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PrEP: What It Is and How Sex Workers Can Use It

Truvada, the only HIV medication approved to be used in PrEP so far. (Photo by Jeffrey Beall, via Wikipedia Commons.)
Truvada, the only HIV medication approved to be used in PrEP so far. (Photo by Jeffrey Beall, via Wikipedia Commons.)

Lindsay Roth cowrote this post with sex worker ally and colleague Cassie Warren. Roth and Warren work together at PxROAR (Research, Outreach, Advocacy, and Representation), a program for community activists which offers training and support around biomedical HIV prevention research and advocacy. Readers can contact them with questions about PrEP at lindsay@swopusa.org and cassandra.r.warren@gmail.com.

So you’re telling me you can take a pill to prevent HIV?

Yup. We believe that if done right, PrEP has the potential to be one of the best tools brought to market for receptive partner protection and power since the pill in the 1960’s. PrEP doesn’t double as a contraceptive, but it does reduce your risk of HIV by 90% when taken correctly. It’s still a sweet tool to have in your make-up bag, hard femme box, tool kit, whatever you call it. We are still in the middle of an epidemic, with trans and cis women, men who have sex with men, and injection drug users still being hit hard and unjustly. We deserve to have access to all the options that protect us against HIV.

In what follows, we’d like to lay out the basics of PrEP (no really, what is it? does it cost the first month’s rent?), add context to some of the controversies, and offer our take on what this means for sex workers. We do not anticipate that we’ll be able to answer all the questions people have in this one post, and we hope that you will comment or reach out to us directly if you’d like to know more.

What the heck is it?

PrEP stands for Pre-Exposure Prophylaxis. The main part to note here is “pre,” implying treatment before exposure. In this context, we are talking about exposure to HIV (Human Immunodeficiency Virus). So, PrEP is a medication an HIV-negative person would take to prevent them from becoming positive. Currently, Truvada is the only form of PrEP approved by the Food and Drug Administration.

Truvada is an NRTI (nucleoside analog reverse transcriptase inhibitor) which is just a fancy name for an HIV medication. It has been used to treat HIV since 2004. We used to know HIV as the virus that caused AIDS, and knew AIDS as a death sentence. However, because of advancements in the treatment of HIV, positive folks can live long, healthy lives. Folks can even be positive, on treatment, and unable to transmit the virus to anyone else. Recently the medical establishment stopped giving AIDS diagnoses: Because of new treatment options people can be at various stages in their HIV diagnosis, and we now classify HIV as stage 0, 1, 2 or 3 HIV.

Many readers may be familiar with PrEP’s sibling, PEP, or post-exposure prophylaxis, the use of antiretroviral drugs—ARVs (again, a fancy name for HIV medications)—to mitigate the risk of HIV transmission after a potential exposure. Any doctor can write a prescription for PEP, most Medicaid programs pay for it, and Gilead, the large research based pharmaceutical company which makes Truvada, has a patient assistance program to cover the the costs for the uninsured or underinsured, regardless of immigration status.

To summarize, PrEP vs. PEP:

  • Truvada as PrEP is taken before an exposure to HIV, specifically one pill a day, every day.
  • PEP is taken after an exposure to HIV, specifically within 72 hours, and consists of 30 days of full-regimen HIV treatment medication.
  • Both prevent you from acquiring HIV.

How does PrEP work?

The rationale behind PrEP is based on the way most doctors are treating HIV-positive individuals with ARVs. Truvada is a combination of two medications, tenofovir and emtricitabine. If HIV is presenting itself in one’s body, this medication blocks the replication of HIV in the body. Doctors currently prescribe one pill a day, as the medication must be present in the body to do its work. However, there are trials underway to test the efficacy of other ways of taking PrEP. So far, the results of the iPrEX OLE (open label extension) say that if you take it 2-4 times a week you are protected 85% of the time against HIV, and if you take it 5-7 times a week, you are protected 99% of the time against HIV (not other STIs or pregnancy). If you take it less than 2 times a week you have zero protection. 1

Can I take it right before I meet a date?

No. PrEP acts like a full metal jacket around your T-cells, so if HIV is introduced to your body it can’t get into the cells it wants to infect and replicate itself.2 It takes about seven days to make this metaphorical metal jacket around the cells in the rectum (drugs taken orally are absorbed quicker in the digestive track), and about 20 days to make a metal jacket around the cells in the vagina (our apologies if you call your junk something else) and in the bloodstream. So, for full protection, you’d need to be taking it every day for a week before you’re protected during anal sex, and every day for three weeks before you are protected during vaginal sex or during any activity in which you would share blood (e.g., sharing needles for tattoos, hormones, drugs, piercings, etc.).

