The Next Condom Conundrum

When Adam, an HIV-negative Bostonian in his mid 20s, was dating an HIV-positive man last year, he made a conscious decision not to use a condom when they had sex. Instead, he popped a tenofovir, an antiretroviral drug that may help prevent HIV infection. "My partner didn't insist on [barebacking]," says Adam, who asked that his last name not be used in this story. "I thought it would bring us closer together." Now single, Adam says he regularly uses condoms again, although he hasn't been tested for HIV since the relationship ended.

Like Adam, many gay men around the country are opting to forgo the standard defense against HIV -- a condom -- in favor of a highly controversial and thus far unproven method of protection known as pre-exposure prophylaxis, or PrEP. Whether in a serodiscordant relationship or just looking for a fun night (or weekend) out, guys are trading rubbers for HIV drugs like tenofovir, known commercially as Viread, in hopes of preventing infection. The idea is inspired by post-exposure prophylaxis drug regimens long given to people possibly exposed to HIV -- such as health care workers, rape victims, or those who've experienced condom mishaps -- and by the AZT and Nevirapine pills that HIV-positive pregnant and nursing women routinely take to prevent mother-to-infant transmission.

And while PrEP's not new -- guys have been popping a T, or "disco dosing," as the practice is sometimes called, for several years, acquiring the drugs from friends, partners, or drug dealers selling "party packs" including crystal meth and Viagra -- a host of studies are now under way seeking to determine if it actually works. If proved effective, PrEP could revolutionize what it means to have safe sex -- at a time when HIV infection rates are rising among gay men.

Doctors don't condone this underground prevention method, even if some informally discuss it with their patients. The medical consensus is that guys who use PrEP are putting themselves at risk of contracting an incurable disease and that no one should abandon condoms. But health care professionals also acknowledge that the practice of PrEP will continue even without the approval of any medical group. "Gay men have traditionally been ahead of scientists in trying to lower their risk," says Bill Stackhouse, director of the Institute for Gay Men's Health at Gay Men's Health Crisis in New York City. "Unfortunately, this [approach] comes with complications."

"Clearly, sex is more exciting without a condom: They're not very convenient, they're not sexy, they don't feel natural," says Rob Garofalo, deputy director of the Howard Brown Health Center in Chicago. "People are clamoring for a strategy that works."

No one knows how widespread the use of PrEP is. A 2006 survey by the San Francisco Department of Public Health of 1,819 men at two California circuit parties and a variety of city locations found that 16% had heard of the practice, although fewer than 1% had tried it themselves. A 2007 study of HIV-negative gay men in Boston funded by the National Institute of Mental Health yielded similar results, though the sample size was only 227.

But physicians are definitely hearing from their patients about PrEP. When he was in private medical practice in Harrisburg, Pa., A.C. Demidont says several patients told him they had tried it or knew someone who had. His patients at New York's Callen-Lorde Community Health Center have asked about it, but PrEP is not offered there. Los Angeles physician Tony Mills says some of his patients with HIV-positive partners employ PrEP. He says one of his patients told him, "We don't have safe sex. Every time we have sex, I take Viread." And Antonio Urbina, who is medical director of HIV/AIDS training at St. Vincent Hospital's HIV center in New York's Greenwich Village, says he's seen two patients who have taken HIV drugs before going out for "PnP," or "party and play" -- that is, spending a night or weekend on crystal meth while having often-anonymous sex.

"You can get Viread at many gay bars or clubs," says Bob Adams, managing editor of The Advocate's sister publication HIV Plus, adding that when it is sold along with Viagra and crystal meth the combination is known as "MTV" -- meth, tenofovir, and Viagra.

Guys who don't get the drugs from a dealer get them from friends on the meds -- who can call in a refill early or tell their doctors they lost their prescription -- or from personal connections at medical facilities. Antiretrovirals aren't a controlled substance, after all. "Patients don't get the fifth degree if they say they've run out," says Kenneth Mayer, who directs Brown University's AIDS program and is medical research director for Fenway Community Health in Boston. "It's easy enough to get more."

In some cases, doctors are even prescribing the drugs directly to PrEP followers -- not that they'll acknowledge it on the record. "I've heard from doctors who do it only for patients who are engaging in risky sex and refuse to use condoms," Adams says. "All the counseling in the world has done nothing for them, so it's a last resort."

Now science is trying to catch up with these guys and their innovative -- if perhaps foolhardy -- attempts at HIV prevention. If PrEP is shown to work, there's a host of questions to be answered: How long before sex -- and how often -- does one have to take an antiretroviral in order to prevent infection? Does the effectiveness decrease over time or even cease? If a sex partner's viral load (the amount of HIV in the blood) is too high, can it defuse PrEP? Can the drugs weaken the immune system's response to HIV, making people more susceptible to infection when they go off the medication? And if people on PrEP end up seroconverting, would they be resistant to the antiretroviral drugs they've already been taking?

Researchers are currently examining these issues. Preliminary results from studies with lab animals have been promising, and now a coordinated series of clinical trials involving thousands of HIV-negative men around the world is testing various combinations, or "cocktails," of drugs.

And while medical opinions vary on the efficacy of post-exposure prophylaxis (PEP), a monthlong regimen of several drugs used to prevent HIV from attaching to healthy cells, there's at least one known case of a gay man who became infected with HIV after being on PEP and then PrEP. As reported by the Aaron Diamond AIDS Research Center in New York, the man was prescribed PEP after a possible HIV exposure and then stayed on the regimen long after he was directed to do so. It's unclear whether the treatments delayed or hastened his seroconversion, but it may explain his strong immune response and slower disease progression.

Any endorsement of PrEP by medical professionals also raises the thorny ethical dilemma of whether their approval actually encourages barebacking. "You could have a further erosion in how gay men practice safe sex," Garofalo says, pointing out the other sexually transmitted diseases, like syphilis, that one can get without a condom. "If you get one of those [diseases], you're five to 10 times more likely to contract HIV."

But even if PrEP is proved effective, "doctors will still recommend people use condoms," says physician Albert Liu, a researcher in the San Francisco health department. "It would need to be combined with other strategies."

If effective, PrEP could have a powerful impact on the national and international fight against HIV/AIDS. Not only could gay men benefit, but so could any at-risk group of people: sex workers, injection-drug users, and women, particularly in developing countries, who are unable to insist that their partners wear condoms. With the vaccine effort stalled, other prevention techniques like microbicides still being tested, and no AIDS cure in sight, PrEP is a cause for cautious optimism.

"I hope it works," says Scott Kellerman, of the international health group Population Council, "because we're running out of tools in our toolbox."