A standing-room crowd turned out to discuss changing rules around condomless sex and other HIV prevention options at a recent Real Talk forum sponsored by the San Francisco AIDS Foundation, Magnet, Positive Force, and the Stop AIDS Project.
Today safer sex goes beyond just condoms and includes strategies such as serosorting (having sex with people of the same HIV status), seropositioning (choosing sex acts and top or bottom positions based on status), and using antiretroviral drugs as prevention before or after exposure. About 40 percent of HIV-negative gay and bisexual men and half of HIV-positive men reported using any seroadaptive strategy, according to a 2008 Stop AIDS Project survey.
An anonymous audience smartphone poll at the December 3 forum, held at Magnet in the Castro, revealed that 100 percent of attendees had ever had sex without a condom, 80 percent said the rules around condomless sex are changing in San Francisco, and only 37 percent thought condom use is now the norm. Most reported that they'd had sex with someone of a different HIV status, or didn't know whether they had.
"Condom use has been a pendulum," said Daniel Ramos of the AIDS Healthcare Foundation, who is HIV-positive and until recently was in a long-term sero-discordant relationship. "People got exhausted being force-fed the message to use them."
Based on his experience as an HIV test counselor and community organizer at Magnet, Jared Hemming believes gay men are using a broad range of tools. "The rules are definitely changing and people are using different strategies," he said.
"We have come a long way since 'Play Fair' and 'How to Have Sex in an Epidemic,' and we have more tools in our toolkit," agreed Alan Guttirez of the Lavender Youth Recreation and Information Center, referring to two pioneering safer sex resources.
But "getting new technologies and strategies doesn't mean letting go of old strategies that are working, it means diversify," emphasized Chrissy Scardina of Stop AIDS, which is now part of the AIDS foundation.
Dr. Joanna Eveland of Mission Neighborhood Health Center gave an overview of local HIV and sexually transmitted infection trends. According to figures from San Francisco City Clinic, gonorrhea, chlamydia, and syphilis rates rose between 2008 and 2012, suggesting that more people are having unprotected sex. But the rate of new HIV infections has remained stable, which may indicate that more men are using safer sex strategies that protect against HIV but not other STIs, she explained. There was small uptick in HIV incidence between 2010 and 2011, but it is too soon to tell whether this is the start of an upward trend.
"San Francisco is ahead of the game" when it comes to HIV testing and treatment, Eveland said. While the Centers for Disease Control and Prevention estimates that 20 percent of people with HIV nationwide do not know they're infected, that figure drops to around 7 percent locally.
San Francisco was the first city to recommend that everyone who tests HIV-positive should consider treatment regardless of their CD4 T-cell count, both for their own health and to reduce the risk of transmission. While only one-quarter of people with HIV nationwide have been tested, entered care, and achieved viral suppression, according to the CDC, in San Francisco the proportion is closer to half. San Francisco also has a lower average "community viral load" than other cities with high HIV rates.
What about PrEP?
One of the newest tools in the prevention toolbox, PrEP, or Pre-Exposure Prophylaxis, received considerable attention. An audience poll showed that 23 percent had either used PrEP or had a partner who had done so.
The iPrEx study of men who have sex with men found that daily PrEP using Truvada, Gilead Science's tenofovir/emtricitabine combination pill, lowered HIV infection risk by 44 percent overall, and by more than 90 percent among participants who had blood drug levels indicating that they took it regularly, Hemming explained.
But Eveland stressed that Truvada "is not a morning-after pill" and must be taken every day. Studies are under way looking at intermittent PrEP taken before and after sex, but so far research only supports daily use with good adherence.
Scardina recalled that he first heard about PrEP after doing antiretroviral post-exposure prophylaxis, or PEP, after sex to prevent HIV from establishing infection. He then enrolled in City Clinic's PrEP study, which provided him with a year's worth of Truvada.
"Truvada has worked really well for me," he said. "I haven't relied solely on PrEP and still use condoms depending on the situation."
Speaking from the audience, activist attorney David Waggoner said he started taking Truvada PrEP four years ago before it was approved by the Food and Drug Administration for this indication. He, too, had taken PEP after unprotected sex and asked his doctor if he could just stay on antiretrovirals for prevention.
As for why PrEP has not "caught on like wildfire," Hemming noted that it can be a challenge to take pills every day. In a majority of PrEP studies, most people did not take it as directed. Some people are also concerned about PrEP after seeing the debilitating side effects of older antiretroviral drugs.
"People are scared of what it's going to do to their body," he said.
Truvada is generally well tolerated but can sometimes cause kidney problems and bone loss. According to Eveland the most common side effects are fatigue and gastrointestinal symptoms. But Scardina said he has had "barely any side effects," while Waggoner reported that he "never had any side effects at all."
The cost of Truvada - about $1,000 per month - is also a potential barrier. Scardina just turned 26 and has to go off his parents' health plan.
"I'm running out of pills and I don't have insurance," he said.
Even for people who are insured, Truvada for prevention may be hard to come by. Waggoner related that a friend seeking PrEP from Kaiser Permanente was required to go before a panel of doctors to be questioned about his sexual behavior and level of risk. However, Waggoner noted, Gilead offers a patient assistance program for people who cannot afford Truvada.
Slut-Shaming
Several panelists and audience members brought up the issue of "slut-shaming," or moralistic objections to people who use PrEP or other risk-reduction strategies instead of always using condoms.
"Science is still lower on the hierarchy than morality," Waggoner said. "Puritanical ideas are guiding social policy."
Said Ramos, "As a positive person, I feel if I said 'I love to take loads and give them' I'll be stigmatized ... People will say 'Typhoid Mary is running around.' The onus on the positive person has been unfair for awhile, and it's good to see negative men now taking responsibility."
Guttirez said shaming is a scare tactic.
"Not having the trauma of losing all your friends has impacted the way [younger gay men] have sex and the harm reduction strategies we employ. Shaming from elders in an effort to be supportive comes off as a scare tactic that I don't think is successful," said Guttirez. "There's a lot of room for queer and trans people to grow together talking about HIV intergenerationally. We don't have to leave these conversations in the bedroom."