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Condoms optional: Promoting the PrEP philosophy

Posted in: Safe Sex, Features
By Jay Bennie - 14th March 2015

BlueBaily_350w.jpg
Blue Bailey
An outspoken advocate for backing off primarily reliance on 'condoms every time' as an HIV prevention measure says New Zealand's gay and bi men should instead rely on “gut feel,” trust and a conversation to decide whether a potential sex partner could infect them with HIV.

And he believes promoting condom use shames and stigmatises men who have sex with men.

The views of San Francisco-based porn performer Blue Bailey, currently in New Zealand filming a documentary about himself, are in line with a rising movement in many overseas gay population centres such as London, San Francisco and, closer to home, Australia.

Before we meet Bailey and discuss his stance, let's background the situation vis a vis HIV prevention techniques and results.

Almost uniquely in the world, ongoing research indicates strongly that New Zealand men who have sex with men have a sufficiently high level of condom use, giving us one of the lowest domestic HIV infection rates of any comparable western nation. Only in a couple of Scandanavian countries and the Canadian province of British Colombia is this also the case.

In the rest of the world, over the three decades of the HIV epidemic, a condom culture never caught on sufficiently amongst gay and bi men to get HIV under any semblance of control. The consequence has been massively high levels of HIV in those communities and a skyrocketing increase in new infections. For example, one in four San Francisco gay and bi men are infected with HIV and in the gay-dense suburbs of Sydney the figure is similar. In desperation, and backed up by emerging medical research, those other communities have reached out to two medication-based techniques which have become available in recent years.


PREP TO WARD OFF HIV

The pre-exposure prophylaxis, or PrEP, technique relies on those who don't want to, or can't, use condoms instead adopting a pill regime of anti-HIV medications in order to see off the virus should they be exposed to HIV. The medications, mostly based on the Truvada pill, must be taken regularly and reliably, are not necessarily effective against those mutations of HIV which have or will become resistant to it and are way more expensive than the few cents a condom costs. For example, in the USA state-funded Medicaid programmes and health insurance companies - for those who are insured – will contribute towards the approximately $NZ1,700 monthly cost of Truvada alone.


TREATMENT AS PREVENTION

The other drug-based HIV prevention technique, treatment as prevention, relies on identifying as many HIV-positive men as possible and getting them on to rigorous HIV combination drug therapies as soon as possible. If successful, and it frequently is, this 'drug cocktail' approach can lower the level of HIV (aka 'viral load') in the body so low - it never entirely disappears - that the person's immune system is not under such constant attack and they are also unlikely to pass on their virus to others. But the down-sides are similar as for PrEP and there is much research to show that people, gay or straight, are not as good at maintaining their vital medication regime as they believe they are.

Blue Bailey, a San Francisco-based porn actor in his late 20s who has HIV and whose videos have included bareback sex, is getting ready to leave the erotica industry. He has teamed up through social media with a small New Zealand video production company to make a documentary centered around this transition from porn to law student.

“I'm very outspoken about my views about HIV and PrEP and [the producer] thought that was very interesting and he really liked the aspect of transitioning out of porn into a law career... I thought it would be an awesome opportunity and open up many doors to become perhaps more of an advocate for young men living with HIV and to promote new research that's coming out and educate people.”

One of his most contentious porn videos featured, in the prim description of the South Florida Gay News, “a jar of white liquid poured into his body. The film horrified as many people as it titillated. Viral Loads has been accused of fetishising HIV.”

Like increasing numbers of men living and fucking in HIV-dense gay communities overseas, Bailey believes promotion of condom use to prevent HIV infection is out of touch with the reality of the HIV epidemic today. “Safer sex practices have evolved in that safer sex doesn't necessarily mean abstinence or condoms only,” he says. “Safer sex can be a conversation about statuses and positions, for example risks associated with top or bottoming, safer sex can mean getting on PrEP or it can mean playing with somebody who is undetectable and can't transmit the virus. There are many more options in the safer sex arsenal as opposed to just condoms only.”

Amongst men who have sex with men, here in New Zealand as overseas, many sexual encounters are casual. Does a man relying on such a conversation know that the person he is talking to is either being honest or even genuinely knows his HIV status at that moment in time?

