PrEP is not yet available on the NHS, but some argue it should be.
Humans have always found new ways to get high and get laid. Last month, an op-ed in the British Medical Journal warned that "chemsex"—mixing strong drugs such as ketamine, GHB, and crystal meth with sex (often in groups)—is on the rise.
"Increasingly we are seeing patients who say that they use drugs as part of their sexual life," says Hannah McCall, a sexual health nurse with the Mortimer Market Centre (MMC) in central London who co-authored the piece. "But I wouldn't want anyone to get the idea that everyone who is into chemsex has their health damaged—the majority of our clients say it is not a problem. They feel that they know what they are doing, they know what the risks are; they know not to share needles."
But, she continued, "Although many men feel safe, they might not actually be as informed as they think. And even those that are informed might make different (i.e. less safe) decisions when they're high."
Swapping of both needles and partners is likely contributing to the inevitable: the UK has seen a rise in diagnoses of HIV and other STIs including gonorrhea, syphilis, and Hep C. One in 10 gay men in London is HIV positive and a quarter of infected men don't know they have it, according to the National AIDS Trust.
Some HIV activists and medical experts are increasingly concluding that one way to tackle a rise in HIV might not just be continued campaigns preaching condom usage, but a drug that protects against the virus itself.
PrEP, or pre-exposure prophylaxis, involves taking the antiretroviral drug Truvada—one of the drugs in the cocktail of antiretrovirals (ARVs) given to HIV positive men to reduce their viral load and stem damage to their immune system—to prevent HIV. It's not 100 percent effective, but studies have given estimates sometimes up to 92 percent. Enough to give some peace of mind.
In New York and San Francisco, Truvada as a form of PrEP is available free of charge to at-risk and low income residents. In public healthcare-averse America, PrEP is easy to acquire. France approved its prescription on the public health bill this month. But in the UK it is not yet available on the NHS—and it should be, says McCall.
"It seems pretty clear to me that this will become a big public health problem if we don't do something about it now"
In the parlance of public health strategy, it's a form of "harm reduction." Rather than trying to discourage people from having casual sex, or making blanket statements telling kids not to do drugs, many public health experts believe the best approach to reduce overall harm is to mitigate risks in ways that are more realistic. The MMC focuses its efforts with injection drug use with chemsexers, for example, not on chastising its patients but on helping them reduce their risk in realistic ways, such as providing free "slamming packs" with blue, green, and red needles that make it that bit easier to avoid sharing.
In the BMJ, McCall wrote in her editorial that understanding and addressing the risks of chemsex "needs to become a public health priority." Even if you're not into chemsex, the people you have sex with might be. As those telly ads use to tell us, when you have sex with somebody, you're having sex with everyone they ever had sex with.
"It seems pretty clear to me that this will become a big public health problem if we don't do something about it now," says McCall.
Alarmist scare-mongering? Absolutely not, says Greg Owen, a London-based writer who is HIV positive and gay. "The landscape has changed in so many ways—this is the perfect storm," he says.
Nobody knows how popular or prevalent chemsex is, but it's bigger than those outside of it seem to realize. "When ten times in a row you go to a bar to meet somebody through Grindr, and before going to your place they tell you they first have to call their dealer, it's tiresome," says Alex Craddock, co-founder alongside Owen of www.iwantprepnow.co.uk, a website with information on PrEP and links to sources for the drug.
"If you can only afford the prescription because you are rich, frankly, that makes me uncomfortable"
The key, says McCall, is to ask gay men directly what help they actually want. "Otherwise we're just spending money on things that won't really help anybody," she adds. The answer, she says, is PrEP—and though you can pay for it (you can get PrEP from UK clinics such as 56 Dean Street for £400 a month), it should be available for everyone.
"If you can only afford the prescription because you are rich, frankly, that makes me uncomfortable. It is frustrating as a health professional that you can't give people something that can clearly help them," she says. "To be able to relieve people from the anxiety of worrying about catching HIV or giving it to somebody else—that is something that as a society we should be proud of."
Owen had intended to suck it up and pay the fee—and wrote a diary entry on his blog on the way to the clinic—but it was too late. When he had his HIV test to get the green light for PrEP, he discovered he was infected with the virus. "I was three months too late," he says. "If the information and the awareness had been there, this is one transmission that could have been prevented."
Which is why he and Craddock set up I Want Prep Now, which campaigns for PrEP to be made available on the NHS and provides information on sources to buy drugs online.
"The truth is that HIV is not as stigmatizing now—you can have HIV and still be healthy. It's not a death sentence, and you can still look good and get laid," says Owen. "So a lot of men have, frankly, lost the fear of HIV, and condom adherence is minimal, especially because the ARV drugs mean that many men are 'undetectable' and cannot pass it on easily."
"This is about being responsible for yourself and everyone else. PrEP is an opt in—HIV is not an opt out"
Perceived ambivalence on condoms has already drawn critics.
"A lot of people on the scene don't want to discuss chemsex, as they feel it's shameful and that people just perceive it as 'Oh look, there go the gays going wild again,'" says Craddock. "Now when we ask that this prescription be available on the NHS, people say, 'Oh, this is just an excuse to bareback.' Mate, people are already barebacking. This is about being responsible for yourself and everyone else. PrEP is an opt in—HIV is not an opt out."
Does taking PrEP mean men, gay or otherwise, won't wear condoms, and other STIs will rise in step? Craddock and Owen point to the "PROUD" study, conducted by the Medical Research Council, which tracked the HIV status of men on and off PrEP, and found that giving study participants PrEP had little to no influence on their rate of infection of other STIs. In the plain language of medical science: "We detected no difference in the occurrence of sexually transmitted infections, including rectal gonorrhoea and chlamydia, between groups, despite a suggestion of risk compensation among some PrEP recipients."
Dr Mags Portman, a consultant in sexual health and HIV at Mortimer Market Centre, says the PROUD study changed her thinking about PrEP. "At first I didn't understand why we would spend money on prevention in this way when we know that giving HIV positive people ARV drugs to lower their viral load will help prevent them from passing the virus on," she says. "Working on the PROUD study completely changed my thinking and I am now a vocal advocate for PrEP." The researchers halted the study early because the difference in HIV infection rates were so drastically different between men on and off PrEP. The PROUD study has found a reduction in HIV incidence of 86 percent.
If the stats show that making PrEP available reduces HIV infection rates, why the resistance on the part of the NHS, which has delayed a debate on the matter until June 2016? One reason is the high cost of the drugs and an already-strained NHS budget.
But Owen opines that it's a cost that will save the NHS money in the long run, and is in everybody's best interest—and the resistance no different to that toward making birth control easy and cheap to acquire in the 60s.
"People used to shame women for going on the contraceptive pill: 'Why wouldn't you want to stick to the system of getting married and having babies?'" laughs Owen. "They thought they were sluts—and they thought they were dumb. Today they might still think they are sluts, but they certainly don't think they are dumb. It's the same thing for the gays: you might think I'm a slut for taking Prep and sleeping around. But if [you] stay HIV negative all [your] life, you might be a slut… but you definitely are not dumb."