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How We F*** Now
July 30, 2014 7:19 AM   Subscribe


 
Well, I dunno, first things first: Larry Kramer is an idiot. Cowardly to take Truvada instead of wearing a condom? Fuck off. Wearing condoms (etc..) is about mitigating risk in the face of behaviour which can transmit disease. Truvada does the same thing. The simple reality is that a ridiculous number of gay men bareback, and a not-insignificant percentage of those men either a) don't know their HIV status, b) haven't been properly educated so don't get the concept of the window period, c) know their HIV status and don't disclose, or d) flat out lie. Taking Truvada is like providing teenagers with condoms: it's accepting that certain behaviour is simply just going to happen no matter what, so may as well make it as safe as possible. Also I'm pretty sure that Truvada is a much-more-widespread-in-the-USA thing; I certainly haven't heard much mention of it as PReP here (not zero mention, just not much).
"And I have honestly lived in terror of HIV for my entire life"
Rings painfully true.

This piece also reminded me, somehow, of a weird erotic short story I read in the late 90's. Published in some sort of collection. It was a story about two guys who happened to meet (duh) and found out they had both taken the safe sex messaging and fetishized ultra safe sex--jerking off together with condoms, without ever touching each other. Given how much us MSM tend to fetishize, well, everything, I'm vaguely surprised I've never (knowingly) encountered this kink in the wild.
posted by feckless fecal fear mongering at 7:39 AM on July 30 [3 favorites]


Well, I dunno, first things first: Larry Kramer is an idiot.

You might think his position on Truvada is idiotic, but Larry Kramer is no idiot. Take a good read of "1,112 and Counting." It was published in March of 1983, when “doctors who had seen you for years [would] not treat you, and we had to work hard to find funeral directors who would agree to bury our dead."
posted by roomthreeseventeen at 7:47 AM on July 30 [3 favorites]


You might think his position on Truvada is idiotic, but Larry Kramer is no idiot.

I respectfully but firmly disagree. He may have had useful and important things to say at the beginning of the plague, but he hasn't for many years now.
posted by feckless fecal fear mongering at 7:51 AM on July 30 [1 favorite]


I think it's much to early to say whether or not Truvada is a good solution for gay men. We do know that it has to be used pretty damn close to perfectly, and we don't know, 20 years from now, what sexually-transmitted disease might be out there. Maybe it is fear mongering, but at least Kramer has experience to back it up.
posted by roomthreeseventeen at 8:00 AM on July 30


Larry Kramer is a shit stirrer. He has been since the beginning of the epidemic and he still is today. In 1994, he compared GMHC to Dachau and AIDS Project Los Angeles to Auschwitz (page 80). This was the year of the highest AIDS mortality in the epidemic. We were working 80 hours a week trying to get people any drug out there and housing and food and someone they could rely on and he was calling us SS guards, thought police and enemies - talk about Godwinning...fuck.

As for today, Larry Kramer can go fly off a roof. He would have been screaming from the top of the World Trade Center to get Truvada to gay men for free, in bulk, in the water in 1990, to prevent infections, but now it's cowardly. Fuck the hell off.
posted by Sophie1 at 8:05 AM on July 30 [6 favorites]


roomthreeseventeen - it needs to be used, but not perfectly. In the Fem-PrEP and the VOICE studies, the numbers were so bad because More than 50% of the women had no detectable tenofovir at any point during the study.

From the International AIDS Conference last week:

Adherence to tenofovir/emtricitabine (TDF/FTC) "has to be good, not perfect," according to researchers analyzing protection from HIV with preexposure prophylaxis (PrEP) among men who have sex with men (MSM) and transgender women who have sex with men in an open-label extension of the iPrEx trial. Risk reduction reached 100%, they found, when participants took 4 to 6 TDF/FTC tablets weekly. (Grant RM, Anderson PL, McMahan V, et al. Results of the iPrEx open-label extension (iPrEx OLE) in men and transgender women who have sex with men: PrEP uptake, sexual practices, and HIV incidence. AIDS 2014. 20th International AIDS Conference. July 20-25, 2014. Melbourne. Abstract TUAC0105LB.)
posted by Sophie1 at 8:12 AM on July 30 [4 favorites]


Sophie1, granted. That's why I said almost perfect. Anyway, I'm sorry that this thread has turned into shitting on Larry Kramer, who I have met and think is a good guy.
posted by roomthreeseventeen at 8:13 AM on July 30


Larry Kramer's role is to throw firebombs. Sometimes agitation is useful, sometimes it derails a more thoughtful conversation. I gasped a little when I read a reference to "the elderly Larry Kramer". But the guy is 79, and I imagine seems pretty distant from the lives of young queers.

