Poppy Morgan went to her primary care doctor in 2010 because she desperately wanted to take a risk. Specifically, she wanted to stop using condoms so she could have a baby the old-fashioned way with her HIV-positive husband.
As risks go, it wasn’t much of one, scientifically speaking. Her husband’s viral load—that is, the amount of virus circulating in his system—was so low that her husband’s doctor said it would be vanishingly difficult for her to contract the virus through unprotected sex.
But Morgan (not her real name) did want some protection. So she asked her doctor to prescribe Truvada, an HIV drug that research had begun to suggest could keep her from contracting the virus if she were exposed.
But Morgan’s doctor didn’t just say no; she told the now-39-year-old San Franciscan that she would no longer treat Morgan if she went ahead with her plan.
It wasn’t a waiting period to have an abortion, or a transvaginal ultrasound, but the message seemed the same to Morgan: It’s your body, but you don’t know best. It wasn’t until years later that she realized how crazy that was.
The Food and Drug Administration approved Truvada—a decade old HIV medication made up of two different drugs—for HIV prevention in a method called pre-exposure prophylaxis (PrEP) in 2012, and ever since a debate has raged between people like Morgan, who want another option for HIV prevention, and people who remember the bad old days of the early AIDS epidemic. Detractors worry it won’t work, that people won’t take it even if it does work, that it’s too expensive to be widely useful. And they worry that it will spark risky sexual behavior that could cause a resurgence of the epidemic.
Sound familiar? It does to researcher Julie Myers at the Bureau of HIV/AIDS Prevention and Control in New York City. She wrote a paper, published last year in the journal Clinical Infectious Disease titled, “A Pill For HIV Prevention: Déjà vu all over again?” A pill for HIV prevention; a pill for pregnancy prevention. Both have elicited the same hand wringing and pearls clutching. So far, research shows that none of these fears have been born out with The Pill or with Truvada. In fact, research shows that when you take Truvada daily as directed, it can be up to 99 percent effective, and that those who are most at risk are also most likely to use it. Research so far also indicates that people are not throwing away their condoms because they are taking Truvada.
But for women, the comparison between the two is germane for another reason: For them, the new pill is sparking conversations about women’s rights and risks in sexual relationships. And while gay men argue about it, women have lined up to use it. Of the 2,319 people prescribed Truvada for PrEP in 2012 and 2013 nationwide, almost half were women.
And women are taking it for good reason. Outside of gay enclaves, another HIV epidemic is flourishing that overlaps with but isn’t the same as, the one in gay communities. The African American community has been devastated by HIV, especially in the South. African Americans make up only 12 percent of the population but comprise 44 percent of HIV cases. And it’s African American women who are among the most at risk.
African American women are 20 times more likely to contract HIV than white women. The difference seems to be a combination of poverty, infidelity, and the high number of people who don’t know they have HIV—and are therefore wildly infectious.
So what does HIV risk look like for women? Often, it looks like Oshay Davis, a 46-year-old in Newark. Davis takes impeccable care of herself. She gets regular checkups. She’s vegetarian. She has health insurance and uses it. Even a year into her now-decade-old relationship, she was getting twice-yearly HIV tests.
Then this girl started coming around. It dawned on Davis (not her real name) that her boyfriend may be cheating. She threatened to leave but, on their anniversary, her boyfriend showed up, sweet-talked her and took her dancing. They ended the night passionately—and without a condom. When, hours later, he told her that he had HIV, she couldn’t believe it. Literally. She asked him to take a test. She took a test. They took a test together. She was negative. He was positive.
“When he told me, I laughed. I couldn’t believe it. He had just had sex with me without a condom,” said Davis, who’s sister died of complications to AIDS. “You think, ‘He’s an older man; he’s not playing any childhood games.’”
Charlene Flash sees this kind of thing all the time.
“The real challenge [with women] is risk perception,” said Flash, an assistant professor of medicine at the Baylor College of Medicine and an infectious disease doctor at Harris Health System’s Thomas Street Health Center in Houston, an HIV clinic that prescribes PrEP. “One high-risk man could be having sex with several low-risk women.”
This is where it starts getting uncomfortable, because this isn’t just about how people have sex. The reality of the lives of women most at risk of contracting HIV include things like abusive relationships, incarceration (of the woman or her man), survival sex, lack of access to healthcare or the money to pay for services, and a “don’t-ask-don’t-tell” policy that frees the man to play around on the side. Add in the higher rates of other sexually transmitted infections, which can increase the chance of transmitting HIV, and the fact that black men are less likely to know they have HIV and are less likely to be in treatment if they do, and you have a powder keg of infection waiting to go off in women’s bodies.
The obvious solution is to talk about it. But that’s not so easy, said Morgan. “With gay men, the sex conversation is so much of an easier topic,” she said.
That’s not by accident. Gay men have worked out who they are, and the result is that on hookup apps like Grindr and Scruff, gay men are clear about what they’re looking for, sexually and romantically. Some have even started sharing their PrEP use on those apps. It’s harder to imagine a woman listing Truvada on her OKCupid profile.
Which means that when women find their way to Flash’s office to talk about PrEP, Flash often talks to them instead about communication. Does her boyfriend know his status? When was the last time he was tested? Maybe the couple could get tested together. And if he’s positive, is he taking meds? What’s his viral load?
Sometimes, it means that women leave without a Truvada prescription, but with more power.
“That’s the primary difference between men and women,” said Flash. “If men have risky sex, they are choosing to have risky behavior. Many of these women don’t feel as if they are at risk. Their vulnerability is not necessarily by choice.”
And women are vulnerable for another reason that has more to do with how Morgan was shamed in her doctor’s office in 2010. In 2014, it shouldn’t even be a question that a woman would have control over her own body, or that she should be able to choose her risks, because she understands them and they are hers to take. Even less, 50 years after the introduction of the Pill, should a doctor question a woman’s right to control how and when she had a baby, or whether she had a baby at all.
The fact that Morgan did take control of her body and got a different doctor, who prescribed her Truvada doesn’t change the fact that Morgan felt stripped of those rights in that moment.
“I get comments on my blog all the time—‘You are so selfish; how could you think about bringing a child into this kind of situation? How could you put a child at risk like that?’” said Morgan. “That’s the other layer of, ‘You don’t know how to protect yourself.’”
In 2013, Morgan gave birth to Macey, a healthy, HIV-negative baby. Morgan and Macey remain HIV negative today. Oshay Davis is on PrEP and plans to be on it for the foreseeable future. While Morgan went off Truvada after conceiving Macey, she’s thinking about taking it again. This time, it wouldn’t be for a baby. It would be for pleasure.
The CDC’s guidelines on Truvada for PrEP recommend users keep up with other protection methods, like condoms, since a pill can’t protect you from other STDs and, for women, can’t prevent pregnancies. But after 14 years of condoms, the allure and intimacy of skin-to-skin contact with the love of her life might be worth all the additional blood work, quarterly HIV tests and more frequent doctor visits.
“It would be fantastic,” she said, “if we didn’t have to feel, at our core, like we’re always one-latex-condom-width away from each other.”