Can an anti-HIV drug break down wall between HIV-positive and HIV-negative men?

Rob Easton is a Toronto-based freelance journalist and filmmaker who writes about LGBT issues, urbanism, and politics.

The first time Daniel heard about the use of Truvada as an HIV-prevention drug in 2011, he thought it was a horrible idea.

"I just thought, 'Wow, what an excuse for people to stop using condoms!' I thought it sounded dangerous," the Toronto man says of the drug known as a pre-exposure prophylaxis (PrEP), a once-a-day pill to prevent HIV transmission in high-risk populations such as gay men.

Daniel, 30, whose name is being withheld for privacy reasons, grew up in the shadow of the HIV crisis and saw condoms as the only effective barrier between him and the virus.

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After decades of condoms-first sex education, he says he wasn't ready for what some see as a brave new world of HIV prevention.

Health Canada and researchers studying PrEP don't necessarily see it that way and insist people taking the drug should continue using condoms.

But preliminary results from a study called Preparatory 5 out of the St. Michael's HIV Prevention Clinic in Toronto found condomless sex between HIV-positive men and HIV-negative men on PrEP increased among the study's 52 participants.

"From an HIV stigma perspective, that's a really positive thing to see that we're breaking down barriers that people may have in terms of their comfort with [HIV-positive] partners," says Dr. Darrell Tan, the study's lead researcher, who nonetheless strongly recommends people taking PrEP continue to use condoms.

Daniel isn't a participant in the study, but his experience is similar to what the researchers have noticed.

Health Canada approved Truvada for PrEP in February, but the U.S. did so back in 2012. As Daniel began to hear more and more about its effectiveness, he started to notice a pattern in his sex life: a series of accidents and quick decisions where the condom would break, slip off or not be put on in the first place.

"I recognized that I was having more and more unprotected sex," he says. "It was not something that I was proud of, or generally happy about. But, you know, it happens and then you freak out, and then you go get tested, and then you get tested again in three months."

A recent study from the U.S. Centers for Disease Control and Prevention in Atlanta shows condom use among younger gay men in decline for at least the past 10 years.

'Trying to be honest with myself'

So Daniel, in search of another option, says he decided to start taking PrEP in the spring of 2014.

"I was trying to be honest with myself about the reality of my sex life," he says.

In the beginning, he says he had less sex with fewer partners. He says he decided if he was going to ditch condoms, he would need to be "a lot less frivolous" about his partners. So he chose to meet up with people he knew or with whom he had some prior relationship.

But as he explored this new world of what he considered optional condom use, he says he discovered something profound: "I never realized that sex scared me until I started taking Truvada and I experienced the liberation of what it felt like not to be scared after having unprotected sex that I would become HIV-positive."

His comfort came from the knowledge that Truvada, if taken daily, dramatically reduces the chances of HIV transmission. Its exact rate of effectiveness is a matter of some debate. The drug costs about $1,000 a month without insurance.

And for men living with HIV, consistent use of antiretroviral therapies (ARTs) also significantly reduces the chances of transmitting the virus. ARTs can lower an HIV-positive person's viral load to levels undetectable by most blood tests, which is the main indicator of their likelihood of transmission.

The preliminary results from the St. Michael's study suggest the power of PrEP, if it were to become widely prescribed, combined with the success of ARTs, has the potential to chip away at a wall that's divided HIV-positive and HIV-negative men for decades.

Before PrEP and undetectable viral loads, there were only two primary defences against HIV transmission: condoms and/or choosing partners based on HIV status. Known as "serosorting," the practice divided the gay community, as men without the virus would usually try to partner with other HIV-negative men, and HIV-positive men tended to partner up amongst themselves. 

Daniel now says he actually prefers meeting up with men who are HIV-positive with an undetectable viral load.

"I thought HIV was really rare until I started asking people, which I did a lot less frequently than I do now and I began to realize that a lot of people I knew had HIV," he says. "And suddenly I became a lot less afraid of HIV and what that did was to open up this world of new partners who are people living with HIV who didn't scare me anymore."

Researchers still recommend wearing condoms

An HIV-positive person's health-care team closely monitors viral loads, other sexually transmitted diseases and other health issues, Daniel says, which is one of the reasons he says he prefers "poz" partners with undetectable viral loads.

"I can separate the fact of their being HIV-positive from getting to know them, having sex with them, enjoying sex with them. And that is a liberating thing that I'm actually really proud of, proud to say has happened to me."

Despite the effectiveness of PrEP and ARTs, researchers like Tan say PrEP shouldn't replace the use of condoms.

Tan is helping to craft a set of national guidelines for PrEP that will recommend use in conjunction with condoms in order to provide the greatest possible protection against HIV.

He says PrEP is a new tool that should be used along with condoms, which are effective, cheap and help prevent other sexually transmitted diseases. The reality, he says, is few people successfully use condoms every time they have sex and that's where PrEP can be an effective second line of defence.

And when Health Canada approved PrEP back in February, it recommended testing for HIV before starting the drug; screening for and, when necessary, treatment of sexually transmitted diseases; regular and frequent testing for HIV while using Truvada; and the use of condoms.

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PrEP doesn't protect against other sexually transmitted diseases such as syphilis, gonorrhea and chlamydia, all of which have been on the rise in recent years.

Daniel is aware of this, but says he chooses to have condomless sex for now and will monitor the situation closely.

"You know obviously nobody wants to get an STD, but for the moment they're treatable."