This Buzzfeed article is pretty good. I like that it takes what's been a private conversation among gay men and puts it in public. I also appreciate them framing everyone's opinions by their ages and relationships with AIDS.

I'm 42, gay, grew up in the shadow of the spectre. I think about the time that men used to fuck each other without worrying about dying and am intensely jealous. I also can't help but look on that promiscuity as somehow morally responsible for AIDS, even though I know that's unfair and cruel and not well motivated scientifically. Truvada is now shifting the whole discussion again and it's confusing. I don't know what I think. Discussions like this are important.
posted by Nelson at 8:16 AM on July 30 [5 favorites]


The article is really interesting and the Kramer thing is just a tiny part.

When I started realizing I was attracted to men, one of the assumptions I made was that HIV/AIDS and being a gay man were inextricably linked.

If Truveda or another intervention successfully broke that currently inextricable linkage, the psychological aspect, as they discuss, would be huge.

Given how much us MSM tend to fetishize, well, everything, I'm vaguely surprised I've never (knowingly) encountered this kink in the wild.

I've seen erotica that tried to fetishize safe sex, but never very convincingly.
posted by Dip Flash at 8:20 AM on July 30


Sophie1 has the truth of it. Kramer was and is a shit stirrer, and that was enormously important in the early years of the epidemic, and more of a hindrance afterwards. It's worth contrasting the hugely positive reception of the HBO adaptation of The Normal Heart, written in 1985, to the American history book (that he actually started before The Normal Heart) that has been delayed several times and the hook for which is that it supposedly proves that Abraham Lincoln was gay, based on a secret journal that only Kramer has seen. It is no smear on the important work that he has done to note that sometimes he really is just yelling at clouds.
posted by Halloween Jack at 9:13 AM on July 30 [1 favorite]


I've seen/read others, Dip Flash, but that one is the only one that's stuck to my memory. It was pretty convincing though not (for me) erotic.
posted by feckless fecal fear mongering at 9:19 AM on July 30 [1 favorite]


I think that Truvada has amazing potential to prevent the spread of HIV. However, I have yet to read an article that notes that while it shields you from HIV, that protection doesn't extend to other STIs! It disturbs me that there is very little mention of the risks that Truvada doesn't prevent...
posted by Strass at 9:19 AM on July 30 [1 favorite]


Strass, that's exactly the point.
posted by roomthreeseventeen at 9:22 AM on July 30


I have yet to read an article that notes that while it shields you from HIV, that protection doesn't extend to other STIs!

I literally just had this discussion with a doc in our clinic. Syphilis and gonorrhea, while problematic, are not fatal and do not require lifetime treatment. Gay men, like all humans, go through phases in their sexuality. If a gay man in his 20's and 30's is having unprotected sex and gets HIV, he is going to be on treatment for life. If he is on PrEP (which, BTW is not going to be limited to Truvada for long) he is going to be on it during a phase of unprotected sex for a decade +/- depending on the individual and then he goes off therapy. And then he can go on it again if necessary, but it is not lifetime treatment with a combination of 3-4 medications.
posted by Sophie1 at 9:27 AM on July 30 [3 favorites]


we don't know, 20 years from now, what sexually-transmitted disease might be out there

I think this may really be part of the problem/stigma/etc surrounding HIV and AIDS. While it can be transmitted sexually that's just because it's present in certain bodily fluids, whereas with something like chlamydia e.g., pretty much the only transmission route is sexual. So I think maybe there's been a category error in some ways. It's not a fully formed thought, just something I was thinking about in relation to this article while I was waiting at my doctor's this morning.

It disturbs me that there is very little mention of the risks that Truvada doesn't prevent

Apart from the antibiotic-resistant chlamydia (or was it gonorrhea? I can't remember) that popped up a while ago, most STIs are easily and quickly treated. There's herpes obviously but a condom isn't necessarily going to protect you against that. Like I said above, the use of PReP is more about mitigating one risk factor; MSM who are barebacking (I mean, as briefly mentioned in the article, outside a monogamous relationship) DGAF about other STIs anyway--and if we can't get people to use condoms on a regular basis for a disease that can actually kill you, it doesn't seem likely there's going to be much headway on ones that are, at worst, briefly unpleasant. I was born in 79 so like Nelson I grew up under the shadow of this spectre, but it's my understanding that the idea of safe sex was just... foreign to gay men for the most part until transmission routes for HIV were identified.
posted by feckless fecal fear mongering at 9:28 AM on July 30


You know, I hear the same harping about birth control pills - they don't prevent diseases, apparently nobody is aware of that and probably everyone should just stop taking them because they also don't prevent the common cold, toenail fungus, or fleas. (Plus only sluts need birth control pills unless they are married and so not sluts anymore so don't take contraception because that'll make you not have sex and you won't be a slut yay!)

