Sex With PrEP, Like Life, Is Never Without Risk

Like so many who use PrEP to prevent HIV, I was fairly confused and dismayed when I originally learned the news that a second individual acquired HIV while consistently adhering to PrEP. Even as someone who has been teaching and speaking about PrEP for the past four years, I was shaken. I couldn't help but consider, I have been taking PrEP since July 2011 as a bottom who doesn’t use condoms with total strangers. What if I’m next?

After the information was public October 18, I immediately saw similar concerns verbalized on my Facebook group, “PrEP Facts; Rethinking HIV Prevention and Sex.” With over 15,000 international members, many of whom are also enjoying condomless connections on PrEP, there was a fairly strong outpouring of concerns, trepidation, uncertainty, and worry. Many expressed a similar concern, “I fear what happened to this man may happen to me.”

Then I took a slow breath and reminded myself of the facts. Yes, two people have now acquired HIV with measured adherence. But over 100,000 people in the U.S. are currently using PrEP without seroconversion, without incidence, without disruption, without media attention. Meanwhile, the Centers for Disease Control and Prevention announced over the summer that a record low number of new HIV infections were reported in 2014. For the first time since the beginning of the AIDS crisis, new infections were down to 44,073, which is a 9.3 percent drop from the year before. It’s no coincidence that 2014 was the same year the CDC announced its protocols for providers to prescribe PrEP, and the World Health Organization provided international guidelines for PrEP use. All these events combined illustrate how powerfully effective PrEP is as an HIV prevention tool, and demonstrate the potential for PrEP to significantly reduce HIV rates worldwide. 

But to be completely truthful, lingering doubt still weighed in my mind. I still wasn't able to completely let go of the thought, If it could happen to those two guys who seroconverted while using PrEP consistently it could happen to me too. What if the next guy I hook up with on Scruff is one of the few people on earth who could transmit HIV to someone using PrEP?

As fate would have it, I was riding the subway into Manhattan and saw a sign that read, “145 People Were Struck by Trains in 2014; 58 Were Killed.” That got me thinking about the risks I take every day in my life just by riding to work. Then, thanks to Google, I was able to ascertain more stats that showed about 133 pedestrians are killed in New York City by cars each year simply while walking. And at least 3,000 Americans die annually from the flu. It made me realize that I was more likely going to be hit by a subway train, struck by car on the way to a trick's house, or getting a life threatening flu from the guy I’m with than getting HIV while using PrEP daily.

This second case of HIV acquisition on PrEP reminded me that life itself presents a regular set of uncertain dangers and challenges. At the time of this writing, 46,193 Americans have already been killed by gun violence in 2016 (about 155 per day). There were 38,300 people killed in car crashes in 2015. Accidental overdoses are the cause of 42,000 deaths per year. More than 480,000 tobacco-related deaths occur each year. Over 12,000 Americans are severely injured and burned frombyholiday decorations. There are 8,800 deaths from alcohol-related events; 3037 die from food poisoning; over 900 die from bicycling injuries; 626 die annually in boating accidents; 100 die from skiing.  

With all this danger lurking around out there, it hardly makes sense to leave the house at all! But whoops, more than 18,000 Americans die every year from injuries that take place in the home, so that strategy doesn’t seem to work either. 

Given the gargantuan risks that every day life poses, I’m left with a simple question: How do I choose to live today? Do I want to be fearful, regretful, timid, and angry? Or do I decide to be present, loving, engaged, and active? For me, the choice is obviously the latter.

What’s fascinating here is how people in my group, and Americans in general, perceive and respond to risks and unfavorable outcomes. It is rare in high-traffic areas not to know someone who has been in a car accident of some sort, yet most people still drive daily. It is rare not to know someone who at some point in their life had an adverse reaction to a prepared meal, yet most continue to enjoy eating out in restaurants. Our society doesn't stigmatize the victim or radically call for people to change their behaviors when they are hit by a car, poisoned from a kitchen, injured by a holiday decoration. But when two people contract HIV on PrEP over a period of nine years, it is cause for widespread fear, panic, and shame.

So I took another deep breath and came to this conclusion: I accept that sex is risky. I understand that PrEP doesn’t eliminate risk of contracting HIV. Just as I’m clear that I can get shot anywhere in the U.S., killed on the subway, run over on the street, food-poisoned in any restaurant, or burned alive if I live in a building with a Christmas tree. 

This second discovered case of HIV acquisition won’t change my pleasure of bottoming without barriers, nor will the third or fourth. I will take reasonable precautions to live my life fully such as using PrEP every day, looking both ways before I cross the street, and reminding my neighbors about safer use of electrical outlets during the holidays. Even while taking proactive measures, adverse outcomes can happen. That is the price of admission I’m willing to pay to live my life fully, enjoy my work productively, and engage in sex pleasurably. 

DAMON JACOBS is the HIV prevention expert at TheBody.com.