Dirty Tony's Mick Frasca Speaks Out:
About why he decided to go on PrEP, and why you may want to consider doing the same. During this interview, he talks candidly about his own experiences with HIV, slut shaming, porn and how our community can move forward and become proactive in the fight against HIV. This interview is audio and runs approximately 25 minutes. Please email any comments to [email protected]
About why he decided to go on PrEP, and why you may want to consider doing the same. During this interview, he talks candidly about his own experiences with HIV, slut shaming, porn and how our community can move forward and become proactive in the fight against HIV. This interview is audio and runs approximately 25 minutes. Please email any comments to [email protected]
Is the LGBT community PrEPared for PrEP?
By: Timothy P. Holmberg
If you are part of the LGBT community or have a friend who is, you may have noticed an acronym showing up lately - PrEP or Pre-Exposure Prophylactic. The name is usually intimidating enough to get most to scroll past, but what it stands for is a new concept in HIV prevention. A tool that could have a profound impact on the HIV epidemic, or could be a pandora's box, depending on who you ask.
The program uses one of the common medications that make up the drug "cocktails" that stop HIV in its tracks to actually help prevent new HIV infections. The concept is an unremarkable development considering the idea of prophylactic use of HIV-fighting medications has been in use for over over two decades. The FDA approved prophylactic treatment for HIV positive mothers to prevent transmission to their unborn child in 1995, and the medical community has used such treatments for even longer than that.
The medication that has shown exceptional potential as a preventative is commonly known as Truvada (its much longer clinical name defies annunciation). The idea behind PrEP is that if you can enlist high risk individuals to be placed on Truvada as preventative, then you can keep them from progressing to more expensive treatments were they become infected. Beyond that, there is hope among activists and some treatment professionals that this could become a more broadly applicable weapon in the fight against HIV.
But that hope is not without some significant caveats. First among those is that Truvada's potency as an HIV preventative is still under study. Though preliminary results are encouraging, Truvada's efficacy is not expected to equal that of the much cheaper alternative - condoms. Truvada therapy currently costs on the order of $13,000 annually, your average condom costs $10.99 for a 12 pack (even if you went through one pack a month that's still only $109.90 annually).
So why is their a search for another option beyond condoms?
Since 2006, new HIV infections in the US have hovered at nearly 50,000 a year (though that is likely well below the actual number). Condoms have been pretty much the only game in town in terms of prevention, unless you count abstinence (a non-starter for most anyone much less your average 20 something gay man). But condoms-only prevention methods have been faltering in dramatic fashion within the gay community. How dramatic? A recent study found that nearly 60% of gay men have had unprotected sex within the last year. Furthermore, another study showed that 94% of gay men surveyed would consider not using a condom with an attractive partner. The tragedy is that those statistics are falling heavily on minorities who typically have greatly diminished access to healthcare resources.
Add to that statistic the fact that annual medication costs for treating an infected person averages $23,000 (some therapies reach $36,000) and you start to realize why there is a search for something beyond condoms. If you do the math, new infections could load an additional $1.15 billion annually to overall HIV treatment costs. That trend is clearly not sustainable over the long term, and many state-based HIV medication assistance programs are already overburdened by the influx of new patients. Federal spending alone for HIV already topped $20 billion in 2011. As it stands, overall spending for HIV is expected to increase over the next three years by 23%. Treatment specialists are quietly admitting that in the face of mounting budget pressures, we could be headed for a train wreck.
The building prevalence of what is commonly called bareback sex confuses most outside the LGBT community and a fair number of those inside it as well. It seems a rather simple dilemma to resolve - use a condom. But the issue is much more complex than simply unrolling condoms. To understand why that is, you need to look back at the emergence of HIV, and some decisions that were made early on that are having profound implications now.
The House That Fear Built
In 1984, fear and panic were gripping the gay community as scores of gay men began filling isolation wards at hospitals across the country. The previous year scientists had identified the virus that causes AIDS, and guidance had come down that condoms could block transmission. With a mounting death toll, epidemiologists and organizers in the gay community agreed to harness the fear around HIV into action. The gay sexual revolution was dead and condoms, it was determined, would become our bomb shelters. Gay men could wait out the viral nuclear winter there until a cure was found. How long could it take? Ten to fifteen years before a vaccine was found? Nobody liked condoms, but ten to fifteen years hiding in condoms was far preferable to the holocaust unfolding within the gay community.