I'm almost certain that people who are aware of Truvada are aware of what it does and does not do, and that saying it does one thing is not automatically implying it does the others.

Yes, there are other diseases. None of them are as deadly as HIV. This is a terrible reason to talk people out of using Truvada/PrEP.
posted by Lyn Never at 9:29 AM on July 30 [5 favorites]


Syphilis and gonorrhea, while problematic, are not fatal and do not require lifetime treatment.

That's a really good point. I'm not saying that gay men shouldn't take Truvada, or hesitate to get a prescription. Hell, I'm in a committed, monogamous relationship and I'm still thinking about asking my doc for a prescription next time I see him because HIV is super scary.

I'm just saying that personally, I think it's harmful that many sources I've seen present Truvada as a panacea for sexual health (or demonize it for 'encouraging' people to not use condoms). I think that a middle ground, "Truvada is incredibly effective at preventing the spread of HIV but doesn't protect you from other STIs" is not only more true, but a more responsible way to present the drug.
posted by Strass at 9:37 AM on July 30


Like... as a 23 year old gay male, I can see how that first narrative ("Truvada will protect you from HIV") is amazingly compelling and I just think it's important to also note that it doesn't just get rid of all the risks of having unprotected sex/sex with strangers.

I really hope I'm not coming across as anti-Truvada or casual sex, I just want people to be safe and healthy!
posted by Strass at 9:43 AM on July 30 [1 favorite]


If you're in a committed monogamous relationship, why would you need Truvada? (That's more of a rhetorical question, I'm not asking you to reveal the details of your relationship). HIV is pretty scary, for sure (though I'm certain I've been to fewer funerals than other people in this thread, I've still been to too many), but its best use isn't for people who are seroconcordant and monogamous, it's for people who aren't one or the other or both.

"Truvada is incredibly effective at preventing the spread of HIV but doesn't protect you from other STIs" is not only more true, but a more responsible way to present the drug.

It might be, sure. But... well let me put it this way: how many guys do you know who bareback with strangers/casual flings/nonmonogamous relationships? How many ads have you seen on craigslist/grindr/squirt/growlr/etc looking for bb? These are guys who already don't care about a life-altering and potentially fatal disease. That's who Truvada is aimed at, primarily. Sure, there's no argument, I think, that the availability of it may well give some guys who'd usually or often use condoms the freedom/permission not to use them, but I think the concern that it'll for sure lead to that for a lot of MSM is perhaps misplaced in the same way "giving condoms to the teenagers will make them have sex" is misplaced. You know?

Really, I'd like to see Truvada marketed towards women a lot more. Again, how many sex/personal ads have you seen that are from (straight)married guys fooling around? There's an awful lot of WSM out there who are HIV+ (and may well not even know it, because why would I get tested for something when we're married and obviously my husband only likes women?) because of that duplicity.
posted by feckless fecal fear mongering at 9:58 AM on July 30


It's the kneejerk reaction that bothers me. Truvada? But all those other diseases, I'm just worried about your health! But just like contraception, a failed condom shouldn't have to mean a permanent life-altering condition, be it HIV or parenthood/an abortion you wanted to avoid etc.

If you're in a committed monogamous relationship, why would you need Truvada?

Because your partner is HIV positive? Because you work in healthcare in a high-risk population? I mean, there are other reasons like monogamishness or you just don't trust the fucker or whatever, but it could also be because you are routinely exposed to HIV in your life.
posted by Lyn Never at 10:03 AM on July 30


You probably should have read the sentence right after the one you quoted, Lyn Never. "its best use isn't for people who are seroconcordant and monogamous, it's for people who aren't one or the other or both. "
posted by feckless fecal fear mongering at 10:07 AM on July 30


You're correct. I'll amend my reasons to "trust issues" then, as I'm not sure there is any other recourse (aside from the obvious) if you just aren't sure what the other person is up to.