Ask Ms. Harm Reduction: Getting High With Clients

If your session looks like this, Ms. Harm Reduction urges you to read this month's column. (Image by Flickr user Doki hawk)
If your session looks like this, Ms. Harm Reduction urges you to read this month’s column. (Image by Flickr user Doki hawk)

Dear Ms. Harm Reduction,
I’ve been escorting and doing pro domme work for a year and a half. Sometimes I do a gram of coke with regulars, or even do drugs with new clients on occasion. I’d like to be smart about this, but I feel like I can’t ask the the sex workers I know for advice because none of them would ever take that risk in the first place. Do you have any tips on how to stay safe while partying with clients?
Wilder Than (my) Friends

Bareback: Re-Opening The Dialogue On Safer Sex In The Age of U=U

Bareback sex feels fucking amazing.

I know, we’re not supposed to talk about that. We’re not supposed to talk about bareback fucking without following it up with that ubiquitous “but use a condom!” statement. However, many communities face significant barriers to condom use and have very legitimate reasons for foregoing them—and these are the communities whose voices have largely been excluded from broader conversations defining “safe sex.”

That’s a big problem. As harm reductionists and sex educators, we can’t talk openly about what people are really doing behind closed doors. We aren’t supposed to legitimize sex without a condom as an option, or rather, we aren’t supposed to acknowledge that it may be the only option for many marginalized people. And that’s exactly the kind of dishonesty that allows HIV stigma to proliferate.

As an HIV counselor and longtime public health activist, as well as an ex-sex worker and IV drug user, I want this attitude to change. We need to re-open the conversation around what safe sex means in America and internationally, because while condoms can be an excellent means of STI protection, they are by no means a realistic option for every person in every situation. And sex workers in particular need to be involved in this conversation, since it is the most marginalized groups among us—drug-using sex workers, sex working trans women, street workers, sex workers of color, and people who fit into many or all of the above categories—who most often find ourselves in situations in which providing bareback services is our only option if we want to make a living.

Ask A Pro: Oral STIs and Throat Swab Protocol

Ask A Pro 1 is a our new column focusing on work and health, intended to share straightforward information about what you can do to keep yourself as safe as possible while on the job. Questions will be answered by sexual health expert Sarah Patterson, M.Ed. (See full bio below.) Questions you’d like to have answered can be sent to sarah.elspeth.patterson (at) gmail (dot) com, or to our info (at) titsandsass address. Full anonymity is guaranteed. 

Dear Ask A Pro,

I’ve been escorting for about six months and I usually don’t require that my clients wear condoms during blowjobs. I’m not having symptoms of anything, but I asked my gynecologist if I could do a test for oral STIs to be safe and she said I didn’t need it. She knows I’ve had some unprotected oral sex, but she doesn’t know about my job. I think she was trying to save me money but should I go back and tell her it’s important to me to get it? How at risk am I from giving bareback blowjobs anyway? I’ve heard that spitting isn’t much safer than swallowing but does that make a difference?

Sincerely,

Swab Seeker

It Happened To Me: I’m An Escort Who Thought She Had Gonorrhea

World War II military propaganda poster, circa 1940 (Image courtesy of the National Library of Medicine)
1940 World War II military propaganda poster (Image courtesy of the National Library of Medicine)

I was in the midst of a pretty good day when I received a phone call from one of my non-client lovers. The poor boy had come down with a case of throat gonorrhea, which I didn’t even know was a thing.  He was just calling to let me know I had been exposed the last time we had sex, since we had made out with great vigor and he had also gone downtown, like the sweetheart he is. I thanked him for letting me know, told him to feel better, hung up and began to evaluate the situation in the calm and rational fashion that any sex-positive, non-monogamous person might try to evaluate a situation such as this.

Gonorrhea. No big deal, right? I have always expected to contract an STI at some point in my life, and as far as STIs go that’s not such a bad one. I was feeling a little funny in the junk, which I figured was probably due to a yeast infection. It seemed likely to me that I might, in fact, have gonorrhea, and I should probably get tested ASAP either way.

Then I remembered what I do for a living. I remembered that there weren’t just lovers whom I may have exposed, albeit unwittingly, but possibly about three clients as well. Even worse, I remembered that I desperately needed to make the money I was planning on making over the coming weekend— or else I wasn’t going to be able to pay my rent.

Mother. Fucker.

In my work as a full-service escort, STIs had always been a sort of intellectual, if abstract, concern. It is something I knew could be a really detrimental thing to have happen to my business, but it hadn’t happened yet, so I wasn’t too worried about it. Now here I was, in the exact situation I had only considered in the abstract. The one where I need to make money but can’t really figure out an ethical way to do so without exposing myself as every client’s worst nightmare: the poxy whore.