Fear no more - our health, our right!
By Henning Mikkelsen
“And don’t forget your condoms!” You have heard it forever, and probably practised it quite a bit - European gay and bisexual men are among the most experienced condom users in the world. Indeed, condoms are a blessing, and they have stopped millions of HIV and sexually transmitted infections.
But condoms alone don’t do it. For the last ten years, HIV has been on the rise among gay, bisexual and trans people in Europe, particularly fast - by more than 300% - in the countries in Central, Eastern and South-Eastern Europe, the countries which were spared from the first ravaging wave of the AIDS epidemic in the 1980s.
'Well, couldn’t you just remember those condoms?', your gay-friendly straight doctor might say, looking you sternly in the eyes. While you may think, when was he last using a condom? Did he always remember? Or, did he, like you, at times end up in situations when the condom was not where it should be - for reasons of love, lust, dope, or booze? Maybe they were simply not at hand when needed, or you were not in position of control.
Many of us are paddling through our sexual lives, using condoms regularly, but also encountering the exceptions, leaving behind the fear - before, during and after sex - hanging like a Sword of Damocles above our heads. Is it now that HIV will become my life companion? - bringing along buddies of stigma, discrimination and isolation, and maybe eventually disease and death?
Better not to think, better to push away - so we forget the regular HIV testing, difficult to get in many places anyway. Far too many - 38 % of gay men testing positive - are diagnosed too late for optimal treatment, at a stage when their immune system is already weak.
Such misery - but it does not have to be. Today we have new knowledge, tools and experiences that can effectively stop HIV. Only, many of us do not know about it, and European governments at large are failing to introduce these new tools and approaches.
Firstly, treatment works! Today there is no reason why people living with HIV should not live a full life, as long as anybody else, especially if they start treatment early. Living with HIV is still no walk in the park, though. The pills only work as a brake, for now they have to be taken daily and lifelong. And the ugly buddies are still around.
Secondly, effective treatment blocks HIV transmission. In 2016 a study investigating 22,000 condomless anal sex acts between HIV negative gay men and positive partners in effective treatment found zero cases of transmission Still, this important news - now campaigned as Undetectable (of virus) = Untransmittable - remains unknown to many, as Esther and Nikos from EATG blogged earlier this week.
A recent US survey found that the majority of HIV negative gay men and one third of HIV positive gay men did not consider this message accurate. It’s likely that the situation is the same in Europe, where public health authorities have been remarkably shy in sharing this important knowledge.
Certainly, if you are negative and looking for new sex partners, this knowledge may be of limited value. After all, you cannot see whether people are undiagnosed or in effective treatment. So better stay with condoms only, or the more dubious 'sero-sorting' of partners into perceived HIV positive and negative?
Wrong! In 2015 studies in the UK and France showed beyond any scientific doubt that the Pre-Exposure Prophylaxis (PrEP) pill can block HIV transmission. It has a less effective twin, called PEP, post-exposure prophylaxis, where you start a course of treatment soon after exposure to a risk of HIV infection. PrEP works - provided that you take the pills, on a daily basis, or on demand, following a recommended schedule. Just as condoms work well, when they are on. But condoms must be used in the heat of the moment. PrEP you can take when you are most in control, for example at breakfast.
Does that make condoms useless? Certainly not, for many they work well, and unlike the pills, also prevent many sexually transmitted infections. The pills, like any medicine, can have side effects, even if they are few and modest. And PrEP may not be for everyone, always. For most people, PrEP may be preferred during some parts of their lives, at other times condoms will work best.
No more fear - we are entering a brave new world where we once again can be in full control and enjoy our sexual health and sexual pleasure, where the sorting of people into positives and negatives becomes futile - as many PrEP users experience.
We are, however, only at the threshold of that world. What keeps us from entering is politics. European governments are extremely slow and reluctant to introduce the new tools and approaches - easy access to HIV testing, PrEP, immediate treatment for those found positive, and screening for sexually transmitted infections.
Dean Street, the most popular sexual health clinic among gay and bisexual men in London, has seen a 90% drop of new HIV infections since they adopted the new approaches two years ago. Now they plan to completely eliminate HIV transmission among gay and bisexual men. But government cuts are hitting sexual health clinics, and a decision only to allow 10,000 people access to PrEP in England is getting in the way.
Since 2012 PrEP has been available in the US. In 2018 across Europe, only France, Belgium, Norway and Scotland ensure access to PrEP for people at high risk for HIV infection. The rest of us live in countries with no or limited access, or only at excessive prices, and no public promotion of PrEP.
The LGBTI movement in Europe has been remarkably slow in recognising and reclaiming our right to a sexually healthy life, free of HIV infection. It is high time, we speak about sex, our health and pleasure and make it a political priority. If we do not, who will? Some are fearing a new wave of promiscuity - do we really accept that a disease should define who we are and what we do?
Henning Mikkelsen is a Danish gay and HIV activist, now consultant for UNAIDS, and has worked since 1988 for the international response to AIDS with WHO, the European Commission and UNAIDS.
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