What Is Safe Sex? The Raw and Uncomfortable Truth About Truvada

When I'm single, I don't bareback on purpose usually. I practice safe sex often enough to consider myself "always safe," even though that's not quite true. While the overwhelming majority of times that I've had casual anal sex, I've had the wherewithal and self control to stop and put on the condom I've already made sure is within my reach, there have been times when pre-sex teasing has led to penetration. I've slipped. There are times when a few condom-free strokes don't seem like they'd hurt anyone and we were both down so… I've given in to requests of full-on bare sex to orgasm on occasion, depending how hot and convincing the invitation was and how turned on I already was. It's always the exception, though. "That's not me," I tell myself during and especially after.

It's easy enough to sweep this all under the rug if nothing comes of it. If you don't contract HIV from bareback sex, was it unsafe? What does it even matter? Just do better next time and take solace in the personal rules—somewhat informed, somewhat arbitrary—that you suspect are keeping you protected: I've never gotten fucked raw by anyone who wasn't my monogamous boyfriend—I never need to bottom so badly that I'd ever let a casual acquaintance enter me without a condom.

But what hasn't harmed you in the past, if you're one of the luckily negative like I am, could still harm you when you do it in the future. Owning up to this fact is a crucial step in choosing to take Truvada, the antiretroviral drug cocktail of tenofovir and emtricitabine that's manufactured by Gilead. For years, Truvada had been used to treat HIV, but in 2012 it was also approved as pre-exposure prophylaxis (PrEP), to protect HIV negative people from picking up the virus. A study suggests that taking Truvada everyday reduces HIV transmission risk by 99 percent.

For some—say barebacking enthusiasts, sex workers, or people in serodiscordant couples (in which one person is HIV positive and the other is negative)—Truvada is a no-brainer. There are plenty of us, though, who occupy a gray area, in which barebacking isn't exactly a lifestyle, and in which contracting HIV doesn't exactly seem like an inevitability. For those of us in that group, the kind of introspection that Truvada requires is hard.

The understanding that I might benefit from using Truvada dawned on me slowly, like I was stuck permanently at 6 a.m. for a few months. It was other guys who helped prompt my decision, like the ones I had the sense not to fuck raw when they assumed that's what we'd be doing on first meeting, or the ones who tried to fuck me bare so casually, it was like they were going in there to check their mail. It was the guy who told me, "Yes, I'm negative—I was tested in February," in October. It was the guy that I hooked up with who then proposed a threesome via text: "My friend said he wants to fuck raw." This was a few texts after I told him, "I play safe," and he said, "Yeah, me too." A few texts later, he admitted he'd already fucked raw with our prospective third.

And it was the condoms that have come off or broken during sex, rendering that session raw anyway.

For an explanation of what it means to come to terms with Truvada, I reached out to University at Buffalo's Director of Humanities Institute Tim Dean, who wrote Unlimited Intimacy, the mind-blowing, highly academic 2008 book about barebacking culture. Among the several things that book taught me was to stop being so fucking judgmental toward guys who bareback regularly. In an email, he summarized the pre-Truvada thought process perfectly:

The whole idea of PrEP requires acknowledging that men want raw sex and they're gonna have it even with the risks involved. One of the major points of my book was that, for some men, increasing the risk makes sex more exciting, so that HIV/AIDS prevention programs that think in terms of risk reduction are kinda missing the point. But to acknowledge that we want raw sex entails a big risk in itself, because that doesn't fit in with the image of the good, responsible gay man who dutifully practices safe sex. To ask about Truvada for PrEP can feel like a failure for some gay men or an acknowledgement that they want to do something that even the mainstream gay community has coded as immoral. It removes the excuse factor for having bareback sex (I was too drunk/too high/too caught up in the heat of the moment). Thus part of what is challenging about Truvada for PrEP is owning your fantasies in the cold light of day, not just when your dick is hard.

Recent coverage of Truvada has asked why more people aren't taking this wonder drug that can protect them from HIV infection. In December, the New York Times reported that 1,774 people took Truvada as PrEP from January 2011 to March 2013. Almost half of them were women. "So why haven't more gay men signed up?" wrote David Tuller. "Why Is No One on the First Treatment to Prevent H.I.V.?" wondered the headline of Christopher Glazek's New Yorker piece on the drug in October. A Slate post by Mark Joseph Stern in Janaury posed the question and answered it: "The fault lies squarely in the gay community itself."

