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Letter from Brussels: Does PrEP Polarize?


by De Ket in Columns & Opinions , 18 April 2019

Dit artikel is ook in het Nederlands beschikbaar
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Dear Neighbors to the North, Since June 1, 2017, PrEP is reimbursed in Belgium. According to scientists, it is effective prevention against HIV and would drastically reduce the number of HIV infections. That is the theory. Practice - as often - shows a different picture.


As with every drug that is reimbursed, there are a number of criteria that you must meet before you can claim reimbursement in Belgium. Some criteria are of a medical nature; others are related to sexual behavior. For instance, those who are struggling with kidney problems do not qualify for PrEP. Furthermore, you should give at least one positive answer to one of the following questions: did you have anal sex in the last six months without a condom, with at least two partners? Have you had more than one sexually transmitted diseases (STDs) in the past year? Have you started a PEP course several times in the past year? Do or did you have regular sex under the influence of drugs or alcohol? Does your partner live with HIV and is his viral load detectable? Do you inject drugs and or share your needles? Are you active in sex work and do you have unprotected sex?

They all seem pertinent questions and they justify the reimbursement of PrEP. But what the legislator does not take into account is the fact that there are gay men who look for additional protection in the form of PrEP, but don’t meet any of the above criteria. There is - fortunately - a whole group of HIV negative gay men, including myself, who have never had an STD or needed a PEP course. Who never have sex under the influence of drugs and who never enjoy anal sex without a condom. This describes the situation of a friend of mine who went to a Belgian health facility for HIV/AIDS care. He wanted to know whether he could get PrEP. He was regularly tested and always had safe sex.

“Then why do you need PrEP,” asked the doctor? “Because no one wants to have sex with condoms anymore, because apparently everyone is either on PrEP, or they claim that their viral load is no longer detectable with their current treatment.” “If everyone would argue this way, we have to get all Belgian gay men on PrEP and that is not our intention,” was the answer. The doctor sent him home, asking him to rethink everything. He should come back if he wanted to get PrEP then. It was not a blunt refusal, but they certainly showed him.

Gay men who have safe sex must first have unprotected sex or an STD to convince a doctor to describe PrEP. That’s how the cookie crumbles. The question is whether this is ethical. Gays can lead a reverberant sex life without getting nasty infections. Even though when I talk to friends, this has become much less evident with PrEP. “It seems as if everyone is on PrEP. At least that is what they claim. But when I ask them the name of the drug they are taking, or when they swallow their pill, they don’t know what to say. So, they are not on PrEP, but lie.” The problem with PrEP is that you can’t be certain if someone takes PrEP, and when. So, you really have to start using PrEP yourself to make sure that you are protected when not using a condom during anal sex.


The same goes for an HIV positive man who claims to have a non-detectable viral load. That may be true, but certainly not all the time. But in both cases, gays usually indicate that they do not want to have sex using a condom. And there you are, on a date, looking for safe sex with a condom, while the other claims to either use PrEP and use it correctly, or – in case of an HIV positive person - he claims that his viral load is undetectable, and that using condoms is no longer necessary. They also claim they are regularly tested and do not have an STD.

Over the last few months, I have heard quite a lot of similar stories from friends. Every two to three months, someone tries to discuss this issue with me. That they are no longer dating, they have little or no confidence in sex partners, and are still scared to death of an infection with HIV. PrEP should remove a lot of that uncertainty, but in practice, the problem is more complex than people think. At least for those who always have safe sex, in all circumstances. PrEP can therefore lead to a form of polarization, in which those who are using PrEP no longer want to have sex with a condom (fortunately there are still men on PrEP who do want to use a condom) and are not interested any more in those who still want to have safe sex while using a condom.

When push comes to shove, everyone needs to determine for himself whether they want to have safe sex, with respect for the wishes of the other sex partner(s). But then you have to accept that if you only want safe sex, you either have to use PrEP yourself or have to live with the fact that not as many people will want to have sex with you.

Yours sincerely,

De Ket
 




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