PrEP – How did I end up here? [Part 2 of 3, by Marc-André LeBlanc]

bv Marc-André LeBlanc
Gatineau, Canada

• Multiple sex partners? Check

• History of STIs? Check

• Partners of unknown or HIV-positive status? Check

• Inconsistent condom use? Check

This is the second installment of a three-part series.
Click here to read the first installment. Click here for Part 3.

On April 5, 2013 I took my first dose of Truvada as pre-exposure prophylaxis (PrEP). How did I end up in this situation where I feel like I need PrEP? 

As I mentioned in my previous post, a look back at the phases of my sex life gave me some clues about why PrEP makes sense for me now. After more than 20 years of being sexually active, I only recently found myself veering away from perfect 100% condom use.

How did that happen?

Ironically, this is in part because I’ve been working in HIV for 20 years, including the last 10 years focussed on tracking biomedical HIV prevention research. I know what the research is telling us about HIV transmission. I know what proportion of new infections is driven by people who are undiagnosed. I know what undetectable viral load means for transmission risk.

I started serosorting, but not in the conventional sense. More and more, I’ve been dividing guys up into 3 categories.

1. The first category is small. With HIV-negative guys I know and completely trust, we arrive at a form of negotiated safety—if we have been tested for HIV and all STIs recently, and not yet had sex with others, we usually have condomless sex.

2. The second category has been steadily growing—positive guys. We have discussions about treatment, viral load, STIs and decide how to proceed from there. Sometimes without condoms.

3. The third category is basically everyone else—HIV unknown or undisclosed, and HIV-negative men I don’t know well. I consider guys from this third category as potentially being in the acute infection phase, whether they know it or not. This is the category of men with whom I am most adamant about condom use. All too often, their prevention strategy is dubious at best (e.g., “r u clean? how big r u? wanna bb?”). If I see another highly stigmatizing "disease free"/"no poz" message on an online profile, meant to be some kind of stand-alone, ill-informed HIV prevention strategy, I might reach through the screen and cyber-throttle someone.

So gradually, I’ve found myself feeling much less worried about having condomless sex with a positive guy after a conversation with him about treatment and viral load and STIs than about having condomless sex with a guy who says he is negative, but could be in the acute infection phase with sky-high viral load without even knowing it.

Paranoia? Rational, effective, evidence-based risk-reduction strategy? Both? You be the judge.

But let’s be honest. I also started “slipping up” more and more often because, well… sex feels better without condoms. *gasp* That’s right folks. Sex without condoms feels freaking amazing. You heard it here first.

So while I still maintained a relatively high rate of condom use, I found myself having condomless sex every once in a while. Of course, I also know how effective inconsistent condom use is over time (i.e., not very).

 

An illuminating peek inside the Little Black Book

Three years ago, I started to keep track of my sexual encounters in a proverbial little black book. (OK fine, it’s blue and has a Global Campaign for Microbicides logo and a Rectal Pride for Microbicides sticker on it. It’s super pretty and seemed appropriate). Every time I have sex, I write down what we did, what I know about my sex partner’s HIV status, and whether or not we use condoms. Yup, every time for 3 years. I do this partly so I have very accurate information at my fingertips to relay when I get tested for HIV and STIs. Partly so I have very accurate information at my fingertips when I start to worry. I can look at my list since my last tests and say: look, you had this many encounters, this is what you did with whom, this is how often you used condoms, and this is what you know about his HIV status. Sometimes that helps alleviate the occasional panic attack and insomnia. Sometimes.

I had never seen myself as being “high risk” for the first 20+ years of my sex life. But I’ve been working in HIV for 20 years. So I know the behavioural characteristics of “those people” at high risk. Armed with about 3 years of hard data about my own newly evolving behaviour (i.e., my stylish little blue book), I decided to look at it objectively.

• Multiple sex partners? Check

• History of STIs? Check

• Partners of unknown or HIV-positive status? Check

• Inconsistent condom use? Check

Well then. It’s hard to ignore what this spells.

I like to think I’m at least moderately intelligent. I know how HIV is transmitted. I know how effective condoms are.

I like to think I understand the consequences and the stakes. Yes, people living with HV are doing much better today. But I saw my dad die of AIDS in front of my eyes. I saw countless other friends, colleagues and clients become HIV-positive or die of AIDS. That leaves an impression, to say the least.

I like to think I’m a responsible person. I get tested frequently. I stay informed.

I like to think I have high self-efficacy. I have several years of experience using condoms consistently, and I am more often than not the one wearing the condom, so little to no negotiation is required.

I’m not depressed. I never drink. I don’t so drugs. My judgement is not clouded by any of those.

I’m not in denial. I know that the combination of inconsistent condom use, multiple partners, history of STIs and having partners of a different/unknown HIV status is a very strong predictor of seroconversion over the course of a few years.

If all of this doesn’t make me an ideal candidate for consistent condom use, I don’t know what more it would take, short of using Super Glue to permanently bond a condom to Mr. Happy.

Yet here I am.

So as a smart, responsible, well-informed, sexually active gay man with good self-efficacy and good access to healthcare and accurate information, I’ve come to the conclusion that PrEP makes sense for me at this point in my life. I don’t know how long this new “PrEP phase” will last. But I am glad it is available to me while I need it.

***

There are a million other things I have to say about PrEP. Well OK, maybe only half a million. But luckily others have already addressed many of them, and have done it so eloquently. I encourage everyone to check out the following remarkable first-person accounts:

• Len Tooley did a series of interviews on PositiveLite.
• Jake Sobo has been writing a whole series of articles on his blog, “My Life on PrEP”.
• Several other first-person accounts can be found right here on the “My PrEP Experience” blog.

Len and Jake are so friggin’ smart and insightful and articulate, I want to marry both of them. It has been a tremendous source of help and support to read the thoughts of everyone who shared their stories publicly. A big hairy thanks to Jim Pickett for starting the “My PrEP Experience” blog because he recognized that amidst all the heated debates and discussions and policy decisions about PrEP, we weren’t hearing the voices of real-life flesh-and-blood people actually using PrEP.