World AIDS Day is a good day to remember not only those we've lost, but those working hard to eradicate the disease for future generations. A few weeks ago when actor and OUT 100 Artist of the year Zachary Quinto ignited a firestorm with comments about the efficacy and ethics of PrEP, I paid a visit to Dr. Ken Mayer, Medical Research Director of the Fenway Institute at Fenway Health--the largest LGBT community clinic in the US (and my own one-stop healthcare resource), to ask him what he thought of the ensuing kerfuffle.
Mayer has been on the front lines from the beginning, as both a clinician and a researcher in the vanguard of antiretroviral-based prevention, as well as an investigator on the HIV/AIDS Prevention Management Team study HPTN 052 and the iPrEx trials that paved the way for FDA approval of PrEP. While the Fenway's new facilities are calm, quiet and orderly, he describes the atmosphere in the early days of the epidemic as "a war zone". Between 1981 and 1996 "we were just trying to catch our breath, to stay on top of providing services for people who were very, very sick, and prevention was really much framed around behavioral issues and condom promotion. By the mid-90s when we had effective treatment we could step back and say, gee, we now have this structure, we have federally-funded research trials on vaccines, we're monitoring people, we have all these medical services." During this time, as an organic response to crisis, the Fenway became not only a center of research but a model of community and LGBT-centered health care.
It was this crucible of crisis and care that produced current treatments like PrEP. "People have been thinking about PrEP for twenty years," Mayer says, since the first anti-retroviral medication. But getting Pre-Exposure Prophylaxis on the market in its current form took a lot longer, due to the tricky logistics of conducting trials. Once the FDA approved Truvada, many in the media hailed it as the beginning of the end of HIV. Mayer never thought of it quite like that. "I don't see prep as a panacea, but I think it's a mistake to reject new technologies that can be helpful for some subset of people." In fact, the idea that PrEP is one-size-fits-all may account for some of the backlash. "PrEP is not like childhood vaccination. This is very much an individual decision. PrEP circa 2014-15 is not what PrEP is going to be in 2025. This is very much like oral contraception in the 1960s."
In other words, this is just the beginning. Mayer sees a future where there are more and more options for prevention. "At the end of the day, one size will not fit all," Mayer cautions. "Until we've got a perfect cure or a really highly effective vaccine it's worth looking at all these things because they'll be different niches of people who will benefit." Mayer emphasizes that any cure for HIV/AIDS will involve a combinaton of behavioral and biomedical approaches. "There's a sort of false dichotomy. Taking a pill is a behavioral activity, thinking that one's vulnerable involves behavioral and social issues. Having support for how one decides to protect oneself against HIV has a lot of social and behavioral contexts."
Mayer agrees that the behavioral issues Zachary Quinto brought up in his comments on PrEP are vital, but only as part of a much more nuanced picture. While it is important to shine a light on personal responsibility in sexual practice, there is a larger crisis in access to health care in America, and the ability of young LGBT people to get regular preventative care. Despite the advances toward universal health care in recent years, we do not have a culture of preventative health care in America, and we certainly do not have a clinical culture that is LGBT-friendly across the board. What Quinto sees as the "laziness" of millennials may have its root in lack of information: an education system stripped of science-based sex ed and a health care system that is not equipped to provide much-needed lifelong education to patients. Health care divorced from any concept of community, that does not see individuals in the context of their relationships, that leaves out empathy and vital information sharing, will be understandably ineffective in providing resources to vulnerable populations like LGBT youth.
Mayer sees this as one challenge in the fight for a cure. "I feel like we have to step back and be a little more holistic ... and try to understand intentionality and make sure people understand what they're getting themselves into." He says in the best-case scenario talking about PrEP is a teachable moment. "When a person either initiates it or discusses with a provider and then decides to start, they're thinking more intentionally about their sexual behavior." Of course, fear of judgment from health care providers is a big factor holding people back from engaging with their health care. "The person thinking about taking PrEP has to understand his or her vulnerability and have providers they're comfortable talking to. To my mind it's a prevention package that a good clinician would be talking to patients and trying to understand the motivations for a patient wanting to go on PrEP... and work with them so that it's not on autopilot for the next fifty years, but that it helps a person through a period of time where they're not in a mutually monogamous relationship." Considering how many frogs most of us have had to kiss to get there, I think we can all empathize with the struggles along the way.
"Some people see this as a dichotomy," Mayer observes. "You have a group of gay men who are being irresponsible and having lots of condomless gay sex, and you have the push for marriage equality and other kinds of civil liberties, and it's a zero sum game. But I think we just have to broaden our perspective. We're not trying to promote PrEP as much as we're trying to promote people being honest and realistic about their sexual behaviors and understand that there are a bunch of different options."
Now, Zach: if we can just get Ken in the next Star Trek movie (and not as a Red Shirt) we'll be all set to boldly go into an HIV-free future.Together.