What would it be like to live in a world where preventive medication has rendered HIV completely non-infectious? In the general population, this question may seem somewhat less pressing, but among gay and bisexual men, especially those who live in urban centers like New York and San Francisco, it’s been a topic of intense debate during recent weeks. Timothy Murphy’s New York magazine article explores a wide variety of gay men’s candid opinions about Truvada—the first drug being used to prevent HIV transmission in potentially widespread numbers.
Also called PrEP (pre-exposure prophylaxis) when Truvada is prescribed specifically for HIV prevention rather than treatment, the medication has been touted as nearly 100% effective in preventing transmission of the virus. Some question the accuracy of recent studies that have reached those conclusions. Still, it’s hard not to wonder what would become of the long-standing stigmatization and fear of HIV, both in the wider population and among gay and bisexual men, if the disease does soon become entirely preventable through medication.
AIDS and gay rights activist Peter Staley, one of the most eloquent speakers featured in the Academy Award-nominated 2012 documentary How to Survive a Plague, feels that HIV stigma is deeply entrenched in the gay community and will be very difficult to eradicate. “I don’t think we’ll ever get to that state of nirvana where HIV stigma isn’t a problem,” Staley said when I interviewed him by phone. But the current debate about HIV and PrEP plays a useful role: “Getting that stigma out in the open has been a net plus. It’s started a huge discussion that was long overdue, and it’s forced many younger gay men to think about their HIV risk in a more conscious way. The harsh wall between HIV-negative gay guys and HIV-positive gay guys is beginning to come down for some.”
Yet the situation between HIV-negative and HIV-positive gay men may never return to the way it was during a brief window of time in the late 1980s and early 1990s, while Staley was instrumental in the New York activist group ACT UP (AIDS Coalition to Unleash Power). Gay and bisexual men abandoned shame and HIV stigma during that era of activism in order to fight the disease and survive. They also had to overcome their own fear of one another. Although Staley feels that this sort of communal bond will not be revived today, he mentioned that the attention surrounding PrEP provokes important changes. “We’re going to see some exciting stuff in New York,” Staley said, “like subway and bus station ads for PrEP. That will help convince gay men to stop ignoring HIV, and it keeps the conversation going. Silence makes HIV seem rare and avoidable, giving space for the next generation’s stigma.”
As a gay man living in Boston for the past two decades, I’ve personally felt the effects of what Staley describes. Stigma and fear of HIV circulate quietly but constantly within the gay community. The lack of truly open dialogue has often put some members of the gay community at greater risk for exposure to the virus, perhaps less out of a feeling of invincibility than a lack of communication that’s rooted in shame. One HIV-positive man whom I dated briefly a few years ago was stunned when, after he revealed his seropositive status to me, I said that it didn’t change the way I viewed him at all. Sadly, he replied that it’s something he’d never been told by any other gay man he’d met. There’s a fear of illness, mortality, and social ostracism attached to HIV that no other medical diagnosis has ever brought about in exactly the same way.
Recent studies have found that only 16% of sexually active gay men use condoms every time they have sex, so Staley argues that PrEP would now be the most effective method of combating HIV. The question of whether widespread use of PrEP would lead to more unprotected sex among gay and bisexual men, potentially increasing levels of other sexually transmitted infections, has been fiercely debated in both the gay community and the scientific community. Staley feels that the resulting “slut-shaming” that’s happening in the PrEP controversy between opposing factions of gay men “isn’t new stigma. It’s the exposure of existing stigma.”
The stigma surrounding HIV is more concentrated in cities, which is why New York City’s initiative to stamp out the virus is such a big deal. Governor of New York, Andrew Cuomo, recently announced a plan to limit the annual number of new HIV infections in New York to 750 cases by the year 2020. That figure would be roughly 5% of the new HIV cases that were diagnosed in New York back in 1993, 12 years into the AIDS epidemic.
The close attention that New York officials are currently giving to HIV/AIDS seems especially necessary for gay and bisexual men at this crucial moment in the disease’s history. A new report released by the CDC earlier this month concluded that between 2002 and 2011, whereas the infection rate for the US population-at-large decreased by one-third, the HIV infection rate during the same period among younger men who have sex with men jumped by 133%.
This dramatic increase in new HIV infections is even more pronounced among younger gay and bisexual men of color. Because men who have sex with men are statistically a vulnerable group in that regard—a subculture that’s often both stigmatized and stigmatizing where the issue of HIV is concerned—those men now need as much assistance as the global medical community and government officials can afford to provide for them. The World Health Organization recently recommended PrEP for men who have sex with men as “an additional HIV prevention choice within a comprehensive HIV prevention package.” If there was ever a time for a preventive medication like PrEP to succeed as a method of eliminating the transmission of HIV, that time is now.
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