My response to The Irish Times PrEP piece

On Thursday 20 April The Irish Times published an article Anti-HIV Drug Removes Personal Responsibility

This article was positioned as an opinion piece and one thing we can be sure of is that opinions have no place and hold no authority over facts based evidence. Presenting accurate facts and providing an opinion based on those facts is fully acceptable but this article failed to deliver that.

Several HIV experts and organisations including Professor Chloe Orkin for BHIVA and Dr Paddy Mallon for UCD School of Medicine have already highlighted the inaccuracies and errors in the very damaging statements made by the journalist.

I will be speaking from a community perspective. As co-founder of the world’s highest traffic and most widely used PrEP website, I am dismayed that a publication such as The Irish Times would run such a piece. As an advocate and activist who identifies as a gay man I accept that our community and its members will have differences of opinions on PrEP, HIV prevention and sexual health initiatives. It is concerning that rather than reach out and share learnings and experiences this journalist instead chose to write what appears to be a click bait vanity piece. This is not responsible. This is not community. This is not healthy. This is not contributing anything of worth to the debate.

Fear based messaging has never worked. It will never work. No one responds well to being judged, shamed or blamed. To further muddy the waters and confuse sound HIV prevention with moralising and toxic internalised personal issues is damaging and indicative of a lack of understand of self and of the complexities of gay life and sexuality on a community wide level.

“What I fear at the moment is a resurgence of the old “gay plague” rhetoric of the 1980s whereby gay and bisexual men are viewed as irresponsible and apathetic in relation to their sexual health.
What PrEP is in danger of promoting, in my view, is a policy of play now, pay later which the gay population can ill afford to embrace.”

We really need to work on deconstructing this concept that at some point we will “pay” for being gay. Being LGBT+ is not wrong. Living as our true authentic selves and all that comes with that, including enjoying the sex we choose is not something we are ‘afforded’ that must be charged back to us at some point. It is what we deserve. We are different as LGBT+ folk but we are not ‘less’. Different does not mean we aren’t equal.

Setting up arguments like these about “being responsible” creates a double bind. The notion that if I get HIV I’m irresponsible, if I try to prevent myself from getting HIV (using THE most effective method) I’m irresponsible.

And as if to clarify completely for anyone who is unsure: the journalist’s closing paragraph is a total contradiction in itself and of his entire ‘opinion’.

“The danger lies in transferring responsibility for risky sexual practices on to a tiny pill taken once a day rather than making informed choices and encouraging a culture of prevention rather than cure.”

I second Professor Chloe Orkin’s proposal below:

“I therefore propose that we [BHIVA] submit for publication a letter of clarification to better inform your readership of the latest evidence and guidance around PrEP.”

#TasP vs #PrEP

I have a few issues with treatment as prevention (TasP). More specifically I have issues with Public Health England trying to pass off the recent drop in HIV as predominantly due to TasP and other mutlifactorial approaches including more regular HIV testing. I have issue with this for several reasons. Here they are:
In the U.K. we have excellent free HIV care. We treat people living with HIV because we have to – otherwise we’d die. Simples. But when I start seeing bodies like PHE tagging substantial drops in HIV to TasP over PrEP my bullshit alert goes into overdrive. We have to treat people living with HIV or we’d die, I’ve said that already but how convenient is it for people managing budgets to then attribute drops in diagnoses to this ‘treatment’ – VERY! If you can spin this shit you remove the need for an appropriate prevention budget/spend. Which hasn’t been upscaled in years as it is. It was lacking years ago – it’s even more lacking today. I’m not buying that. And I will challenge anyone who tries to spin this. 

Then by focusing on TasP rather than PrEP we are ignoring a very key fact. The HIV epidemic in the U.K. is not being driven by HIV+ people. Let me explain, the majority of people diagnosed with HIV in the UK are on treatment and virally suppressed. We’re talking 80%-95% depending on which aspects you look at. That means that HIV in this country is being driven by “HIV negative” people. Or more accurately people who have seroconverted since their last HIV test and are unaware. I saw some data over the last few days that suggested the average HIV test lapse times are 2 years. Treatment as prevention is not gonna help here! PrEP will! PrEP is and PrEP scaled up WILL!
Then there is this suggestion with a focus on TasP that us people living with HIV are somehow responsible for managing HIV prevention for our sexual networks and our communities- WE ARE NOT! Our treatment needs to be first of all seen and respected as treatment. NOT PREVENTION. It is each HIV negative person’s responsibility to maintain their HIV negative status. I say that as a person living with HIV who embraces and encourages TasP but also as my former HIV negative self too. It was always my responsibility. It is yours too. 
And on the topic of more regular HIV testing for super high at-risk people! Wise up! If you gave these people PrEP you wouldn’t need this!! We could then focus on other STIs and actually we could maybe focus on other stuff above and beyond “disease” and “infection” and “prevention” and “risk” we could actually maybe start to look at the person and ask about feelings and worth and HEALTH. 
Finally all this only works for people linking into care. What we have done here in the U.K. with self sourcing PrEP is we have created a community health care system. I genuinely believe we are reaching people who can’t or don’t want to link into care. This is a double edged sword. It creates as many concerns as it does reassurances. But ultimately we are missing an opportunity here. Online and self managed sexual health is they way forward. It is the ONLY way some people will be able to or want to engage with sexual health. Why are we not building on this?