Dear Ms. Harm Reduction,
I am transitioning into full service work, and need help getting clients to use condoms. One sugar daddy in particular has had a vasectomy, and a recent clean test, so he prefers no condoms for any activity. But I still feel uncomfortable with this. How can I negotiate to protect myself? On a related note, do you know where low income/uninsured women can get the HPV vaccine for free? I am over 26 years old, in California, if that matters. I really want to be as safe as possible while still earning money in this industry.
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 email@example.com and firstname.lastname@example.org.
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.).
Dear Ms. Harm Reduction, About six months ago I had my first ever genital herpes outbreak. I am a cis female and a full service provider. I don’t do bareback, but I do still continue to work. I am on herbal suppressive therapy (lysine, other immune boosters and stress management) and haven’t had an outbreak since the first one. I know it’s controversial, but I love my job and I don’t want to do any other type of work. I just want to know how to be as safe as possible. Also how big of a risk is this? Am I totally fucked up for working? For the record I would never work during an outbreak, but outside of that, is it ok? I was also wondering if internal condoms (female condoms) offer more protection because they cover external surface area?
I am non-monogamous by choice, not just by de facto circumstance because of the fact that I am an escort. I live with one of my serious partners, and have a few other partners and sexy friends. I’ve never been suited to monogamy, and sex work has always played a role in that for me. When I was a baby sex worker and dancing at a sleazy club, my emotionally abusive boyfriend at the time asked me to quit, after initially telling me he was fine with it. His reasoning was that he just couldn’t stand the thought of me even flirting with other men. I quit quickly after that conversation, telling myself it was because I hated the work and not because of his jealousy. It was mostly because I didn’t want to lose him, though. He continued to abuse me after that, eventually forcing me to isolate myself emotionally from anyone other than him. His jealousy forced me to work jobs that were even less emotionally healthy for me than dancing at that club or PSOing and camming were. He used heteromonogamous norms to assert complete control over every aspect of my life. Eventually, I woke up and quit him for good. He retaliated by smashing out the windows on my car. I consider myself pretty lucky to have never been physically assaulted by him.
After that, I refused to have anything to do with anyone who felt they had any dominion over my sexual choices. I was in a couple of relationships that were monogamish in between then and now, but always with the understanding that I was free to have sex with whomever I pleased if the circumstances were right. Now I will only be in relationships with people who fully understand that I am my own person who makes my own choices, both sexually and emotionally. While I am not the sort of person to tell people what do with their lives or how to structure their relationships, I find the expectation that every relationship should be monogamous to be highly problematic.
Last week I awoke to the news of what happened to Christy Mack, the adult film star who was sexually assaulted, severely beaten and nearly killed by her ex-boyfriend, mixed martial arts fighter Jonathan “War Machine” Koppenhaver. According to a statement she released last Monday, she and a friend were attacked by Koppenhaver when he showed up at her house unannounced and found them there together. One part of her statement stuck out to me, and I’ve been thinking about it all week. In Mack’s words:
When he arrived, he found myself and one other fully clothed and unarmed in the house.
What really got me was the choice to state that her friend and she were fully clothed. This woman was assaulted by her ex to the point of being hospitalized in serious condition, and she still felt pressure to highlight the fact that Koppenhaver had not caught her in an act of sexual indiscretion. It shouldn’t matter; not only because he is her ex, it just shouldn’t ever matter. Catching someone having sex with someone else should never be an excuse to attack them.
I actually didn’t know who Christy Mack was until I started seeing articles about her attack flying around the internet last week. But her story is one that is familiar to me. Intimately familiar.
I stripped for eight years, in a dozen clubs across New York, Pennsylvania, Ohio, Michigan, Iowa, Minnesota, Colorado, and Georgia. I met strippers who were also full service sex workers inside or outside the club, sugar babies, cam girls, and adult film stars. I’ve seen co-workers “graduate” into Playboy and Hustler. I’ve seen every combination of education, economic background, race, size, upbringing, parental status, and religion, so when I overhear non-sex-workers talking like we’re all a certain type, I can only laugh.
But one thing we all seem to have in common is an abuse story, either one of our own or of someone very close to us.
One thing I noticed early on in my career is that stripper locker room talk is brazen and honest. There is some high speed bonding that goes on over trays of eye shadow and half-finished drinks. As a more-or-less good girl going to state college on my parents’ dime, I was no stranger to boozy heartbreak stories, but stripper stories almost always went somewhere darker, faster. Without even knowing a co-worker’s name, I might hear the details of how her ex-husband broke into her house, or how she was borrowing a phone from another girl after receiving threatening texts from a stalker. I’ve had girls show me pictures of men on their phones with the warning, “If he shows up, tell the bouncer and come warn me. I don’t care if I’m in a VIP, just come tell me.”
There’s this recurring theme in our love lives— a man will admire us for our independence and freedom, and of course, our money. We’ll thrive on the attention for a while and we’ll enjoy spoiling him with gifts or trips. Maybe he moves in because his roommates are irresponsible, or maybe we move in with him because we’re sleeping over all the time anyway. And then the fights start.
“Where the fuck were you until five in the morning?”