Truvada mon amour

By David Caron

Photo: Wikimedia Commons

Condoms. That’s all we heard. For years. Condom condoms condoms.

That’s probably why I remember the first time I came across the word: it was the summer of 1985, in the Southside neighborhood of Morgantown, West Virginia. I was not a kid, but a French undergraduate, and I’d come to the U.S. to spend a vacation with my American boyfriend. I was sitting on the front steps of the house where he rented the attic, reading an article on AIDS in Time Magazine, and there it was—the word.

“Nathan!” I called out, “What’s a condom?” He rushed out, half shushing and half laughing, and muttered through his teeth, “The landlady can hear you!” As if she hadn’t figured out what we were doing up there.

That summer, Rock Hudson had just admitted to having AIDS, and the supermarket tabloids were going berserk. “So, poor ol’ Rock’s got the disease,” said Nathan’s friend as soon as he opened the door. It was such big news. We didn’t know at the time that this moment would mark a turning point in the public perception of the epidemic. We knew, though, that it was momentous and very scary and that we could no longer assume Morgantown, West Virginia would be spared.

Los Angeles, four years later: Exit Nathan, enter Alex, France seems a distant past. By then I knew exactly what a condom was, and as a graduate student instructor, I could draw big laughs out of my students by explaining that in France food had little to do with les préservatifs. I remember an audience at the famous New Beverly Cinema clapping at a clever condom PSA preceding a movie. I remember thinking how convenient it would be if they sold them at Trader Joe’s, but it was no worry—you could always get some for free at any gay bar. I remember the Sunset Junction Street Fair in Silver Lake, where a young gay guy demonstrated to a mixed crowd of gay and Latino residents how to use condoms, explaining that he had totally eroticized them since he’d never had sex without one. I remember how far he could stretch a dental dam with his tongue. (A dental dam was a sheet of latex that . . . Oh, forget it!)

I also remember the time Alex and I had sex without a condom because we ran out or something, and he didn’t pull out in time, and how upset I was. You see, even though we were both negative and almost perfectly monogamous, we never fucked without a condom. In the four short years between Rock Hudson’s confession and the New Beverly PSA, it felt like the practice had just become so established.

Today we live in the era of treatment, and now comes this new thing, a whole different way for people who are HIV negative to reduce their risk of infection—a pill. This pill, this one pill, may change a lot of things for the better, among them what it means to be living with HIV in the midst of other gay men who aren’t.

And the reverse: the ways HIV-negative guys envision themselves in relation to potential lovers, or others, who are positive.

Among gay men at least, many of the arguments for or against the use of “pre-exposure prophylaxis,” or “PrEP,” have revolved around the open question of its consequences. Will PrEP increase vulnerability to other sexually transmitted infections? What kinds of long-term effects can we expect from the medications’ toxicity? Are we now on the verge of a form of liberation akin to that of the birth-control pill in the 1960s? No one knows the answers for certain.

We also need to remember that using condoms has never been the only way to enjoy safer sex; non-penetrative sex, for example, presents virtually no danger of infection. Yet from the late ’80s on, condoms all but become synonymous with protection among gay men who came of age during and shortly after the height of the AIDS epidemic. Long gone are community attempts to reimagine gay sex creatively, to reinvent it just as we had invented it to begin with. So the idea that we may no longer equate safe anal sex with condoms feels so foreign to so much of what many of us have internalized that the very mention of it can stir intense passions and ignite heated debates.

Photo: Fotocommunity

Photo: Fotocommunity

Approved by the FDA in 2004, Truvada, the brand name for a combination of two antiretroviral drugs, tenofovir and emtricitabine, has been commonly prescribed in combination with other antiretrovirals as part of multiple-therapy treatments. Extremely effective at keeping the virus in check, and with few known side effects, its use was approved by the FDA in 2012 for prevention as well. HIV-negative people whose sexual practices make them especially vulnerable can now take the pill once a day to prevent infection.

The Center for Disease Control worked on a set of clinical practices that were approved by the U.S. Public Health Service in May of this year. The truth is, many gay men discovered the preventive power of Truvada before researchers began to look into it. Popping pills before having sex without condoms appears to provide some degree of protection. Now studies are underway to look into the ongoing practice and determine its scientific validity. How reliable is this pill? According to the typically prudent CDC, the success rate of Truvada stands at 92%, and strict adherence matters, just as it does for those who take it for treatment. If you skip daily doses, protection starts to decrease. Of course, contradictors will always come up with doubts and what-ifs and find failures and flaws. Shortcomings do happen, of course, but they always have.

