Features  PrEP: redefining safe sex

The politics and accessibility of HIV prevention

I was in France when I first considered taking PrEP. I went to my family doctor to see if she could give me more information about the pill and how to take it. She asked me what PrEP was, and I told her that “it’s a drug one takes every day to prevent HIV transmission, it’s working and everyone’s talking about it!” Her tone switched from confusion to disbelief: “well, the best method is still to protect yourself!” [i.e. using a condom]. I blushed, ashamed: I could see the images she saw when she clicked her tongue. I could taste the disgust in her dismissal. The door of the doctor’s office closed behind me as I processed what had just happened. “What a fucking asshole!” I shouted in the street, witnessless. Without even knowing about my sexual practices — we had never discussed them — she had felt entitled to judge me on her own perception of gay sex as diseased.

What is PrEP?
Pre-exposure prophylaxis (PrEP) is a prevention treatment that commonly refers to the drugs taken to prevent HIV transmission. When taken properly, it is 99% effective at preventing the transmission of HIV, more effective than condoms, which are estimated to be around 96% effective. But, unlike condoms, PrEP doesn’t prevent other sexually transmitted infections (STIs). The pill is made of emtricitabine and tenofovir, and commercialised under the name “Truvada.” Other generic versions have been available in the US since 2004. The drug can be taken in two ways: either by taking a pill every day or by taking it on demand for a few days surrounding sexual encounters. Common side-effects include nausea, vomiting, fatigue, and dizziness, but in most cases, these minor symptoms resolve themselves over time. To receive a PrEP prescription, one has to be considered “at risk” by a doctor and go through health tests. Once prescribed PrEP, a recipient must meet with their doctor every 3 months for a health check. PrEP was only approved by Health Canada in 2016. PrEP is only now becoming more widely accessible in Canada, although access to PrEP also depends on provincial health regulations.

PrEP or PEP?
PrEP is a pre-exposure treatment, whereas PEP is a post-exposure emergency treatment you can get within the 72 hours after an encounter you think might have exposed you to HIV. You can request the treatment in hospital emergency rooms. The chances of PEP protecting you from contracting HIV are high if you take it right after exposure, but its efficacy decreases quickly after 72 hours.

In Quebec, a bottle of 30 PrEP pills, which lasts about a month if taking it on a daily basis, more if taken on demand, costs about $85 CAD under the RAMQ coverage. This price has remained the same despite the fact that the price of the medication has been decreasing as more generic versions of the drug are being produced. When PrEP was initially distributed, it cost $830. Generic versions of the drug have driven the cost down to $242. Although the Quebec government pays a quarter on PrEP of what it previously did, PrEP users in the province are paying the same price.

In Montreal, PROTEGES is a program for men who have sex with other men, which allows you to access PrEP for free if you don’t have the means to. The program also offers access to doctors and nurse to prescribe you the drug, follow your health, and have access to a sex therapist for free. The program is trans-inclusive.*

U=U
U=U stands for “Undetectable equals Untransmittable” which is a slogan to remind people that HIV+ people who take antiretroviral therapy (ART), achieve, and maintain an undetectable viral load have no risk of sexually transmitting the virus to someone else.

Prejudice in the doctor’s office
The McGill Daily sent out a survey regarding people’s thoughts on PrEP in Canada. Twelve people on the pill and five people not on the pill responded. According to the respondents, the most common barrier to access was economic (13 out of 17). The other reported barriers of a medical nature (i.e. not being considered “at risk” or not finding a doctor to prescribe it) (7), racism (3), informational barriers (i.e. didn’t know much about the drug) (3), transphobia (3), immigration status (2), health (i.e. side effects) (1), age (i.e. having parents potentially knowing) (1) and serophobia (1). The size of the surveyed population does not allow for broader generalizations, but it does convey certain medical reluctances to administer the drug. These reasons often perpetuate injustice with regards to class, race, gender, and sexuality.

The question of accessibility to PrEP is therefore political. HIV rates are found disproportionally in marginalized communities: of all the people living with HIV, men who have sex with men are the most represented category amongst adults (44%). Moreover, while Indigenous peoples and Black people make up 4% and 3% of the Canadian population, they each represent 21% of the people living with HIV in Canada, totaling 42% of people living with HIV. Those populations are also disproportionately living in poverty depending on whether they are Indigenous, what their race is, on their gender, and on their immigration status, which affects negatively their access to health.

The McGill Daily contacted the Alliance for South Asian AIDS Prevention (ASAAP) to inquire about the awareness of PrEP in South Asian communities in Canada. In response, the Women’s Health Coordinator for ASAAP told the McGill Daily that “the awareness and usage around PrEP in South Asian communities is not nearly as much as what is seen amongst white cis gay men. […] A lack of agency and social mobility continues to be a leading cause for the lack of usage of PrEP amongst South Asian women. Women are also far less likely to inquire about PrEP for fear of stigma associated with being on PrEP. Many women do not even disclose to their doctors that they are sexually active because of how it is perceived in South Asian communities. There is also the misconception that they are not at risk of HIV if they are in ‘monogamous’ long-term relationships.”

