It is an insensitive feeling to have, but it is what it is: a sense of relief that I did not live through the 1980s as a gay man. It is not just the suffocating homophobia institutionalised in law, fanned by the media, rampant in public opinion – all of which lesbian, gay, bisexual and transgender (LGBT) activists fought with courage and often at great personal cost.
To my generation, the emergence of HIV in the early 1980s seems like an almost unbearably nightmarish episode. Clusters – what a grim, clinical term – of young, healthy men succumbing to Karposi’s Sarcomi, a rare cancer previously thought to afflict predominantly older, eastern European men. Partners tending to their loved ones as their bodies were fatally ravaged with disease, knowing that they themselves would succumb alone. Diagnoses that were death sentences with no appeal; gay men attending weekly funerals; and treated like lepers by an unsympathetic public. No cure, no successful treatment, no hope.
Today’s reality is profoundly different. HIV is no longer a death sentence, but a chronic condition treatable with a combination of drugs. Max Pemberton, a doctor, says he would prefer a diagnosis of HIV to diabetes: a welcome evidence-based riposte to the stigmatisation of HIV-positive men and women. That is not to belittle HIV – it is a life-changing condition, and some of the treatments have their side-effects – but, as HIV expert Prof Jonathan Weber put it to me, the treatment regimens developed in the mid-1990s are “so successful it’s like a miracle”.
But this awareness has led, in part, to complacency. There are an estimated 40,000 gay men living with HIV in Britain, and it is believed that one in five are not even diagnosed. That’s bad news, because treating HIV in its later stages risks more complications, and without drugs which suppress the virus, the undiagnosed may unwittingly infect others. In London, as many as one in 12 gay men active on the scene could be infected. Over 6,000 Britons were diagnosed with HIV in 2012, and nearly half were men sleeping with men.
It is time, then, to import a debate from across the Atlantic. Back in 2010, the results of a three-year clinical trial of a drug called Truvada were published. The drug was already approved by the US Food and Drug Administration (FDA) as a treatment for HIV-positive patients. But this trial investigated the impact of the drug on HIV-negative individuals at high risk of infection.
For those who took it as prescribed, it had a near universal success rate in preventing the transmission of HIV. It provided cells with a protective chemical shield, blocking the replication of the HIV virus and aborting its invasion of the body. Cue excited talk of the “new condom” and the “gay man’s birth control”, though the technical term is pre-exposure prophylaxis (PrEP). Barack Obama rang the research team to congratulate them. The FDA approved its use for those without HIV. Many medical insurance companies have even agreed to cover the cost.
A powerful addition to the arsenal of weapons against the increasingly besieged HIV virus, you might think. But Truvada has caused divisions among doctors and LGBT activists alike. Claims have circulated that it will merely encourage unsafe sex and risky behaviour, encourage the proliferation of other sexually transmitted infections and undermine stable relationships among a group of people who are already more promiscuous than their straight counterparts.
The president of the LA-based Aids Healthcare Foundation, Michael Weinstein, has even referred to it as a “party drug”. It’s a reference to the small minority of gay men who use disinhibiting drugs like mephedrone and crystal meth before having unprotected sex. Could Truvada make this behaviour more common? The circulation of such claims is probably partly behind the small take-up of the drug. Since the 2010 study, an estimated 150,000 Americans – a third of them in their 20s or younger – have become infected.
But the trial contradicts the Truvada naysayers. It revealed no evidence that men taking the drug used condoms less or become more risky in their sexual practices. Weber offers me a number of crucial caveats. “I’m not a fan of PrEP as a public health matter,” he says. “It probably works, if you take it regularly and can adhere to the dosing.”
The problem, he believes, is that many will struggle to commit to taking it every day, and could even end up developing resistance to a crucial drug they may need if they do become infected. Those taking it have to be regularly tested, and healthy people may resist being absorbed into the health system. And there is a big cost involved. The most effective means of combating the virus among the population is a vaccine, such as was behind the eradication of smallpox.
Nonetheless, Weber is open to its use for certain groups and individuals, even if it does not offer a comprehensive solution to the global HIV pandemic. As Cary James at the Terrence Higgins Trust puts it to me, Truvada is “very promising”. Above all, it gives gay men “that extra peace of mind” and “takes the fear of HIV out of sex, perhaps for the first time in their lives”. In other words, it offers a safety net, rather than a substitute for condoms.
Now that it has been approved in the US for high-risk groups, it should surely be approved in the UK too. Those terrifying 1980s Aids adverts may have helped combat the spread of the virus, but many gay and bisexual men have been left with a real sense of terror. Internalised homophobia often fuses with fear of HIV: many gay men tell me that every time they get a cold they fear infection, even if they have engaged in no risky behaviour.
Approval for the UK would break down obstacles for HIV-positive people to have loving, lasting relationships. Along with more safer-sex awareness campaigning, the encouragement of regular testing among groups at risk (which is paying off) and the continued fight for a vaccine, Truvada could help stem the spread of HIV. It is no miracle drug, and certainly no total victory over an infection that has blighted too many lives. But surely its benefits are sufficient to justify the NHS offering it to those at risk? Three decades after the pandemic began, it is certainly a debate we should be having.