Since it all began, whatever good news came our way, some degree of disappointment always followed. AZT and ddI didn’t work that well in the end, and the first successful treatments had horrific side effects. The more recent and widely prescribed treatment, Atripla, has been found to lead to depression in some patients. And to top it all off, it appears that we (those of us taking Atripla, anyway) could drop dead from a heart attack at any time without warning. Not to mention the fact that people living with HIV—either those with potent medications or those with potent narcotic habits—keep pumping toxic stuff into their bodies, day after day, with no clear idea of the long-term consequences of their chemical cocktails of choice. PrEP won’t change any of that. Drugs are drugs, you know. They heal at one end and poison at the other.

Still, we could be facing a small revolution—one that extends beyond the borders of the self-identifying gay community, while at the same time reconfiguring what goes on within them. PrEP’s most immediate and far-reaching impact may not be epidemiological at all. HIV and the familiar ways of combating it have given rise to a series of laws—literal as well as figurative—governing disclosure, dictating how we talk not just about the disease but about ourselves. Even at a time of stunning political and legal advancements, they’ve divided us more than they’ve brought us together. If that rulebook changes, we will, too. I won’t speculate, then, on what PrEP may bring in medical terms. I prefer to wonder what it could bring about for gay men collectively as a messy, dynamic tangle of social relations fueled by fucking and the ingenuity required to keep fucking.

Now that Truvada is on the market, change is already underway, with effects that could be far-reaching. Think of the millions of women worldwide who, should they gain access to PrEP, will be able to protect themselves privately, without being suspected of infidelity or promiscuity for asking their male partners to wear condoms. Think of sex workers who may no longer need to choose between health and higher pay. Think of the young gay men, especially young gay men of color, among whom the rate of new infections increases with alarming regularity. Talking about HIV in a sexual context is not always easy, and it may not even cross the minds of kids who believe the epidemic is over or don’t identify as gay in the first place.

Maybe this new tool will help them and other vulnerable groups. Maybe it will come as a relief to men—and there are plenty—who don’t enjoy sex with condoms, simple as that. And in all likelihood, PrEP, if it takes off, will lead to a profound reevaluation of the identity and behavioral categories that have long determined prevention efforts but whose contours have shifted—not just because of the growing presence and relative acceptance of gay people in mainstream culture, but also thanks to advances in medicine and increased access. In 2008, a Swiss study now famous in HIV circles showed that HIV patients with an undetectable viral load and no other sexually transmitted infections cannot transmit the virus sexually. This view now largely prevails among European researchers. (Their litigation-averse American colleagues remain cautious in public and stick to a 2011 study here that shows 96% protection.) As a result of these findings, treatment itself has become the centerpiece of HIV prevention campaigns worldwide. The more people you treat, the less transmission occurs. The idea is that when more people are receiving treatment than are becoming infected, the pandemic will have reached its tipping point.

And now we have PrEP, at long last a safer way for men to sodomize each other without latex, the way nature intended.

But now that PrEP is spreading, so are its critics, many of whom are longtime HIV advocates who still consider all condomless sex an abomination. One of them, David Duran, coined the infamous phrase “Truvada whores” in a 2012 blog post in the Huffington Post. I know what you’re thinking, but the intent wasn’t the compliment it sounds like to you and me—and to Gilead, the makers of Truvada, where the conga line must already be in full, if discreet, swing. (Seriously, what surer sign of success is there for a product than to have its name followed by the word “whore”?) As expected, pro-PrEP people reversed the original insult in no time and made it a badge of honor. Queers do that a lot. Duran himself expressed an “evolved opinion” in another post two years later. Jokes aside though, the popularity of the phrase indicates that, both as an insult and in its positive resignification, it touched a raw nerve and exposed a rift among many gay men. What’s at stake here, I think, is nothing less than the ways in which we think about HIV and relate to one another as gay men.

I bring this up because gay PrEP users can face a moral judgment not that different from that passed on HIV-positive people, who are often considered slutty and irresponsible. Yet the notion that groups of people with different HIV statuses may be shamed together on the basis of how they seek pleasure hints at a far more seductive kind of social relation than anything serosorting could ever allow.