But much like the original bomb shelters that were sold by catalog in the 1960's, condoms were less than perfect. Condoms at their best reduced HIV transmission by 85% - better odds certainly, but in practical terms, even during the scariest days of HIV, real world outcomes show that human factors could never be overcome to the extent needed to drop infection rates further. The type of sustained behavioral changes that would be needed for condoms to lower infection rates further among gay men have never been achieved with any other population segment.
Whatever messages were promoted in HIV prevention campaigns, fear clearly underpinned their capacity to instigate behavioral change. But by 1994, nearly 20,000 new cases of HIV were diagnosed among gay men (an increase from the previous year). Cracks were emerging, and it should have come as no surprise to anyone. While fear is a great short term motivator, behavioral science has demonstrated that over the long term, fear is very poor at generating lasting behavioral change.
According to the American Journal of Public Health - "Health promotion campaigns are typically designed to elicit fear, yet the use of fear is often ineffective in achieving the desired behavior change. Campaigns which attempt to use fear as part of a punishment procedure are unlikely to succeed. Consistent with established principles of learning, fear is most likely to be effective if the campaign allows for the desired behavior to be reinforced by a reduction in the level of fear."
The problem with HIV prevention campaigns that attempt to harness public fear is that not only are they ineffective in generating sustained behavioral changes, they actually work counter to their objective by maintaining fear levels within the target population. Looking more closely at fear's effect on the gay community, some behaviors that seemed almost inexplicable, like "bug chasers", can actually be seen as entirely predictable from a behavioral science standpoint. Not only predictable, they match behaviors of other populations when faced with similar omnipresent fears. Looking back at the plagues that swept through Europe in the Middle Ages, similar patterns emerge. Not everyone responds to fear the same. Some experience fear more intensely, and the more intensely you sense fear, the more a person will seek relief from that fear.
Condoms-only prevention faced a significant problem - they offered an imperfect respite from fear. Condoms require a much more active effort on the part of the individual and therefor many more points of failure. If you were drunk, or high, if you ran out or forgot to bring a condom with you, if the condom broke or you were allergic to latex, or as is the common practice today in the gay community, you tried to sero-sort (i.e. took the word of the other guy). And what about blow jobs?
From Fear To Hope?
Epidemiologists have been at somewhat of a loss for a new tactical prevention plan since AIDS wards emptied out in 1996. For a while after the dying stopped, image conscious gay men were held in check by the visually striking side-effects of the new "cocktails". Those who were saved from AIDS in essence became de-facto prevention posters. But within a few years, new treatments emerged that had none of the more shocking side effects. In practical terms this has meant that fear began to evaporate in the gay community around 2004. And those who are positive have not only emerged from the shadows, but are visibly living healthy and happy lives.
The new generations of gay men emerging today know nothing of the past suffering save for some stories that bear little relation to their experiences. Moreover, younger gay men are claiming a level of sexual freedom that many older gay men had to forsake in exchange for survival. Added to this are forty-something gay men who have lived most, if not all, of their sexual lives in their condom bomb shelters and for a variety of reasons are beginning to emerge.
The last major tactical shift we had in the fight against HIV came in 2006. A new initiative began focusing on an emerging realization that those who were primarily spreading HIV were not those diagnosed positive, but rather those who thought (mistakenly) that they were negative. The tactic sought to take advantage of a side effect of the newer medicines - namely that they were so effective, they actually sequestered HIV in those being treated. This marked a shift in focus from those who were negative, to the new target - the newly positive. In truth, this was also a tacit admission that condom based prevention efforts were delivering diminishing returns.
