Waiting for the gay men’s sexual health revolution – Part 3, PEP

This is the third installment of a series looking at new and emerging HIV-prevention options and the barriers that are slowing down the beginning of what could be a sexual revolution for queer men. Previously: PrEP , U=U

Have you ever felt anxious, nervous, uncomfortable after a hookup? Have you ever regretted a choice you have made after the heat of the moment has passed? Have you ever felt, after the excitement has passed and you begin to entertain those sober, cold-shower-thoughts, that you may have put yourself at more risk than you are comfortable with?

Of course you have. We have all been there. I very rarely meet queer, HIV-negative men who have not had at least one experience they consider to be a ‘close call’ with HIV.
Maybe you were having trouble keeping it up with a condom, and he told you it was okay – that he trusted you. You went for it, but afterwards started to question his judgement. I mean, you knew you were HIV-negative, but how did he? Did he trust every stranger he met on Grindr?
Or maybe you did use a condom, but it broke. He didn’t seem as upset as you did. As you talk afterwards he tells you he has never been tested for HIV because he feels fine, and anyways he didn’t finish inside you so whats the big deal? Your heart flutters with panic.
Or maybe you didn’t say much to each-other at all. Maybe you were both intoxicated, or maybe it was an exciting quickie in a washroom stall, the baths, or somewhere pre-game chit-chat didn’t feel like an appropriate part of the fun. Even though you usually have at least a brief conversation about ground rules, you got caught up in the moment, and when he took control and guided you inside him without telling you to put on a rubber first, you were surprised but didn’t argue – it felt good and you didn’t want to stop it, so you just suppressed your concerns in the moment. But now that the moment has passed and anxiety is coming back to the surface.
The experience can make you feel helpless. You know it will be some time before you can have peace-of-mind, and a lot of guys think the only thing they can do is wait until it’s been three months to get outside the window period and know for sure if their status has changed.
It doesn’t have to be that way. There is an emergency option, and the fact that a lot of guys don’t know about it, or know how to access it, quite frankly sucks.

Post Exposure Prophylaxis, or ‘PEP’ is a course of treatment that can be taken after an exposure to HIV and is a last line of defense against the virus taking hold in your body. Its like a morning-after pill (except one you have to take daily for three months). It is a very time-sensitive intervention (treatment must be started within 72 hours of exposure to HIV, and it most effective when started within 48 hours) so it is generally something you need to access through a hospital emergency room.

It is also unacceptably difficult to access this option, considering the difference it could make to HIV prevention efforts if it was simpler. PEP is also not widely advertised or talked about because it is expensive, often an emotionally taxing process to get ahold of, and is an emergency option, not advisable as a ‘strategy’. A lot of sexual health educators would rather talk about better on-going prevention options like PrEP.

PEP is admittedly not a great prevention strategy, especially when other great options like PrEP are available. But the unfortunate truth is, a lot of folks don’t want to think about HIV prevention until they are confronted with the reality of HIV risk, until they have had a ‘close call’. As we talked about in the piece on PrEP, so many of us are able to convince ourselves that we are not the ‘kind of people’ who are at risk. And then we do something that puts us at risk. Perhaps we might be willing to consider PrEP now, but it won’t do us any good if its too late. So guys need to know about PEP too.

I believe it is important to be very clear about the reality of HIV and the reasons we need to care. It is a challenge to communicate this effectively, because we must always do our best to avoid stigmatizing people who are living with HIV, while also ensuring that HIV is being taken seriously enough to prevent new infections, especially those of us who are at high risk (as gay, bisexual queer and other men who have sex with men continue to be). It is true that HIV can be managed well through modern treatment, that people living with HIV can live long and healthy lives, and that HIV should not be feared anymore. It is also true that, leaving aside stigma-related consequences to becoming HIV-positive, that it is not an easy walk-in-the-park to manage HIV. Getting the best health outcomes requires ongoing treatment and intense healthy living practices for the rest of your life. It is a chronic condition, similar to conditions like diabetes, where you will never be cured of it, but you can still manage it well and with the right medication, diet and exercise, you can stay healthy. It is a burden that is preventable, and its important to do what we can to prevent it, while also showing solidarity with and support for people in our community who are living with it (and who, as previously noted, are not a risk for further infection when they are adherent to their HIV care). We don’t need to fear it, but we do need to respect it.

Having said that, lets be clear about another thing – the three example  scenarios at the beginning of this article are all definite grounds to consider yourself to be having a medical emergency. In each case, there is no certainty that the your partner is living with HIV. There is no certainty that if he is HIV-positive that he is not undetectable (and therefore not an infection risk). There is no certainty that even if he is HIV-positive AND has a detectable viral load that the virus found a point of entry into your bloodstream. There is also no certainty to the contrary.  Any of these three examples, or any time you have a high-risk sexual encounter (penetrative sex with a partner of unknown HIV status and no prevention option like PrEP or condoms has been used)  is absolutely reasonable grounds to get yourself to an emergency room.

