The Time For Debate is Over. The Time to Implement PrEP is Now.

Published: April 30, 2013

So much has changed since when I began writing this column last October. When I started “My Life on PrEP,” most people were wholly unfamiliar with the concept and its implications for HIV prevention. Apart from the spiteful attempts of AIDS Healthcare Foundation director Michael Weinstein to do everything in his power to kill it, there was a deadening silence that seemed poised to strand PrEP on the island of misfit prevention toys alongside the female condom and post-exposure prophylaxis.

I began writing “My Life on PrEP” to break the silence and shatter the Pollyanna narrative that PrEP was only for good gays who used condoms or had poz boyfriends. Like most of the guys that PrEP is going to help keep negative, I’m not a good gay. I’m a Truvada whore. And I’m proud of it.

I am thrilled to say that this column has reached mission fulfillment. The national – perhaps even the international – conversation on PrEP has changed. Community forums abound. Guys on PrEP are starting to come out of the woodwork and talk about their experiences, and those curious about it are better able to find reliable, sex-positive information. I’m not the only troublemaker to credit for this sea change, of course – folks like the glorious and charming Len Tooley up in Toronto have helped to crack open Pandora ’s big, pink, furry Box. (Len’s got some serious charisma, uniqueness, nerve, and talent to come out as a PrEP-user without a pen name to hide behind. I wish I had his courage.)

The word is out, and the time for engaging in contentious theoretical debates is over. It’s time to roll up our sleeves and get our hands dirty. The question cannot any longer be if we implement PrEP, but how. Gay men – especially black gay men – continue to get infected by the tens of thousands. We have the tools to keep some, indeed many, of these men negative. Public health, ASOs, and clinicians have an ethical duty to act. Continuing to live in a condom fantasyland isn’t just willfully ignorant, it’s immoral. To the powers that be: consider the gauntlet thrown.

I’m not naïve, of course. There are serious challenges to making PrEP a reality. Our primary care infrastructure in the US is woefully ill-equipped to handle an intervention like PrEP that requires regular follow-up and providers who are knowledgeable and willing. While Obamacare is poised to help address some of these serious gaps in access, many questions remain about how those without private health insurance will get access to PrEP. Perhaps the most tragic outcome possible will be if PrEP simply becomes a niche intervention available only to privileged few with the knowledge and resources to get their hands on it. I’ll give you one guess as to what those people will look like (if you guessed they will look like Jake Sobo, you’re right!).

There are creative solutions arising that suggest these obstacles are not insurmountable. Take the work of Seattle-based Dr. Joanne Stekler, who is working with Gay City to set up something of an ad-hoc PrEP clinic to get folks without health insurance access to Truvada through Gilead’s Medication Assistance Program.  Dr. Stekler and Gay City deserve serious kudos for this innovative work. As I have written before, providers can be a barrier to getting access to PrEP. But as Dr. Stekler is proving, that need not be true. They can also be leaders in expanding access and ensuring equity. I hope that every single healthcare provider in the US reading these words who is committed to gay men’s health is considering what they can do in their own communities to ensure equity in access to PrEP. Seattle-based readers without health insurance who are interested in PrEP should get in touch with Dr. Stekler.

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