Hot PrEP Seeks Same for BB

Back in the day, meaning the 1980s, New York magazine could always be counted on to produce sloppy, embarrassingly uneducated, heartless, but fortunately blessedly few articles about AIDS and its effects on gay men. The editor-in-chief at the time, Edward Kosner, was much more interested in the inane “Mr. Peepers” society column thrown up by his wife than in the horrifying tragedy engulfing our community. A staff member once told me that the copy for one of the worst articles New York ran about AIDS contained no statistics whatsoever; the writer simply inserted blank spaces where the numbers should have been and left the research to the fact checkers.

The brilliant Adam Moss now edits New York. Creative, discerning, and openly gay, Moss would never permit the stupidity that was not only tolerated but effectively promoted under Kosner’s shitty regime. So I wasn’t surprised to see the recent cover story “Forgetting HIV” by Tim Murphy. What took my breath away was the teaser under the title: “A pill called Truvada can block infection. But it cannot easily erase decades of sexual trauma.” Good grief, I thought — they finally get it. The grief, I mean. “Sexual trauma.” Wow! When was the last time the mainstream press covered the impact of AIDS on gay men’s sense of sexual well-being?

Murphy’s article is frank, to say the least. He treats gay men’s sexuality not as a filthy unmentionable but as a natural and pleasurable fact, a positive characteristic not to be hidden or euphemized. Interview subjects tell their personal sexual histories without shame. In fact, some of them are downright proud of their promiscuity. As they should be.

Media Circus

Illustrated with headshots of shirtless gay men that reveal only their bare shoulders, the article spends a good amount of space on real New Yorkers making practical decisions about actual sexual behaviors. Murphy discusses the prevalence of drugs and alcohol in gay life without censoring or downplaying it. The openly gay Murphy acknowledges his own druggy past: “It’s not that I consciously wanted to have bareback sex,” he writes, “but I did want to get to the point where I wasn’t thinking about condoms and HIV and risk all the time and I could lose myself. Drugs got me there.”

The confessional mode is dangerous for a writer; it risks turning the article into an ode to oneself. But Murphy smoothly slips his own history into the wider story he’s telling — the story of the terrible mental and emotional price gay men have paid trying to adhere to a life of 100 percent safe sex all the time, year after terrifying year, decade after bleak decade. The dozen or so gay men Murphy interviewed are candid, brave even, when talking about their sex lives. None has had an easy time of it. Nor has any of us.

The mainstream media rarely cares about the toll AIDS has taken on gay men’s mental health. Why not? Because to pay attention to our complex emotional lives means confronting our sex drive in general and our sexual practices in particular — all the icky things we do that straight people don’t like to think about. “Forgetting HIV” is one of those rare pieces of journalism that wasn’t written with the goal of placating straight America’s disgust at the physical realities of gay sex. The LGBT media is rarely as joyfully blunt about butt-fucking as was Murphy’s article in New York. It took courage for Murphy to write it, and it took courage for Moss to make it a cover story. Hard cocks shoved into hairy asses just don’t have the same public relations value as tasteful same-sex wedding announcements in Sunday Styles, a point Murphy himself makes, though a bit less colorfully.

Here’s where Murphy gets into hot water: “When taken every day, it’s been shown in a major study to be up to 99 percent effective,” he writes of Truvada, which is the brand name for a preventive HIV treatment known as Pre-Exposure Prophylaxis, or PrEP. Truvada is the only anti-HIV drug that’s been FDA-approved for preventive purposes. The major study Murphy he refers to is known as iPrEx, short for “Iniciativa Profilaxis Pre-Exposición,” based on a clinical trial begun in Peru and Ecuador and later expanded throughout the Americas and in Africa and Asia.

I say hot water because Murphy’s reference to Truvada being “up to 99 percent effective” caught the attention of Josh Barro, who pivoted off that statistic in “The Upshot” column in the New York Times. Barro’s two cents on the Truvada story makes sense in the big picture, but some of his details are way off base. Regarding Murphy’s reliance on the iPrEx findings, Barro writes, “This is a claim I hear thrown around a lot among gay men in New York. And it’s wrong.” He’s certain of this. “The 99 percent figure isn’t a study finding; it’s a statistical estimate, based on a number of assumptions that are reasonable, but debatable.”

