This article by Mathew Rodriguez first appeared on TheBody.com here.  

As a licensed therapist working with people living with HIV, Damon Jacobs heard about pre-exposure prophylaxis (PrEP) as an HIV prevention strategy. When he found himself newly single after being out of the dating game for almost a decade, he re-entered a dating pool that was not at all condom-friendly. To deal with this, and to finally come to terms with his distaste for condoms, Damon began taking PrEP in July 2011 to stay HIV negative.

Now, almost two years later, he's never missed a single dose -- and he's become an advocate for education around PrEP, though he acknowledges that it may not be the right strategy for everyone. From dispelling myths around anti-condom attitudes to advocating that people be able to talk to their doctors about all aspects of their sex life, Damon reminds us that sex isn't dirty, and we can have sexual pleasure, but we have to be smart and know our own bodies.

Can you tell us a bit about your background and experience in the HIV community?

I'm a licensed marriage/family therapist in New York state. I'm also licensed in California. That means that I work with people in relationships. Sometimes I work with couples in the room. Sometimes I work with individuals who are in couples.

I was getting my formative education and training in psychology in the San Francisco Bay Area in the mid-early 1990s, in the early days of HIV/AIDS -- or, actually, it was after the first wave. That was a time when loving people with AIDS and knowing people with AIDS meant losing people with AIDS. You would see people one day and then the next day, you wouldn't see them. That was before we had treatments. And that really affected a lot of the way that I continued to want to be active in the HIV prevention, education and treatment community -- also as a therapist, as someone who could help people infected and affected by HIV to have lives that were still meaningful and purposeful and pleasure-filled.

That's really been the mission that I've had for the past 15 to 20 years, is trying to promote a sense of empowerment, and mental and spiritual health for people infected and affected with HIV -- people that are, often, in relationships with other people who are HIV positive, and a lot of serodiscordant relationships (meaning that one person is negative, one person is positive) -- and helping them negotiate the boundaries and agreements and how they discuss issues around sexuality, around sexual expression.

When was the first time that you remember hearing about PrEP?

The first that I remember hearing about PrEP was actually around Thanksgiving, the day before Thanksgiving, of 2010. I try to keep up with the latest research, and I had just heard about this study. I didn't really know anything about it. I just heard that there was this study called "I-Something." I thought it was like an Apple computer or something, because it was called the "iPrEx study." I heard about some sort of pill that could potentially prevent someone who was negative from becoming positive. And I thought, "Well, that could be interesting." Then I didn't really think any much more about it for another six months.

During those six months, a long-term relationship of mine was coming to an end, and I was getting back into the dating world. Also, the cruising world. I realized that in the seven years that had passed since I was last single, a few things had changed. For one thing, the partners I was meeting had a very different attitude around condoms than they had had in the early 2000s. They didn't want to use condoms. And to be honest with you, there were times I didn't want them to use condoms, either. For the very first time in my life, I was in this confusing state of, "Wait a second, I've been this prevention advocate about condoms and lube for all these years. And here I am, not exactly holding myself to the same standards."

So, I heard about this information session about PrEP that was going to be happening at GMHC in about June of 2011. And I thought, "Well, I just want to know more about this." I didn't think it was going to apply to me in any way. But when I got there, there were some of the researchers and some community advocates that were sharing the information that was available. And when I heard the researchers say that the variable aspects of efficacy in the iPrEx study ranged from 44 percent and 90 percent ... well, 44 percent wasn't going to sell me. I wasn't going to play that game. But when I heard that it was 90 percent amongst participants in the study who actually took the medication consistently, between 90 and 92 percent, that's when my ears perked up. I was like, "Wait a second, maybe this is something for me. Maybe this is something that would not only positively impact the people who I work with and my friends and my clients, but maybe this is something I would benefit from." Again, I was having a much more difficult time maintaining the consistent use of condoms than I had had before. Realizing that there could be a medication that could actually assist me in maintaining my HIV-negative status by about 90 to 92 percent made me want to learn more about it.

I talked to the researchers, and I got some of their information after this event at GMHC. I then learned more about the iPrEx study, and by that point the CDC (U.S. Centers for Disease Control and Prevention) had a page on their website for doctors to go to if they wanted to prescribe this as an off-label medication, because it was not yet approved by the FDA (U.S. Food and Drug Administration) at this point. It would still be a year away before the FDA would approve it. But there was still plenty of information about the iPrEx study and information and guidelines for doctors -- even in 2011.

So, I printed all that out, took it to my doctor, who I have a very good relationship with, and said, "Look, this is what I'm learning. This is what the research is saying. And, I'm having a harder time in my early 40s staying safe than I ever had in my 20s or 30s. I think this might be the right thing for me." He looked it over, he thought about it, and said, "Yep, I agree with you." That's when I started PrEP. I started July 19, 2011, and I've not missed a single dose since. We are now in March of 2013.

What I've since learned and what I've become more knowledgeable of, what we've become more aware of, in the time since the iPrEx study, is that the participants who took Truvada (tenofovir/FTC) seven days a week -- who did not miss a dose -- appeared to be 99 percent less likely to contract HIV. The original estimate that they were putting out there was around 90 to 92 percent. Maybe it was always known, or that knowledge was not made readily available, that that subsection of the 2,500 participants who took this seven days a week appear to be 99 percent less likely to get HIV.

Now, condoms, which I've relied upon to stay negative, despite having positive partners, despite having positive boyfriends, which I always have, those are about 98 percent effective. So I knew when I was being sexually intimate with a positive partner with condoms and lube, there was 98 percent protection, and I could work with that. With PrEP now, with 99 percent efficacy -- if taken everyday -- wow. Wow. Revolutionary.

