I RECENTLY had a serious H.I.V. scare after an episode of unprotected sex. The next day, at Whitman-Walker, a clinic in Washington that specializes in treating gay patients, I began a monthlong regimen of the drug Truvada, a form of post-exposure prophylaxis, or PEP. It has to be taken within 72 hours after potential contact with the virus that causes AIDS. The price tag would normally be $1,200, but I was able to get a subsidy the manufacturer gives to low-income earners.
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"You can only get this deal once," my doctor warned.
"Jeez, I hope so," I said. "I mean, it's not like there are PEP regulars, right?"
She sighed. "Oh, there are."
More than 30 years since AIDS emerged, and two decades since antiretroviral drugs transformed that epidemic into a chronic but manageable disease, conversations about H.I.V. remain awkward, especially for gay men.
When were you last tested? Did you test only for antibodies, or was it a full polymerase chain reaction test? What have you done sexually since you last tested negative?
It can be tough to rekindle any bedroom passion after such questions come up.
Two recent developments could make these conversations less awkward, or even render them moot. But they also raise troubling questions about promiscuity and responsibility that are reminiscent of debates from the 1980s.
The first development was the approval, last summer, by the Food and Drug Administration of an over-the-counter rapid-response at-home H.I.V. test kit. The test, called OraQuick and available nationwide since October, gives results 20 minutes after a cheek swab. The second is the increasing availability of PEP and of pre-exposure prophylaxis, or PrEP.
PEP — the medication I am taking — has been called the H.I.V. morning-after pill, and PrEP, to follow the analogy, is akin to birth control. A study in the British medical journal The Lancet this month found that drug-injecting addicts who took PrEP were half as likely to become infected with H.I.V. as those who did not; other studies have shown that the drug reduces transmission of the virus from mother to child, and transmission among both gay men and heterosexuals.
The at-home OraQuick tests, at $20 a pop, are a bigger phenomenon than drugs like Truvada, which can be used as either a pre-exposure or a post-exposure prophylaxis, and can cost more than $10,000 a year.
A study by Columbia University researchers, published last year in the journal AIDS and Behavior, found that the at-home tests could be effective if widely used. It gave at-home testing kits to 27 gay men who reported having routine unprotected sex. Over three months, the 27 men had a collective total of 140 sexual partners; 124 of them were asked to submit to testing before sex, and 101 agreed. Of the 101, 10 tested positive (six learned of their H.I.V. status that way). None of the men had sex with a partner after learning that the partner tested positive.
The at-home test, OraQuick, also is not a sure thing. It tests only for antibodies, which sometimes don't emerge for months after infection. So the newly infected, who are 8 to 10 times more likely to be infectious, can still test as negative.
As for the pre- and post-exposure pills, cost is not the only barrier. Of 403 H.I.V.-negative gay men surveyed in a different study by Columbia researchers, only half said they would take PrEP on a regular basis. A 22-year-old art director on the Lower East Side told me of a recent scare he had after he took home a handsome but sometimes homeless man he met at a bar. Very drunk, they had unprotected sex. The next morning the art director panicked, but eschewed the post-exposure pills, he told me, because "I'm pretty health-conscious and careful about what I put in my body, especially medicine." (Weeks later, he did a regular H.I.V. test, which came up negative.)
Dan Savage, the nationally syndicated sex columnist who coined the concept of "monogamish" relationships, expressed similar worry, fearing that clinicians do not understand the psychology of the population they're trying to help. "The guys these sensible health care folks are trying to reach are not sensible," he told me. "They are self-identified idiots who can only be saved by a vaccine." Right now, in the final weekend of Lesbian, Gay, Bisexual and Transgender Pride Month, it is a good moment to reflect on these issues. In the nearly two decades since "Rent" and "Angels in America," a generation has grown up in a world where AIDS did not equal death. That has led to a complacency that helps explain a troubling increase in new H.I.V. infections among young men who have sex with men.
I fear that, for all their potential benefits, at-home tests and the new pre- and post-exposure H.I.V. medications might give some gay men an exaggerated sense of safety, and encourage the promiscuity that Larry Kramer, the playwright and activist, has spent so many years railing against.
When a gay crowd gathered Wednesday on Christopher Street, where the modern gay liberation movement was born in 1969, to celebrate the Supreme Court's rulings on same-sex marriage, there was much cheering and talk about progress. But I wondered what the crowd did with the rest of their night.
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