This article originally appeared in French on The Warning’s website here.
An emerging trend
We are now seeing the emergence of profiles where guys self-identify as PrEP users on cruising sites and apps like Grindr and Squirt. Is this a signal that PrEP is now a part of gay men’s sex lives? I decided to check out one of these sites to see what was happening.
I chose BBRT to see if guys were self-identifying as PrEP users. Actually, HIV prevention workers in Toronto are the ones who planted the idea in my head. A few of them told me that more and more guys were asking questions about PrEP after noticing that Americans who were in town for World Pride last July mentioned PrEP in their profiles (including on BBRT).
First, a bit of context. Many of the cruising apps and sites don’t offer a specific option to indicate your HIV status (for example, Grindr, Growlr, Squirt, Gay411). Of course you can always choose to write it in the open text section. Other apps and sites (for example, Manhunt, BBRT) include HIV status among the demographic information you can disclose.
BBRT is the acronym for Bareback RealTime. The site is available in English only. BBRT was created as a space where HIV-positive men could meet without facing some of the rejection and stigma that is still all too common in other spaces.
The site acknowledges that positive guys don’t always use condoms when having sex together. There are also an increasing number of negative guys who prefer condomless sex on the site. Many of them are looking for a space that is less stigmatizing towards condomless sex, as well as for sexual partners who are positive and undetectable, whom they see as being less risky than guys who say or think they are negative.
In addition, BBRT offers what is probably the largest range of options for serostatus. Indeed, there are currently ten options:
- Poz + Other
- Neg + PrEP
- Neg + Other
- Do not care
- Ask me
The fact that there are so many categories for serostatus on a website dedicated to barebacking is significant. Let’s be honest; this is considerably more nuanced than what we see in most prevention messages and HIV-related studies.
Neg + PrEP
The fact that there is an option for ‘Neg + PrEP’ is significant as well. The same goes for ‘undetectable’, separate from ‘positive’.
So how many guys in Canada* have selected the ‘Neg + PrEP’ option as their serostatus? Here is a table summarizing the evolution over the past three months.
- Although there are relatively few guys who identify as being ‘Neg + PrEP’, the fact that there are any at all is significant. And the numbers are quite a bit higher than I would have expected, especially given this is just one cruising site (though admittedly a popular one; 10,000 Canadian users? Wow!).
- I don’t want to over-analyze three months worth of ‘data’, but the numbers are going up. In fact, they doubled in two months.
- Montreal has more ‘negative + PrEP’ guys than Toronto, which is a larger city and one that is more anglophone (BBRT is exclusively available in English). Why? Maybe for some of the following reasons:
- Clinique l’Actuel has been publishing ads about PrEP in the gay magazine Fugues for several months. In fact the three large clinics located in the Village that have a mostly gay clientele (L’Actuel, Quartier-Latin, Opus) all have doctors that now prescribe PrEP.
- Quebec is the only province to have published PrEP guidelines.
- For those who don’t have private insurance, the Régime d’assurance-médicaments du Québec (Quebec’s public drug insurance plan) covers most of the cost of the drug. There is no equivalent in Ontario.
- The Ipergay trial has been providing some visibility for PrEP in Montreal for some time now. Which begs the question… are some Ipergay participants identifying as being on PrEP, despite the fact that they have a 50% chance of actually being on placebo, and that the ‘on-demand’ protocol’s effectiveness is precisely what’s being investigated in the trial?
Here are the age categories for guys who identity as ‘negative + PrEP’.
As a comparison, this is how the age categories break down for all 9,980 Canadian profiles as of August 1, 2014:
- Under 35 y.o. = 34.5%
- 35 to 49 y.o. = 47.4%
- 50 y.o. and over = 18.1%
Side note: I chose this particular age breakdown based on the ‘AIDS generations’ proposed by the American researcher Phillip Hammack. Although he proposes five generations, I merged some of them to form three generations. Gay men who are 50 + represent the generation that has arguably been most affected by the AIDS epidemic (saw the onset of the epidemic, lost a large number of their peers, probably have the highest rates of seropositivity). Phillip Hammack divides these men into three distinct generations: Stigma Generation, Stonewall Generation, AIDS 1 Generation. Those who are 35-49 years old correspond to Hammack’s ‘AIDS 2 Generation’, and while they did not generally experience as much personal loss as their older peers, they came of age as gay men during the onset of the epidemic and equated Gay = AIDS = Death. Those who are under 35 are the ‘Post-AIDS Generation’, who never knew a world without HIV/AIDS, did not grow up with the same fear of HIV and AIDS, and grew up in a context where marriage equality and Gay-Straight Alliances came into existence.
A few observations about the age of ‘negative + PrEP’ guys:
- PrEP users on this site are younger than the average BBRT users.
- This is not very surprising in my view for several reasons. The older the cohort of gay men, the more likely they are to be HIV-positive. Online cruising is more popular with younger guys, quite probably. I think young people are generally more open to prevention options other than condoms, including PrEP.
For now, BBRT offers us the best glimpse into the ways in which gay men are identifying themselves as PrEP users on cruising sites and apps. Will other sites and apps start to offer a greater range of options to indicate serostatus and PrEP use?
Will the HIV prevention field find more nuanced ways to discuss serostatus and the range of risk reduction options that are now available? In Australia, they have recently taken a step in that direction. One thing is certain. While the HIV prevention field continues to ponder whether and how this information can be conveyed to gay men, in their own way gay men are attempting to give meaning to the information and they are integrating it into their sex lives.
*Editor's note: In Canada, Truvada is approved by Health Canada as a drug for the treatment of HIV infection. Gilead Sciences, the pharmaceutical company that manufactures Truvada, has not applied to Health Canada for a ‘new indication’— in other words prescribing Truvada to those who are HIV-negative to reduce the risk of acquiring HIV. It has only sought approval for this use for Truvada in two countries so far: the US (where the Food and Drug Administration or FDA approved it in July 2012) and South Africa (decision pending). As a result, at the time of writing, everywhere in the world except in the US, Truvada as PrEP has to be prescribed ‘off-label’, which means a use other than what it was approved for (as per its label).
Off-label prescriptions are legal in Canada and relatively common practice. However, getting access to PrEP in the Canadian context requires having a healthcare professional willing to prescribe Truvada off-label, one with whom you’re comfortable having a conversation about your HIV risk. And having the means to cover the cost of the drug (around $900/month). Depending on where you live in the country, this could mean that you’re covered by a provincial public drug plan (Quebec), that you’re covered by a private drug plan (we are aware of no plan that has refused to cover PrEP), or that you have no coverage at all and would have to pay out of pocket.
All of this, combined with generally low awareness levels about PrEP and the fact PrEP is not a suitable option for everyone for all sorts of reasons, explains why uptake is relatively low so far.