For some reason, dangerously, the gay community has calcified around the condom – a method of HIV prevention – as opposed to the idea of HIV prevention, and what a complicated, difficult beast it is that we are called to fight. By framing conversations on HIV prevention and PrEP around condoms, our community is committing one of the original sins of HIV prevention – looking at the epidemic as a largely sexual epidemic. And, yes, I know the numbers on how much HIV transmission happens sexually.
In a recent survey of 90 PrEP users in the Kaiser Permanente AIDS prevention program, 45 percent of survey respondents self-reported that they had engaged in condomless sex since going on PrEP. Just to do some quick math, this means about 41 people in the study had engaged in condomless sex after going on PrEP. Not captured in this data is how many of the respondents engaged in condomless sex with primary partners or casual partners (not that it matters), whether they had condomless sex one time or many times (not that it matters) or whether they were receptive or insertive partners (not that it matters). You see, for all that we don't know, a select few have really tried to read a lot into this rather small piece of data. They've pulled a lot of slut-shaming rabbits out of a tiny PrEP-shaming hat.
Unfortunately, there are a lot of questions that went unasked on that survey. Did they ask whether the respondents felt less anxious? Did they ask respondents what it felt like to give or receive their partner without a condom for the first time – if it was the first time – or perhaps without worry for the first time? Yes, STIs are important to talk about, but there is a mental health aspect to natural sex that rarely gets discussed. As noted queer author Eric Rofes said in a 2004 interview, “The act of getting fucked and having the sperm dumped in a condom may have very different meanings for a man than getting fucked and having the sperm shoot deep inside your butt. Like it or not, using a condom likely changes the meaning and the practice of anal sex in significant ways. For some men, the meaning and pleasure comes from having another man's sperm deep inside his ass. If you add a condom to the picture, that meaning and pleasure will not occur.”
But even Rofes, who I love, only reads the epidemic as a sexual one! We must go beyond sex. We must reframe this conversation as beyond "condoms vs. PrEP" to one of "sexual response to the epidemic vs. structural response to the epidemic." And sitting down to discuss these results any further will not help us.
Pitting PrEP use against condom use is a false dichotomy. When pitting PrEP against condoms, it turns PrEP into a purely sexual intervention and, even more dangerously, paints HIV as solely a sexual phenomenon. The real dichotomy is looking at HIV as a sexual epidemic versus looking it as an epidemic that affects those most heavily marginalized in America – people of color, those living in poverty, those who are differently abled, etc. We cannot move forward with HIV prevention if we continue to look at HIV through the lens of sexuality. We've gone as far as we can. The idea that the condom is the end-all, be-all of HIV prevention has us caught in a holding pattern against progress.
There are cacophonous, nefarious Internet trolls who will comment on almost any PrEP article with the same shtick – "Put on a condom! If I can do it, so can you!" "I've always used a condom!" Now, I do not know every internet commenter's experience, and I definitely understand that many internet comments are quick, knee-jerk reactions to pieces that often embrace the "PrEP vs. condoms" dichotomy, but here's the deal: when discussions of HIV prevention revolve around condom use, then that is not HIV prevention in earnest. That is a way of asking that HIV be kept out of your sexual networks. And that's fine, as long as you own it. While it is important to adopt a way to prevent HIV infection in your own body, there are still ways that we must challenge ourselves to look beyond our own bodies to win this battle.
HIV prevention is complex. It's complex because it's a part of human health, and every aspect of human health is complex for a multitude of reasons. The main one, of course, is because we live in a country that does not value its citizens' health. The most comprehensive piece of health legislation we've seen in forever is a law that requires everyone in America – except for undocumented immigrants – to purchase private health insurance. It's not a law that finally drops down the barriers between people and the things that keep them healthy. It's a law that requires that all people become versed in a nonsensical, highly wrought and flawed system.
Debates about condoms vs. PrEP stronghold HIV into an epidemic that is purely sexual, which we know it is not. HIV is an epidemic that is fueled and buttressed in marginalized communities by poverty, racism, access to health care, and more. People in my community – young gay men of color – won't benefit from this conversation. In fact, we're losing the war on AIDS because the conversation is stuck here. If we began to look at the "of color" part of the "young gay men of color" category and began to discuss the intimate ways that my community knows structural racism and structural violence, then we could make some headway in this fight. But looking at us as purely sexual beings, just like our white gay counterparts, but with a tan, is not the way to do it. It will not bring us home. It will not keep us negative. It will not liberate us.
That 41 people who decided to have condomless sex in San Francisco tells me nothing about how we're going to end HIV. Our failing approach to the end of AIDS is more apparent in the back-and-forth argument in the days following the release of the survey than anything that the survey said itself. How long do we have to discuss the sex lives of 41 San Franciscans while my community continues to fight a war in our bedrooms with no aid, no support? What about those who are struggling with drug addiction, those who are struggling with homelessness and those who are being crushed by the unflinching stress of structural inequality?
The HIV epidemic is at once curiously intimate and casually impersonal. It lives with us, intimately, nagging us in our minds. Reminding us to put on a condom. Scaring us into paralysis. But, it is also so different for every person that there will always exist gaps in experience between you and someone else's epidemic. And HIV prevention begins when you can understand that you may not be the direct benefactor of the work that we are being called to do.