PrEP and the gay sex revolution

Arti­cle taken from The Face Volume 4 Issue 002. Order your copy here.

The front seat of a car parked on the outskirts of Watford isn’t exactly the most idyllic setting for your first sexual encounter. Being tossed off by a stranger (no kissing) is hardly the stuff of teenage dreams. Still, it’d taken Nick Perry years to get this far and he wasn’t going to let romance get in the way of getting off.

It was 2008 and Nick, then 36, had downloaded gay hook-up app Grindr a few months earlier after hearing about it from the most unlikely of places – on the blokey British TV car show Top Gear albeit coming out of the mouth of gay actor Stephen Fry. Nick had chatted to plenty of guys, but until now, he’d been too scared to actually hook up with them.

When we meet at his home in north-east London, Nick tells me he’d been in denial about his sexuality since childhood. It’d been easier to ignore his urges than to engage with the fact that he was gay. He was abstaining from sex and missing out on the intimate relationships that come with it. Feelings of anxiety, shame and loathing are fairly common for LGBT people starting out on a journey of self-exploration. Over time, most of us start to find our way. But for Nick, something was stopping him from taking his first tentative sexual steps: his fear of HIV and Aids.

Growing up in the 1980s and early 1990s meant Nick had seen the infamous ​“Aids: Don’t Die of Ignorance” tombstone adverts on TV. And heard the term ​“arse-injected death sentence” thrown around by kids at his school.

“Back then, our lack of knowledge meant many people thought you could catch it by sitting on toilet seats, sharing drinks, or just by looking at a gay person,” the now 47-year-old remembers. The terror that built up inside meant that decades later he was still scared of sex.

“I just couldn’t shake the paranoia: what if there was still cum on my hands when I ate something after? What if it got in my eyes?” The chances of contracting HIV this way from anyone – whatever their status – are all but non-existent. And Nick didn’t know that, when used correctly, condoms are a simple method of prevention. Although he gradually started to feel more comfortable as he became more sexually active, what transformed his sex life the most was spotting a poster advertising a drug trial for pre-exposure prophylaxis, or PrEP. Nick signed up.

While the science behind PrEP is complex, the practicalities are fairly simple: if taken correctly, the drug almost eradicates the risk of contracting HIV through sex. A single pill taken once daily will constantly protect you when having sex. For men sleeping with men (or anyone else who only does anal), there’s also event-based dosing: by taking a double dose at least two hours before having sex, and then single pills 24 and 48 hours after the first two, you can prepare for potential sexual encounters.

Getting on to the National Health Service trial, which started in 2017 in selected sexual health clinics, marked the start of Nick’s sexual revolution. And he’s not alone: across the UK many gay men are beginning to learn what it’s like to fuck without fear. PrEP is a game-changer for those who consider themselves cautious, as well as for those who expose themselves to a higher risk of contracting HIV.

While finding yourself HIV positive is no longer the death sentence it once was, the virus still permanently changes lives. There’s the daily medication, but it comes with other baggage, too. Politicians aren’t publicly calling for the murder of gay men as a solution to HIV and Aids (as some were in the 1980s), but the stigma hasn’t fully disappeared. There’s also inherited trauma: even if today’s young gay men didn’t live through the height of the Aids crisis, learning that by 1995 in the US, one gay man in nine had been diagnosed with Aids and one in 15 had died, can leave you feeling shaky. Whether born before, during or after the worst of the epidemic, HIV continues to have a profound impact on men who sleep with men.

PrEP could help eradicate new transmission but the fight for access to it is still not won. On 16 July 2012, the United States Food and Drug Administration announced it was approving PrEP as a drug combination to prevent the acquisition of HIV through sex. Four years later, the pills got the European authorities’ green light. In Scotland, the drug is available to anyone who wants it through the NHS, but in England, Wales and Northern Ireland it’s still only available through partici­pating clinics.

The trial isn’t to test whether or not the drug works – that’s already been proven. It has been suggested that it is simply a way of giving people access to the drug without the right-wing press being outraged that the NHS is paying for the ​“perverted” and ​“unsafe lifestyle choices” of gay men. Currently the trial is still limited, and other communities which are also affected by HIV and would benefit from access to PrEP (including migrants, trans people, sex workers, drug users and people of colour) are not getting the access they deserve.

It’s the state’s responsibility to keep the public healthy. But, as it stands, senior officials and government bodies are still refusing to fully roll out the drug. ​“All clinicians who work in sexual health and HIV think PrEP is great,” says Joe Phillips, an HIV nurse practitioner at London’s Dean Street Clinic. ​“Unfortunately there are restrictions on what we can do. We want to prescribe it to people who need it without having to go through the process of recruitment onto the trial.”

From his desk in a consulting room on the fourth floor of the busy Soho health centre, Phillips speaks of the impact PrEP has had both on himself as a user and his patients: it’s led to better and safer sex. ​“I’m certainly seeing a reduction in anxiety around HIV. PrEP takes away the worry if you have a condom break on you, or if you’re high and someone fucks you without one.” As Phillips puts it, both he and his patients on PrEP feel more in control and empowered, no longer having to rely on someone else.

When he started working at Dean Street six years ago, the number of new HIV diagnoses was increasing. At one point there were 85 cases at the clinic in just one month. ​“Now it’s much fewer. We’ve got this campaign to get to zero and that hasn’t happened just yet, but we’re on maybe 10 a month, which is in the right direction. Across the UK there was a six per cent drop in new diagnoses between 2017 and 2018, and a 28 per cent drop compared to 2015.”

