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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.).

The Truth Will Come Out: An Interview With Jill Brenneman and Amanda Brooks

Bruises Brenneman sustained from one of the beatings she suffered at the hands of men hired by Isgitt. (Photo by Amanda Brooks via her blog, courtesy of Amanda Brooks and Jill Brenneman)
Bruises on Brenneman’s back from a beating she suffered at the hands of Isgitt’s hired men. (Photo by Amanda Brooks via her blog, courtesy of Amanda Brooks and Jill Brenneman)

Interview co-authored by Josephine and Caty

Content warning—the following contains descriptions of extreme injuries and rape suffered by two sex workers due to a campaign of violence by an abusive client, as well as an account of child abuse.

Jill Brenneman and Amanda Brooks are veterans and heroines of the sex workers’ rights movement.  As a teen, Brenneman suffered years of of brutal abuse in which she was coerced into working as a professional submissive. In the early aughts, Jill made an amazing conversion from membership in the prohibitionist movement to sex workers’ rights activism. She set up SWOP-EAST from the remains of an anti sex work organization she’d led. SWOP-EAST grew to be one of the most vital sex workers’ rights organizations of the era. Brenneman was also a frequent contributor to early sex workers’ rights blogs like Bound Not Gagged.

Amanda Brooks is the acclaimed author of The Internet Escort’s Handbook series, the first one of which she published in 2006. They served as an important resource for escorts advertising online back when there were few other how-to sources on the topic. She was also one of the earliest escort bloggers starting in 2005, writing entries brimming with eloquence and common sense at After Hours.

The two fell off the map recently.

When they returned, we were shocked to read Brooks’ blog post about what they’d endured: a campaign of terror by one of Brooks’ clients, affluent lawyer Percy LaWayne Isgitt. Isgitt—Brenneman and Brooks call him “Pig”—caused both Brenneman and Brooks severe brain injuries when his arrogance and negligence piloting a plane the three of them were in led to a catastrophic “hard landing.” Despite the fact that Brooks was clearly incapacitated and near death, Brenneman had to browbeat Pig into taking her to the hospital the next day. Once Brooks was checked in, Pig fraudulently signed in as her relative and attempted to control her treatment. Despite her still severely injured state, Brooks continued to see Pig as a client for two sessions after her hospitalization, in desperate need of money to pay for medical bills. When she finally tried to break ties with him, he hired people to make threatening phone calls to both women. In response, Brooks went into hiding, so Pig sent men to stalk, rape, and beat Brenneman on a number of occasions, trying to discover Brooks’ location. Neither the police, nor the many medical facilities that misdiagnosed them along the way, nor the personal injury lawyer they hired were any help to the two women against a deranged, abusive man with wealth and social capital.

The injuries Brenneman suffered from the plane crash combined with the injuries she sustained from the attacks led to the fatal exacerbation of her previous medical conditions. Her doctors have told her she has very little time left to live.

This story illustrates the insidious way institutions empower abusers to commit violence against sex workers. The only people they can often rely on in these situations are other sex workers. You can read the original account here and donate to their Giftrocket account using this email address: abrooks2014@hush.com. Donations will be shared equally between them to cover their respective medical costs.

Amanda, you write in your blog post, in reference to Jill’s past abuse:

To those who doubt, her stories are true. They’re things only men would think up and most of the time, it’s the mundane details that stand out the most to both of us. I’ve read stories from so-called trafficking victims who describe ridiculous “Satanic” rituals or elaborate set-ups. The truth is, the men who were Bruce’s [Jill’s captor’s] clients weren’t very bright, in my opinion, and they had a lot of the same stupid fantasies and beliefs that most vanilla clients do—only much darker and violent.

This factor plays into your story of how Pig hurt you both, too. There’s a voyeuristic undertone to the way people listen to stories of abuse. People expect the “elaborate set-ups,” and yet abuse is usually no different than other misbehavior in kind, if not in degree—abusers do it because they want to feel big, or because they care about themselves a lot more than they care about anyone else. How do you think the fact that often stories of abuse are mundane and banal makes it harder for victims to get help?

Jill Brenneman: People don’t want to believe the mundane stories, they want to believe the exotic stories. Like a wife who gets hit. Unless she’s put in the hospital, no one cares. Or she returns home because she has children. But the trafficking victim imported from Estonia gets all the attention.

Amanda Brooks: Because they’re too believable or not dramatic enough. [Pig] raped me twice, yet it’s not something most people acknowledge as rape. It even took me a while to realize that it was rape, despite how I felt about it. People like to parse situations down to the point where the only way it’s “real” is if it’s outlandish.

Jill, you were held captive by a sadist for three years in your teens, and forced to endure unimaginable abuse. As an adult you returned to sex work voluntarily to make a living, and then you went through this ordeal with Amanda at Pig’s hands. What unusual problems have you faced as a sex working abuse survivor? What can we do as a movement to make things better for the abuse survivors among us?

Jill: The ordeal that Amanda went through made me livid and still does.