While the new effort made tactical sense, it faced a significant obstacle - the newly positive were a shifting and elusive target. In the end we never got to see how effective it might have been. In 2008, the Great Recession intervened. Not only did it undermine already thin prevention budgets, it resulted in legions of the HIV positive losing their health insurance. The combined effect overwhelmed local health government agencies which are still struggling to this day to pick up the pieces. AIDS Drug Assistance Program (ADAP) enrollment has swelled dramatically forcing waiting lines to get into the program. As of mid-2011, there were 8,869 people on ADAP waiting lists. And that, in and of itself, is a bad situation.
To understand why there is significant hope in the medical community for the potential of Truvada, one can look at teen pregnancy trends over the last 60 years. The most significant drop in those rates came with the introduction of the birth control pill. Prior to then, condoms were the biggest players. To this day, the pill is still the most widely used form of birth control and teen pregnancy rates are still declining.
What Truvada represents to some is a chance to switch from being reactive in the fight against HIV, to being proactive. One thing that is clear, is that without some new tactics the situation is likely to get much worse.
To some in the gay community, the statistics for unprotected sex that have developed over the last decade have been fueling a quiet fear. When HIV first descended on the gay community, the public's reaction was callous indifference. It was only when confronted with the horrors of the epidemic that the public was eventually stirred to action. Since then, it has been a long uphill fight for the LGBT community to gain broader public acceptance. The fear that is building in some quarters of the gay community is that a new wave of infections will destroy public sentiment in favor of gay rights, and even worse, destroy the public's support for Ryan White and other HIV programs.
Truvada and PrEP have in a sense crystallized that fear and drawn battle lines within the gay community. As was the case with clean needle exchange and the birth control pill, some suggest that PrEP will encourage risk taking and ultimately cause more infections than it prevents. But no one is debating the efficacy of clean needle exchange. According to the CDC -
"An impressive body of evidence suggests powerful effects from needle exchange programs....Studies show reduction in risk behavior as high as 80%, with estimates of a 30% or greater reduction of HIV in IDUs."
If PrEP is combined with the same harm reduction strategies that were developed for clean needle exchange, there is every reason to believe that it could deliver a significant blow to infection rates. But that hope will require broader acceptance of PrEP within the gay community. So far, the reaction has been mixed. Beyond that, the cost of Truvada will have to come down if it is to be more broadly applicable, and there is no indication yet that the maker, Gilead, is willing to do that.
For more information on PrEP and Truvada, visit:
http://start.truvada.com/#
Comments can be emailed to [email protected]
All comments are printed as-is except for correcting minor spelling errors. Please insure that you include your name and general location with your comments.
By: Timothy P. Holmberg
If you are part of the LGBT community or have a friend who is, you may have noticed an acronym showing up lately - PrEP or Pre-Exposure Prophylactic. The name is usually intimidating enough to get most to scroll past, but what it stands for is a new concept in HIV prevention. A tool that could have a profound impact on the HIV epidemic, or could be a pandora's box, depending on who you ask.
The program uses one of the common medications that make up the drug "cocktails" that stop HIV in its tracks to actually help prevent new HIV infections. The concept is an unremarkable development considering the idea of prophylactic use of HIV-fighting medications has been in use for over over two decades. The FDA approved prophylactic treatment for HIV positive mothers to prevent transmission to their unborn child in 1995, and the medical community has used such treatments for even longer than that.
The medication that has shown exceptional potential as a preventative is commonly known as Truvada (its much longer clinical name defies annunciation). The idea behind PrEP is that if you can enlist high risk individuals to be placed on Truvada as preventative, then you can keep them from progressing to more expensive treatments were they become infected. Beyond that, there is hope among activists and some treatment professionals that this could become a more broadly applicable weapon in the fight against HIV.
But that hope is not without some significant caveats. First among those is that Truvada's potency as an HIV preventative is still under study. Though preliminary results are encouraging, Truvada's efficacy is not expected to equal that of the much cheaper alternative - condoms. Truvada therapy currently costs on the order of $13,000 annually, your average condom costs $10.99 for a 12 pack (even if you went through one pack a month that's still only $109.90 annually).
So why is their a search for another option beyond condoms?
