So there is a war raging in the gay men’s community. The war is about how we have sex. Some, like Jack Merridew in the video above, think sex can only happen with a condom on. This is the group that screams at people who get infected, blaming them with “How could you POSSIBLY get infected? Everyone KNOWS how to prevent infection! Just wear a fucking condom!” The other group understands that sex and risk reduction decisions are fluid things, and realize that “wear a fucking condom” is, at the end of the day a useless message for a variety of reasons from poverty to power dynamics to access issues.
The pro-condom crowd is operating in a constructed fallacy queer men have been perpetrating on themselves for decades. There is a myth, that has been assigned to us, that gay men always wear condoms when they have sex, that it is a responsible thing to do. It appeared in the late 80s as a way to counter the “irresponsible” homosexual meme pushed by the moral majority about HIV and gay men. The condom myth was a political vaccine.
The problem? It’s a lie, and it always has been. Since 1988, surveys of gay, bisexual and other men who have sex with men, (that moniker includes, frustratingly the mis-gendering of transgender women who are not, in fact, men, but women. Sadly public health refuses to acknowledge that reality. But that’s a rant for another post and another day) have consistently found that half of men who have sex with men didn’t use condoms in with a hook up in the previous six month period. And by use a condom, surveys mean for anal intercourse. You know, buttfucking?
And our friends in the Centers for Disease Control and Prevention in Atlanta who always have the queer communities’ best interests at heart (right, cause they are so progressive thinking *Cue sarcasm music*) had gobs of science to back up their recommendations to use a condom correctly and consistently for each and every sex act when they adopted that guidance in 1987. Am I right?
Actually, no. Sadly, the recommendation (and the efficacy of condoms as prevention method in HIV) are based on heterosexual sex — vaginal/penile intercourse if you will. In fact, until 2013, there had never been a study on the efficacy of condom use in preventing HIV transmission during anal sex. That study found that using a condom for every episode of anal sex was 70 percent effective in prevention transmission of the virus — that’s compared to the 80 percent efficacy rate from vaginal/penile sex promoted by CDC. What’s more, the study found that intermittent use of condoms had no effect on HIV transmission rates.
Despite these facts, the shaming of condomless sex continues, as does the tyranny of the condom mythology. Hell, an AIDS Service Group in Los Angeles successfully pushed a ballot measure to force porno producers to make the performers use condoms — because you know there are no amateur condomless sex videos available for free online anywhere in the entire world or internets, am I right? *Cue the sarcasm music again*
The sad fact is that condoms are no longer the only effective way to prevent HIV infection. In fact, one could engage in condomless sex and STILL be acting in a way to reduce their risk of infection — despite what the condom tyranny of the condoms mythology would have you believe.
AIDS Map details a comparison of risk reduction options here. That report, however, does not discuss chemical prevention methods.
Let’s start with Treatment as Prevention. We all know that HIV medications on the market today are fantastic tools in controlling the virus in the human body and preventing the spiraling decline that is most commonly referred to as AIDS (World Health Organization calls it HIV Disease Stage 4, and I prefer the staging construct over the misused, misunderstood AIDS moniker. For an example of it being misused, watch Jack’s video above. One doesn’t transmit AIDS, one can transmit HIV, however). But they also have a side effect that has government health officials crowing. When a person is on successful treatment — defined as an undetectable viral load, or count of virus in the blood, for six months of more — they can’t transmit the virus. That’s right. They can’t transmit the virus. There is not a single documented and proven case of HIV transmission from a person with an undetectable viral load to an HIV negative person. Not one. As a result, government and medical officials are pushing HIV treatment as a form of prevention.
And it works, to a point. The problem, of course, is that not everyone who is infected knows they harbor the virus. And even among those who do, only about 25 percent are engaged in care and have achieved fully viral suppression. There are a ton of issues related to this miserable ability to get people with HIV into successful care, but again that’s another blog post.
That cohort of people living with HIV who are unaware of their infection are significantly more likely to transmit their infection to another person. Three and a half times more likely, in fact.
Which brings us to other chemically assisted prevention options.
First is the proven 28 day course of post exposure prophylaxis (PEP). This was originally developed in the late 80s using AZT for medical workers exposed through needle sticks. But it was approved for community use in the 2000s and is referred to as nonoccupational post exposure prophylaxis (n-PEP). This intervention is a high dosing of a combination of three anti-HIV drugs, administered daily for 28 days. If the medication is begun within 72 hours of an exposure, it is about 83 percent effective in preventing infections.
Next is the controversial Pre-Exposure Prophylaxis recently approved for use in all high risk groups in the US by the FDA. This is the daily use of one anti-HIV pill, Truvada. If taken daily, the pill has been shown to prevent infections almost 73 percent of the time. But a recent study from Uganda found the pill taken daily was 100 percent effective in preventing infection. Either way you slice it, PrEP is statistically more effective in preventing HIV infection than condoms.
Here is an awesome video about PrEP and how it works:
With all this information available, isn’t time to stop describing condomless sex as “unprotected?” The implication in this kind of wording is that condoms are the ONLY way to protect against HIV and that is imply untrue. It also leads to an ability to blame people with HIV who choose to have condomless sex with having an intent to transmit their infection. Neither is true.
So, let’s drop the moniker and start having some real talk about HIV prevention and risk reduction options without creating the holy gospel of queer fucking that may not be a one size fits all approach.
