July 11, 2014
I am a doctor who specializes in LGBT health and HIV medicine. I have spent the last 30 years working to help my patients who have HIV live with the illness and trying to help those who are HIV negative stay that way. I am also a 60-year-old gay man who has spent those same three decades trying to keep myself from becoming infected with HIV. I am tired of being scared, so I am starting on PrEP (pre-exposure prophylaxis). I hope that by sharing my story I may help others make decisions about protecting their own health.
Five days before my 60th birthday in April, I was at my doctor's for a routine visit and review of my labs. He walked in and said, "There is something strange about your labs -- you are testing positive for HIV." My Western blot and ELISA tests were both positive. Anyone who's heard those words knows how I felt right then. He then added, "But your HIV viral load is undetectable." It made no sense. If I was positive, it had to be a relatively recent infection as I'd tested negative only a few months before and I should have had a high viral load, not none. We could only figure that it had to be an error. I returned to my office and, over the next two days, ran every test I could think of to look for HIV. And then I waited. Finally, everything came back negative. Needless to say, I was relieved, but it was a bittersweet birthday to say the least.
What I was ashamed to tell my doctor, and what I did not tell anyone else for weeks, was that when I heard the results all I could think of was that I had had unprotected sex. For 30 years I had faithfully used condoms for intercourse and they worked for me. I don't have a lot of sex anymore these days, a fate I know I share with most single gay man of my age. In January, however, I'd started dating someone. When we finally had sex, I couldn't maintain an erection with a condom. Too much wine, pain from recent surgery, being 60 -- who knows what caused it? But I was pissed off. And embarrassed. So I pulled off the condom and entered my partner. It lasted less than 2 minutes. My partner was HIV positive but had been undetectable for years. I knew my risk was minimal if any, but when I heard the positive test results, all I could think was that those 2 minutes were going to undo everything I had done for three decades.
That's when I started to really think differently about PrEP. I'd prescribed it for a number of patients in the previous year, but I was not pushing it hard except for those who were refusing to use condoms at all and those who were constantly going on PEP (post-exposure prophylaxis) after risky sex. After my experience, I began to seriously wonder just how many others were in the same boat as me, afraid to talk to me no matter how nonjudgmental I was in the exam room because of their own shame?
I swore to myself I would redouble my commitment to using condoms for intercourse and if I couldn't get it up, I'd just do without. Anything not to go through again what I had gone through before my birthday.
But then it happened again. Several weeks ago, I found myself in bed with someone who I really, really liked. Again, he was HIV positive and undetectable. Everything was going great until I tried to put on a condom. I lost it again. And again, I was embarrassed, angry and really wanted to have sex with my partner. So I entered him without a condom.
Afterward, I was not sorry that I did it, but I did decide to go on PEP. It was the first time I'd ever done that. I'd never been at risk from a sexual or occupational exposure in all these years.
Twice it had happened and I was scared. I could promise myself all I wanted to that I would be safe, and that I really, really meant it this time, but I realized that I couldn't guarantee that I wouldn't do it again. So I've decided to go on PrEP. I'm a 60-year-old single gay man. After all I've seen, I cannot get the shadow of the epidemic out of my head when I'm having sex. I don't have the luxury of having a steady partner. I can't predict when I'll have sex again. If there is something out there that can reduce my risk of getting HIV by 95%, I will use it. I'm tired of being scared of HIV.
I recently had a conversation about all of this with a good friend who has been an HIV provider for a long time and is working on multiple prevention initiatives. PrEP seems to be opening the door for a host of new possibilities when we discuss stopping new HIV infections. If the risk from a positive person who is on medications and undetectable is decreased by 97% and the risk to an HIV-negative person on PrEP is decreased by 95%, do condoms add anything to risk reduction?
Personally, I will continue to use condoms. I want to decrease my risk of getting HIV and also of getting STIs (sexually transmitted infections). Far too few places are testing for STIs in the anal and oral areas and far too many of my patients are getting infections there and not in the urethra. PrEP will not protect against these infections, but condoms will.
I hope that my example will help others and perhaps, in some small way, what I'm doing can serve as a tribute to Dr. Charles Farthing, who died recently at far too young an age and who famously offered himself as a subject for an early and controversial HIV vaccine. Let it also honor all those patients and friends who have been putting their bodies on the line to end this epidemic for the last 30 years.