In a nearly packed auditorium at the 20th International AIDS Conference (AIDS 2014), a group of panelists led by author and activist Sean Strub addressed the changing HIV prevention landscape — a landscape that now includes condoms, PrEP (pre-exposure prophylaxis), PEP (post-exposure prophylaxis), serosorting and seropositioning, and that will likely include microbicides and other interventions in the near future.
Strub opened the session by pointing out that sexual risk analysis includes both the rational — scientific data that show that condoms and other prevention options greatly reduce the risk of HIV transmission — and the irrational, which includes two big components: desire and pleasure. He noted that the factors that go into that risk analysis, the equation that produces the eventual sexual encounter, are constantly changing due to advances in the sensitivity of condoms, biomedical prevention, treatment as prevention, PrEP, PEP and microbicides.
Udi Davidovich, a researcher and lecturer at the University of Amsterdam whose work focuses on the social determinants of HIV and sexually transmitted infection risk behavior, added that behavioral science, though involved with the HIV epidemic since the very beginning, has done a very poor job of incorporating questions around pleasure into research. According to Davidovich, the fact that condoms are as widely used by gay men as they are (most estimates put the number at 60%-70% consistent condom use among gay-identified men) is miraculous given that prior to the onset of the HIV epidemic, condom use was at about 20%.
Right now, Davidovich asserted, behavioral science should be addressing the 30%-40% of gay men who do not practice consistent condom use. Greeted by cheers and claps from the crowd, Davidovich went on to point out that society has made the most natural kind of sex — condomless sex — "problematic sex" and that we have dedicated thousands of research dollars to find out why people are engaging in what may be the most natural kind of sex available to people. Behavioral science, he implied, should focus on helping people find a way to have sex that is most natural. For about 12% of men who have sex with men (MSM), condom use results in a loss of erection and an inability to finish penetrative sex. With the current and pending landscape of alternatives, Davidovich called the element of pleasure "very important, because we’ve ignored it through the years."
Garrett Prestage, an Australian sociologist, spoke about the interpretations that researchers favor when answering questions around why gay men don’t use condoms. Many are quick to point to things like trauma and low self-esteem, while many discard the realities of desire and sexual pleasure. Prestage shared that, from his own research, it is clear that it is often well-educated men who understand the consequences of sexual risk that are willing to take that risk in order to feel more pleasure. "When faced with the opportunity to have a good time, [gay men] would rather go ahead and have a good time than live in morbid fear of sex," he said.
Addressing the many concerns around and critics of PrEP, Prestage pointed out that we cannot abandon PrEP as an HIV prevention strategy, just as we haven’t abandoned condoms because of potential problems with the strategy. In fact, he said, any failure of a certain intervention "says more about health and education services than gay men’s capacity to use them." He reserved his harshest critiques for those who use thinly veiled moralism to demonize those who are using PrEP, especially since those who use PrEP are engaging in an option that best suits their desire to have pleasurable sex and stay HIV negative. Prestage called such moralism "anti-science, anti-sex and anti-gay" and warned against social researchers who have failed to look at PrEP as a liberational tool for gay men who have lived in fear of sex and have instead have seized on the fear of the biomedicalization of HIV prevention.
When Cecilia Chung of the Transgender Law Center asked how many participants had experienced trans-inclusive sexual health education, only about four or five hands were raised in an auditorium of several hundred people. Chung noted that her town of San Francisco has near-universal health care and good outcomes for those living with HIV, but trans women are often left behind when it comes to the success stories. Only 65% of trans women with HIV in San Francisco are on antiretroviral therapy, with only about 40% at viral suppression, which could indicate that treatment is not a priority in trans women’s lives. Chung noted that many trans women who enrolled in the iPrex study (the largest study done so far on the efficacy of PrEP) subsequently dropped out because the study researchers and medical professionals were not well-suited to deal with trans women and insisted on treating them like gay men. "There is no empirical data that PrEP will work in trans women — yet we are a ‘key population.’ Irony, irony, irony," she said. She ended her talk by pointing out that before we can discuss prevention and pleasure among trans women, we must first empower trans women to talk about sex.
Jessica Whitbread, a Canadian activist and artist who is currently the interim director of the International Community of Women Living With HIV/AIDS (ICW), chose to toss some thought-provoking questions at those in attendance. She first pointed out that, as an HIV-positive woman, science has had a very big part in her sex life and has "helped my cause for pleasure in the bedroom." However, she said, "science has done little to challenge gender disparities in the bedroom" and it is still very hard to discuss pleasure among women when women have a hard time negotiating condom use with partners. Whitbread also asked the audience to ponder why all sexual activity that did not include a penis (like what is frequently thought of as lesbian sex) required gloves and dental dams, while male sexual activity focused exclusively on condoms. "As if everyone doesn’t have hands and mouths!" she said. She ended her piece with a short critique of PrEP, acknowledging its merits, but wondering if in its current incarnation it only makes a difference for white gay men of a certain social status in North America.
The final presenter was Sthembiso Promise Mthembu, a human rights activist and feminist from South Africa who spoke about HIV prevention and pleasure in the context of human rights for women. Because so much of her work focuses on human rights, she emphasized that the right to pleasure was one that women should enjoy, but that is being denied to women all over the world. When we discuss pleasure and women’s sexuality, Mthembu said, we can never divorce it from discussions of power in social and sexual situations.
In a comment that truly wowed the crowd, Mthembu pointed out that prevention messaging advocating condoms is almost always male-centric, as women cannot "use" condoms, they can only "negotiate condom use." Though women do have the option of the female condom — which Jessica Whitbread earlier commented she advocates, but personally has only used "a handful of times" — the female condom (or FC2) can often present more problems, as it can suggest to a man that a woman is in control of her own body, which can often be met with violence by the male sexual partner. Mthembu spoke at length about human papillomavirus (HPV) vaccines as a contributor to HIV prevention, but also warned against any approach to women’s sexual health or HIV prevention that was "piecemeal" prevention, or prevention that solely focused on one aspect of women’s health and sexuality at a time, advocating rather for a holistic approach to sexual and bodily health.