Since 2006, new HIV infections in the US have hovered at nearly 50,000 a year (though that is likely well below the actual number). Condoms have been pretty much the only game in town in terms of prevention, unless you count abstinence (a non-starter for most anyone much less your average 20 something gay man). But condoms-only prevention methods have been faltering in dramatic fashion within the gay community. How dramatic? A recent study found that nearly 60% of gay men have had unprotected sex within the last year. Furthermore, another study showed that 94% of gay men surveyed would consider not using a condom with an attractive partner. The tragedy is that those statistics are falling heavily on minorities who typically have greatly diminished access to healthcare resources.
Add to that statistic the fact that annual medication costs for treating an infected person averages $23,000 (some therapies reach $36,000) and you start to realize why there is a search for something beyond condoms. If you do the math, new infections could load an additional $1.15 billion annually to overall HIV treatment costs. That trend is clearly not sustainable over the long term, and many state-based HIV medication assistance programs are already overburdened by the influx of new patients. Federal spending alone for HIV already topped $20 billion in 2011. As it stands, overall spending for HIV is expected to increase over the next three years by 23%. Treatment specialists are quietly admitting that in the face of mounting budget pressures, we could be headed for a train wreck.
The building prevalence of what is commonly called bareback sex confuses most outside the LGBT community and a fair number of those inside it as well. It seems a rather simple dilemma to resolve - use a condom. But the issue is much more complex than simply unrolling condoms. To understand why that is, you need to look back at the emergence of HIV, and some decisions that were made early on that are having profound implications now.
The House That Fear Built
In 1984, fear and panic were gripping the gay community as scores of gay men began filling isolation wards at hospitals across the country. The previous year scientists had identified the virus that causes AIDS, and guidance had come down that condoms could block transmission. With a mounting death toll, epidemiologists and organizers in the gay community agreed to harness the fear around HIV into action. The gay sexual revolution was dead and condoms, it was determined, would become our bomb shelters. Gay men could wait out the viral nuclear winter there until a cure was found. How long could it take? Ten to fifteen years before a vaccine was found? Nobody liked condoms, but ten to fifteen years hiding in condoms was far preferable to the holocaust unfolding within the gay community.
But much like the original bomb shelters that were sold by catalog in the 1960's, condoms were less than perfect. Condoms at their best reduced HIV transmission by 85% - better odds certainly, but in practical terms, even during the scariest days of HIV, real world outcomes show that human factors could never be overcome to the extent needed to drop infection rates further. The type of sustained behavioral changes that would be needed for condoms to lower infection rates further among gay men have never been achieved with any other population segment.
Whatever messages were promoted in HIV prevention campaigns, fear clearly underpinned their capacity to instigate behavioral change. But by 1994, nearly 20,000 new cases of HIV were diagnosed among gay men (an increase from the previous year). Cracks were emerging, and it should have come as no surprise to anyone. While fear is a great short term motivator, behavioral science has demonstrated that over the long term, fear is very poor at generating lasting behavioral change.
According to the American Journal of Public Health - "Health promotion campaigns are typically designed to elicit fear, yet the use of fear is often ineffective in achieving the desired behavior change. Campaigns which attempt to use fear as part of a punishment procedure are unlikely to succeed. Consistent with established principles of learning, fear is most likely to be effective if the campaign allows for the desired behavior to be reinforced by a reduction in the level of fear."
The problem with HIV prevention campaigns that attempt to harness public fear is that not only are they ineffective in generating sustained behavioral changes, they actually work counter to their objective by maintaining fear levels within the target population. Looking more closely at fear's effect on the gay community, some behaviors that seemed almost inexplicable, like "bug chasers", can actually be seen as entirely predictable from a behavioral science standpoint. Not only predictable, they match behaviors of other populations when faced with similar omnipresent fears. Looking back at the plagues that swept through Europe in the Middle Ages, similar patterns emerge. Not everyone responds to fear the same. Some experience fear more intensely, and the more intensely you sense fear, the more a person will seek relief from that fear.
Condoms-only prevention faced a significant problem - they offered an imperfect respite from fear. Condoms require a much more active effort on the part of the individual and therefor many more points of failure. If you were drunk, or high, if you ran out or forgot to bring a condom with you, if the condom broke or you were allergic to latex, or as is the common practice today in the gay community, you tried to sero-sort (i.e. took the word of the other guy). And what about blow jobs?
