The Next Condom Conundrum: Why Use a Rubber When You Can Just Pop a Pill? That's What HIV-Negative Guys across the Country Are Asking Themselves-And Their Doctors. as Condom Usage Is Down and HIV Infection Rates Are Up, Could a Prescription Be the Key to Prevention?

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WHEN ADAM, AN HIV-NEGATIVE BOSTONIAN in his mid 20s, was dating an HIV-positive man last year, he made a conscious decision not to use a condom when they had sex. Instead, he popped a tenofovir, an antiretroviral drug that may help prevent HIV infection. "My partner didn't insist on [barebacking]," says Adam, who asked that his last name not be used in this story. "I thought it would bring us closer together." Now single, Adam says he regularly uses condoms again, although he hasn't been tested for HIV since the relationship ended.

Like Adam, many gay men around the country are opting to forgo the standard defense against HIV--a condom-in favor of a highly controversial and thus far unproven method of protection known as pre-exposure prophylaxis, or PREP. Whether in a serodiscordant relationship or just looking for a fun night (or weekend) out, guys are trading rubbers for HIV drugs like tenofovir, known commercially as Viread, in hopes of preventing infection. The idea is inspired by post-exposure prophylaxis drug regimens long given to people possibly exposed to HIV--such as health care workers, rape victims, or those who've experienced condom mishaps--and by the AZT and Nevirapine pills that HIV-positive pregnant and nursing women routinely take to prevent mother-to-infant transmission.

And while PrEP's not new--guys have been popping a T, or "disco dosing," as the practice is sometimes called, for several years, acquiring the drugs from friends, partners, or drug dealers selling "party packs" including crystal meth and Viagra--a host of studies are now under way seeking to determine if it actually works. If proved effective, PrEP could revolutionize what it means to have safe sex--at a time when HIV infection rates are rising among gay men.

Doctors don't condone this underground prevention method, even if some informally discuss it with their patients. The medical consensus is that guys who use PrEP are putting themselves at risk of contracting an incurable disease and that no one should abandon condoms. But health care professionals also acknowledge that the practice of PrEP will continue even without the approval of any medical group. "Gay men have traditionally been ahead of scientists in trying to lower their risk," says Bill Stackhouse, director of the Institute for Gay Men's Health at Gay Men's Health Crisis in New York City. "Unfortunately, this [approach] comes with complications."

"Clearly, sex is more exciting without a condom: They're not very convenient, they're not sexy, they don't feel natural," says Rob Garofalo, deputy director of the Howard Brown Health Center in Chicago. "People are clamoring for a strategy that works."

NO ONE KNOWS HOW WIDESPREAD the use of PrEP is. A 2006 survey by the San Francisco Department of Public Health of 1,819 men at two California circuit parties and a variety of city locations found that 16% had heard of the practice, although fewer than 1% had tried it themselves. A 2007 study of HIV-negative gay men in Boston funded by the National Institute of Mental Health yielded similar results, though the sample size was only 227.

But physicians are definitely hearing from their patients about PREP. When he was in private medical practice in Harrisburg, Pa., A.C. Demidont says several patients told him they had tried it or knew someone who had. His patients at New York's Callen-Lorde Community Health Center have asked about it, but PrEP is not offered there. Los Angeles physician Tony Mills says some of his patients with HIV-positive partners employ PREP. He says one of his patients told him, "We don't have safe sex. Every time we have sex, I take Viread." And Antonio Urbina, who is medical director of HIV/AIDS training at St. Vincent Hospital's HIV center in New York's Greenwich Village, says he's seen two patients who have taken HIV drugs before going out for "PnP," or "party and play"--that is, spending a night or weekend on crystal meth while having often-anonymous sex. …


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