There's truth to that, which I'll get to, but I think it first lies in gay individuals themselves. It's much easier to go on believing that you don't need it, that you'll be fine because you've been fine so far, that Truvada is for sluts sluttier than yourself.

I get that. There is considerable stigma to using it. Some of my friends were horrified when I told them I was on it. I saw a few different doctors while I was on it, and they routinely asked me if it was because of my "…behavior…?" (I think the translation was, "You takin' raw loads, boy?") I made "Truvada" my Grindr screen name in the hope of finding people to interview for this piece. That didn't happen—most guys who said anything about it did so because they were HIV positive and they assumed I was too, just advertising it in code.

None of this bothered me, by the way. Once you face yourself wholly, people's interpretations of the parts you let them see matter less and less. I've been called worse than a slut implicitly. I've called myself a slut explicitly. I'm not embarrassed.

You think you're doing bad, bad shit, but then you witness the casualness so many other guys seem to have about barebacking and you realize that you're nothing compared to them...and then you come around to realizing that so many people are contributing to this and that maybe "bad" is not the right word for any it. And then you start taking a blue pill, every day, at the same time, because otherwise it might not work.

What Is Safe Sex? The Raw and Uncomfortable Truth About Truvada

There are plenty of reasons beyond allergy to introspection that more guys aren't taking this pill. For one thing, information about its effectiveness is confusing. Two figures are thrown around most often: the 99 percent effectiveness that I mentioned previously, and 42 percent effectiveness, which was mentioned in the FDA's press release announcing that Truvada had been approved for PrEP in 2012. Both figures derive from the same study of men who have sex with men, iPrEx, and both are used by the pro- and anti-Truvada fronts to bolster their arguments.

That difference of 57 percentage points can be explained easily: It reflects frequency of use. When participants in the iPrEx study took Truvada every day around the same time, it reduced HIV transmission by 99 percent compared to the placebo group. However, almost half of the participants who were supposed to be using the drug didn't take it reliably, for whatever reason. So regardless of the drug's medical effects, the overall effectiveness couldn't go much higher than 50 percent.

That may sound convoluted, but it's simplifying matters, actually. There are other numbers besides 99 and 42 percent to consider. The sites of NIH (National Institute of Allergy and Infectious Disease) and NAM (National AIDS Manual) report that iPrEx showed Truvada to have 44 percent efficacy. In a different place on NAM's site, you can find the 42 percent figure again, along with the claim that Truvada "was 92 percent efficacious in preventing HIV infection amongst those who had detectable drug levels." Back to NIH, where it says, "Those who took the drug on 90 percent or more days had 72.8 percent fewer HIV infections."

Is your head swimming yet? To clear up the meaning of it all I got in touch with Dave Glidden, the statistician for the iPrEx study. He gave me a very detailed breakdown, which you can read in the comments below. To keep things moving, I'll summarize:

The 42 vs. 44 clash came as a result of updated results: 42 was the number that the study arrived at after the subjects were studied a bit longer after the initial report. The various numbers on the higher side reflect different ways of defining "Truvada use" in light of the fact that nearly half the subjects didn't take it. Because the point of the trial was that the drug's usefulness as a prophylactic was unknown, he wrote, "this uptake may not reflect 'real-world' use now that Truvada effect is known." When researchers identified who had used the drug by asking subjects about missed doses and by checking their refill records, they found it had been 73 percent effective. When they restricted themselves to the subjects whose blood tests showed they really had taken the drug daily, they got the 99 percent figure.

Jim Pickett, the director of advocacy for the AIDS Foundation of Chicago, gave his interpretation of the results in an email:

The numbers fluctuate depending on what discrete sample of the overall study population is being analyzed. So, I am comfortable saying something along the lines of, "When Truvada as PrEP is used consistently and correctly—meaning taking a Truvada pill every day—the level of HIV protection is 90 percent and higher." While the 99 percent figure is out there, and is based on data, I am not comfortable myself using that, because that is in the context of perfect use. And perfect is something none of us are, or should even strive for.

