In Maclean’s last week, journalist Josh Dehaas asked if PrEP — a drug that can protect against the spread of HIV — makes sense for gay men. There’s nothing wrong with a journalist advocating for unpopular opinions or asking hard questions about new drugs. The problem is that Dehaas’ piece is dangerously misinformed, sloppily constructed, and supports an underhanded sex shaming that has dogged PrEP from the beginning.
It might be enough to point out that both of Dehaas’ own named, expert sources disagree with him and support PrEP, or that a good deal of the evidence Dehaas supplies does not support his own conclusions. But Dehaas’ take represents such a common gut-level revulsion to PrEP that it’s worth dissecting his article piece by piece.
Let’s start with Dehaas’ core argument that PrEP is being pushed as the go-to choice for all sexually active gay men:
“The takeaway seems to be that PrEP is not only effective, but the safe and socially responsible choice for a typical gay male like Scott, who uses condoms but has sex with different guys on a regular basis.”
While it’s possible that some gay men, especially in urban centres, feel pressure to use PrEP, nobody in the medical world is arguing that all or even most gay men should be taking it.
TheSexYouWant.ca, the Ontario website Dehaas points to as promoting PrEP, still highlights condoms as the number one method of preventing HIV infection.
The doctors I’ve interviewed in two years of writing about PrEP would be very unlikely to recommend it to Dehaas’ subject, Scott, who has no problem wearing condoms.
“We’re not going to tell anyone what to do or not to do,” says Joshua Edward, the program manager at Health Initiative for Men, the Vancouver organization behind GetPrEPed.ca, which Dehaas also targets. “We’re in an unprecedented era for HIV prevention because for the first time we have multiple methods to prevent HIV. We want individuals to be making choices based on evidence and science.”
Both Edward and the manager of the Ontario site say Dehaas did not ask them for comment.
Both sites are quite clear: PrEP is a drug for people who are at high risk, because they have HIV-positive partners, have problems with condoms, enjoy condomless sex, or countless other reasons. There’s no evidence too many men are taking it, or that it is being pushed on low-risk men.
Next let’s look at Dehaas’ warning that PrEP will convince gay men to give up condoms, leading to the spread of other STIs such as gonorrhea, chlamydia or syphilis:
“One of the biggest concerns about PrEP is that it emboldens men to ditch condoms. While HIV-AIDS service agencies recommend using condoms while on PrEP, it’s widely understood in the gay community that many men use PrEP specifically so they don’t have to rubber up. To use the words of Ontario’s HIV-AIDS service agencies, they take PrEP so they can have ‘the sex they want.’ But ditching condoms means other sexually transmitted infections will spread quicker.”
PrEP researchers have taken this concern very seriously, but unfortunately for Dehaas, even his own evidence doesn’t back him up.
Dehaas links to a New England Journal of Medicine study that he says shows gay men ditch condoms when on PrEP and end up with higher rates of other STIs. It says nothing of the kind. For one, the study found the difference in infections between men on PrEP and those on a placebo was not statistically significant. More importantly, the men on the placebo did not know that they were on a placebo — that’s what a control group is for — so they did not behave any differently. Dehaas either did not read this study, or did not understand it.
In the real world, scientists have found that PrEP users do, in fact, have much higher rates of other STIs. This is not largely because men on PrEP ditch condoms, however, but because higher risk men are much more likely to ask for and be prescribed PrEP. This is a good thing; it shows the right people are ending up on the drug.
And because PrEP users are so frequently tested for HIV and other infections, they are less likely to transmit infections than other high-risk men. One mathematical modelling study presented this year at a prestigious Seattle HIV summit suggested that if most gay men acted like men on PrEP — and were tested as frequently — the overall rate of STIs would drop considerably.
Drug-resistant STIs are a genuine problem, but nobody who knows anything about them thinks restricting PrEP is the answer. Comprehensive, community-wide testing and treatment works, and in this regard PrEP users are mostly model citizens.
Dehaas also takes issue with the common claim that PrEP is safer than Aspirin, saying the claim deceptively compares PrEP to Aspirin taken as a daily prophylactic against heart disease:
“That doctor is also concerned about side effects, including those that may take many years to reveal themselves. Potential side effects, after all, sometimes get glossed over online; for example, that Toronto pharmacy FAQ calls PrEP ‘as safe as Aspirin.’ What it doesn’t say is that this conclusion was based on a study that compared PrEP’s side effects with side effects of adults who take Aspirin daily to ward off cardiovascular risks. Aspirin has side effects and so does PrEP; they range from mild ones like nausea and headaches to potentially more serious ones like kidney dysfunction and changes to bone density.”
Even if the claim is misunderstood, prophylactic Aspirin is used by a fifth of American adults. The point is that if doctors think the side effects are worth giving Aspirin to millions of Americans for marginal protection against heart disease, they should surely be alright giving a drug with even lower side effects to a few thousand gay men in return for almost ironclad protection against HIV.
The rare stories of PrEP side effects are most often like the one Dehaas presents in his article:
“Several months after starting PrEP, he says he had lost a significant amount of weight, felt tired and kept being told by family and friends that he looked sick. About 10 months after he started, he says his doctor found abnormal kidney function and recommended that he stop taking it. Several months after he stopped, his weight is back where it was and feels normal again. He says every man needs to make his own decision about whether PrEP is worth the risks, but the apparent side effects weren’t pleasant—and those are the ones he knows about.”
A man gets sick from taking PrEP, it is quickly identified by his doctor, he stops taking PrEP, and recovers fully. PrEP users are a relentlessly medically monitored population. This is a story of drug side effects managed right.
I do not think we should be starry eyed about PrEP. As we learn more, we should be vigilant and critical about what drugs we use and how. And there are lots of real problems we need to confront — like how PrEP is currently only accessible to a few wealthy or well-insured gay men in urban centres, how some uninsured men resort to ordering quasi-legal PrEP overseas and taking it without the oversight of a doctor, or how coverage and support for PrEP users varies dramatically across the country.
But Dehaas’ article demands explanation. How did Dehaas interview two experts in the field who told him PrEP was useful and important for gay men, and review a stack of literature that says PrEP is safe and effective, and yet come up with the opposite answer?
He ends his article on a quote from his everyman source, Scott:
“‘Taking a pill every day that has potential side effects, that you have to commit for a long period of time, just to be sexually promiscuous?’ he says. ‘I just don’t see the trade-off.’”
Just to be sexually promiscuous.
I don’t know Scott, or what he thinks, but Dehaas’ choice to sum up with that line speaks volumes. In the face of the evidence, his argument comes down to what resistance to PrEP has always been about: shaming gay men for having the sex they want.
The conversation about PrEP can do better.
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