There’s the question of whether PrEP increases people’s risky behaviour, but Phillips doesn’t think so. ​“I think people behave how they want to behave and they have the sex they want to have. For me, if you want to have sex without condoms, that’s your choice.”

For Phillips, PrEP is just another tool for people to stay safe while making informed decisions about their health. What if NHS England decides not to roll out PrEP once the trial is over? ​“Well,” he says, bluntly. ​“It would be catastrophic.”

It’s only through the efforts of LGBT activists like Greg Owen that PrEP is even being talked about and accessed in Britain at all. Owen, from Belfast, started IWantPrEPNow with his friend Alex from New York. With a six-month supply of the drug from the US, they decided to do their very own 21^st-century digital Dallas Buyers Club (although ­operating within the confines of British law) by setting up a platform that directed visitors to places where the drug could be purchased for personal use for between £20 and £50 a month. There have been over 1.5 million page views since the website launched and today it averages between 20,000 – 30,000 visitors a month.

Thanks to the NHS trial, and by being able to access it online, gay men in Britain are living through a new sexual revolution. With PrEP, sexual encounters no longer need to be interrupted by a serious talk about you or your partner’s status – couples in relationships (open or otherwise) can avoid awkward conversations knowing they’re safe. And for those men who want to fuck in groups, dark rooms, or out cruising, they can do it in a way many have never been able to do so before – free from fear.

“Getting on the trial was amazing,” an excited Diego says. The Londoner remembers visiting Berlin a few years back with his first stash of PrEP and feeling utterly liberated. ​“It was my first experience where I just didn’t have to stress,” he says. For the 32-year-old’s entire adult life, HIV had been a constant presence: an ex-boyfriend had been diagnosed positive while they were together and many friends had become positive in the early 2010s when using drugs like mephedrone (a cheap legal high, which keeps you awake, alert and horny) was at its height. Now on PrEP, Diego’s having much more enjoyable sex.

“Say you’re in a dark room,” he says. ​“You might be getting off with a guy, start being fingered the next minute, and then someone might be slipping it in. It might be just for a second – you can tell them to stop or let them continue. In the past I might have panicked, rushed to stop them, be paranoid even if it only lasted for a second. If someone had cum in my mouth I’d think: ​‘Fuck, what have I done?’ and rush to the clinic straight away the next day.”

Now, Diego says he can do all of that free from worry and guilt. There are other benefits, too. ​“I always struggled getting erections using condoms,” he adds, ​“and I’ve heard this from lots of people. Men who preferred to be penetrated are now doing the penetrating more often and having more holistic sexual experiences as a result. Everything feels so much more fluid. We can do what we want.”

Jacob remembers the night he first fucked on PrEP. He was in Berlin, having spent hours dancing surrounded by beautiful men at Cocktail d’Amore. ​“A mate had given me Viagra,” recalls the 28-year-old. ​“I wasn’t even turned on, but I just started getting this boner in the middle of the dancefloor.” Jacob was quickly shown to the dark room, because isn’t that what friends are for? ​“As I walked in these three guys jumped on me, and in the past I’d have been hesitant – but now I could go with it and enjoy myself.” And he did. ​“Within five seconds I was fucking one of them,” he remembers fondly, ​“and pretty quickly the other two joined in.” Soon the foursome turned into something of a show for the other men present: ​“Other people started watching and rubbing me, it was really hot. And then it ended and I just ran out of the room feeling great,” he says. ​“It was really fun, and I’d never have done that before.”

Without PrEP, the sexual liberation these men and many others are experiencing might never have materialised. For gay and bisexual men who were sexually active in the early years of HIV and Aids, sex was often restricted; pleasure curtailed. The picture of freedom that Diego, Jacob and others paint has striking similarities to a short period in the 1970s when the gay liberation movement had paved the way for gay men to experience more freedom, and HIV and Aids had yet to take hold. Club nights today increasingly have dark rooms and it feels as if gay men on PrEP might be returning to a more stress-free sexual golden age.

Roy Trevelion, who recently turned 70, remembers the days before HIV well. He joined the Campaign for Homosexual Equality in his 20s, and found a community of other liberated young men. ​“I suddenly discovered that gay men could have sex and, unlike our heterosexual counterparts, we didn’t have to worry at all about condoms,” he tells me. ​“We weren’t particularly concerned about STIs [sexually transmitted infections] – it was so freeing.”

They could have sex with whoever they liked without repercussions or risk to their health. Even in the midst of the crisis Trevelion never used condoms: they represented the loss of a freedom he once had, he explains, and honestly, they reminded him of Aids. For a long time he simply abstained from sex. Then, in 1992, Roy was diagnosed HIV-positive.

He now manages the information line at iBase, an HIV-treatment activist group. For the past eight years he’s been dishing out advice to people with questions about HIV, and increasingly callers are ringing to find out more about PrEP. He can’t stress enough the importance of the drug: that by making sure anyone at risk of HIV can access it, as well as by making sure everyone gets tested regularly, we can get closer to zero transmission.

“I had to do heartbreaking things which I never thought I would ever have to do,” Trevelion says quietly, taking a moment to remember the worst days of the Aids crisis. He talks about watching on as the health of his queer family crumbled; about laying loved ones to rest and feeling helpless. ​“I take so much comfort in knowing future generations won’t have to do and see what we did,” he says, smiling. ​“The time is coming when there won’t be any HIV, even if I won’t be around to see the day.”

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