“You don't know and that's going towards the argument that people who are HIV positive and [whose viral level is undetectable due to medication regimes] are actually safer sex partners than somebody who may think they are HIV-negative.”

But how does somebody who is HIV negative and who is making a very important decision based on what a person is telling them know for sure that that person's HIV level really is currently undetectable?

“You kind of have to go by your gut and trust the other person and ask them and trust the response,” says Bailey.

GayNZ.com: Do you believe that all sexual partners can be trusted to tell the truth, or to know?

“No, but I think that if someone is HIV positive it is in their best interests to take their meds. So it just seems illogical that somebody wouldn't be doing that. And of course people screw up but the efficacy rate of taking your meds and screwing up for a couple of days I don't think [the viral load] would be affected. I think you would have to go for a period of time before that risk is really increased.

Given that having HIV is quite debilitating, even at the level of having to take pills day in and day out, does Bailey think it's still valid for somebody to place their entire future, and the effect getting HIV would have on the rest of their life, in somebody else's hands, possibly a stranger who they met just ten minutes ago?

“That's a personal risk that somebody has to make for themselves, I can't make that for them. If that person were on PrEP then that would reduce the chance of transmission and reduce that anxiety and fear of contracting the virus. It all gets down to a personal choice: don't have sex with shady people if you're having a fear of HIV or STI infection. You should be able to have a conversation with your sexual partner and be able to trust their answer... if you can't trust that person then maybe you shouldn't be having sex with that person.”

GayNZ.com: “How do you know who's a shady person?”

“I would define that as... maybe not use the word 'shady' but somebody having sex with a person who's 'partying' a lot or who is having IV drug use then they might not be comfortable having unprotected sex with them. Whereas if you just met somebody at a bar that might be a little different. It's all a personal comfort level.”

GayNZ.com: “Do you think that is worth going on trust just to have condom-less sex? Does the risk balance weigh up there?”

“Yes,” says Bailey, more emphatically that at any other point in the interview. “I think that you should be able to trust your sexual partners, you should be able to trust their answer.”

For a man who contracted HIV from someone who has already contracted HIV Bailey's trust in 'trust' seems anomalous at best. How does a person know when someone is telling them, perhaps genuinely or perhaps not, that they are on medication and therefore their viral load is extremely low - or even that they don't have HIV at all - that that is the situation today? For instance, somebody who had their most recent viral load test a month or two ago and was then undetectable or very low could for any number of reasons today be higher, something that with the best will in the world does happen.

“Again, it goes back to trusting your sexual partner and I believe that it's the norm that if you are taking your meds your viral load should be suppressed."

For this strategy of conversation and trust, how do we educate people so every time they make one of these assessments they get it right?

“We educate people by allowing them every single option available and not stigmatising one option or the other.”

GayNZ.com: "You are HIV-positive, do you think you would have this same attitude if you didn't already have HIV?"

“Yeah, I absolutely would. I actually wish that PrEP was around when I contracted HIV because I don't think I would have [contracted it].”

If he was having sex with another man who asked if they needed to use condoms, what would his response be? For Bailey there are three HIV states rather than the usual and more basic two, of being HIV-negative or HIV-positive.

“First and foremost it is more than likely, certain that I have an undetectable viral load... I would disclose my status as both being HIV positive and undetectable and I think it is important to have both of those statuses disclosed. I really think it's important to add that third status. Furthermore, I would tell him that it's really based on what sex we are having, the risk that he needs to assess for himself. I am more of a bottom so somebody topping me, that's undetectable, bareback... that represents little to no risk. But in the end that's the other partner's choice."

And does Bailey himself know that at that moment he definitely has an undetectable viral load?

“Yes. I have been positive and on meds for seven years and I have been undetectable for every single lab test.”

GayNZ.com: “Do you think everybody is capable of making informed choices at a moment of heightened sexual passion; that they can put aside for a moment the urge to get it on and make a good decision?

“No, I think people sometimes make bad choices or mistakes. But think about this in terms of a condom... when you're in the moment you may not use a condom. However, if you are taking other measures such as taking prep as prescribed then when you're in that moment and you forget to sue a condom then you have an additional layer of protection there.”

