On the second floor of a bland building in east Chelsea, men order rooms and lockers for $39. In between the reception desk and the prison-like portal to this bathhouse is a poster advertising free HIV tests. Practically every inch of this entrance hall is black save for the 8 x 11-inch blue poster and a stack of pink and green postcards promoting HIV-related medications, filed in a cardholder on a black metal table. In this space of discreet caution and desire the realities of sexual liberation and HIV infection compete for attention.
The gay bathhouse, long a symbol of the spread of AIDS, has a new vibe: The availability of a daily preventative pill against HIV has revived a decades-old debate about whether gay men have license to engage in promiscuity, pitting a hard-won sense of freedom and equality against the stigma of disease and casual sex.
If taken daily, the pill, known as PrEP (Pre-Exposure Prophylaxis), or Truvada for the two medications that comprise it, can reduce the likelihood of contracting HIV by 92%, according to New York City Public Health. Some men who have sex with men see PrEP as the ultimate sexual liberator, while others see its distribution as a pyrrhic victory, an incredible medical advancement that will come at a great social cost.
In the large gay communities of Hell’s Kitchen and Chelsea, HIV is a disease between lovers. Male to male intercourse accounts for 74 percent of cases of HIV/AIDS in these neighborhoods, according to the New York City HIV/AIDS Annual Surveillance Statistics website. As of 2012, 6,004 men were living with HIV/AIDS in Hell’s Kitchen and Chelsea. Whereas in some communities HIV is associated with intravenous drug use, here disease and sex are inextricably linked.
David Duran, 34, a journalist, spoke out against the indiscriminate use of PrEP, hypothesizing that gay men will become “Truvada whores” because the pill might be used as a potential carte blanche for reckless “barebacking”—sex without condoms. He has since moderated his opinion. “Sex is a very different experience for each individual and there is no need to justify why some gay men prefer not to use a condom,” wrote Duran in an e-mail conversation, “Why do we need to scrutinize anyone’s personal sexual habits? Instead we should be celebrating those people who opt to protect themselves.”
Adam Zeboski, 26, a San Francisco HIV counselor, is trying to re- appropriate this term and make it a “badge of honor” through a #TruvadaWhore social media and t-shirt campaign. “A Truvada Whore is someone who cares about his health and preventing the spread of HIV, is intelligent enough to research his options and make an informed decision, motivated enough to take action, determined enough to be persistent, and brave enough to not be intimidated from doing what he knows is right,” said Zeboski.
The power to choose whether or not to wear a condom is at the core of this debate.
“I mean, that’s the whole point. If I was going to use condoms, I wouldn’t take the pill,” said Paul Leasure, 37, a manager at Therapy, a bar in New York City’s Hell’s Kitchen neighborhood.
Leasure was young during the AIDS epidemic and said he remembers watching celebrities like Madonna and Janet Jackson do public service announcements about condom use on MTV. “Now I’m not afraid. I can have sex with anybody,” said Leasure, “I think it’s responsible.”
Besides the arguments supporting individual choice, the distribution of PrEP might just be good public health policy. Corey Johnson, City Council Member for District 3, which includes Hell’s Kitchen and Chelsea, said he advocates for an emphasis on condom use as a preventative measure, but he conceded that some people are just not going to use condoms. This rubber-averse subset of the population should think about going on PrEP, he said, “because it would make transmitting much more difficult, if in fact they did engage in risky behavior.” Johnson has been on Truvada for HIV for several years because he was HIV-positive. In fact, he had his freshly delivered pills on his office desk at the time of his interview.
The Center for Disease Control’s federal guidelines on the use of PrEP, released in May 2014, recommend PrEP for men who have sex with men “at substantial risk of HIV acquisition.” According to the Center, an appropriate candidate for PrEP might be someone who is in a relationship with an HIV-positive individual, has condom-less sex, or has multiple partners. The cost: between $8,000 and $14, 000 annually, according to the New York State Department of Health. Some insurers and New York State Medicaid will cover the cost.
Kole Loftin, 23, smiles with his tongue pressed up against his teeth and could very well be a Public Health poster boy. He takes PrEP because his boyfriend is HIV-positive, but he still uses condoms. “I want to be safe,” he said, and his boyfriend wants him to be as healthy as possible.
New York City Public Health is not being shy about its outreach on PrEP. Unlike in the 1980s, when it tried to shut down bathhouses, Public Health is advertising in the virtual hubs of male-to-male intercourse. PrEP and PEP, Post-exposure Prophylaxis for emergency treatment, are both being advertised on male-only social networks like Grindr and Scruff, which are mostly used to find hook-ups. Advertisements come up as push-notifications. Grindr claims 426,710 users in New York City, second only to London for highest number of users.
The pride in sexual promiscuity coupled with resistance to condom use is a public health challenge that some say will be aggravated with the wide distribution of PrEP. Andrew Frazier, 54, a client navigation specialist at Gay Men’s Health Crisis (GMHC), lost his best friend from high school to AIDS. “There’s a philosophy in the gay community that part of freedom is to liberally engage in sex, whenever and wherever we want,” he said. To Frazier, “PrEP is one weapon in the arsenal of safe sex practice. PrEP is not meant to give you the green light to freely engage in unprotected sex.”
Dr. Victoria Harden, 70, the founding director of the office of the National Institute of Health History said it comes down to individual choice. While condom use is a highly effective preventative measure, that “doesn’t mean anything when you have two people in the bedroom.” She asked the essential question of this debate: “If we can get HIV under control with these antivirals, it’s going to drastically reduce disease. Does that mean we can go back to our 1970s ways of living where we did anything we pleased without protection?”
The 1970s marked an explosion of sexual liberation in the American gay community, which, as Jonathan Engel, 49, author of The Epidemic: A Global History of AIDS, pointed out, preceded political and legal reform as the mobilizing conviction in the gay community. “A large part of the identity of gay men was to have good sex,” he said.
Some older gay men see this debate as a product of generational disconnect. According to a recent report by the Kaiser Family Foundation titled “HIV/AIDS In The Lives Of Gay And Bisexual Men In The United States,” only eight percent of young American gay and bisexual male survey respondents (18-34) said they “lost someone close to them to the disease,” while 47 percent of respondents ages 35 and older had lost someone to AIDS. The “younger generation doesn’t visualize what we have been through,” said Frazier.
“My generation is the only generation left that witnessed what happened,” he said, “Have we progressed any further? Sometimes I don’t think so.”
Larry Kramer, playwright and HIV activist who founded GMHC in 1981 and ACT UP in 1987, caused outrage for his views on PrEP. In a New York Times article from May 2014 he is quoted as saying, “Anybody who voluntarily takes an antiviral every day has got to have rocks in their heads. There’s something to me cowardly about taking Truvada instead of using a condom. You’re taking a drug that is poison to you, and it has lessened your energy to fight, to get involved, to do anything.”
While organizing his files and accounts before a Friday night at Therapy, Leasure said, “I never lived in a time when I can just have sex.”