The question of perfection divides people's attitudes toward the drug. What explains the valley between the numbers—those in the 40 percents and those that soar up into the 90s—is that Truvada is far more effective when taken regularly, as opposed to not. And that is enough for some people to be fundamentally against it.

"It doesn't work, based on the data, because people won't take it on a consistent basis," is how AIDS Healthcare Foundation president Michael Weinstein put it to me when I talked to him by phone in December. AHF has been extremely vocal in its anti-Truvada stance. Take, for example, this AHF press release regarding a survey the organization put out in response to iPrEx, in which Weinstein is quoted as saying, "There truly is 'no magic pill' when it comes to HIV prevention."

AHF reported that according to its survey, "only 63 percent of respondents said they would be 'Very Likely' to remember to take the prevention pill every day." When I was on Truvada, remembering to put a pill in my mouth and swallow it was the easiest part of my day, but Weinstein painted me a picture of people for whom remembering to take a pill every day could prove impossible, or at least very difficult.

"The theoretical possibilities for preventing infection based on people taking it every day is largely irrelevant if people don't take it," Weinstein told me. "And the evidence is that they're not taking it. So it doesn't work, from my point of view. There's no question about the fact that people will stop using condoms if they're taking this medication and they'll think they're protected when they're not. And their partners will think they're protected."

The pill assumes a baseline level of responsibility. "A person who's taking crystal and is on a bender for three days isn't going to remember to take their [Truvada]," he told me. I don't know what it's like to be on such a bender, but the scenario sounds plausible.

At the same time, though, that line of argument seems to create villains within our community—those drug-and-sex fiends who can't do anything right, who fuck it up for everybody and uphold the stereotype that gay men tend toward chaos. They're less competent versions of those reckless barebackers whose risk-taking is exacerbated by Truvada, not alleviated by it.

Countering that latter image is this study, which asked Truvada-taking, HIV negative men about their behavior and tested them for syphilis in addition to HIV. The results suggest that Truvada didn't increase the chance of infection. "Our results revealed the opposite: rates of both HIV and syphilis infections went down, and there was no increase in sexual risk behavior," said Julia Marcus, postdoctoral fellow at the Kaiser Permanente Northern California Division of Research and first author of the paper presenting such information.

Iain J. MacLeod, a research associate at the Harvard AIDS Institute, supported this with a caveat via email:

These were well-constructed studies. We're not entirely sure how the population-at-large might behave, but following those who continued to receive PrEP after leaving clinical trials seems to suggest that their behavior isn't significantly altered.

What Is Safe Sex? The Raw and Uncomfortable Truth About Truvada

What goes on outside the research environment? I talked to a few other guys who were taking Truvada as PrEP, as I had, and found the results mixed. One, Mike*, almost exclusively bottoms and is in a couple. They enjoy bringing in a third (a top) from time to time, and when they do that, they usually bareback. Here's how Truvada changed their shared sex life, according to Mike:

"Since I started taking Truvada, we have had less sex," he told me. "Because we do prefer to bareback, we are less apt to have the random Scruff hook-up with a condom than we are to just wait and do it with the guys we trust. So while many people think, 'Oh you're on Truvada now, you're just going to take loads all the time.' It hasn't been the case."

I asked a friend of a friend, Ben*, if he found that his Truvada use incentivized barebacking.

"I wouldn't say 'incentivize,' but I would say it increases the threshold for me to use a condom," he replied. "There have been situations in which I haven't used a condom where maybe I would have [otherwise]. So yes, that would be a downside, but I say that having done a lot of research on the effectiveness of condoms."

Figures range, but Planned Parenthood points to this meta-analysis of 25 different studies of condom use in heterosexual couples, which concludes, "Generally, the condom's effectiveness at preventing HIV transmission is estimated to be 87 percent, but it may be as low as 60 percent or as high as 96 percent." None of those numbers are as high as the highest numbers analyzing Truvada's efficacy, and the surveyed sex in those studies, by the way, was likely to be overwhelmingly vaginal and not the riskier anal variety. There's been no such meta-analysis on gay men, though a sort of exit poll of men who'd been diagnosed with HIV in a clinic in Seattle suggested that consistent condom use was 76 percent effective in preventing new HIV infections.