It confuses me why more people don't know about this. It may not be the right decision for everybody. For me, I really had to think about it from a medical perspective. From an emotional, sexual perspective, I had to think whether this was the right choice for me or not. But, the fact is, it has been approved by the FDA for this use since July 16, 2012. And the majority of the people I know, the majority of the people I talk to, don't even know it exists, much less that it has been approved -- and that many insurance companies pay for it. It baffles me how we can have such an effective tool in the fight against HIV and so little information out there about it.

Can you tell us about your PrEP regimen? How do you remember to take your pill, and when do you take it?

I have a pretty consistent routine, and I always have. Well, not always, but as long as I've been health conscious. I take vitamins. I'm not a health food nut; to be honest with you, I hate healthy food. I live off pizza. That's the thing. But, I take multivitamins. I take multivitamins that are rich with all these dried-up vegetables; they come from a special farm in Wisconsin. They're really good for you. So, that's really an important part for me, is to maintain a vitamin regimen and to eat breakfast every single day. Which is another thing we often do, all of us do, to neglect our self-care. It's so important. And I drink coffee. So, I wake up; I have my breakfast; I have my vitamins; I have my coffee. That was already an established routine in my adult life. Those are important things I do to take care of myself and start the day right. PrEP was just one thing to add into that. It wasn't anything that was inconvenient. It hasn't been something I've forgotten. It's just with the vitamins now. It's on the same little thing that the vitamins sit on, so I don't forget.

Did you feel that you had to go through a Truvada "coming-out process" where you had to tell people in your life that you were making a decision to go on PrEP? I mean friends and family, not sexual partners.

Who likes to talk about anal sex with their friends and family? I mean, I kinda do, because that's the field I work in, and those of us who work in the HIV field often do anyway. Nevertheless, it's not always a common conversation that you have at the dinner table with your parents. And before it was approved, honestly, I was concerned about talking about it. I was concerned that my insurance would cease supporting this if I was open about it. The shift in me now telling my friends and family and trying to get the word out there is because the FDA did approve it. It's all on the record with the insurance companies.

So, yes, it was weird. I had to explain this to my parents before talking about this publicly, because I'm friends with my mom on Facebook, and I thought that, quite possibly, she's going to see some of my shenanigans. So, I explained to them, "If I was a woman and I told you I wanted to take birth control pills, would you support me?" And my parents were like, "Yeah, we'd support you on that." Then I said, "Well, if I told you that there was a pill that could actually prevent me from becoming HIV positive by almost 99 percent, would you support me on that?" And they said, "Why would you need that?" Ugh, not what you want to hear. So, basically, I explained to them the idea of oral prophylactics, of prevention, of responsibility, of prioritizing my mind, my body, my spirit. That's consistent with the work I've always done, both personally and professionally. And this was very much in alignment with that. That they got; that they understood.

The other thing with friends is just that people don't believe it -- because there's so little information out there, because this has not really been covered very much. So, the friends I told about this, they didn't disapprove, they were just scared. They didn't really believe that this works. They didn't think this was real. They just thought I was going out and being self-destructive. They don't think that now, but in the beginning when I was starting to talk about this, my friends were concerned that I was on this binge of self-destructive, hedonistic, bug-seeking anarchy. And didn't really understand. So again, I did my best to show them the research, show them the data that were out there. Explain to them that this was being done with a doctor. Time has shown that, OK, we're on the right path here. We know what we're doing.

How do you broach the subject of PrEP with potential sexual partners? Do you feel like you can say, "Oh, it's OK, I'm on a pill." Run us through that whole song and dance.

Well, as I said, dating in 2013 is really different from 2003, and one of the biggest differences is that the condom conversation doesn't happen half of the time. In San Francisco in the 1990s, there was no treatment, and half of the men in San Francisco were positive. So, it was pretty much a given that, if I was going to be sexually active, that 50 percent of the people I was going to meet were going to be positive. So I just assumed everyone was positive, regardless of what they told me, and acted accordingly. But there was often a conversation; there was some acknowledgement that a condom was being used.

A lot of guys don't use condoms and don't talk about condoms. Now, from an education, from a prevention standpoint, that's terrifying! But it's also for real. But to answer your question, it doesn't always come up. The conversation doesn't always happen.

When I am with a partner, or if I'm dating someone who is positive, they will tell me that they're positive, and I will tell them about PrEP, and sometimes the response is "Phew! Good!" And other times, the response will be, "Well, we're still using condoms, because never in a million years would I knowingly put someone at risk for HIV. I just won't do that. That's not my principle." And that's a response I often get from the positive community. Here's what I say: "All right, cool, I understand. But here's what I also want you to consider. Daily use of PrEP has been shown consistently in different research studies to be 99 percent effective in preventing HIV. Daily use of antiretrovirals by someone who is positive has been shown to be about 96 percent effective in reducing the transmission of HIV. On my side, I've got 99 percent protection, on your side, you've got 96 percent protection. The likelihood that I will be getting HIV from you at this point in time is pretty miniscule."But, to be political on another subject, when you look at the escalation of gun violence in this country, and you see that about 30 murders a day are happening in America in which people are being killed by guns, I feel like the likelihood of me getting shot right now is higher than the likelihood of me becoming HIV positive with those odds. So, I put it like that to partners and then I say, "So, what do you think?" Sometimes, they say, "Nope, I still will not have sex without condoms." And there are people who are like, "OK, I see where you're coming from. Let's get busy." And I respect people's right to use condoms. Which is one of the biggest misconceptions about people who take PrEP. We're not the anti-condom police.

They think that you're the "barebacking brigade"?