The practice known as serosorting surfaced in 2006, about ten several years after the arrival of the first successful treatments, as one way to enjoy condomless sex and reduce the likelihood of HIV transmission. The idea—not a bad one on the face of it—was to have sex only with partners who have the same HIV status as you: poz with poz and neg with neg. A number of gay men, however, have criticized the practice for two main reasons, one pragmatic, the other political. First, a guy who claims a negative status may be lying or, as is the case with a great number of people, he may not know that he has already been infected. Second, sorting out men living with HIV socially and sexually quarantines them within a culture where the two are intertwined. Among advocates and others, many have reacted with outrage at what they see as nothing less than viral segregation. Early AIDS activists, in fact, rallied against this form of exclusion because it undermined our struggle as a community. When I told a negative friend who had once participated in some of ACT UP’s actions in New York that, for a long period, my sexual rejection rate in Ann Arbor, Michigan was a flat 100% if I disclosed, the depth of his outrage clearly reached far deeper than the veneer of political correctness; it testified to a betrayal on the sense of solidarity that defined us back then.

The simple fact of being queer in a place like New York, San Francisco, or Los Angeles made an AIDS person of you one way or another—through activism, advocacy, volunteering, caregiving, mourning, even worrying like mad or feeling shitty for not doing your share.

That said, it’s hard to deny that having sex with someone who’s HIV+ like you makes a difference. It provides, sometimes, a safe haven from the fear of rejection as well as a sense of connection that feels at once more immediate and affectively stronger for being unencumbered by the power differential and sheer awkwardness that otherwise creeps in. Still, serosorting can’t be considered acceptable when you’re positive and not when you’re negative. Any practice that risks placing two sets of people on different moral grounds, and thus produces inequality, cannot be sustained, nor should it be.

PrEP could very well make serosorting obsolete. Some men who are not living with HIV can now decide to go on the same medication as those who are, for the implied purpose of having sex with them. Ironically, this desire for connection reminds me of the “old days” of safer sex to which PrEP opponents keep hanging on despite HIV’s new realities. Within a few years into the known epidemic, AIDS had engulfed pretty much everybody in the urban gay communities of the western world; it was a common thing then (in both senses of the term), and for a while it defined us. There was no real need to disclose your status if you didn’t want to, since it was often assumed to be a shared characteristic, whether you actually “had it” or not. The obvious thing to do when having sex was to behave as though your partners were infected. I’m generalizing a little, probably, but this rule of thumb made a lot of practical sense.

It also meant that the decision whether or not to protect yourself was based on the assumption of sharing, not separating. The peak years of ACT UP, from the late ’80s to the mid-’90s, were a horrendous time, but they also saw gay people come together in unexpected and unprecedented ways.

Image: Bilerico

(That last thing? That would be me.) At that moment and in that context, safe sex, too, functioned as a type of connective mediation. Using condoms has never been about one’s own protection alone. For all its drawbacks, and perhaps because of them, the practice also entailed a tremendous amount of generosity.

Please don’t accuse me of nostalgia for the unspeakable sorrow, discrimination, and endless death during a period of staggering public indifference. I don’t miss those days. My point is simply that AIDS once played a defining role in our social and sexual lives that it no longer does. At least, not automatically. Not until somebody discloses his positive status to you—you being the negative guy considering sex. Not until you find yourself forced to choose who you want to be: the neg guy who doesn’t mind sleeping with a poz guy and may even ask about treatment and viral load—because, hey, it’s important; the neg guy who never sleeps with a poz guy period—sorry, dude; the neg guy unsettled by the ethical dilemma that this unexpected knowledge suddenly dropped in his lap. However you decide to respond will situate you, ethically and socially, in relation to a gay man living with HIV. And if you care about such things, the cultural shift from an implicit positive status to the one, these days, that must be made explicit has not simplified your life.

According to the CDC, thirty-three states in this country have laws concerning people living with HIV. Many make it illegal for such a person not to disclose their HIV status before engaging in sexual relations. Penalties vary, but those convicted can face prison terms and inscription on a sexual offender registry—most of this, of course, irrespective of transmission or actual possibility of transmission. If one lives in a smaller community, as I do, the legal requirement is pretty much impossible to ignore; the danger’s too high. You know, to disclose one’s HIV+ status to playmates because the law requires it sucks. I hate it. I’m not joking, I fucking hate it. In fact, I hate it even when the law doesn’t require it. And this doesn’t get any easier with time, believe me. Imagine a flight attendant opening her routine speech on safety procedures with, “This plane could crash, killing you and everyone on board, but . . .” Even I sometimes want to walk, not run, to the nearest exit.