I would agree that a lot of women don't even know about Truvada when they should. I don't know anyone who's been dating in the past 10 years who doesn't have a story of a man at least trying to sneak without a condom, some of them successfully.
posted by Lyn Never at 10:14 AM on July 30


Am I the only person who plans to continue using condoms after I start using Truvada? Truvada for me is like a condom for my anxiety that actual condoms don't do enough to assuage.

Actually, considering what I know about the behavior of my friends (gay or straight), I'm probably one of the few people who actually still uses condoms anyway.
posted by BuddhaInABucket at 10:15 AM on July 30 [1 favorite]


Truvada costs between $8000 and $14000 a year, depending on various factors, if you don't have insurance that will cover it.

I think I'll stick with the tactics that have allowed me to be sexually active and HIV- for the past decades. I don't feel I'm lacking for sexual experience or pleasure, and I know what my risks are and am entirely comfortable with them.
posted by hippybear at 10:20 AM on July 30 [2 favorites]


Eh, I use condoms for fucking outside the context of a monogamous relationship with no trust issues, if we're both past the window (and then some) and have been tested to be sure. But like others here I grew up with the sex=death messaging. I think a lot of the reason for barebacking amongst MSM is either guys who are too young to remember how bad it once was and have never seen late-stage AIDS patients or been to funerals, and the ones old enough to know but have forgotten or just don't care.

It's kind of shocking how many times I've had guys say to me "I want it bb, but don't worry, I'm clean." And then get annoyed with me when I ask them when the last time they were tested was and how many partners they've been unsafe with since six weeks before that, and I'm all "Yeah, no" when their answer is "Last year, and I don't know." (The answer would be "yeah, no" in any case, but the point is they think being tested last year and guys saying "Don't worry I'm clean" is the same as safe sex.)

Truvada costs between $8000 and $14000 a year, depending on various factors, if you don't have insurance that will cover it.

Which is probably why it's not really a Thing in Canada. Because we have socialized healthcare, not a lot of people get insurance that covers medication unless it's coming as part of a corporate benefits package, or they have money to burn.

I'd expect, also, that insurance companies will (try to; not sure how ACA would affect this) raise rates on people making claims for Truvada scrips because they could indicate risky (and thus more expensive for the insurance co. long term) behaviour.
posted by feckless fecal fear mongering at 10:26 AM on July 30 [1 favorite]


Truvada is included in Covered California plans, AND the company that makes it will help you with $200 a month of your costs, so I think you're generally good to go.

There's a facebook group that has a lot of information and discussion about Truvada that I've found very helpful.

I'm one of those people for whom HIV transmission is not a huge concern- I'm not promiscuous, have safer sex, am tested regularly... but grew up with the gay=dies of AIDS messaging that has really hurt my ability to enjoy sex at all, even under the parameters in which I have it. I really appreciate the psychological buffer that Truvada gives, and hope to one day have sex without having to think of my sure death from a disease that everyone in my family will blame me for.
posted by BuddhaInABucket at 10:33 AM on July 30 [2 favorites]


I should have added: when a friend needed PEP a few years ago because of some poor choices, the cost at the pharmacy counter was well north of $3000. HIV medications are ridiculously and prohibitively expensive; thankfully the epidemiology/infectious diseases unit at a nearby hospital was able to provide him the meds free of charge.

Personally, I'd be all for every government in the world to break patents on HIV meds, and socialize further research. Including forcing pharma companies to hand over every single piece of data they have. But I'm a communist or something.

the company that makes it will help you with $200 a month of your costs, so I think you're generally good to go.

Oh how nice, they give a meaningless discount on ridiculously overpriced medication that will prevent deaths. Not snarking at you, snarking at Big Pharma assbags.

I really appreciate the psychological buffer that Truvada gives, and hope to one day have sex without having to think of my sure death from a disease that everyone in my family will blame me for.

Fair enough. I'm with you on the not a huge concern thing, but it is always in the back of my head. I guess I'm lucky in that it really hasn't impacted my ability to enjoy things. Would be very interesting if someone did a study on that, I think.