From Fear To Hope?
Epidemiologists have been at somewhat of a loss for a new tactical prevention plan since AIDS wards emptied out in 1996. For a while after the dying stopped, image conscious gay men were held in check by the visually striking side-effects of the new "cocktails". Those who were saved from AIDS in essence became de-facto prevention posters. But within a few years, new treatments emerged that had none of the more shocking side effects. In practical terms this has meant that fear began to evaporate in the gay community around 2004. And those who are positive have not only emerged from the shadows, but are visibly living healthy and happy lives.
The new generations of gay men emerging today know nothing of the past suffering save for some stories that bear little relation to their experiences. Moreover, younger gay men are claiming a level of sexual freedom that many older gay men had to forsake in exchange for survival. Added to this are forty-something gay men who have lived most, if not all, of their sexual lives in their condom bomb shelters and for a variety of reasons are beginning to emerge.
The last major tactical shift we had in the fight against HIV came in 2006. A new initiative began focusing on an emerging realization that those who were primarily spreading HIV were not those diagnosed positive, but rather those who thought (mistakenly) that they were negative. The tactic sought to take advantage of a side effect of the newer medicines - namely that they were so effective, they actually sequestered HIV in those being treated. This marked a shift in focus from those who were negative, to the new target - the newly positive. In truth, this was also a tacit admission that condom based prevention efforts were delivering diminishing returns.
While the new effort made tactical sense, it faced a significant obstacle - the newly positive were a shifting and elusive target. In the end we never got to see how effective it might have been. In 2008, the Great Recession intervened. Not only did it undermine already thin prevention budgets, it resulted in legions of the HIV positive losing their health insurance. The combined effect overwhelmed local health government agencies which are still struggling to this day to pick up the pieces. AIDS Drug Assistance Program (ADAP) enrollment has swelled dramatically forcing waiting lines to get into the program. As of mid-2011, there were 8,869 people on ADAP waiting lists. And that, in and of itself, is a bad situation.
To understand why there is significant hope in the medical community for the potential of Truvada, one can look at teen pregnancy trends over the last 60 years. The most significant drop in those rates came with the introduction of the birth control pill. Prior to then, condoms were the biggest players. To this day, the pill is still the most widely used form of birth control and teen pregnancy rates are still declining.
What Truvada represents to some is a chance to switch from being reactive in the fight against HIV, to being proactive. One thing that is clear, is that without some new tactics the situation is likely to get much worse.
To some in the gay community, the statistics for unprotected sex that have developed over the last decade have been fueling a quiet fear. When HIV first descended on the gay community, the public's reaction was callous indifference. It was only when confronted with the horrors of the epidemic that the public was eventually stirred to action. Since then, it has been a long uphill fight for the LGBT community to gain broader public acceptance. The fear that is building in some quarters of the gay community is that a new wave of infections will destroy public sentiment in favor of gay rights, and even worse, destroy the public's support for Ryan White and other HIV programs.
Truvada and PrEP have in a sense crystallized that fear and drawn battle lines within the gay community. As was the case with clean needle exchange and the birth control pill, some suggest that PrEP will encourage risk taking and ultimately cause more infections than it prevents. But no one is debating the efficacy of clean needle exchange. According to the CDC -
"An impressive body of evidence suggests powerful effects from needle exchange programs....Studies show reduction in risk behavior as high as 80%, with estimates of a 30% or greater reduction of HIV in IDUs."
If PrEP is combined with the same harm reduction strategies that were developed for clean needle exchange, there is every reason to believe that it could deliver a significant blow to infection rates. But that hope will require broader acceptance of PrEP within the gay community. So far, the reaction has been mixed. Beyond that, the cost of Truvada will have to come down if it is to be more broadly applicable, and there is no indication yet that the maker, Gilead, is willing to do that.
For more information on PrEP and Truvada, visit:
http://start.truvada.com/#
Comments can be emailed to [email protected]
All comments are printed as-is except for correcting minor spelling errors. Please insure that you include your name and general location with your comments.
