in all effective strategies, vigilance, structural interventions, and above all, a greater degree of compassion and neutrality. May Throwback Thursday help us move down that road toward the end of AIDS together by showing us how far we’ve come and how far we have to go.

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