FS Magazine Upfront PrEP and sex shaming By Matthew Hodson | @matthew_hodson How do you feel about the sex that you have? Is it all good fun, or is it something that, deep down, you still feel bad about? Is the sex that we enjoy something to be celebrated or something to be ashamed of? And how do you feel about the sex that other gay men have? It may seem odd to even ask these questions but really, there’s nothing more central to improving sexual health than to consider how we, as gay men, feel about the sex that we’re having. Lurking in the back of many of our minds remains the notion that the sex we have (i.e. sex between men – for the majority of FS readers, in any case) is wrong. Within our communities there is a rich seam of disapproval of other people’s sex lives. You hear it in the stigmatisation of gay men living with HIV: that they deserved it because they had the wrong type of sex, or sex with the wrong number of people. I see similar corrosive language used to describe PrEP (pre-exposure prophylaxis – a prevention technology where HIV-negative men take some of the drugs that are used to treat HIV, which helps to prevent them from acquiring HIV if they are exposed to it). You don’t have to dig deep into any discussion of PrEP before you come across people who will dismiss it on the basis that it ‘just encourages irresponsible behaviour’. This leaves me wondering whether there is an element of that conversation that comes from a belief that all gay sex is somehow a bit wrong and that therefore we don’t really deserve to enjoy it. Before effective treatment came along, when we had lost thousands of lives to AIDS, I’m sure the idea of a pill that could prevent infection would have been hailed as little short of a miraculous gift. Now, with a greatly reduced death toll, just such a treatment has been tested and found to be effective. In fact, the evidence of PrEP’s effectiveness is so great that two major trials have just closed down their control groups (i.e. participants who weren’t actually receiving PrEP) on the basis that it wasn’t ethical to risk their health when infections within these groups could be prevented. Instead of greeting this news with joy (and demanding availability on the NHS) voices have been raised suggesting that PrEP is just the final proof that gay men are not fit or responsible members of society. PrEP isn’t a magic bullet. It isn’t going to prevent all future HIV infections. For one thing, and this is crucial, many men just aren’t interested in taking it. The prospect of having to take daily medication, potentially with side effects, is a cost higher than some are willing to pay. It also won’t do anything to prevent other STIs, such as gonorrhoea or herpes. Condoms are far cheaper and have fewer side effects. But just as PrEP isn’t going to work for everyone, neither do condoms. The truth is that for some men the cost of wearing condoms (in terms of loss of spontaneity, intimacy or sensation) is too great for the benefit of the considerable reduction in the risk of transmission. You may not agree with that particular cost/benefit analysis, you may think it’s self-destructive or selfish – plenty of people do – but can you convince that individual that they’re wrong? If you can’t we need more options. I’m not advocating that we medically treat our way out of this epidemic. I’m a proud advocate of condom use – and also of any other strategies that can prevent new HIV infections. However I am happy to argue that we should take advantage of any tools that are presented to us that can prevent transmission. I’m not arguing for all gay men to be put on PrEP but there are a number of men who, by their behaviour, are likely to become HIV-positive in the next year. They are not hard to identify. They are showing up at GUM clinics on a regular basis with a range of STIs. For these men, PrEP could make the difference between sero-converting, or remaining HIV-negative. That’s the difference between a lifetime of treatment and care costs and a much smaller bill for providing an intervention when they most need it. It’s time to stop blaming and shaming. It’s time to support and prevent. If you would like to add your name to the many organisations and individuals who are calling for PrEP to be made available to those who need it, please sign the petition at: http://www.prepaccess.org.uk/. More about Prep: www.gmfa.org.uk/PrEP Matthew is the Executive Director for NAM.