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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 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

Outdated Fear: Criminalizing HIV+ Sex Workers

(Image via the Stigma Project)
(Image via the Stigma Project)

With thanks to members of SWOP-USA

Laws that criminalize HIV exposure are supposed to benefit public health, but in practice are extremely harmful to public health and to the targeted HIV-positive individuals. Sex workers are highly vulnerable to these laws, which sometimes target HIV-positive prostitution specifically. Many require forcible HIV testing, and sometimes they simply criminalize HIV but in reality are applied to sex workers more frequently than to other populations.

The criminalization of HIV-positive sex workers and mandatory post-arrest HIV testing arguably violates international human rights treaties signed by the United States. Treaties with applicable provisions include the International Covenant on Civil and Political Rights (ICCPR) and the International Convention on the Elimination of All Forms of Racial Discrimination (ICERD), specifically their provisions on privacy, rights to equality before the law, and sanctions against inciting hatred and racial bias. Recent forced HIV testing in Greece provoked outrage among international human rights organizations such as Amnesty International and Human Rights Watch. WHO/UNAIDS (World Health Organization/the Joint United Nations Programme on HIV/AIDS) made a statement opposing forced testing. It is widely accepted that best practices for HIV testing, with the best public health outcomes, involve three key principles—consent to testing, the provision of counseling before and after testing, and confidentiality of results. The imposition of felony offenses on individuals who are said to be engaging in sex work while living with HIV punishes members of already vulnerable communities. They are prosecuted even when they use condoms and engage in less risky forms of sex with their partners, sometimes even if they have disclosed their status to their partner. Information about their HIV status, sometimes accompanied by photographs, is often distributed widely by the media in their communities, placing arrestees at risk of retaliation and other abuse. This incentivizes avoiding testing and does nothing to encourage treatment or safer sex practices.

Five Reasons Sex Workers in the US Should Care About the International AIDS Conference

Photo by ReikHavoc on Flickr

1. Because this is the first time in more than 20 years that the U.S. has hosted the event. The IAC will take place in Washington, DC from July 22 to 27. The conference will feature both formal meetings and presentations (with a registration fee) and a Global Village with cultural and activist events (free admission). Interested in pitching an abstract for the conference or a cultural event for the Global Village? Learn more here. The main deadline for abstracts is February 15.

2. Because although Obama lifted travel restrictions against HIV positive people in 2009, there are still travel bans against sex workers and drug users. This means that people who have sold sex or used drugs, even if doing so is legal where they live, are not allowed to enter the United States.

3.Because the sex workers who won’t be allowed into the U.S. are counting on us to make some noise in DC. There will be an international gathering of sex workers happening at a hub conference in India, and we’ll be able to connect with them digitally before and during the conference to share resources and strategies.

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.).