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By Ryan M. Leach
In the arsenal of tools available to us to help prevent the spread of HIV, it is important we understand that there are viable options to consider in addition to condoms. Although condoms have proven to be very effective in preventing numerous sexually transmitted infections, relatively easy to access, and considerably the most widely known, there are other forms of treatment and prevention that can add another layer of protection to what condoms already provide. For people who are HIV-negative, there are other options like PrEP, or Pre-Exposure Prophylaxis known as the drug Truvada, administered as a once-daily pill that has proven to be over 90 percent effective at preventing the transmission of HIV. For people who are HIV-positive, there is a prevention tool with the two-fold benefit of improving and extending the life of the HIV-positive person as well as creating another barrier of transmission between an HIV-positive person and their HIV-negative partner. That tool is called “Treatment as Prevention” or “TasP.”
The stigma surrounding HIV has had a lingering effect on people who are HIV-positive. The sting of rejection is often a familiar feeling for many people who are living with the virus. This is due in large part to how HIV was addressed in its early days and then the subsequent criminalization of people who were HIV-positive as a reaction to the disease. Much of the early response to the virus was out of fear. It was not until people outside of the gay community started contracting HIV that the U.S. government even acknowledged there was a major pandemic happening, and even then it took the LGBTQ community and groups like ACTUP (AIDS Coalition to Unlock Power) to draw attention to the necessary research needed to bring us to where we are today—an imperfect but improved world for many living with HIV. Ironically, when people reject alternative forms of prevention because of stigma it can lead to more infections.
“TasP” or “Treatment as Prevention” is an HIV-prevention intervention where treating the HIV-positive person with antiretroviral medication is used to reduce the risk of transmission of the virus to a negative partner. Of course, the primary purpose of antiretroviral treatment is to treat HIV in order to improve and extend lifespan. TasP is a secondary benefit of treatment. It is important that we understand the value of TasP in this fight to end HIV, because in doing so it opens up opportunities to help prevent the virus from spreading by educating people—both negative and positive—that there is life and love with and for those with HIV.
I will be the first to admit that I was skeptical about TasP. As a person who grew up in the early days of HIV, I too suffered from the stigma of HIV. At a young age I felt that as a gay man it was my destiny to become infected with and die of HIV/AIDS; this in large part lead to my time in the closet. Although sex education expanded its scope to educate people about the benefits of condoms, there was always the specter that condoms are not 100 percent effective and that if you use them and they break you will get HIV and you will die. This is also the same approach some educators have to preventing teen pregnancy. My experience may be a bit overwrought, but it is not unique. Our society’s perspective on sex and sexual health is puritanical. However, the problem with using fear or shame as a prophylactic is that it has never effectively prevented the transmission of HIV. Condoms, PrEP, and TasP have a significantly higher success rate. The looming effects of shame cause people to hide. People who are hiding are not actively engaged with the most effective methods of prevention and still they have sex.
I had the opportunity to talk with John, a man living with HIV who recently ended a long-term relationship with his HIV-negative partner. John asked not to use his real name, as his ex-partner was uncomfortable with being associated as a person who dated and was intimate with an HIV-positive person. John, who is also a professional in the HIV treatment and prevention field, said this, “Throughout our relationship, we always used condoms. I was fine with that, but I realized that I wanted to have a deeper level of intimacy. I knew that I was taking my medication as prescribed, that I was healthy and that my viral load was undetectable. I also knew that he had access to PrEP and that the science showed that because of my treatment as prevention it made the chances of transmission even less than with use of condoms or PrEP. We were in a loving, monogamous relationship for years, and we never had condomless sex. I needed a different level of intimacy and I knew that it was supported by science, but he was unable to take that next step, so we decided to end our relationship.”
As I was listening to John, I wondered if I would have had the same reaction as his ex. As an HIV-negative person who is on PrEP and well-informed regarding HIV-prevention methods, it is still difficult for me to come to terms with the fact that proper treatment and preventative measures will protect me form transmission when I know that my partner is HIV positive. I needed more information. I found studies tracking this particular topic that supported what John said. They indicated that TasP is effective.
In August 2011 the HIV Prevention Trials Network published results from a study that showed that early initiation of antiretroviral therapy (ART) reduced sexual transmission of HIV among serodiscordant (one HIV-negative partner and one HIV-positive partner) heterosexual couples by 96 percent. This reinforced several other previous studies with the same outcome. In regards to men who have sex with men, the San Francisco Men’s Health Study found the introduction of ART in 1996 was potentially linked to a decreased incidence of new HIV infections within gay serodiscordant couples. This was true even though not all of the men in the study consistently adhered to their treatment regimen. There is however limited evidence to show that TasP provided the same prevention benefits to non-monogamous couples as it did to monogamous.
John put it to me like this: “I always encourage people to use condoms if they are engaging in sex with partners with whom they do not actually know their status or level of treatment. Just because someone tells you they are ‘undetectable’ or even HIV-negative, it doesn’t mean that it is true. It is also important to remember that PrEP and TasP may only protect from transmission of HIV, and they are only effective if you are taking the medication as prescribed. Neither of these forms of prevention will protect you from other STDs. However if you are in an intimate relationship with someone where you know all parties are taking care of themselves, then you have other options. My point is that we do not have to be afraid of dating or even being intimate with a person because they may be HIV positive. You can have a healthy, intimate relationship with that person because the tools are out there.”
The point of TasP, PrEP, and condoms is not to encourage or discourage people from engaging in certain behavior. Preventative tools don’t come with an endorsement or a judgment. They are there to help us all be healthier and happier. They are there so that we can look past our misperceptions about HIV or any other disease and really look at the person. To mischaracterize the intent behind preventative tools is dangerous and will ensure that HIV or any other disease is never eradicated. No one has ever looked at a box of condoms and thought, “You know what, I wasn’t going to go have sex with a stranger today, but I think I will now.” However, people do find themselves in situations where they are engaging in sexual activity and are a lot happier to know that those tools are at their fingertips.
You have options when it comes to preventing HIV and other STDs, and those options open up the doors to new personal opportunities—maybe even falling in love with someone that stigma might have prevented you from loving before. LGBTQ people have never won any of our victories in the closet, and no disease was ever eliminated in the closet, either