Radical barebacking brigade! On the streets! We're talking about PrEP as one strategy to prevent HIV, not the strategy to prevent HIV. It is one strategy to prevent HIV. Along with condoms, along with positive people knowing that they're positive and taking antiretrovirals so that they cannot give HIV to another person. It has been an opportunity for people in serodiscordant relationships, including myself, to experience more intimacy and more pleasure than ever before in the 32 years of this thing called AIDS. And I, honestly, didn't know if I would ever see that in my lifetime. I really didn't think I would ever see that in my lifetime, to be honest with you. It's really been a revelation in that way. So, to answer your question, sometimes I talk about it, sometimes I don't.

Does the condom conversation ever come up around STIs (sexually transmitted infections) other than HIV, since PrEP only protects against HIV? Or do people just not talk about it?

I'm telling you from my experience: People are not talking about HIV and they are definitely not talking about STIs. I'm not saying that's good. I'm not saying that's right. I'm not saying that's healthy. I'm just saying that's the reality of many hookups and of many of the conversations, or lack of conversations, out there.

This is why it is so so so important for people to have medical care with a doctor who they trust, who they respect. I always say, "If you can't talk to your doctor about getting fucked up the ass, then you have the wrong doctor!" You need to have a doctor who you trust. If you feel judged or criticized or condemned by your doctor because you have a healthy sex life or a sex drive, find a doctor who you trust. They are out there. In some areas they are easy to find, and in some areas they are not so easy to find.

You are a consumer. Not the patient. You are a consumer. That's a very different paradigm. Because a "patient" is passive, and just has to do what the doctor tells them do. A "consumer" can say, "If you don't treat me with a certain level of respect, and if you don't engage in a sophisticated, adult, respectful conversation with me about anal sex, then I, as a consumer, can go to somebody else who is willing and able to do that with me." That's the reason we have to have really positive relationships with the medical community, because part of taking PrEP is that it's so important to see your doctor consistently, have your blood drawn consistently, and get tested for other STIs, because PrEP does not offer ANY protection against syphilis, gonorrhea, herpes, all that fun stuff. There's no protection there. So, I do get my blood and urine drawn from my doctor every three months to screen for that.

If someone were to come up to you and ask you, "Hey, who should be in the conversation about PrEP?," what groups would you name?

We know, statistically speaking, that there are about 50,000 new infections in the United States every year. For those of us who want to champion prevention efforts, I think we did a great job in the '90s of bringing down new infections. I used to stand on the corner of Sanchez and Market in San Francisco with those pins that said "100%" and give out condoms and lube and pins, because the message was "100 percent condoms and lube all the time!" Not fully understanding at that time how we were inadvertently creating a shame around those people who didn't use condoms and lube all the time, and kind of making their voices silent.

But, I will say this: If you look at the infection rates during the '90s and the early 2000s in this country, they continued to decline until 2004. Since 2004, almost the last 10 years, it's been about 50,000. So, who are these 50,000 people? In New York City, it's overwhelming black gay and bisexual men between the ages of 18 and 25. These are the group of people that are testing newly positive most frequently in New York, and I think that's also occurring in major urban areas across the United States. This is the population that needs to know about this. It's important that 40-year-old white guys know about it too -- like me! It's really important that everybody knows about it, but especially to help the message get into the communities where HIV is being transmitted at the highest rate.

Fifty thousand new infections in this country is 50,000 too many, especially now that we have a new, effective prophylactic prevention tool. There's no need to have 50,000 new infections in this country. There's no need to have 25,000 new infections in this country. But what if we could at LEAST reduce the number of infections by 50 percent? Wow. Wouldn't that be something? Well, you know something? PrEP, even when taken inconsistently, has been shown to be 44 percent effective. Even with people who took it once or twice a week. Forty-four percent is not enough, but it's still more than what we've had for the last decade. It's more than what just condoms and lube are doing if they're not used. So, I would say that anyone who is sexually active right now -- regardless of age, regardless of gender -- because we're also seeing a lot of new, I don't think it's that many, but there's always been a subsection of men who are in their 50s who did survive that first wave of HIV/AIDS, survived it as HIV negative, and experience something called condom fatigue. Or just think "Screw it" or "Hey, the meds are out there" or "At this point in my life, I'm going to die from something else, so why not, who cares about HIV." That's also the group who needs to know that there is a non-latex alternative to safer sex. So, it needs to be out there for people who are on Grindr, on any of those cruising websites, and are hooking up, and are not using condoms 100 percent of the time. We simply do not have any reason for the infection rates in this country to continue to be that high.

Have you had any personal medical side effects from taking PrEP?

Not a thing. I would not even know I'm taking it, except it's a little blue pill that I take every day. No nausea, no nothing. My doctor is monitoring my blood to see if there are any side effects that I can't anticipate, that I couldn't feel, like kidney impairment or bone density reduction. Knock on wood, so far, so good. I personally have no side effects.

How would you recommend someone start the conversation about PrEP with their doctor?

Bring information with you. The great thing is that now the FDA did approve it. So there's so much official information -- FDA, CDC stuff, the stuff that's on TheBody.com -- there's a lot of really credible websites now that have valid, intelligent information about PrEP.

Talk about the research side. That's what doctors want to know, for the most part. Some of them may say, "That all sounds good, but I don't want to give you a prescription to go out and get HIV." And you say, "Oh, but look, I've actually found out -- study after study -- that if I take this seven days a week, I can be 99 percent protected from HIV. I'm not saying I'm going to go out there and get exposed to HIV." I've even said go and ask your doctor, "What if there was a vaccine for HIV? Would you ask your doctor for a vaccine if that was available? Well, we don't have a vaccine, but we do have something that's 99 percent effective until we do have a vaccine." Or I often say to gay men, "Think about if you were a woman: How would you approach your doctor about taking birth control pills?" The idea is, you can have sex for pleasure without adverse consequences.