HIV, HIV+, HIV- and AIDS
HIV is the abbreviation for Human Immunodeficiency Virus, which can (but not necessarily, especially under treatment) lead to Acquired Immunodeficiency Syndrome (AIDS). Everyone has a serological status: HIV positive (HIV+) or negative (HIV-), positive meaning one lives with the virus, while negative means one does not. HIV status can be transmitted but AIDS cannot, as AIDS is not a virus.

Sex workers also face political barriers to accessing PrEP: a 2012 study surveying sex workers found about half of the respondents have experienced anti-sex worker stigma with doctors. The study outlined “whore stigma” as a social phenomenon shaming sex workers “for transgressing gender norms, such as asking fees for sex, satisfying men’s lust and fantasies, being vectors of disease, and being a source of transmission of sexually transmitted infections, including, HIV/AIDS, into mainstream society.” State criminalization of the buying of sex under Bill C-36 fosters this kind of attitude by marginalizing sex workers and by furthering the idea that sex workers are a threat to society’s moral health, endangering them both at work, at the doctor, and in their everyday life.

Some provinces have tried improve access to PrEP among marginalized communities. First Nations and Inuit people with Indian status have technically been able to access PrEP for free in British Columbia (BC) since 2013. However, information about this program was poorly disseminated and as a result only 23 people are benefiting from it. As Métis and non-status Indigenous people are not recognized as Indigenous under the Indian Act, they have been excluded from this program. BC has furthermore made PrEP available to all British Columbians for free as of January 1st, 2018. Despite these efforts, however, PrEP remains inaccessible for many populations. Rural populations especially face serophobia and homophobia. The Daily Xtra reported a lack of access to information about the drug, few doctors willing to prescribe PrEP or do the quarterly check-ups required for taking the drug, and people tearing down posters around HIV prevention.

What is serophobia?
Serophobia is the fear of people living with HIV. It comes in different forms. For example, on dating apps, people sometimes write that they are or are looking for someone “clean” or “healthy” (i.e. HIV negative/STI-free. People living with HIV or with an STI aren’t dirty or unhealthy; you can be healthy while living with HIV. Less stigmatizing formulations such as simply “HIV negative” should be used.

Barebacking, sex-ed, and safe sex affordability
The Daily also surveyed people’s opinions on the drug and what it meant for their habits and their community. Of the people taking PrEP or in the process of getting it, many (7) linked it to reduced anxiety and/or increased feeling of security around having sex. PrEP for some (3) meant more condomless sex but, overall, people seemed to have the same amount of sex, and increased safety for those who had condomless sex regularly previously. Critics of PrEP will say that the drug encourages less safe sex, and many critics blame PrEP for the recent drastic increase in STI rates. Although PrEP might encourage condomless sex for some, it is important to remember that it comes to prevent transmission of HIV for many people who had condomless sex regardless before. Moreover, the relation between PrEP and increased STI prevalence is actually a misconception; a study presented at the annual Conference on Retroviruses and Opportunistic Infections showed that PrEP is actually reducing the rate of other STIs such as chlamydia and gonorrhea by up to 40%. Indeed, people on PrEP have regular 3-month tests that are often paired with STI testing, and have access to more information about safer sex and STIs.

PrEP is redefining safer sex, but not everybody is on board. Respondents to The Daily’s survey on PrEP talked about being potentially perceived as a “bareback whore,” (barebacking, i.e. the practice of condomless sex) while others that weren’t on PrEP noticed a greater insistence for people on the drug to look for barebacking, and expressed the fear that PrEP would lead to the resurgence of other STIs. With PrEP, safer sex comes to be redefined: taking PrEP is a new safer sex practice that comes with a certain protection from HIV and regular checks that also give people access to general STI prevention tools and knowledge. PrEP’s redefinition of safer sex has evolved in a context of misinformation about STIs, a lack of political will, and political backlash to sexual education, akin to the Ontario government’s scrapping of its 2015 sex-ed curriculum to reinstate its 1998 version. A 2010 document from the Sex Information and Education Council of Canada (SIECCAN) reported that although sexual health has gotten better in Canada over the years, “the prevalence of sexually transmitted infections among Canadian young people is unacceptably high and poses a significant threat to their current and long-term health and well-being”. In a context of a population poorly educated on safer sex practices, redefinitions can challenge people’s preconceptions and foster tensions.

The criminalization of HIV
In many countries, including Canada, people living with HIV are being convicted of serious criminal offences and sentenced to significant time in prison for not disclosing their HIV status — even when there is no transmission and people have taken highly effective precautions that mean the risk of transmission is exceedingly small. In other cases, people are facing more serious, discriminatory charges simply because they have HIV — even when there is no risk of transmission.

PrEP redefines safer sex and helps prevent the transmission of HIV. Nevertheless, PrEP’s redefinition of safer sex, which, although helpful in many ways and to many folks, is still marked by enduring power dynamics of class, race, sexuality, and geography. PrEP, and other methods of practicing safer sex, are only affordable and accessible to a restricted number of people, mapping health inequality further onto dominant power dynamics, from the doctor’s office to the bedroom.

*To learn more about PrEP & get a prescription:
– The Montreal study on PrEP under which you can be prescribed the drug and see a sexologist for free: PROTEGES. You can contact them to set an appointment at proteges@rezosante.fr or (514) 714-8176.
French Facebook group about PrEP
Rezo’s page on PrEP