These days, everything is about the "selfie." We listen to our personalized music playlists on our phones, binge-watch entire seasons of our favorite program on demand, and target our social media shout outs to specific people on our friends list.
So it’s no surprise that you can now customize your strategy for staying safe from HIV. Choice is empowering. Yet too many new choices can be confusing. So here’s the new menu of choices for staying safe. Create your safer selfie.
Lots of guys use condoms when they hook up with someone who looks like he gets around, but then skip the rubbers when they meet a "quality" guy. Even quality guys may have had playful pasts, and many are telling the truth when they say they don’t think that they’re infected … even though they haven’t tested in years. So how well do condoms protect you?
• Best case: If a condom appears intact after use, you’ve lowered by 125,000 times your chance of catching HIV. Condoms also offer this undeniable benefit: you can check to see if the other guy is really wearing one right now.
• No guarantees: Condoms only work when someone is wearing them. Gay guys who claim to use condoms all the time reduced their HIV risks by 70%. Rule out the guys who seem to be forgetting the nights they skipped the condoms, and protection is much higher. Condoms break or slip off in as few as 0.4% to 0.6% of uses, and even these numbers are driven up by the people who fumble with them drunk or use wildly inappropriate lubricants. CDC recommends that gay men always use condoms, even if you also take other steps to protect yourself. Still, if you just can’t stand using condoms, there are other choices that can reduce your risks.
Never heard of it? You will. With PrEP, an HIV-negative guy takes the anti-HIV combination medicine that people living with HIV take. The difference is that he takes it every day before a possible exposure to HIV. That’s the “pre” in PrEP.
•Best case: PrEP can offer almost complete protection from an HIV exposure. In the largest studies conducted, none of the guys who took at least most of their PrEP medications became infected. PrEP does take advance planning, though. You can’t start taking PrEP the day you’re planning to have sex (it takes about a week to build up in the body).
•No guarantees: Truth is, in the largest PrEP study, new HIV infections were only reduced by 44%, mainly because some people who said they were going to start PrEP never did, or they only took a few of their pills. So just like condoms, you have to use it to get the benefits.
Treatment as prevention
If your HIV+ partner is taking anti-HIV medications, that helps him and protects you. Less virus in his bloodstream makes him far less contagious. The first large study said that the risk of catching HIV from a treated person drops 96%. There were some holes in the study: nearly everyone in the study was heterosexual and married, so would the results translate for gay men? In this year’s newer PARTNER study, about a third of the people living with HIV were gay men, and none of their partners got infected either.
•Best case: taking anti-HIV treatment is something many positive guys are already doing .
•No guarantees: there’s no way to see if the other guy is taking his treatment the way you could check for a condom. Once they’re off the meds, the drugs start draining out of their system, and that means you’re not protected anymore.
Test twice, talk, and trust
This is not the same as only hooking up with guys you think are HIV-negative. Here, you take an HIV test with your partner, and discuss whether you’re both comfortable having a “closed” relationship (or open only with protection). If you both are, you test again to confirm neither had a new HIV infection that the first test missed, and then you may choose to take the condoms off.
•Best case: Many guys have been using this strategy for years (including me), and it appears to work for those who follow all the steps.
•No guarantees: If you do allow “playing,” remember that condoms protect better against HIV than against some other STDs that are easier to transmit. Also, once you’re in the habit of condomless sex at home, it may be harder to stick to your pledge of protected playing outside.
Whichever safer selfie method you choose, if something goes wrong and you realize you’ve been exposed to HIV, there’s one more option. If you get on a six-week prescription of anti-HIV medicines right away (“post-exposure”), you can often stop the virus from “latching on.”
•Best case: Officially, you have 72 hours to start treatment, and your odds of becoming HIV+ drop by about three-quarters.
•No guarantees: Don’t take the deadline too literally, and wait out the whole weekend. The same studies show that the earlier you start PEP, the better the protection.
Why choose any option?
Maybe you just don’t consider staying HIV-free that important anymore. If and when you catch it, you’ll just take a pill a day, and live forever. Well, you’re not entirely wrong, but there’s more to it than that.
•Best case: If keep to your doctor’s appointments and take your medicines faithfully, you can live a long life these days with HIV. Some studies predict that people can live with HIV for three or four decades, or even up to 53 years. I’ve never been as hopeful for my friends and community as I am these days.
•No guarantees: HIV treatments still cause side effects, from the unpleasant and common ones (diarrhea, fatigue, sleeplessness) to the silent bodily changes that can add up over time to cause other serious health problems in some people to trigger cardiac events, kidney failure, liver failure, and bone fractures. Then there’s our community’s dirty little secret of stigma: some guys still act as if HIV makes you sexually radioactive. If you’re HIV-negative now, life’s probably easier if you can stay that way.
Whichever safer option you choose, the best thing you can do is just to make a choice. Condomless sex is up 20% among gay men over the past five years. HIV is still causing the equivalent of five "9-11s" in U.S. deaths each year. Almost all new HIV infections are happening to guys who aren't following any of these strategies.
So pick one, stick to it, and make a safer selfie.
Stephen Fallon is the President of Skills4, a healthcare consulting firm that provides services to CDC and HRSA funded providers, primarily gay- or minority-based agencies and clinics.