Most of us grew up in a sex-negative paradigm, meaning -- especially for gay men -- there's a part of our brain that has internalized, "Sex is bad. Sex is dirty. Sex is embarrassing. Sex is shameful. I 'shouldn't' have these desires. And if I do feel these desires, then it's kind of wrong to feel good about them, or to talk about them." What I try to do is to get people to get around that and talk about sex as an affirmative, healthy activity that people can do. It can be done with respect, it can be a physically gratifying experience, it can be a spiritually gratifying experience, and there's nothing to be embarrassed about for enjoying that.

So know that. Own that. And take the data to your doctor and have a conversation. She or he may need some time to digest all that. They may not have heard of it. If you are the first patient or the first consumer to come to them and say, "Hey, I want this," they might need to digest that a little bit. They might need to look through some of your research or they might need to do some research of their own. They might need to do some consultations with some colleagues. Let them have that. They might need a few weeks. That's OK. But then, follow up, and find out. And if they're not going to support this, you don't have to continue to see them.

Now, all that being said, there may be medical reasons they don't agree with you taking PrEP. If you have certain medical conditions that could make you more susceptible to kidney failure or bone density reduction, your doctor may not advocate for this on medical grounds. But that's different from moral grounds. So I would say be clear in your heart, be clear in your mind, about asking for something that will empower your body, your mind, your spirit. That will keep you healthy in the long run, and don't be ashamed of asking for that.

Have you gotten any negative reactions from any communities about taking PrEP, and if so, how have you dealt with them?

The only negative feedback I've gotten has been when I've done something public or gone on a website or done some kind of presentation where it was on the Web and people would leave comments. These are the kind of websites where anything you put there's going to be negative comments, so I don't even read them to be honest with you. Those are anonymous; they're indirect.

The only negative response I've gotten has been from a specific service organization that has been publicly opposed to this -- that, for their own reasons, which I don't fully comprehend, don't think that it's wise for people to have the education and the information and the tools to keep themselves safe and HIV negative. I can't explain their motivations -- only they can -- and when they try, it makes no sense to me anyway. That's really the only negative feedback I've gotten.

You might be able to tell, I'm a pretty independent thinker. I've kind of always been headstrong and stubborn and done things my own weird way. So, people who know me already kinda know that this is Damon's life, and comments are not solicited. Friends and family who know me have expressed concern and I understand that and I respect that. But no one has come at me with a sex-negative "should" about this.

Is there anything else you want to say to our readers about PrEP? Something you want to touch on?

I certainly hope this makes people think about what's right for them. It's not up to me to tell anybody what's right for them. But if people want to know more, they're welcome to contact me at my email, This email address is being protected from spambots. You need JavaScript enabled to view it. , or contact TheBody.com, or contact your local HIV/AIDS resource organization. Ask more questions. Ask me questions. I don't know everything, but if I don't know, I'm happy to help people get the answers.

But here's the most important thing! This is not a drug that can be taken casually. This is not a medication you start, stop, start, and stop. This is not a Fire Island weekend party drug. This is my concern about PrEP. This is my worry. That is where there is danger for resistance to come in, and I'll explain what that means. What happens with Truvada in HIV-positive people is that Truvada is used in combination with other meds to keep the viral load down to zero, so that someone who is HIV positive can have a long quality and quantity of life. Truvada is used with other meds to make that happen. And so, in someone who is negative, Truvada is used alone. Truvada is the only medication.

What happens is, if someone is HIV positive and starts Truvada alone without other medications, their body can build resistance to Truvada. Let me say that again -- if they don't know they're positive and they start Truvada alone without taking it in combination with other meds, they can build resistance to Truvada. So, someone may think, big deal, who cares, there are 20 million meds out there. The big deal is that the most effective HIV meds on the market and all of those one-pill-a-days contain an element of Truvada in them. So, if you are resistant to Truvada, you are taking a lot of medicines off the shelf that can't help you if you are positive.

This is the danger. This is why it has to be done in tandem with a doctor, with a medical professional. Because what your doctor will do is first make sure that you are HIV negative. That you are not positive. But, today's Thursday, if I'm positive and I don't know it, and I'm like, "Party weekend! Black party! I'm going! I've got my Truvada, I'm ready!" If I take it without knowing I'm positive, then I might build resistance to Truvada and it's going to make the possibility of living a long, healthy, satisfying life as a positive person much more challenging.

So this is what people need to know. Take it with a doctor. Make sure you are HIV negative first. And do not take this sporadically as a party drug. Because that's where people can get in trouble.

This transcript has been lightly edited for clarity.

Mathew Rodriguez is the editorial project manager for TheBody.com and TheBodyPRO.com.

Follow Mathew on Twitter: @mathewrodriguez.

“Seed is a gift, it’s love, it’s acceptance. Taking a man’s cum – in your ass, down your throat, rubbed into your skin, whatever - even if you don’t know his name, is closeness. It’s an act of love and trust.  Even if yawl just met. Both the bottom and the top will walk away smiling . . . and content. Now it’s a sleazy affair that boys get cracked out of their mind for. Like it’s an embarrassing nasty secret thing to want. This is so fucked.”

From HIV-positive bareback blogger Geek Slut, quoted in "Unlimited Intimacy  . .". .