But fear of unjust judicial retribution isn’t the only factor at play in HIV disclosure, even though that alone could (and should) enrage anyone. Pressure also comes from sexual partners who have grown to expect disclosure as if it went without saying, so to speak, as if we owed it to them. Apparently, responsibility for their safety has been lifted from their shoulders and now rests solely on those of people living with HIV. And in the name of what, exactly? Solidarity with our vulnerable negative brothers? A shocking reversal of direction. HIV disclosure poisons our relations with one another. Worse, it poisons them in the name of honesty.

In our everyday lives, transparency has become a cardinal virtue, the supposed bedrock of any healthy relationship, be it social or personal. Forget that the obligation to be honest or face the consequences negates its own premise. (What’s honesty worth under duress?) Failure to comply can nonetheless mark a person as an outsider. The rhetoric of transparency, in other words, has been deployed around HIV as yet another means of erecting barriers between people according to their status—and this at a time when it has never been so safe to have sex with someone who is HIV+. It pains me to realize that some gay men have become enforcers of HIV discrimination.

In the years of greater danger and tighter solidarity, it was opacity that brought lovers together.

As you may have guessed, the new contours of division do not work in favor of those of us who are HIV positive. Telling my HIV status to someone I would like to sleep with, even though doing so would pose no threat of infection, is not a gesture of honesty on my part but a painful and unnecessary creation of inequality. Whether I choose to disclose freely or obey a legal mandate makes no difference in that respect. Whenever I disclose, I find myself forced into a position of vulnerability. Will the other guy reject me? How will I feel if he does? How will he feel? Disclosure, not HIV, is the poison among us.

PrEP has the potential to change that. Imagine: a poz guy can ask the other to disclose whether he is taking Truvada. The thought is amusing, but the real progress is that a guy who announces he takes Truvada does not need to ask his sexual partner for his HIV status. More important, and in line with the safe-sex collective mindset of the pre-treatment phase of the epidemic, PrEP revives the idea of shared responsibility for the burden of HIV infection, most of which now resides in one-way disclosure. To a much greater extent than condoms ever did, taking meds—the same meds—on both sides of HIV infection brings about a kind of involvement with the disease that rests on a willingness to share.

Conceiving of self-care as mutual care means re-embracing the idea that, be they positive or negative, all men who have sex with other men are HIV people. Once we accept that fact, we may then turn to other affected populations with solidarity, rather than distant benevolence.

A decade here, a decade there, and before you realize it, the past has become history. The early years of the epidemic, in particular, have become so distant a history that many of my students don’t know what ACT UP is. They watch old footage of protests and arrests as they would images of the Civil Rights movement, only this time it’s a struggle they’ve never heard of.

I had the opportunity to witness this infuriating, endearing ignorance during a Q&A that followed a screening of United in Anger, Jim Hubbard’s documentary on ACT UP. A couple of weeks before, the same theater had screened the better-known How to Survive a Plague, by David France, which covers similar territory. The triumphant New York revival of Larry Kramer’s play The Normal Heart in 2011, followed by a film adaptation on HBO this year, has canonized what many of us once considered a literary and political embarrassment. A number of recently published books, many of them biographies and memoirs of major figures of the era, as well as academic essays, likewise signal that the epidemic has entered a new period in popular consciousness.

The recent turn to the social and political history of HIV and AIDS in western countries coincides with a spectacular string of victories and advances on the path to integration, from marriage equality to the gradual public recognition of homophobia. It is safe to assume that these developments have aroused interest in the history that led to where we are today. But I also see the recent flurry of cultural production around earlier years in the AIDS crisis as an attempt to consolidate and amplify the gay rights movement by anchoring it to the overall narrative of American history. (Look out for the ten-part series by Ken Burns airing soon on PBS!)

Today, watching these documentaries, and reading about people whose works I’d read or whose lives I’d read about before, sends me back to a period I lived through, too—even though I was neither an AIDS activist nor HIV+ at the time. I was a foreign graduate student at University of California at Irvine, living in the Los Feliz neighborhood of L.A. with my longtime boyfriend. The crisis in California generated devastating, angry art, plays, and performances that hit like firebombs, furious zines mixing the sharpest political analysis with humor so unsparing it made your jaw drop. And literature too. I made an unexpected turn and decided to write my dissertation on it, in the middle of it.

