I started taking PrEP. As a person in queer and trans communities I’ve had sex with bisexual, gay, and straight identifying men who have sex with other men. These people comprise a higher risk group when it comes to HIV transmission. Lately my tendency is sex with partners I’m not regularly involved with. People I’m intimate with have sex lives I know little about, as might their other partners, and so on. I engage in the occasional blood play scene, and teach play piercing. Even though I’m not regularly (or frequently) sexually active, PrEP seems a fair precaution to take. HIV is one of the STIs* I’d like to place further from reach.

If a condom broke, didn’t get used, or I was put at risk in another manner, I can take an injection or pill to clear up Chlamydia, Gonorrhea, and Syphilis. I’ve already had my Hepatitis B vaccinations, and I test positive for HSV 1 which I contracted 20 years ago when someone went down on me. In the past I’ve tested positive for HPV (which they don’t test AMAB people for), and a significant portion of the population is positive with this virus already. Until the HPV vaccine is affordably available to people over 20-something years old, HIV is the unaccounted for STI that I can do something about in a prophylactic manner. As for pregnancy, it just so happens that the assigned male at birth (AMAB) partners I have who are semi-regular (therefore more likely to engage in unprotected sex with) have all had vasectomies. I’m also on Testosterone which makes it harder (though not impossible) to conceive.

I screen for sexually transmitted infections (STIs) every three months and whenever else might seem appropriate. Probably the number one thing I do to avoid STI transmission though, is have “the talk” with each person I hook up with before we engage in risky behavior. I run through my history with STIs, share my most recent test results, bring up any risky behaviors or new partners I’ve engaged with since my last test, and answer whatever questions they have for me. Then I ask for that same information from my playmate. I’m astounded that approximately 95% of the time I’m the one to bring this conversation up, and a lot of people say they’ve never had this conversation before. Happily, most of the people I chat with get tested relatively regularly and can speak to their histories and experiences. If after the conversation we don’t feel like engaging in risky contact, there’s always mutual masturbation, and other safe forms of intimacy which don’t risk exposure, but feel sexy and great!

Being the sex nerd I am, I wondered to what extent PrEP actually protects me, and in doing research I found out I’m not in the same situation as AMAB people who take it. This is a complicated bit of research to chase reliable information down about. The recommendation to wait 7 days after starting PrEP applies to receptive anal intercourse only. If you’re interested in vaginal intercourse the recommendation increases from a week to 20-30 days. Similarly, while PrEP boasts being around 90% effective for receptive anal intercourse exposure, there is only about a 70% rate of effectiveness for intravenous drug users, and nothing I can find which specifically addresses exposure from receptive vaginal intercourse. It seems generally to be agreed upon that receptive vaginal intercourse is a more risky activity than receptive anal intercourse.

A lot of people believe (and it’s advertised as such) that PrEP is 99% effective. That number was found specifically amongst gay men in a controlled study, yet those findings have not been replicated en mass in the real world. When PrEP is used correctly, in conjunction with condoms, and limiting one’s number of sex partners, it seems as though its effectiveness is closer to 90%. Among gay men who do not regularly use condoms and who do not limit their sex partners the rate of effectiveness is closer to 86%. I find it frustrating that I cannot get a clear account of PrEP’s effectiveness for people who regularly engage in receptive vaginal sex.

There is at least one rare strain of HIV which is resistant to PrEP and has infected at least two people in the past couple years who were on PrEP. One other person reported contracting a non-resistant strain of HIV after having unprotected sex with multiple partners while on PrEP, even though he tested with appropriate levels of the drug in his system. He was reported to have had unprotected sex with a high number of people, and to have contracted Chlamydia and/or Gonorrhea a couple of times during the period in question. So, what does this add up to?

In short, it’s very important to test for HIV before you take PrEP. If you are already infected, the regular and continued use of PrEP can develop a drug resistant strain of HIV within your own body, which might then potentially infect partners. This is also why it’s important for people taking PrEP to be tested every 3 months, and to take their medication regularly and without fail. Aside from continued use of condoms in conjunction with proper PrEP use, the recommendation to limit one’s sexual partners seems a reasonable precaution as well. There is little information about exactly what factors should be considered when looking at the case of the person who contracted a normal strain of HIV while on PrEP. Was it the number of partners he had, or the number of potential virus types his body may have been contending with that led PrEP to fail? Was is the sheer amount of sexual activity he was engaging in, leading to more micro-tearing of his anal tissue and increased access to the bloodstream? Could it be that other STI infections he contracted lowered his resistance to HIV? Or it might it be something else entirely? So far that data is not available.

Theories on safety: Getting tested for STIs regularly is important for one’s sexual health. Period. I like to think about regular testing as a form of self care which is also community care. This is an ethic I have in mind when I find I’ve tested positive for an STI. If I consider talking about STIs as self and community care, it helps me gather up courage to contact anyone I might have exposed or been exposed by, in order to let them know they should get tested and/or seek treatment. Talking frankly to past and present partners about sexual behavior and STIs is a responsibility of mine as a sexually active individual, and as a loving individual.