Barro then drags his readers on a difficult tour of statistical analysis in an attempt to prove that Murphy and all the gay men he encounters around town don’t comprehend the issue as well as he does. The “And it’s wrong” is a conspicuously dramatic flourish, especially because Barro is as wrong as Murphy – that is, if either of them could be considered wrong.

Barro’s claim that “the 99 percent figure isn’t a study finding” is rubbish. Public health research depends on statistical modeling to reach its conclusions. Why? Because to wait for real numbers to emerge would take years — years during which real human beings would be living their lives lacking specific advice on what to do. We rely on statistical estimates to produce responsible guidelines to make policy decisions, and public health studies — yes, Josh, they’re legitimate studies and are called “studies” by the public health professionals who conduct them — perform that function.

Barro goes on to quote the director of the Bridge HIV prevention research unit at the San Francisco Department of Public Health, Dr. Susan Buchbinder, who was one of the iPrEx investigators, saying, “I don’t think we can be quite so precise about the exact percentage.”

Fussing over the “exact percentage” is misleading, not to mention pointless. Barro brings Buchbinder back to express “particular concern that the estimate relies on a comparison of people who chose to take their pills daily with those who did not — unlike in an ideal study condition, where subjects are randomly assigned to take medication or not.” (These are Barro’s words, not Buchbinder’s.) In point of fact, the scenario Barro proposes would scarcely present “an ideal study condition.” The mere fact that a subject is “assigned’ to take a pill every day doesn’t mean that the subject will actually take a pill every day. Barro’s “ideal study” wouldn’t determine Truvada’s effectiveness. It would simply be another effort to quantify PrEP’s success as public health policy. Whether the number is 99 percent or 92 percent or 90 percent — or if we can say of Truvada simply that it is “highly effective” and can “drastically” reduce infection risk, as Buchbinder would — this is still cause for celebration.

“We know that people who take their pills regularly are probably different from people who don’t take their pills regularly on a number of levels,” Buchbinder opines, creatively sliding from “we know” to “probably” in the space of just a few words. Barro provides examples: “They could use condoms more frequently or have fewer sex partners, and those behaviors could help them avoid HIV independently of Truvada’s effects.” Some public health researchers — Buchbinder apparently among then — assume that adherence to drug regimens correlates with worrying and risk aversion: people who take their pills every day are the type who would continue to fret about seroconverting, so they’d augment their Truvada with condoms and keep the number of their sexual contacts low.

But this is pure speculation, and it’s not universally shared among health policy experts. In fact, the opposite may be true. Might it not be the case that men in the study who were taking Truvada every day would be more confident about their ability to dispense with condoms and yet remain safe?

Barro doesn’t entertain this possibility, but he does let his Harvard show as he tries to explain the iPrEx “model itself, what statisticians call a regression analysis.” Conceding that none of the study’s “high-adherence subjects became infected,” but noting that in a study of sero-discordant heterosexual couples, there were two such infections, he complains that “none of the rare circumstances [that] make infections possible among people with high blood levels of the drug” would “be reflected in the model.”

Which leaves the discussion pretty much where the 90 versus 99 percent left us: The circumstances of infection would be “rare.”

As annoying as his piece is, Barro ends it with a valuable take-away: “The failure of a 90-percent effective method is terrible luck; the failure of a 99-percent effective method is verging on a freakish accident. Putting too much weight on the 99-percent figure may lead some PrEP users to perceive virtually zero HIV risk when they should really be thinking about very low risk.

Something would-be PrEP users certainly have a need to understand. Still, Barro acknowledges that “from a policy perspective, the difference between 92 percent and 99 percent is not necessarily very important: Either way, PrEP looks to be a highly useful tool for reducing the spread of HIV.” And for that public health advance, we should all be cheering.