"Consistent" is the key word here. The anti-Truvada argument, after all, is that the drug doesn't work, because some gay men won't use the drug consistently. But why does it make sense to hold Truvada to a standard of perfection? Condoms are something else that a lot of gay men don't use: A 2012 George Mason University/Indiana University study of men who have sex with men concluded that "one in three acts of anal intercourse between men are condom protected in the U.S." A recent study of young gay men in London by the University of Westminster found that eight out of ten of them had bareback sex with a stranger.

"Condoms aren't enough," Pickett told me in a phone interview. "If condoms were enough, we wouldn't be having this discussion, we wouldn't have a global pandemic, we wouldn't have 2 million new infections a year, because everyone would just embrace condoms and use them each and every time they had sex."

Pickett pointed to a variety of reasons why people fail to use condoms, among them getting caught up in the moment and "forgetting," or not having a strong enough erection.

I'll add another reason to that: Condomless sex is just better. The best sex I've had, sex that has made me understand gay culture in new ways, has been raw. I generally don't have problems with condoms, but on a sensory level, I'd always rather not be wearing one.

For all the statistical and medical issues I looked into surrounding Truvada, the heart of the question was barebacking. That is what we talk about when we talk about Truvada. That is why we don't always like to talk about Truvada.

Truvada discussions have a way of devolving into the worst sort of online shouting matches. Discussing gay sexuality, especially of the promiscuous sort, is not easy. The culture has swung from the bacchanalia of liberation to the life-or-death insistence on sexual responsibility in the shadow of AIDS. Sometimes it feels that we've learned responsibility too well. There's this belief that we're going to scare the straight people repulsed by our sex away from granting us our rights. There is an urgent mandate to behave, which means not engaging in risky sex and for god's sake not talking about it.

Before you condemn the community or irresponsible gay men, it is probably helpful to think about these words from Pickett:

"You're here because people barebacked. Your grandmother was a barebacker. That secretary in your office, when you're invited to her baby shower, she's a barebacker. You're bringing gifts for someone who engaged in risky fucking behavior. What the fuck are you doing? She's a bad person. We would never [say] that. We're like, 'Yay! You're pregnant! What is it? Woohoo!' With a gay man, it's like, 'Oh my God. You're reckless, you're careless, you're insane, you're self-destructive, you want to hurt yourself and others.' And we ignore the fact that gay men have the same needs to feel close and intimate and pleasure. For a lot of people, condoms get in the way. That just is. That's just a fact. And if you can use a condom yourself and that doesn't interfere, again, great for you. Hallelujah! Keep doing it. But if you can't, that's not a mark against you."

What Is Safe Sex? The Raw and Uncomfortable Truth About Truvada

Pickett, like many of the pro-Truvada people that I spoke with, believes in having multiple prevention options for people and acknowledges the reality that Truvada is often used on its own. If one is going to choose sides between condom and PrEP, he said, Truvada's is a reasonable side to choose:

"Truvada actually has a level of forgiveness that condoms don't," he said. "[Truvada's drug levels] don't plummet if you miss one day. They don't go from 100 to zero in one fell swoop. So they're thinking that taking three or four doses a week keeps enough drug in your system to be protective."

But keeping the drug in the system means also exposing yourself to a new set of risks, from its possible long-term side effects. Truvada can reduce bone density and alter kidney function, though recently published results from the ongoing iPrEx study found that kidney function returned to normal when Truvada use was stopped. Said MacLeod:

There are limited data at the moment on long-term side effects of Truvada use in HIV-negative individuals. The majority of the work has been with HIV-infected individuals who are clearly expected to be taking Truvada for a long period of time, with the major possible side effects being kidney damage, and loss of bone density (which could lead to increased risk of fractures/breaks). HIV itself is a risk factor for kidney dysfunction, so we have to tease out the effects that Truvada may have when using PrEP in HIV-negative individuals. A study was published in early September that followed HIV-uninfected men for two years while using PrEP, and other than some back pain, there were no adverse side effects associated with taking tenofovir (of the two drugs in Truvada, the one that is thought to be more toxic).