Recently writer Tim Dean gave a presentation on the subculture of barebacking and its mores to an attentive audience of 200 at the Gay Men’s Sexual Health Summit in Toronto.  PositiveLite.com editor Bob Leahy caught up with him afterwards and sat down with him for this frank talk.

Bob Leahy: Tim. Thank you for talking to PositiveLite.com – and welcome to Toronto. I’d like to talk to you about your book first of all.  Tell me, how did you come to write about barebacking? What interested you there?

Tim Dean:  I came to write that book because I was living in the Bay Area of San Francisco and I was going out a lot and having a lot of sex – this was in the late 90s – and what I encountered in public sex environments were lots of guys who wanted me to cum inside of them. There was never a conversation about status, there was never a conversation about condoms, and I realized fairly quickly that this was something new in the history of the epidemic that I needed to think about — to think about what was involved and what had changed.

There is a substantial body of research that went in to the book.  Tell me about your research method.  How did you gather the information - through conventional methods?

I would say they were not very conventional methods. Much of the information was what I gleaned from personal experience, that is, hanging out in sex bars, sex clubs, bathhouses to a lesser extent, and also talking to people. That’s something I do in my life and I was using that material to reflect on. I also got very interested in bareback pornography and was able to use my training as a critic to analyze what is going on in this kind of pornography, what makes it different from other kinds of pornography.

Let’s talk about the bareback porn industry in a minute. Writing the book, you chose very consciously to be non-judgemental, is that right? You could have injected your own views in to it, but you chose to be descriptive.  Why did you do that?

That was a very important decision on my part, influenced by two things. One was to take a kind of anthropological approach to the study of sexual subcultures, where you limit what you can learn if you decide ahead of time whether something is good or bad, positive or negative. The other was a kind of psycho-analytic influence where the suspension of judgment allows thinking to achieve its full potential so that it was very, very important to me not to judge.

And what was the reaction to that approach? In your refusal to judge, did people think it sounded like you were endorsing barebacking?

Yes, some people did. And the fact that I wanted to write about this subculture without judging it and on the other hand saying that I’m also participating in this subculture, the refusal to judge was often understood as a kind of backhanded way of endorsing or excusing what I was doing.  I didn’t see it that way at all.  For me, it was an ethical decision to suspend judgement. Some people got that.  Some people read it differently.

So did it feel comfortable writing from the perspective of a participant in the barebacking culture? It’s kind of brave, I think.

It seemed sort of inevitable, in the sense that a lot of what I found out, I found out by doing it. Certainly in the literature I read at the time on “unsafe/unprotected sex” it was always assumed that somebody else was doing it, it was others who barebacked. It was very important to me to dispel that illusion. I was not going to be closet-y about the fact that I was barebacking. There is still a stigma attached to it and it’s hard to come out as somebody who enjoys bareback sex. But I don’t think we actually get anywhere by pretending we are not doing things . . . 

OK, let’s talk more about this. We haven’t defined barebacking.  Are we talking about people who identify as barebackers, part of a barebacking culture, or people who slip up occasionally - or both?

I used the decision when writing the book to use the term “barebackers” very broadly, to cover both the subculture and also people who may not consider themselves ‘barebackers” but who sometimes or occasionally do have sex without condoms, or want to have sex without condoms. It’s too easy to place the blame on a small subset who are very committed barebackers and I wanted to avoid that by using the term broadly.

I wanted to ask you about the allure of barebacking. There are so many stigmas and potential risks, why do people do it?

I think there are lots of reasons. The first and most obvious is that men often prefer sex without condoms, it feels better . . .

You called it “enhanced genital stimulation”.

Yes. That’s the most obvious reason. Beyond that there are all the meanings that are attached to exchanging semen, to receiving someone else’s cum. I think HIV prevention discourses have not been very good at acknowledging how important semen is to gay men – their own and other peoples’. Sometimes you want lots of guys’ semen inside of you.

Well, you’ve talked a lot about disgust with bodily fluids, and you mentioned spit as an example, but semen must be the same kind of thing, that we have a sort of love/hate relationship with it - in that in some contexts these fluids are very hot and in others they disgust us.

I think that’s true. I think that semen, because of HIV and the epidemic, has become even more loaded with meaning, in becoming dangerous, in becoming dirty . . .

Toxic.

Yes, In becoming toxic it has become potentially hotter. That is, on the one hand we are told we must absolutely keep it outside of our bodies, and on the other hand it becomes something very exciting to get inside.

Well, let me throw out a quote from you on that. I think you said “the fact that sex may be unsafe may be the sexiest thing about it.” Is that true?

I think for a number of people that’s absolutely the case. It’s a mistake to think we don’t like risk. Risk can be very exciting.

I suppose you can think then of public sex. We think public sex is very hot because we might get caught. But are we saying bareback sex is hot because we could get infected with HIV?

In some cases, yes. Your question makes me think of straight couples who like to fuck in the bathroom of a plane. There is a risk involved, it’s not comfortable, maybe the sex isn’t all that gratifying because of the conditions, but there is a risk involved which makes it very exciting. And that translates for some gay men in terms of HIV too.

Is the transgressive thing important in bareback sex too, the chance of something bad happening.

Yes, and also stepping away from being a normal responsible adult in our society, and everything that goes along with that. You know part of the appeal of public sex is that it happens outside the house, it happens in a space where someone can be somebody different. Therefore it’s hot. We are also inundated with safe sex messages and sometimes for that very reason stepping away from that and doing something that is “unsafe”,  that’s ”risky”, can be the hottest thing to do.

The other allure you’ve described is in the title of your book. “Unlimited Intimacy.” That’s important for barebackers, isn’t it?

