It is human nature to embrace what we know while greeting what is new with skepticism. In generational divides, elders view the youth as reckless, disrespectful and even foolish. For their part, younger generations often see their predecessors as out-of-touch and rigid. This phenomenon is playing out in the current debate over PrEP, the pre-exposure prophylaxis regimen against HIV/AIDS transmission recently approved by the FDA.

 

I was a teenager in the mid 80s, just as AIDS was making headlines in the mainstream press. I was part of a new group for whom sex and AIDS were linked from the get-go. I remember walking home terrified after my first sexual encounter with a man. All I could think about was a Newsweek magazine cover with a test tube full of blood and the word ‘EPIDEMIC’ in bold type.

 

For those even a year or two older than me, AIDS was something that blindsided them. It was a death sentence that attacked without warning and wiped out a broad swath of gay men like a hurricane ripping through the community. I found myself in a relationship with a man 13 years my senior. His handwritten phone book, once full of numbers and addresses, had so many names crossed out or erased that dozens of pages had to be ripped out and discarded. By the time we broke up, his phone book was so thin it was hardly useful.

Conversely, for those younger than me, AIDS is viewed as a manageable illness. We developed drugs, and the drugs got better. Gone are the gaunt skeletons the older generation saw walking down Santa Monica Boulevard, and with them the constant, dispiriting barrage of death notices and memorial announcements. The younger generation never saw these faces, much less knew them. There is a casual callowness to some of today’s conversation (or lack of conversation) surrounding the epidemic and what it means to our lives.

I find myself in a divide between these generations, straddling an eerie turning point in history, one demarked by an epidemic.

 

Studies are showing remarkable efficacy in the prevention of HIV transmission when HIV-negative people take the once-a-day cocktail Truvada, developed originally as a treatment drug for HIV. Truvada’s FDA approval as PrEP cited a ninety percent reduction in HIV transmission for those taking the drug. Further studies have shown a stunning zero infection rate when Truvada is taken on a daily basis.

 

I’m a big proponent of PrEP. As a man who has been in several sero-discordant relationships, I started taking Truvada immediately following its FDA approval in 2012. My medical insurance covers the drug and I’ve had no adverse reactions. Like many, and in defiance of initial FDA advice to the contrary, I use PrEP as a substitute for condoms. Part of the FDA’s (and cautionary activists’) concern with PrEP is that while it may be potent at blocking HIV transmission, it has no effect at all against other sexually transmitted diseases like hepatitis C and herpes. Condoms, by contrast, are varyingly effective at blocking non-HIV STD infections. So condoms remain a very important tool. But for those of us who are in monogamous relationships with a sero-discordant partner, and for whom STDs other than HIV are not a large concern, PrEP is ideal.

 

Predictably, while many younger activists and health advocates are heralding PrEP as a major, across-the-board breakthrough in addressing the HIV/AIDS epidemic, a number of older activists have been less than enthusiastic.

 

In 2011, Michael Weinstein, founder of AIDS Healthcare Foundation, lobbied against the FDA approval of Truvada, saying, “I believe this would be a catastrophe for HIV prevention.”

 

Weinstein has continued to be a vocal opponent of PrEP. Earlier this year, he dismissed Truvada as “a party drug.” In response, some younger activists and community members are calling for his ouster as head of AHF, and a moveon.org petition with that as its goal has garnered about 3,500 signatures.

 

Larry Kramer is another notable PrEP opponent. Arguably the most influential AIDS activist since the inception of the epidemic, Kramer has been a noisy and tireless advocate for health care and rights for those with HIV/AIDS. With Kramer’s play ‘The Normal Heart’ being made into an HBO film, he was garnered increased public attention lately, and has used that attention in part to rail against PrEP.

 

"Anybody who voluntarily takes an antiviral every day has got to have rocks in their heads,” Kramer said recently. “There's something to me cowardly about taking Truvada instead of using a condom. You're taking a drug that is poison to you, and it has lessened your energy to fight, to get involved, to do anything."

To me, Kramer is both wrong and off-key, especially in the last sentence of this quote where he engages in hyperbole bordering on the absurd. Certainly, Kramer has never been one to mince words. But this quote begs the question of why a man so intelligent and thoughtfully educated on this issue would take such an extreme position.

 

I smell fear. I sense a distrust of new direction. How one means of prophylaxis versus another is cowardly versus admirable is for Mr. Kramer to mull. May the rest of us dismiss it in favor of more useful questions.

If there are studies or statistics that support Mr. Kramer’s claim that Truvada lessens one’s energy to fight or causes apathy, I’ve not seen them. I suspect Mr. Kramer is engaging in deductive logic that skips important steps. Fear makes us do that sort of thing.

 

The campaign to oust Mr. Weinstein from AHF was launched by Los Angeles activist Eric Leue, who notes, “If a person takes Truvada when they are supposed to, they take it every day, then their chance of becoming infected with HIV is close to zero.”

 

Mr. Leue is factually correct. And to me, he’s pointing us in the right direction. There are valid questions of compliance, availability and cost of PrEP. But for those who can get the drug and are responsible enough to take it as prescribed, it’s highly effective. And that’s enough reason to support it.

 

So, big picture, are the young activists right and the older activists wrong? No. Mr. Kramer and Mr. Weinstein raise valid concerns about PrEP, though they’ve delivered them in dismissive and sometimes insulting language. Perhaps we can chalk that up to age and the skepticism with which older, battle-wearied warriors views those who’ve taken up the charge after them.

 

The best answer for all of us, and especially for those like me who reside in the HIV/AIDS generation gap, is to try and take the caution of the past and marry it with the enthusiasm and audacity of younger activists.

There must be a balance. While keeping an awareness of PrEP’s limitations, we should promote it as loudly and widely as we are able, and work to make it accessible and affordable for as many human beings on the planet as we can. Through a marriage of older activists’ long-sightedness and younger activists’ fearlessness, we just might bring this epidemic to its knees.

 

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The PrEP Generation Gap

 

 

By: Ben Patrick Johnson

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