PS – I emailed Jack on Nov. 14, 2013 pointing out all the errors in his video. He never responded. It is reprinted here:
Dear Mr. Merridew,
I wanted to reach out to you about your recent YouTube video “Wear a Fucking Condom.” As a person who has been reporting about HIV for the past 7 years routinely, and whose work is cited by the UN, the CDC, and in Congress, as well as some one who does risk reduction education for college students I am deeply concerned about the messaging you have created.
I absolutely appreciate the effort you took in making the video, I want to be really clear on that.
However, I am afraid you provided way more misinformation than accurate information — which may in fact being accidentally placing MORE men who sex with men at risk for HIV infection.
1. HIV rapid testing is most often being conducted using a drop of blood obtain by breaking the skin on a finger. There are oral swab options approved by HRSA, but the blood drop test is preferred by most local health departments and AIDS Service Organizations. (http://hab.hrsa.gov/deliverhivaidscare/clinicalguide11/cg-209_rapid_testing.html)
2. Flavored condoms (the only ones you have showed) are recommended for use in oral sex only, and not recommended for vaginal sex (let alone anal sex): [see disclaimer: http://wowcondoms.com/Condom_Search/Flavored_Condoms%5D
3. The FDA actually discourages use of condoms during anal sex:
Are condoms strong enough for anal intercourse?
The Surgeon General (C. Everett Koop, Surgeon General 1982-1989) has said, “Condoms provide some protection, but anal intercouse is simply too dangerous to practice”
Condoms may be more likely to break during anal intercourse than during other types of sex because of the greater amount of friction and other stresses involved.
Even if the condom doesn’t break, anal intercourse is very risky because it can cause tissue in the rectum to tear and bleed. These tears allow disease germs to pass more easily from one partner to the other.
In fact, until spring of 2013 there had been NO full fledged study on the efficacy of latex condoms during anal sex. A meta-data study released in the spring at the Conference on Retroviruses and Opportunistic Infections found that consistent use of condoms during anal sex had a 70 percent efficacy in preventing infection (compared with 80-94% for vaginal sex, and there only in pregnancy prevention). Occasional use of condoms has no protective action at all. http://www.aidsmap.com/Consistent-condom-use-in-anal-sex-stops-70-of-HIV-infections-study-finds-but-intermittent-use-has-no-effect/page/2586976/
4. Use of a condom must be facilitated by lubricant, however, lubes may increase the risk of HIV infection (and other STIs) in anal sex: http://www.msmgf.org/html/videos/lubesafety/lib/playback.html
5. Most men who have sex with men douche prior to anal sex, increasing the risk of transmission of HIV and other STIs:
From a 2007 study:
“Although some rectal douches result in surface epithelium loss and potential increase of HIV transmission, men who have sex with men (MSM) continue to use them. ”
6. Condom use 100 percent of the time is less effective than Pre-Exposure Prophylaxis (72.8 percent efficacy when taken 90 percent of the time: http://www.niaid.nih.gov/news/QA/Pages/iPrExQA.aspx), Post Exposure Prophylaxis (about 81 percent effective in preventing infection when started within 72 hours of exposure: 83 percent efficacy: http://www.aidsmap.com/Efficacy/page/1746573/; sero positioning (topping HIV positive or unknown status partners) was 75% effective, while topping only was 86% effective in preventing infection: http://www.aidsmap.com/Serosorting-does-help-prevent-HIV-up-to-a-point/page/2287223/ (incidentally pre-exposure prophylaxis is an FDA approved HIV prevention intervention: http://www.cdc.gov/hiv/pdf/risk_PrEP_TalkingtoDr_FINALcleared.pdf
7. The vast majority of new HIV infections in young MSM, according to the Office of National AIDS Policy, are happening in the context of primary sexual relationships (ie boyfriends, friends with benefits etc). That would be 68 percent of those infection. On top of this, the majority of men who have sex with men are not being tested often enough, add to this serial monogamy and versatile sexual activity and you have a much higher potential for transmission of HIV. Studies say that a person who is infected with HIV is 3.5 times more likely to transmit HIV. A 2010 study by the CDC found that 1 in 5 gay/bisexual men in 21 US cities is infected with HIV, of those who were infected, 44 percent were unaware of that infection. The number increases as the age of the man decreases (it is 60 percent in 13-24 yo MSM). Another study released by ONAP reports that HIV prevalence in the current 20 yo cohort of MSM is 10 percent overall, 20 percent in black MSM. At current infection trends, half of all the 20 yo MSM in the cohort will be infected in 30 years, and 70 percent of black MSM in the cohort will be infected.
8. Studies since 1988 have CONSISTENTLY shown that only about half of MSM actually used a condom in their last sexual encounter. We’ve been hammering the condom only message since 1985, yet half of men who have sex with men don’t use them. Maybe, just maybe, it’s time to drop the moralizing messaging which is based in false assumptions and acknowledge that one can reduce their risk for HIV infection without just using condoms. (Incidentally that includes men living with HIV using medications to suppress their viral load which has an estimated reduction in risk of transmission by 96 percent. Add that low risk to the already low risk of per incident risk of transmission — which is .5 percent in receptive anal sex — and you have a negligible risk factor. Sadly too many people have been raised to be terrified of HIV and presume it is hyper infectious, which simply is untrue http://www.cdc.gov/hiv/policies/law/risk.html
So, I guess the question now, is how do we work together to address this misinformation you have accidentally thrust upon the community?
Thank you in advance for your time and thoughtful response to serious matter. Sincerely
Todd A. Heywood