(And that being said, no matter how safe I've been I still get hyper-anxious when waiting for HIV test results. Thankfully that waiting period is now 2-3 minutes, not 2-3 weeks.)
posted by feckless fecal fear mongering at 10:41 AM on July 30


Kaiser Permanente covers PrEP at $30 a month.
posted by Sophie1 at 10:41 AM on July 30 [3 favorites]


FFFM: Thank god for rapid testing. Except for the counselors that try to talk to me to keep me distracted while the results come. Shut up and let me do my breathing exercises! Haha.
posted by BuddhaInABucket at 10:46 AM on July 30 [1 favorite]


oh my god for reals. SHUT UP AND LET ME FRET PLEASE YOUR TALKING JUST MAKES IT WORSE

...is what I say on the inside, seething.
posted by feckless fecal fear mongering at 10:50 AM on July 30


Oh how nice, they give a meaningless discount on ridiculously overpriced medication that will prevent deaths. Not snarking at you, snarking at Big Pharma assbags.

And you trashed the sentence above that saying that the state insurance plan covers it. Nice.
posted by emptythought at 12:01 PM on July 30


Um, like I said, I was snarking at Big Pharma. I don't know what part of that wasn't clear? I didn't think that insurance covering the meds needed to be commented on.
posted by feckless fecal fear mongering at 12:07 PM on July 30


I mean, i just thought it was weird snarking. It seems like obamacare covers it, and they're giving you $200 to cover whatever the difference is.

That seems like a one two punch of making it free, no? Especially since paying the penalty for not having ACA insurance is often the same or even more as not having it.
posted by emptythought at 12:49 PM on July 30


Let me put it another way... "We've made this hideously overpriced drug that saves lives, but since we're SO NICE we'll take $200 off the already overinflated cost!"

I suspect the reality is not taking $200 of the cost, it's that the list cost minus $200 is actually what they were aiming for in the first place. Classic marketing. Which is bullshit on a cracker when it comes to preventing people from dying.
posted by feckless fecal fear mongering at 12:53 PM on July 30


Truvada ... the company that makes it will help you with $200 a month of your costs

They could "help" more by disclosing their cost of production. (That may be 'out there' and I haven't seen it.) Then it would be clearer just why it costs between $8000 and $14000 a year.

If the difference will somehow help finance a cure, that'd be great. Otherwise producing it seems like a great long-term investment strategy ... which would not work for a cure, and which makes MSM themselves a product. (Yes I've learned some cynicism recent years.)
posted by Twang at 1:57 PM on July 30 [1 favorite]


Yea, fair enough FFFM

They could "help" more by disclosing their cost of production. (That may be 'out there' and I haven't seen it.) Then it would be clearer just why it costs between $8000 and $14000 a year.

The issue here is that it's like saying an iphone only costs $100 or less to make. The actual material costs of production don't include things like "This cost us XYZ in lawyer time/application costs/etc to get it approved, used X amount of time on ABC pieces of multi million dollar lab and low volume test production equipment and wasted lots of expensive materials to test, and a lot of that gear only has a limited service life, used Y time of biochemists/lab technicians/etc"

It might only cost $12 a pill to produce in raw materials, but there's a lot of other costs associated with it that people discount. Do i think there's fucked forces in the system that, through opaqueness, are driving these companies to vastly overcharge for these medications simply because they know they can get it? yes. But i don't think that disclosing raw production cost would do anything but empower a lot of uninformed and misinformed internet activists to scream price gouging without knowing the real costs. The only real useful info would be a huge balance sheet that outlined all the costs involved from start to finish of the initial research to consumer sales.

God, i sound like i'm defending corporations i hate here in saying this, but the problem is the fact that they spend millions researching and producing this sort of thing and then they have to get that money back from consumers. This is exactly the kind of problem that some sort of subsidization or single payer needs to solve because yes, it's expensive to develop and produce these drugs, and the companies going "then what are we supposed to do?" sort of have a point even though it's fucked up that the end result is "pay $14,000, sorry dude".

And i think, in the end, that the real solution here is to socialize this research and the production of these drugs. The CDC should be buying out the patents and rights for these, and the government should be contracting out their production at materials cost only. It should cost as much as a flu shot if you can afford to pay, and be fully subsidized and free if you cant.

It will be possible as soon as it's politically the Right Thing To Do, so we need to make it that. It makes me genuinely angry that the state mailed everyone boxes of CFL bulbs for free and no republicans freaked out, but this can't get done.
posted by emptythought at 2:12 PM on July 30 [1 favorite]


emptythought: I could have been clearer; by 'cost of production' I meant the whole 'ecological' cost (lawyers, labs, research, trials, et.al.). More transparency into those costs would be helpful in evaluating what's going on. (As I noted, it may be 'out there'.)
posted by Twang at 3:09 PM on August 2


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