Yes, I think it is. Men who have a lot of casual sex with a lot of casual partners are not in flight from intimacy but actually searching for a particular kind of intimacy. The phrase “unlimited intimacy” came from a barebacker in an interview I read and that seemed to me to be a perfect way to encapsulate intimacy beyond the couple.

So there is nothing more intimate for some people than exchanging bodily fluids?

Right.

Sometimes we talk about casual sex, but it sounds like what you’re describing is very intense sex.

It’s incredibly intense. It’s very meaningful, completely spiritual. If you are having sex with a bunch of strangers, group sex can be something that feels like communion.

I think you’ve mentioned too in the book that there is very much a sense of belonging.

Sure. It’s about finding and making a community with people you don’t necessarily need to get to know to be part of.

OK I want to find out about barebackers and what is their relationship to risk. I think what you say - and this is probably grossly simplifying – is that this is an equation, where barebackers recognize the risk, but then balance it against the pleasure. Is that what’s going on?

Sure, I think that’s part of it. But one of the other things I want to add that’s going on is that the majority of barebackers do NOT want to infect sero-negative guys. They are not trying to put other people at risk. They are interested in an experience of risk for themselves that is maybe more a risk in fantasy than in actuality in some cases.

So they do care about the possibility of HIV transmission?

Yes.

Do you think people think they don`t care.

I do. It's hard for people to wrap their heads around the fact that people can be barebacking and still wish to reduce transmission. I think it's a mistake to think about barebackers as simply irresponsible hedonists.

Tell me why you’ve been using the word “disgust” a lot lately.

I’ve become very interested in disgust for various reasons.  One, in the world of academic theory I inhabit, people don’t talk about disgust, they talk about shame. Shame is connected to identity.  For me, disgust is connected to acts and in order to have a discourse about sexual acts we need to think about and talk about disgust.  Disgust is really complicated because disgust in the context of food simply pushes you away from food.  Disgust vis-à-vis sex or bodily fluids can draw you to those things. Sometimes sex can be intensified by doing things that you actually feel can be kind of disgusting.

Or that other people find disgusting?

Which is why large amounts of bodily fluids, especially semen, are important in the subculture and within some of the porn. One of the things that interests me is that some people find “sloppy seconds”  disgusting, that is using multiple loads, using cum as lube. But a lot of guys, including straight guys, find it very hot.

And isn’t it a staple of bareback porn? I’m thinking of the porn classic Dawson’s 20 Load Weekend?

Absolutely.

Tim, I think one of the take-home messages I got from listening to you is that if we find an act not to our liking, it becomes morally wrong.

I want to make the distinction between moral disgust and sexual disgust so that we can hold on more tightly to the idea that just because you don’t like something does not make it morally wrong. That seems to me very important.

Is anything morally wrong in sex?

Absolutely.

Give me an example of what is morally wrong in the context of barebacking?

I think coerced sex is morally wrong. I think lying to people is morally wrong. I think treating people badly is morally wrong. The ethics have to do not with the act you are actually doing, but how you treat your partner. To me it’s very important in the book — and in my life — to understand that other people are not objects to be used for one’s gratification. Other people are not sexual commodities. We may play out a fantasy in which I use you as my sexual slave and we both may enjoy that, but within the broader context of our encounter I treat you like a human being with respect, etc.

Let’s talk about the breeding, gift-giving subculture. Some people have played it down and suggested it’s mostly fantasy and that it’s very hard to track down real bug-chasers for research, for instance. Is this really a big part of bareback culture?

It’s certainly a big part of the fantasies that animate the subculture. In that way it seems to me important. I think in the process of writing the book and when I was giving lectures, people wanted to know, “How many gift givers, how many people are there out there doing this?” I don’t think that can be answered because the fact is it’s a very exciting fantasy for a lot of people but how that translates into practice is very, very hard to know.

But are there some people out there who really want to be poz?

I think so, yes. They see being poz as an inevitability, as giving them licence to bareback without worrying.

How do you feel about that?

Well, I think part of the reason I want to talk about fantasy is not so much that I’m psycho-analytically oriented – although I am – but because American culture does not have a very good way of talking about fantasy. Therefore it does not have a very good way of distinguishing between what is a fantasy and what is something you actually want to do. I’ve done some work on this around rape fantasies.  A lot of people have a fantasy about being raped, but that doesn’t mean they want to be raped. It means they want to enact a fantasy; and it seems to me you can make an analogy with guys out there who say they want to become poz.

OK, I want to talk about bareback porn.  It’s very different to mainstream gay porn, isn’t it? It looks different, I’m thinking in particular of Treasure Island Media  (NSFW link) which has a home-made feel. Actors can be overweight, older, not conventionally attractive. Why is that?

I’m very interested in Treasure Island Media and Paul Morris’s whole politics, ethics and aesthetics of making porn. He sees himself as a documentary pornographer, documenting what guys are already up to and therefore the guys in his films should not be some kind of fantasy ideal with perfect bodies.  

They should look like us?

They should look like us. They should look like the guys we are and the guys we meet.  Some people don’t like his porn for that reason.  They say the guys in it are ugly. That’s not my view on it. The range of body types makes it real.  It makes it hot. It’s clear you can be older, overweight, you can be hairy, you can have an imperfect body, you can look like a poz guy – and still be a porn star, still be the subject of sexual pleasure. That’s important.

Do you have any views, Tim, on the role of barebacking porn in encouraging or stimulating bareback behaviour?

People want to be able to draw a very clear line between pornography and behaviour – and I don’t think you can draw that line. I think it’s been proven again and again that watching pornography, of whatever kind, will not simply translate into imitating those behaviours. It’s not that pornography has no influence. Of course it has influence over what we find exciting, what our fantasies are.  But what interests me is that even with this iPhone you are recording this interview on we can go in to the bathroom and make pornography and put it on line . . . .