Still, the recent memorializing of AIDS activism in films like How to Survive a Plague—no matter how compelling and heartrending the movie is—transforms the collective struggle into little more than a backdrop to the prescient and noble heroism of a few (or many, for that matter). Yes, there were extraordinary individuals back then. They battled bravely and selflessly, and a great many of them died. But to portray the fight against AIDS in hindsight as sentimental heroism serves a purpose singularly at odds with that of the fight itself: to erase from history what was in essence a genocide perpetrated against vulnerable minorities because their government and fellow citizens abandoned them.

Sadly, to acquiesce to this historical revision, to choose to see it as a national tragedy and an opportunity for growth, appears to be a condition for gay people’s acceptance into the very culture that made the epidemic possible and then watched it unfold.

As others have said before me, we don’t need to memorialize the people who died of AIDS; we need to remember them, to remember what happened to them and why. PrEP offers us an opportunity to relearn a lesson at the core of AIDS activism that too many, if not all of us, have forgotten: the ethic of self-care as mutual care. In the past decade or two, that idea has largely retreated into the realms of medicine, social work, and advocacy. It exists today only in pockets and at the periphery of gay life. As Truvada becomes more widespread, we’ll be all but forced to pause and reevaluate how we care for ourselves and for each other, and at least to consider that the two may in fact be one and the same—that is, if we still want to think of ourselves collectively.

Sooner or later, there will be no more use for PrEP. But when new infections bottom out and this fucking epidemic starts to vanish at long last, we, the HIV positive, will still be here.

What will happen with us then?

Photo: Wikimedia Commons

It is no longer tenable to reject the agenda that has led to the irrepressible move toward full marriage equality that we are now witnessing, even as we recognize that all this may have been achieved at the expense of sexual justice as a whole. I remember that morning in San Francisco, when I came across a middle-aged male couple in matching suits walking toward City Hall on the first day they could marry legally (until Proposition 2 passed a few months later and invalidated it). I’ll tell you, as corny as the whole thing sounds sometimes, and as goofy as these two guys looked, the happiness I saw on their faces put a serious damper on my critique of assimilation as a misguided and possibly harmful political agenda.

Still, we must recognize that we, like many before us, paid dearly for the rights we are entitled to. Who, for example, is advocating for the guy who didn’t disclose his perfectly harmless HIV+ status and ended up living under a freeway overpass for that? Who is fighting to get rid of these repugnant laws that criminalize people living with HIV? Some activists are, but that fight is taking place in the shadows of the equal rights agenda when it could have marched hand in hand with it.

There may still be time for that. PrEP, as an idea, was first presented in the nonspecialized media as a means for serodiscordant couples to enjoy their sex lives together without risking contamination. Of course, it isn’t these guys who are attracting most of the attention and generating controversy; it’s the Truvada whores. But who are Truvada whores if not people who refuse to behave as though not just HIV but people with HIV didn’t exist? Even if the epidemic has now shifted from view and gay men, as a group, no longer consider it an imminent threat, we do exist. Gay men now have the tools to upend old tenets of HIV prevention and make it work for us, too, who are living with HIV. We cannot leave that task to researchers and public health officials alone. This is about making contact with one another—physical contact. And if we want to fuck safely without the needless anxiety that disclosure and rejection entail for all involved, we need to talk.

If all this sounds overly optimistic, I hope it also sounds pragmatic. Many people won’t want to ingest chemicals for prevention alone, and many won’t have a need for them. PrEP is not for everyone, and that’s precisely the point. But its existence, as an option, means that we may now be able to make sexual decisions according to what we’re in the mood for, not with respect to the use of condoms or to a divide between people who are living with HIV and those who aren’t. In that new freedom there’s an incredibly powerful potential to bring us together, not just in legislatures and courtrooms and in the streets—though there, too—but also in bed. After all, that’s where we’ll have to start if making contact is to remain what we’re all about. And it should be, for fuck’s sake.

OLYMPUS DIGITAL CAMERADavid Caron is Professor of French and Women’s Studies at the University of Michigan. He is the author of AIDS in French Culture: Social Ills, Literary Cures (Wisconsin, 2001), My Father and I: The Marais and the Queerness of Community (Cornell, 2009) and The Nearness of Others: Searching for Tact and Contact in the Age of HIV (Minnesota, 2014).

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