I know many people struggle with the courage or language to talk about sex frankly. In situations where one feels guilt or shame, it can be doubly hard to make that happen. It takes practice to speak openly about sexual health in general, and when fear or shame enters the equation silence can easily win out. Unfortunately silence perpetuates the spread of disease. If you enjoy someone enough — even for an hour — to risk STI infection with them, consider linking that enjoyment to the resilience demanded in order to call them a month or two down the line if an STI shows up positive on your test.

Speaking of STIs should not be linked with finger pointing or shaming. Just like we don’t stigmatize a friend, coworker, or loved one who may have given us a cold. Speaking honestly about STIs could merely be seen as an act of care-taking and routine sexual responsibility. If every person treated for an STI waited the recommended amount of time to become sexually active after, and shared their status with past and present partners, the dividing and multiplying paths leading others to risk would diminish considerably.

Access to regular STI testing is an important factor in keeping individuals STI free, and so keeping the number of infections significantly lower in communities. Easy and affordable access to STI treatment is an important factor in keeping spread of illness down as well. Unfortunately these two very simple and obvious access points to sexual health are absolutely impacted by wealth in the United States. People who can afford healthcare, who get tested regularly, and who are better educated about their risk factors, are more likely to both avoid STIs and get treated in a timely manner if they do not. This helps the spread of STIs minimize in their communities.

If access to testing, access to treatment, and comprehensive sexuality education are what help a society lower certain types of illness, why is it that those things are so hard to come by equally for all people in this country? It seems our sexually repressive social mores are, in fact, an undeniable contributor to the survival and prevalence of sexual disease. It is no coincidence that better sexuality education, better healthcare, and better access to wellness resources are available to those who are wealthier. It follows that these things are not simply about education and access, they are 100% about class.

What can we all do? Probably the easiest thing that anyone and everyone can do in order to make informed decisions about what risks we’re taking with our own bodies and the bodies of our loved ones, is to get comfortable talking about our sexual histories with everyone we come into sexual contact with. Talking about sex is free and all it requires is that you have courage, that you share facts, and that you ask questions. It’s important to consider whether or not you trust the person you’re speaking with, and that you take sexuality education into our own hands by learning about risk factors for various STIs and methods of lowering those risks.

There are lots of sexual and sensual activities anyone can enjoy if you decide you don’t want to risk your health with a particular partner. From less risky heavy petting, to making sure you use appropriate barrier methods (condoms, gloves, dental dams, etc), to sensual and BDSM activities which don’t require fluid exchange, to mutual masturbation, and safe use of toys.

The math: Consider that some people (AMAB people especially) can be asymptomatic for STIs they carry, or might test false negative more frequently. Consider that it can take up to three months (or more) for enough bacteria to be built up in a person’s system to test positive for certain STIs. Consider that many patients are not given “multiple location tests” for Chlamydia, and so while they may test negative from a urine sample they may still be infected anally or orally with that bacteria. Consider that patients are often not coached on how to appropriately take a “dirty” urine sample, instructed not to drink anything, or pee for at least two hours prior to testing — all which can provide a more accurate sample for certain urine tests.

I don’t consider my testing completely “up to date” if I’ve had risky sex leading up to 3 months before my last test. Of course I sigh a breath of relief and emotionally consider myself negative when that’s what my stats say, but in the back of my head I know there’s a possibility that the person I slept with a month prior to testing could well have infected me with something which hasn’t shown up yet. I consider three months to be an appropriate amount of time between testings, and it’s an interval which many sexually active and non-monogamous people generally agree upon. In addition to that, I make sure I get tested after leaving a long term or monogamous relationship, as I’m more likely to have had unprotected sex with that person, and end-of-relationship times are culturally notorious for overlap of undisclosed sexual activities. If I feel symptomatic of anything, especially if I’ve recently had sex with someone new, I don’t wait until my three months are up, I get tested. Some people also wait to have sex with a new partner until they’ve both been freshly updated with recent tests. I enjoy going to a clinic with a partner, it feels supportive and freeing.

I hope this blog has given you some new things to think about when it comes to sexual health and safety. I hope it encourages you to talk with sexy people about all of these things. I hope if you haven’t gotten tested recently you’ll find a place nearby and update your stats, or have an in-depth and accurate conversation with your Doctor about your actual sexual behavior and potential risks for STI transmission. In most areas you can find free STI clinics, some of which offer anonymous resources as well. Consider asking exactly what they are testing you for, as some sites offer testing for only a limited number of STIs rather than the full gamut. As I already know my ongoing HSV, HPV, and Hep C stats, I prefer to update my Chlamydia, Gonorrhea, HIV, and Syphilis tests each time, making sure I’m offered a throat and anal swab in addition to my urine (or cervical) sample for accurate Chlamydia results.

May we all become better at talking about sex openly and without judgement or shame, and accessing the help we need for ourselves, our loved ones, and our communities.

*STI stands for “Sexually Transmitted Infections”, which is a more up to date term than “STD” these days. The word “infection” carries with it less stigma than “disease”. Similarly, when speaking of one’s STI test results it’s more appropriate to say “negative” than “clean”. Cleanliness has nothing to do with STI status and contributes to the feeling of stigma and alienation when one finds out they are positive for an STI, which further incentivizes people not to speak freely and accurately about their sexual histories and status. 

Play On My Friends,
~ Creature

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