Swallow This. On Gays, Pills, and Markets

In 1984, the American Centers for Disease Control (CDC) approached Lyphomed, a drug company that at the time was manufacturing a drug called I.V. Pentamidine, which treated a rare type of pneumonia. The CDC asked Lyphomed about producing a version of the drug to treat PCP, an AIDS-related pneumonia which at the time was the leading cause of death for people with AIDS. Lyphomed responded unwillingly, saying that the market was too small, and posed “no potential profits.”1

Recently a very different drug has come on the market, which treats people of negative viral statuses “who are at very high risk” of getting HIV.2 Ostensibly these individuals might include people who practice bareback sex or who form serodiscordant relationships. The medicine is called PrEP, which stands for Pre-exposure prophylaxis. Its market name is Truvada. When PrEP is taken daily it prevents HIV infection upon exposure to the virus at a rate of up to 92%. It doesn’t prevent STD transmission.

I don’t remember when I first heard of the drug, but it was likely on a gay hookup app, where I’ve noticed it listed as a sort of qualification for sexual eligibility. I’ve also seen advertisements and flyers for it in gay magazines (mainly the free kind one finds at bars, bookstores, and health centers in metropolitan areas) and health center brochures. A new advertising campaign just popped up in New York City subway cars, which advocates we all “Play Sure” by both taking PrEP daily and having sex with condoms.

Harlem United, a community health center in NYC, currently markets the pill with an image emblazoned with the slogan “Swallow This”, which is superimposed over a black man’s outstretched tongue tasting a rendering of the blue Truvada pill. Clearly, the organization’s target market is African Americans (whose HIV-infection rate is 8 times that of white Americans),3 but with its rash imperative it looks to be attempting an appeal to party pill users or generally audacious youths.

At prepfacts.org, a website hosted through an alliance of San Francisco health groups and Gilead Sciences (the antiretroviral pill’s manufacturer), visitors are greeted by the image of a Godzilla-like, turquoise-haired, mustached male hipster flexing and plucking away HIV antibodies attached to buildings in San Francisco’s gay Castro district, a neighborhood where the median rent of a 1-bedroom apartment is currently $3,320/month.4 PrEP’s presence in media and on the pharmaceutical market implies an audience—one that seems to be younger and (somewhat obviously) HIV-negative. Truvada costs between $8–14,000 per year, and even with insurance it is often met with high deductible costs. So somewhere in there is a market that lives comfortably above the poverty line. There are financial assistance programs; specifically one financed by Gilead Sciences but it only applies to individuals who have no health insurance. The low-income health insurance program (Medicaid) in New York state (where I live) covers PrEP, but only a 90-day supply.

I’ve been asking my friends and people I meet on hookup apps if they take PrEP, and what kinds of side effects they encounter. Some people say they haven’t noticed a difference and others have mentioned they get kind of nauseous. One of my friends stopped taking the pill after a few months, and called PrEP’s side effects “its own league of dehydrating.” He said he could drink gallons of water and his piss would still be dark. So he stopped, before having sex on it.

PrEP’s emergence on the pharmaceutical market and in the social sphere arrives at what to me feels like a pivotal stage in American gay politics, which can be linked historically to 2011, when the US Military terminated its “Don’t Ask, Don’t Tell” policy and allowed homosexuals to participate in the United States military program, and more recently to 2015, when the US Supreme Court ruled in favor of gay marriage. Another way of looking at these events is that in the past 4 years, the act of being a homosexual in the US became no longer mutually exclusive with that of being a uniformed soldier, and that gay love could aspire to bourgeois domestic bliss in the same way as it is offered by heteronormative hegemony. (Here two distractions enter my head: How does openly gay service in the military problematize the root of a military fetish? And would it have not been more radical to, rather than be for or against gay marriage, to be simply for or against marriage itself?).

But PrEP makes me wonder a few more things—like, is it good that this pill exists? This question sounds like a ruse. Is this pill benefitting work on harm reduction (HIV prevention)? Is it marketed to a generation of youth that might be unaware of their position as an emerging, consolidated market that, while benefitting from a mainstream embrace may also be less aware of the historical struggle that precedes them? Does this pill have the potential to become an agent of stratification, or of isolation, within an already marginalized demographic? Is the promotion of a commodity that protects against HIV symptomatic not of an embrace or acceptance of individuals who are HIV-positive, but rather a reflection of insouciance towards such individuals, and which jumps past a focus on care towards one that benefits those already advantaged? And is this all indicative of a new phase of behavioral orientation for gays, which incorporates homosexuals more broadly into social norms and services while ushering advantaged individuals of this demographic into postvital standards of living, enmeshing bodies with profit-generating substances poised to become a facet of daily life?