Want to?  (laughs)

(laughs) So that is to say we can all — and lots of people do – make our own porn and put it on XTube and I think that’s an incredibly interesting development.  We can all be pornographers.  If you don’t like the mainstream porn that’s out there, make your own porn – and I think that’s a great thing.

OK. I want to finally get to the intersection between barebacking and HIV prevention efforts. The language of HIV prevention uses words like “intervention” and “counselling” which essentially relate to efforts to change behaviour, or even stop various behaviours. Is there any scope for the world of counselling and interventions to interact with barebackers or do they have their own rationale for what they do and have made up their minds? Are the two worlds apart?

I think there is space for an intersection. When I wrote the book it was very important for me to not to write about barebacking with the desire to understand it in order to stop it. I do think, though, that what counselling offers is a space to think through what one’s desires are, what one’s fantasies are. I think to the degree that counselling makes a space available to sort through the confusion that all of us have in our minds about sex, desire, desirability – that’s good. But if counselling goes in to a situation with the sole attempt to stop something, then it closes off the space in which people can figure out their lives and what kind of sex they would actually like for themselves.

What we’ve seen here is applying a harm reduction approach to barebacking in terms of talking about techniques that might reduce the risk of transmission.  Does that make sense to you?

Yes, it does. But I don’t think it’s all or nothing.  For a long time it was pitched as “use condoms all the time or you are going to become a crazy reckless barebacker who is going to become poz and spread the virus”. It’s not either/or. Thinking in terms of harm reduction makes much more sense.

That’s likely a good place to end.  Tim, thank you so much for talking to us.  You’ve been incredibly honest and forthright about something that challenges many of us.  This has been so useful. It’s been a real pleasure talking to you.

Thank you, Bob

Tim Dean’s book “Unlimited Intimacy, Reflections on the Subculture of Barebacking” is available on Amazon here. 

Tim Dean is professor of English and director of the Center for the Study of Psychoanalysis and Culture at the University at Buffalo. He is the author or editor of several books, including Beyond Sexuality, also published by the University of Chicago Press.

Bob Leahy: Thank you for talking to PositiveLite.com, Julio.  The last time we talked was in January 2012 I think.  How have things shifted on the treatment as prevention scene in the last fifteen months.  Are you starting to feel optimistic in terms of what you’d like to see?

Dr. Montaner: Well as you know I have been feeling quite strongly for quite a number of years now that treatment as prevention truly offers an opportunity to fully realize the potential of antiretroviral therapy, first and foremost at the individual level, secondarily to pay a huge dividend when it comes to preventing HIV, TB and a number of other diseases.  For us the challenge was initially to get enough of a data base that the argument could be made compellingly enough so that every level of decision making, from policy makers to community, could rally behind it. In my mind the evidence, particularly when you weigh it against the challenge we are trying to address, was already overwhelming in 2006. Imagine how I feel now!

I think that since HPTN052 came on board that has allowed us to say this is definitive and conclusive evidence, and that we now need to move on to implementation discussions. And in the last eighteen months we have seen a huge political evolution, from Hilary Clinton to President Obama to (UNAIDS) Michel Sidibe progressively increasing the enthusiasm. To me, Michel Sidibe was incredibly valuable in 2010 when he formally endorsed getting to zero through treatment as prevention but I sense that his level of enthusiasm and eagerness today is exponentially greater, which is a great sign.

Bob: But in Canada, how do you feel about this.  Have we made progress at all here in the last fifteen months?

You know British Columbia has been unique in the sense that I have been able to galvanize political support based on the evidence exclusively and the return on investment, if you want to put it that way. The Province has been 100% behind us. Unfortunately I have to say that I have been disappointed that the same attitude has not really panned out across the country. There has been a whole lot of intellectual discourse, and it’s incredibly frustrating, you know, when you show data regarding the evolution of the epidemic in British Columbia and you juxtapose that against what is happening in Manitoba and Saskatchewan, for instance, where HIV rates are continuing to rise - and it begs the question what else can I do to make my point?

I point my finger directly at the federal government. I think it is Stephen Harper’s fault and the health ministers’ fault all the way from Tony Clement to Leona Aglukkaq, and PHAC’s fault too because they are unable to release themselves from their political masters to say “we have a crisis, we know how to address it, let’s do it”. In an area where the only answer I get is "this is a matter for provincial jurisdiction" then that allows for all kinds of anarchy to occur and basically we are left without a national HIV strategy.

So how about your provincial partners?  Have you been able to make headway with them or are they still looking for more data?

Well that`s the problem. We have had very good conversations with individual leaders all across the country but they have not materialized in to an executive order to move forward  and my frustration is that the lack of attention by the federal government to this issue makes it possible for the chaos to continue.

I know CATIE is trying to foster a dialogue by hosting national consultations on this issue and also convening a treatment as prevention-themed conference in September. Do you regard these as positive steps?

In my opinion, anything that will create a forum for this kind of discussion to take place is a very well received opportunity. I am a little bit frustrated about the fact that in the CATIE consultation last year there was lot of discussion but I would have hoped it would be the ideal forum that people would rally around the idea and say we want more, we want better, we want  targeted outcomes – and it didn’t happen.

OK. Let me ask you something else.  In the room today (at the TasP conference) you could get the impression that Canada, instead of being a leader in treatment as prevention as we once seemed to be, may be falling far behind other nations. How would you characterize our position now in the world?