Perhaps it is no coincidence that Bailey hails from a gay community in which bareback sex activists are particularly vocal, calling themselves 'Truvada Whores,' with branded t-shirts and aggressive promotion and visibility. Why is that attitude so strong in San Francisco, one of the world epicentres of HIV amongst gay and bi men and whose gay population was decimated due to AIDS in the 1980s and 90s?

The Truvada Whore movement is, according to Bailey, “a preemptive strike, to take the words Truvada Whore and take the negative association with it and turn it into a positive and an affirmation. And to claim this word before it is used negatively against our people. San Francisco is one of the gay meccas for the United States and I believe a lot of the preliminary trials started in San Francisco and the pharmaceutical companies are based near San Francisco so we had access to it first.”

Moving from personal to public health, in New Zealand we have a situation which is not common in the world in that we do have a very high reported rate of condom use and a very low HIV infection rate. Does Bailey think that what he is suggesting might lead, in our situation, to a loss of control over the epidemic as has happened in places such as San Francisco?

“Your questions seem all very skewed towards condom use.”

GayNZ.com: “Well, we are skewed very much towards condom use here in New Zealand. It is the predominant culture here.”

“Sure, you're of course going to have a 'high rate of condom use' if the data you are using is self-reported. As for adding PrEP to the mix, you are already having these [condom-less] practices going on so I don't think that is going to affect people's behaviour, I think it's going to add a layer of protection to whatever behaviours are already occurring. If you claim that you have a culture of condom use then why not give people another option.”

Reflecting on his participation in bareback porn, how much does Bailey think people pick up from porn their cues about what is sexually ok, exciting or acceptable... or safe? How influential is porn on how people have sex?

“I personally don't think porn is influential at all for having sex. For example, in people who are predisposed to violence a violent movie might bring out violent tendencies in them... and the same thing if you are predisposed to having bareback sex it may increase that for you. But then you are already participating in that activity so I don't think it's going to change your mind. Porn is entertainment and it is not meant to be educational."

GayNZ.com: “Does it not normalise whatever it represents on the screen?”

“Is not unprotected sex normalised activity? That's how people reproduce. Just because there's a negative stigma attached to gay men who have sex I don't think it's wrong to normalise it.”

GayNZ.com: “And do you think there is a stigma against gay men in this regard?”

“Absolutely. I think that our community had to have a response to HIV and AIDS in the 1980s but I also think that we are in a new era and it's not the same threat that it was before, it's a whole different game and we need to approach it a different way. And we now have new tools.”

GayNZ.com: “They are quite expensive tools aren't they?”

Bailey ignores this question and suddenly swings the conversation over to how his own role in this debate is perceived.

“In terms of being a porn performer there's this weird split where I am viewed as being both some vapid, pretty performer who just goes out and fucks but I am also expected to be an educator for people. It's a weird split that occurs and it just doesn't make sense to me.”

GayNZ.com: Are those the only two choices?

“I believe there is a third choice... porn is entertainment and you have the choice of using your platform to promote something outside of porn but the actual porn itself should be viewed as entertainment. You don't watch a horror movie and all of a sudden want to go out and stab people and you don't watch a bank robbing movie to learn how to rob banks... it's entertainment.”

Perhaps the whole issue of condoms verses PrEP and treatment as prevention is so controversial here in New Zealand compared to overseas because of the mostly widespread condom use that has become ingrained in our sexual culture, in our sexual nature?

“It's the nature of New Zealand because you guys haven't been given the opportunity to explore other options, so of course that's going to be the culture,” counters Bailey.

But here in New Zealand our condom culture works whereas the culture in places like San Francisco hasn't worked. Shouldn't we stick with the culture that works for us?

“I think the culture in San Francisco works perfectly and we'll know in the next few years when we look... there are studies coming out in cases of PrEP [showing] there hasn't been cases of transmission and people are feeling proud about having sex and own having sex and there is no shame or stigma attached to it. And I think that's the way to go. You don't have to shame people and force them to having only the one route of using a condom or abstinence.”




Jay Bennie - 14th March 2015

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