"People who are at risk for osteoporosis they need to understand that it's a medication that can accelerate the development of that," Dr. Stephen Dillon, who has a practice in New York and says about two thirds of his patients are gay. "The reality with PrEP is we're still learning a lot about it. The medical community is still trying to figure out how to best implement this."

Dr. Dillon says he takes a "reasoned" approach, and mainly recommends PrEP to guys in serodiscordant couples or sex workers. For other people, he was much more enthusiastic about PEP, or post-exposure prophylaxis, a sort of 30-mornings-after pill in which a month's worth of Truvada is administered to an HIV negative individual who fears recent HIV exposure (treatment can start any time up to 72 hours after the potential exposure, but the sooner it's taken, the better).

"The other piece to this is if it's not taken daily, the risk of failure is higher and not only that but if a person were to acquire HIV, if PrEP were to fail while they're taking Truvada, the development of resistance to Truvada can happen fairly quickly," Dillon told me. "And as a result, we'd be losing an excellent backbone for most therapeutic combos."

Such resistance is scary on a personal level, for everyone living in the world where HIV infection is a possibility. Antiretroviral drugs have been so effective that this study suggests proper treatment has the life expectancy of HIV positive men approach that of the general population. These meds are key to continued survival.

But it's also scary in terms of the bigger cultural picture. It suggests that by not taking Truvada properly, PrEP men who sleep with men could become responsible for a burgeoning strain of Truvada-resistant HIV that can be transmitted to people who were never on Truvada, people who maybe opposed its use for this very reason.

It's just a new example in a long line of examples of how individuals' behavior can affect the group—or more specifically to this case, how the potential for group harm can cause preemptive condemnation from more sanctimonious members of said group. "Stop doing that, it's bad for the culture," is a common refrain within various minorities, and it's particularly shrill within the gay community.

Pickett told me he believes drug resistance is "something to be watchful for," but not a huge concern of his for a few reasons. One is that resistance is common in the world of HIV medications. He said he's HIV positive himself, and has been on various meds since 1997, building up resistance to "a whole bunch of drugs over the years."

And because maintaining a Truvada prescription requires a comprehensive HIV test every three months, Pickett suggested that there would be opportunity to keep a mutant strain of the virus contained:

"And if you were going in for your refill and it was found out that you were actually positive, they could immediately determine what kind of strain of HIV you have. If it has any kind of genetic alterations due to it being exposed to a certain drug, suboptimal levels of drug, that could be determined. It could also be determined that you don't have any drug in your system. And if you don't have drug in your system, you can't be resistant. You also can't be resistant if you don't become HIV positive. People get confused about that a little bit, like the drug itself can create resistance. Well, the drug has to be at suboptimal levels and come into contact with HIV. If you don't come into contact with HIV, no resistance. If you come into contact with HIV and you don't have any drug in your system, no resistance. It's just that suboptimal part. But it's a harder thing to happen than I think people think about."

Dr. Dillon explained that the regular testing includes kidney function tests, HIV antibody tests, and a test called PCR for viral load. He also named a potential complication in prescribing Truvada:

"Insurance companies are giving us a push-back about covering PrEP," he said. That, I would learn, was almost prohibitive in and of itself.

What Is Safe Sex? The Raw and Uncomfortable Truth About Truvada

My doctor (who, for the record, is not Dr. Dillon) didn't hesitate or attempt to talk me out of it when I told him I wanted to go on Truvada. In fact, he facilitated it beyond his obligation. Acknowledging the push-back from the companies who don't want to pay for the prolonged deviant ways of gay men, he told me that instead of a prescription for a 90-day supply, he'd write me one for a 30-day supply every month. Insurance companies see that and figure it's for a 30-day course of PEP, not the open-ended PrEP use, so it's less likely to raise red flags.

He sent the prescription to my pharmacy. The email notifying me that my prescription was ready informed me that this would cost me $1,389.99. "Welp," I thought. "There goes that idea. I don't need it that badly." Not that I could afford it if I did. Gawker hardly pays me a gay porn salary.

