Written by Yu-Chuan “Daniel” Lin
Image credit: NIAID, CC BY 2.0, via Wikimedia Commons
The treatment of the Human Immunodeficiency Virus (HIV) has been developed in the last few decades such that there are now ways to effectively prevent HIV contraction. One of them is the Pre-Exposure Prophylaxis medication (PrEP), which requires its participant, usually MSM (men who have sex with men), to take it before having sex. Successful in lowering the transmission of HIV, PrEP has been adopted by disease control agencies in many countries. In the United States, for example, the Centers for Disease Control and Prevention (CDC) has recognised the effectiveness of PrEP medication since 2012. Additionally, Taiwan’s CDC also launched a PrEP subsidy program in 2018.
Although PrEP medication seems to have the potential to solve the HIV epidemic, research has found an inadequate number of MSM receiving it. For example, a 2015 U.S. CDC report has indicated that at least one of four gay men should be taking PrEP daily to effectively avoid more extensive HIV transmission, requiring the participation of roughly 1,200,000 MSM nationwide. However, its data showed that no more than 50,000 MSM are doing so, which translates into a poor execution rate (around 3%) of the government’s PrEP project designated to combat the HIV epidemic.
Experts have offered various explanations for this behaviour, including overpriced medication, MSM’s ignorance of HIV, or their zero awareness of PrEP in general. Apart from the individualistic or financial explanation, other scholars have focused on the socio-cultural aspect of this problem. For example, some researchers have raised the concept of “PrEP stigma” to identify the negative connection between taking PrEP and having excessive sex or Chemsex (using drugs during sex) among the American gay community, severely discouraging MSM from taking PrEP. Additionally, others have also pointed out that the distribution of PrEP may stop certain populations of MSM, particularly MSM of colour, from receiving adequate medication as their white counterparts do.
These existing accounts have prompted me to look into the status quo of PrEP among the Taiwanese gay community: What does it mean for them to be “on PrEP”? What motivated them to start taking PrEP? More importantly, what has the “PrEP culture” changed? To discover the answer to these questions, I have conducted interviews with gay men who are currently taking PrEP as a preventive measure against HIV, as well as doctors who specialise in infectious diseases (whom those who desire PrEP must first consult for their prescription) to unravel the meaning and influence of PrEP in Taiwan.
A Double-Edged Sword
Most of my informants have expressed an enthusiastic point of view on PrEP, while some also mention its negative impact on the gay community regarding sexual practices and STDs. However, given how much and how long AIDS has been chained to the LGBT+ community by the heteronormative media and the public, PrEP has effectively reduced many gay men’s anxiety about contracting HIV. One of my interviewees, Dehao, who works as an actor, recounted his relief at finally becoming qualified for the PrEP subsidy program:
Dehao: I have always sensed an internalised homophobia inside me…like I feel like we as gay people will inevitably have HIV someday, so when my doctor recommended me to join this program, my anxiety suddenly got away, and PrEP has been such a psychological comfort for me.
Dehao’s confession echoes the deep entanglement of HIV/AIDS and the gay community, proving that PrEP not only has its epidemiological effect on reducing the HIV contraction rate but also serves as an emotional tranquilliser.
Whereas interviews with gay PrEP takers in the U.S. have found a “PrEP stigma” negatively attaching PrEP intake to the image of excessive sex, my interviews with prep takers in Taiwan mostly receive favourable comments when admitting their PrEP consumption or knowledge. Instead of being criticised for lasciviousness as their American counterparts, Taiwanese gay men have no qualms about disclosing that they are “on PrEP.” Moreover, PrEP becomes a symbol of knowledge capital – understanding how to take PrEP and obtain government-subsidised medication demonstrates how much one cares about HIV/AIDS and sexual health. This could be best illustrated by one of my interviewees, Owen, a freelancer and blogger who has written about PrEP for Taiwan CDC:
Owen: I feel like being able to state my “on PrEP” status means I care about STDs, I know what PrEP is, and I am willing to protect my body. My friends have been supportive of my decision on PrEP, and the more I show my willingness, the more I will influence them to join the program and start taking PrEP as a measure of protection.
Despite their acceptance of PrEP’s good influence, several of my respondents have raised concerns about PrEP’s negative repercussions, one of which is the prevalence of condomless sexual intercourse. Prior to the introduction of PrEP to the LGBT community, the most prevalent method of HIV prevention was to use a condom during intercourse. Now, an increasing number of gay men are performing condomless sex, knowing that if they use PrEP, they will not get HIV.
PrEP, however, is only effective against HIV and not against other common STDs like syphilis or gonorrhoea. The less inclined gay men are to wear condoms knowing they are protected against HIV, the more likely they may develop another type of sexual disease. According to WD, one of my respondents and a medical practitioner in epidemiology, this tendency is known as “risk compensation.” It should be noted that not every gay man engages in risky, condom-free intercourse after taking PrEP. Instead, despite being on PrEP, several interviewees said they would continue using a condom to be extra safe. Others stated that they rejected using a condom, although knowing well that PrEP is solely for HIV because they feel other STDs are curable or preventive through other means.
“On PrEP” as a Means of Risk Management
PrEP has affected not only the way Taiwanese gay men choose to prevent STDs, as previously stated, but also their sexual patterns. This change has a lot to do with how most Taiwanese gay men take PrEP – “on-demand.” While the FDA in the United States does not endorse the “on-demand” approach, numerous European and Canadian health groups have advised it as an alternative to traditional daily PrEP ingestion. This method involves taking only two pills 2 to 24 hours before risky intercourse, one 24 hours after sex, and one 48 hours after sex.
The appeal of “on-demand” PrEP among Taiwanese homosexual men is straightforward: It saves more pills than using PrEP regularly, given that PrEP is not an affordable medication in Taiwan without government subsidies. Besides the financial incentive, “on-demand” PrEP allows gay men to choose when to engage in risky sex. As J.R., one of my interviewees who works in media, stated when asked how he took PrEP:
J.R.: I started taking PrEP daily, but I realised it was a waste because I did not have intercourse as much as I had thought. So I switched to “on-demand.” After that, I am more willing to try something dangerous like barebacking. I don’t fear that much because I now have control over exposure to HIV.
J.R.’s move from daily consumption to “on-demand” suggests that gay men can plan when to engage in risky sex, exemplifying what I call “scheduled risk.” PrEP has thus scheduled the risk: rather than fearing any possible HIV transmission during unsafe sex, gay men may now directly face the danger and manage it by taking PrEP “on-demand.”
To summarise, PrEP has enabled Taiwanese gay men to embrace their sexual lives by lowering their HIV infection and anxiety. According to my interviewees, disclosing that they are “on PrEP” demonstrates their knowledge of sexual health and translates into knowledge capital, which is highly valued in the Taiwanese gay community. Despite the potential “risk compensation” of increased STD contraction, PrEP and its “on-demand” method has become a successful tool for Taiwanese gay men to self-control how and when they perform unsafe sex, scheduling HIV exposure, and psychologically prepare to enjoy sex without much concern.
Yu-Chuan “Daniel” Lin holds a bachelor degree in sociology and completed the Women’s and Gender Studies Program from National Taiwan University.