Being honest with yourself and admitting that you might be at risk is, unfortunately, only half the battle. The first barrier to overcome is realistically assessing your risk – the second barrier often happens at that emergency room, because although I might convince you my readers that this situation is a medical emergency, convincing the hospital can be difficult.

For lots of reasons which can include homophobia, sex-negativity, poor harm-reduction practice, stigma and ignorance, it happens all too often that a person who is having this kind of emergency needs to convince a triage team that the situation is indeed that – an emergency they need to take seriously and addressed quickly. Hospital staff may advise you to go elsewhere – this is not acceptable as the clock is ticking and any hospital should be capable of addressing this situation whether the triage team thinks so or not. Hospital staff may not prioritize you appropriately because they do not realize how time-sensitive the situation is. hospitals generally have good PEP procedures for dealing with people who have been sexually assaulted, or people who have had a needle-stick incident on the job, but all to often these procedures do not extend to people who have self-identified the emergency due to consensual sex that they are now concerned about after the fact. Although this is not always the case, and you may have no trouble, its a good idea to hope for the best and prepare for the worst.

Much of the advice given on PEP is scripted talking points you should use if you are feeling resistance from emergency staff, in order to convince them that you are indeed having an emergency that needs to be addressed quickly. Being explicit and specific about why you consider this to be a high-risk scenario, being specific and explicit about what you want them to do about it, bringing a friend to support you if you do not trust yourself to stay calm, or asking them to contact an infectious diseases specialist to consult over the phone if you do not believe you are being taken seriously are all pieces of advice worth listening to. They are also completely unfair and quite frankly unacceptable responsibilities to put on a patient experiencing an emergency. Life is, unfortunately, sometimes unfair. So be prepared for an experience that may not be pleasant.

And then there is more difficult news. The third barrier is that PEP is rarely available for free, and can be expensive. It is a worthwhile expense if it is going to prevent you from contracting an incurable chronic condition, but is not always feasible for everyone. It is a good idea to ask (repeatedly and persistently, if necessary) for help if you cannot afford to pay for this treatment. Hospitals that house HIV-care practices are sometimes able to provide compassionate medications for people who can’t afford them, but this is not guaranteed. You might ask to speak to the social worker on staff – they may have resources the doctor you speak to does not know about.

At the very least, it is important to ask for a starting dose to take immediately before filling out your prescription, because as said, time is not on your side and the sooner treatment is started the better the chances are it will work and prevent you from becoming HIV-positive.

Admittedly, that is a lot of rough news. The good news is that some hospitals in Hamilton are more able to deal with a PEP emergency than others. Although at this time no hospitals have publicly declared themselves to be the go-to place for PEP in the way that Saint Michaels in Toronto has, Hamilton General Hospital and Juravinski both house sexual assault care centres, and so are in a better position than other Hamilton emergency rooms to prescribe PEP and are more likely to have starter kits on-hand. St Mikes is the best bet in the immediate area if Toronto is a place that is easily accessible to you, but with time being so precious in this situation, it would still be my recommendation to go to a Hamilton emergency room.
The other good news is that PEP is no longer as rough a go as it once was, provided you are prescribed good, newer HIV drugs (the drugs used for PEP are also used for HIV-treatment in people who are living with HIV). Even a few years ago there were often very unpleasant side-effects, but newer HIV medications, even very potent ones, have greatly reduced side-effects. It is possible that you will feel sick though, so being prepared to take time to feel better is a good idea.
The whole treatment needs to be completed, and you need to get an HIV test after you are done three months later, to see if treatment worked. Three months is the longest it would take for HIV to show up in a test, so if you are negative after your PEP course is over, and you haven’t had a possible exposure in the three months since you started it, than you can safely assume that you are HIV-negative. The emergency intervention is over and its time to take a breath and move on.
PEP is an important piece of the new HIV prevention landscape, and there are things you can do to help. Make sure your friends know about this option, it can make a huge difference. Ask the director of your nearest emergency room what their PEP procedure is. Be the buddy a friend may need you to be and go with them if they need some support getting access to PEP. Help us make sure that guys know, there is something they can do, they don’t have to just hope for the best and wait for it to be enough time for an HIV test. It takes a community effort to deal with a community issue, and the HIV-prevalence in our community is too damn high.

And if you have used PEP before, maybe consider a better long-term solution to your own HIV-prevention strategy. If the situation that lead to you being on PEP was a one-off, anomalous thing than keep-on-keeping-on with your condoms or monogamy or whatever it is you are doing. If not, maybe its time to get real with yourself and think about PrEP.

For more information about PEP, or if you have any questions about gay men’s sexual health in Hamilton, contact the Men4Men program of The AIDS Network at men4men@aidsnetwork.ca or 905-528-0854 x 231

James Dee

James Dee is an editor at Bent Q Media, a queer community organizer and sexual health educator in Hamilton, Ontario.

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