Well you heard today about the progress we have together made with China.  I was instrumental in working with the CDC in China, managing to inform their new policy which came about even before HPTN 052, and we have made phenomenal progress there. I’ve been working with colleagues of mine in Rwanda and their work has been incredible, with plans to expand and with a clear national policy, much like China.  It's absolutely brilliant.  And then there’s New York City and San Francisco and Washington D.C. The list goes on and on.

So how does that make you feel?

Well I think individually I feel incredibly pleased and gratified I have been able to do this in my province and be able to export that to willing parties around the world. But it breaks my heart that I haven’t been able to do the same thing for the rest of my country.

Well, why haven’t the other provinces taken treatment as prevention up? What’s behind all that?

I can tell you what have been the keys to our success as opposed to why there is as yet no similar success elsewhere in Canada. Firstly, for us it has been important to have a focussed program; at the BCCFE we have one item in front of us and it’s HIV. Secondly, we have a very aggressive data generation mechanism; we monitor everything and based on that data we can go to politicians and say "this is the evidence about what is happening in your own backyard and you need to do something about it". Thirdly we are very strong advocates, we work with community and with partners to create the urgency that is needed for politicians to feel not only is this what should be done but has to be done. 

Why is this not happening elsewhere in the country? Well, I think we (nationally) need to get our act together. We need to make this something that the politicians cannot walk away from – and I think the elements . . . when you see the state of the epidemic in the aboriginal community and the MSM community, we need to make this a priority.

OK. Now I have to ask you about the issue of MSM and the fact that your numbers of new infections in B.C. have not declined in that population. Why can’t you get the same results there?

Some have argued that treatment as prevention may not work in MSM.  I think that is absolutely wrong. The biology says it does work, it works on the virus no matter where it is. If it works in injection drug users it will work for everyone else. 

So here’s the situation. Treatment as prevention works in serodiscordant couples.  New infection rates among MSM – older MSM – are coming down. The problem is that the rate in young MSM is going up. Because of stigma and discrimination and all the issues around sexuality they come out poorly equipped to protect themselves. They make choices which put them at risk because the environment is not prepared to welcome them in a supportive manner. So they get infected before we can get to them.

So how do we change that piece?

It’s a very tall order to ask a clinician to change that piece, but I have two answers for you. The first one is that if we offer treatment to everyone we possibly can, we make the world a safer pace for gay youth to come out.  Even if nothing else changes, that will help.  Of course that’s insufficient. The second one is systemic change where we access youth before youth come out. Now you ask how difficult that is in places like Abbotsford or Hope or even Vancouver where talking about sexuality in schools is problematic. Beyond that talking about homosexuality, in some school districts, is impossible. We need to change that, because if we cannot have those conversations early on and show that we are supportive of gay youth even before they identify themselves then we will always be trying to protect them after they have got infected.

OK. I want to ask about the role of people with HIV in advocating for treatment as prevention. I’ve had a feeling that the community is absent, somewhat, from the discussion and that the discussion when it occurs tends to be driven top down, as opposed to from the bottom-up, and bottom-up is the way direction has come from historically. Do you agree that there is an advocacy gap there and that is something we need to look at?

Look Bob, I’ll be very frank with you. In my early career working with HIV  - and I’ve been doing this since the eighties – I was there when the community was against us because they didn’t feel we were doing enough, when we were pushed because we didn’t have the answers, they just weren’t available.  I was there when we finally merged and worked together after 1996 to make treatments available faster, to get the regulatory process changed, to get services to the community. But the community has lost its focus. We’ve moved to solve a lot of the problems you have but the sense of urgency to help us solve the next problem is almost no longer there. All the people in the community have different issues. What is missing is that unifying focus that says “Julio, we want you to work with us to end the epidemic.” So I am a lonely ranger here, trying to push for the end of the epidemic.

Well, personally, you know I’ve changed my mind on treatment as prevention. I’m in favour now. And the argument I’ve found most persuasive is that starting treatment early is undeniably good for us.

The reason I started doing this work is not that I had an eureka moment that treatment could prevent transmission.  It was not my priority. This was about my patients, my number one motivation.

I don’t think everyone understands that. I think some people feel that people like yourself have a public health agenda first and foremost.

No. And that is the number one problem.

OK. One more question and that is about the expansion of testing towards more universal testing. I know some jurisdictions have an issue with expanding testing to what we’ve regarded as low risk groups and the issue they have is a cost-benefit one – the cost doesn’t justify the small number of new infections you are likely to bring to light.  How would you respond to that?

Well I met with the Deputy Minister of Health here and said I wanted to do normalized testing, offering testing for everyone who has ever been sexually active in this province.  He said, “Oh no, Julio, here we go again. We cannot afford it”.  I said “you cannot not afford it.” He said “people are going to reject it, they are going to refuse.” I said “Let’s pilot it. We’ll offer testing to people at no risk, either self-perceived or perceived by their physician, who don’t have any conditions that make you suspect they could be HIV-infected and so when they come  to emergency or admittance at three local hospitals with totally different demographics, we offer them an HIV test." We did 10,000 or so tests and found consistently five per thousand came back with HIV-positive results. My colleagues in Argentina did the same thing in acute care hospitals in Buenos Aires – and five per thousand came back positive. CDC in Atlanta says that if you only get one positive per thousand tests it pays for itself.

So that’s your answer. The return on investment is fabulous because you are doing two things – those people change their behaviours, they recognize that they need care and they render themselves no longer infectious. It’s a no brainer.

Julio, you are very persuasive, I must admit.  Thank you so much for talking to us at PositiveLite.com again and thank you too for welcoming us to Vancouver for a great conference.

My pleasure, Bob 

Photo by Bob Leahy.

Read my conference report here.