Working as an abuse survivor led me to more abuse. I learned from [my captor and abuser] Bruce in the 80’s. Bruce was a cliche master sadist. There was never a sense of love or affection between him and I. I was an object. I did what I was was told. I was taught how to relate to clients. I overapplied this training as an adult. I willingly went back to work as a professional submissive. This was a place that I did not belong. Despite there being a 19 year gap between [my captivity and going back to] sex work, I did not belong in sex work —especially as a professional submissive. I needed the money to pay for very expensive subcutaneous blood thinners because of a clotting disorder. I needed to pay the rent, the car payment, food, care for the dog, etc. I took the work that came. I started off with two old pictures of myself, no website, no reviews, and took some pro-sub clients to make money when it was tight. I did not belong in sex work. I was still far too impacted from previous abuse to be doing it but I had no choice, I needed the money.

The most important thing the movement needs to do is work on decriminalization so that we have options.

Amanda: The movement truly doesn’t have the power to deal with this, unfortunately. Until the laws are changed, we never will.

The Healthcare Hustle

ahealthustlefeministryanDanielle is the Care Coordinator for Persist Health Project. Persist Health Project is a peer-led, community-based health and community organizing project for sex workers based in Brooklyn, New York. As Persist’s Care Coordinator, Danielle vets service providers, provides community members with supportive referrals, and helps lead Persist’s Best Practices Trainings.

While many of us dream of the ideal client who will deposit money annually into our retirement fund or enroll us in their kick-ass work health insurance plan, he probably won’t come along for all of us. Here are some things you can do to get quality health care service in the meantime without breaking the bank:

1. First things first, you could be eligible for government subsidized health insurance through Medicaid! Check with an Affordable Care Act (ACA/Obamacare) navigator to see if you are. You can also call a Medicaid Hotline (1-800-541-2831) to check your eligibility. If you make under $1,300 a month (for a single person, that number goes up with family size) in reported income, are pregnant, or have recently had a child, you may be eligible for Medicaid. If you have recently been diagnosed with HIV you are also eligible for AmidaCare through Medicaid.

While open enrollment for the ACA has ended, if you are eligible for Medicaid or government assistance with     your health care plan you are still able to enroll without a fee. Reach out to Callen-Lorde Community Health Center if you think you might be eligible and get enrolled today!

We’re Not Crazy For Doing This: Sex Workers With Mental Illness

“Patients Waiting To See A Doctor, With Figures Representing Their Fears” by Rosemary Carson (via wikimedia)

Most people have some form of a lurid narrative about drugs, exploitation, childhood abuse, and mental illness come to mind when they imagine the life of a sex worker. However, sex workers’ relationships to their identity are far more complex and difficult to characterize than that trite narrative allows for. When it comes to sex workers who do live with the stereotypical trope of also having a mental illness, it becomes even more essential to uncover what these sex workers themselves have to say about their lived experiences of that mental illness and sex work.

People diagnosed with mental illness frequently have their decisions invalidated and undermined by the dominant culture. Many individuals who do not have much experience with mental illness will attribute any socially unacceptable behaviors to “mental illness.” In much the same way, people who have never been in the sex industry tend to sideline the decisions of sex workers by inferring that trauma or abuse must have predestined them to a life in the sex industry. When people who are neither mentally ill nor in the sex industry say these things, they are robbing us of our ability to exert agency.

Amber, a full-service worker from Washington DC, states, “I very strongly believe that the way that society treats sex workers, mentally ill people and other marginalized communities (that often intersect)…[is] based on kyriarchal/patriarchal, colonialist, and capitalist systems of control. In order to treat marginalized people better, I think we all have a lot of work to do regarding the unlearning of certain stigmas and stereotypes.”

The presence of stigma is one the key aspects of institutional violence keeping communities and individuals subjugated. It proliferates because it benefits those in power in this way. Stigma creates legal and moral justifications for the criminalization of sex work in America. It also creates an environment in which mentally ill people can be stripped of their rights through court-ordered institutionalization, coerced medication, and the assignation of relatives as proxies to control them legally and financially. The disqualification of the decision-making abilities of communities on the margins is a weapon of the oppressor.

Tara Johnson, a stripper from Portland, Oregon, elaborates on the ways in which decision making can be invalidated based on association with the sex industry, especially if one also has a diagnosis of mental illness: “Just because I’m (sometimes) crazy, doesn’t mean I’m wrong. My sex work was not me acting out, or indulging in yet another form of self-harm. It was nothing that entitles people to belittle my full humanity. It’s nothing that automatically means that mentally ill sex workers, especially ones who may have other issues too (drug use, etc.) should automatically be deprived of the rights that privileged, able-bodied civilians are entitled to.”

Sex work is not a dysfunctional behavior stemming from our disease. Rather, it is often the best choice we can make to adapt to our mental illness. In truth, many people with mental illness find sex work helpful in a variety of ways as an occupational choice. It gives us a less rigorous schedule which allows for more emotional instability. Sex work can also affirm us as something we can excel at when mental illness has hindered our success in more traditional pursuits.

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.