I think all of these suggestions are true. It’s clear that PrEP benefits HIV prevention, and supplying individuals with these pills can save lives and livelihoods. But the mass distribution of these antiretroviral drugs appears to me to be occurring in too much haste. Are there unconsidered long-term side effects? We could look to the way birth control was administered to underprivileged women of Puerto Rico in the 1950s, as part of a biopolitical program that both transformed domestic life and served as a form of population control, before quickly being marketed to a mainstream audience and all the while sidestepping any public debate over the ways that birth control fucks with hormones and in turn, moods, emotions, and how one goes about daily life. 5

It does trouble me slightly, this possibility that a generation will look to this pill’s arrival as the solution for protection from HIV. Its seeming simplicity, as a form and routine of consumption, appears at this particular historical moment while for some reason the tools and resources to produce this biotechnology weren’t being invested in and marketed 20 years ago. For me, an unhesitant embrace now feels a little too easy, an erasure of sorts. Why are we given this option now? Why was it not offered sooner, and how does this development embody a mistaken faith that the timing of the market is the answer to how life is ordered today? I’m certainly not suggesting that (young) gays should continue to uphold some connection between their sexual orientation and some level of shame or historically-placed trauma, but it does seem to me that a suspect awareness needs to be directed at the way gay subjecthood has been crafted over the past several years, coupled with the fact that just prior to this recent period gays were almost wholly marginalized by mainstream hegemony (I feel obliged to note my own position of privilege in saying all this, while just outside American metropolitan centers and corporate offices gays continue to be bullied, abused, murdered and made victim to ignorance and homophobic sentiments).

But how likely, or possible, is it that PrEP could in turn become a stratifying agent amongst homosexuals—one that isolates as much as it is said to enable us all to “Play Sure” together, as New York City’s HIV / AIDS Prevention office suggests? When I see PrEP listed on hookup profiles it’s often figured as a reciprocal requirement (“On PrEP—u be 2”) to satisfy before having sex with someone. Here I think less about the fact that I’m an ineligible match (I’m not on the pill) and more about how in this event the qualifier to have consensual sex is in fact a product of commerce that, more than anything, is positioned to benefit the corporate pharmaceutical industry. I also find it amusing that this whole marketing effort is structured around the pairing of PrEP and condoms, plainly denying the (likely) possibility that users take their pills as the very means to eliminate condom use during sex. In this way it’s funny that the new strategy for safe sex not only engages in a practice of denial similar to its predecessor (that which encouraged condoms always—with little mention of their discomforting fit and feel, or the very possibility that rejecting condoms could engage a particular element of desire), but it also in practice doesn’t even protect from sexually transmitted diseases other than HIV. Will condoms soon become a marker of social standing?

Taking all of these suggestions as true generates a significant sense of contradiction—so on whom does this conflict fall? Whose role is it to come to terms with these contradictions? It’s definitely not on Gilead, the pill’s manufacturer. Their role is likely the most straightforward, in my view: to invest in and market products that will regain losses and generate capital. It also doesn’t seem to fall on nonprofit organizations and bureaucratic arms of government, whose modi operandi fall similarly in line with corporate strategies, which rely chiefly on data analysis (in this case, how to achieve zero-infection rate). Instead, I think these conflicts fall on gays themselves. It’s up to this demographic (which includes myself) to reflect on how we’ve arrived here, how we were created as a market audience in the first place, and what it might mean if making politics visible were not to hinge on a homogenous voice. I think it’s increasingly important that the contradictions discussed here, and even ones that occur interpersonally or on a routine level, should be drawn into view. Apparent unity can be helpful in communicating desire on a group level, but without contradiction in place we risk producing a totalizing identity, and one that more easily produces a “market audience”. I hesitate in giving my full support towards PrEP, and the share of profits its makers seek. Sexual liberation (itself a historically appropriated term) and sexual protection can both be gained with or without a pill. Fear and desire have a long history of playing out across structures of inclusion and otherness constituted by heteronormative hegemony. With increased visibility and acceptance in the marketplace, gays risk swapping their historical otherness for an inclusion that generates a more homogenous set of fears, desires and social attitudes—is this not still a form of oppression?

1) Group Material, AIDS Timeline, 1989

2) Centers for Disease Control and Prevention, Why take PrEP?, December 2015 <http://www.cdc.gov/hiv/basics/prep.html> accessed 7 January 2016

3) Centers for Disease Control and Prevention, HIV Among African Americans, July 2015 <http://www.cdc.gov/hiv/group/racialethnic/africanamericans/> accessed 7 January 2016

4) Tracy Elsen, Mapping Rent Prices by Neighborhood All Over San Francisco, Curbed SF, September 2015 <http://sf.curbed.com/archives/2015/09/18/mapping_rent_prices_by_neighborhood_all_over_san_francisco.php> accessed 7 January 2016

5) Paul Preciado, Testo Junkie: Sex, Drugs, And Biopolitics in the Pharmacopornographic Era (New York: The Feminist Press, CUNY, 2013), 185-91.