Gilead, the drug manufacturer, offers to defray part of the cost of Truvada through in its Co-Pay Assistance program. A phone call to the company let me know that they pay up to $200, and that only insured parties are eligible to participate.

I called my insurance company. The woman on the phone told me that my prescription hadn't even been run through insurance, and explained that I needed a precertification in order for that to happen.

I got back in touch with my doctor to ask if he could make that happen. He confirmed that he would.

A day or so later, I received a new email notification that my prescription was filled, this time for my normal co-pay of $30. That was not unreasonable, but given the co-pay program, I let Gilead handle it, which meant putting in another call to my pharmacy to give them the information that the drug company had given me.

You can see how someone with less patience for red tape, less inclination to make calls and figure out why the fuck he was being asked to pay more than $1,000 for a 30-day supply of just-in-case medication, might have given up and not bothered getting the pills.

But I persevered and eventually got my supply, paying nothing out of pocket. The next morning I was excited to start taking this thing, as though it would give me something I could feel beyond a reinforced sense of security.

Unfortunately, I discovered that taking Truvada gave me too many new things to feel. Whatever short-term side effects I could get, I did. Less than a week out, I started to feel a deep sense of fatigue every day around 6 p.m. It was something I could power through and eventually shake, but it made me feel like dropping to the floor and passing out instead of going to the gym or attending movie screenings. I had perpetual muscle soreness, especially in my legs, as if I had squatted way more than I should have the day before. My skin got worse. I developed a disgusting, raised rash on my torso that my dermatologist told me was the result of a nickel allergy (I had been wearing the culprit belt for years). I was gassy.

Truvada gets compared the birth control pill a lot. To me, what it had most in common with that contraception was that it was something that was supposed to help people relax about sex, yet it made me more uptight, more self-conscious.

My time on Truvada wasn't a particularly promiscuous time for me, anyway. And soon after starting to take it, I found myself in a relationship that got pretty serious pretty quickly. In that sense, I guess, Truvada did incentivize bareback sex, but it was bareback sex that I would have been having eventually anyway. To me, the freedom to go raw is a prime advantage of monogamy.

I was prepared to take Truvada indefinitely, though, even with the side effects, which seemed to ebb a bit as time went on. I could never be sure, too, what was a result of the Truvada and what was my body just doing bodily bullshit, or even worse, psychosomatic bullshit. Sometimes I get a zit or two for no reason, despite my daily use of a retinoid. That's life.

In that respect, the constant evaluation and causal uncertainty reminded me of the way I regarded by body before I was on Truvada, when every sneeze and cough could be a sign of illness. A-choo! (Is that HIV?) Cough, cough. (Is that HIV?) It will take a drug far stronger than Truvada to rid gay men of their body consciousness and paranoia.

The day I discontinued my Truvada use was the day I woke up with a migraine so bad that I threw up as a result of the pain, despite zero nausea. It felt like a small monster was attempting to pop itself out of my head through my right eye. Truvada is not generally regarded to cause migraines, though an infectious disease specialist I visited told me she had seen the drug affect neurology before. Putting this drug in my system was the biggest alteration that I had done to my body since I quit smoking cigarettes almost nine years ago. I didn't want to risk it and, no longer single, there was little reason to stay on something that I suspected was causing me pain.

The migraines became more frequent in the two weeks after I discontinued my Truvada use. And then they stopped. But the longer I've been off Truvada, the better I've felt. It's been over a month, now, since I've experienced one. It could be causal. It could be corollary. Whatever, I'm better.

Truvada isn't for me, but that doesn't mean I'm against it. Everyone I've talked to who's on it, everyone I've read who has written accounts of their experiences on it as PrEP, says they've experienced little to no side effects. I'm not surprised, I tend to be sensitive to drugs. Most gay men won't go through what I went through, and for that reason, I think most sexually active gay men should at least consider going on it. To me, it sits alongside marriage as something that probably isn't for me, but something I'm damn happy to have the choice to reject, as opposed to having that choice made for me.

*Pseudonyms

The original version of this story misquoted Jim Pickett as having claimed there are 10 million new HIV infections a year. The number is actually 2 million and his quote has been corrected.

[Image by Jim Cooke]