Although the "pills to protect against HIV" are not paid for by health insurance companies, more and more gay men are on PrEP. Matthias*, 38, spoke to us about his experiences and how sex on PrEP is changing.
How did you find out about the possibility of PrEP, i.e. the precautionary use of medication to protect against HIVbecome aware of it?
I can no longer say for sure. As I work in the healthcare sector, I read about it at some point in this professional context. However, I had more of a theoretical approach to PrEP and HIV.
In the last three or four years, however, some of my friends have become positive. Now it affected people close to me. I had a lot of conversations with one of these friends about his HIV treatment and also about what it means to have sex with someone, which is positive but below the detection limit …
... i.e. do not pass on the virus due to HIV therapyn can.
Before that, it would have been out of the question for me to have sex with an HIV-positive person without a condom. Sex without a condom was only conceivable for me in a monogamous relationship.
In the course of these conversations, I also got to grips with PrEP for the first time. The friend told me about friends who were already taking PrEP and getting the tablets in a roundabout way, and I found that interesting. I've been single for three or four years and am very sexually active, and in some situations I just find it nicer without a condom.
PrEP: From theory to practice
Did you realise straight away that you wanted to take PrEP?
I first tried to do some research. But to be honest: I didn't find much back then. I did find factual information, for example at IWWIT, but hardly any personal experience reports in forums etc. I was then lucky that a doctor in my GP practice happened to know a lot about PrEP.
Back then, at the beginning of 2016, PrEP was still legally associated with risks for doctors. My GP could have accompanied me during treatment with PrEP, but we would have had to sign a 20-page contract beforehand to protect him.
The HIV drug Truvada was not yet authorised for PrEP in Germany at the time, so doctors had to protect themselves against possible side effects.
It was clear to me that I would only take PrEP with medical supervision. Simply ordering the tablets online and popping them was not an option for me. When the first PrEP trials were announced, I put my name on the list of interested parties. In the meantime, however, Truvada-PrEP was also prescribableand I was able to get the medication prescribed correctly by my GP, even though he is still not a big fan of PrEP.
What concerns does he have?
Recently, the number of cases of sexually transmitted diseases has risen sharply and he fears that PrEP, i.e. condom-free sex, exposes people to a higher risk of contracting sexually transmitted diseases. For those that are transmitted during anal sex, you would be at least partially protected by a condom. But he also had concerns, because the long-term effects of the medication cannot really be assessed yetwhether they damage the kidneys and bones.
No fear of side effects
Have these arguments made you think?
Not really. The kidney values are checked every three months. So if any problems arise here, I would also stop taking PrEP. As far as bones are concerned, I don't have a family predisposition, so I've ruled that out for myself. And as far as most sexually transmitted diseases are concerned, I've always been pretty relaxed. But of course I keep an eye on them and get checked for them every quarter. For me, that's definitely part of effective PrEP. And if something does come up, I get the appropriate antibiotics prescribed. At the moment Hepatitis A, for example, is currently going around. Of course, I've been immunised against them for a long time. And some really intense stories, where hepatitis C is transmitted, for exampleI don't do that during sex anyway.
So that was the end of your decision in favour of PrEP?
Yes, in November I had a detailed consultation with my doctor, who also carried out all the necessary health tests - and then I was ready to go.
Some people are very sceptical about PrEP. For example, they ask themselves what is so difficult about using a rubber when having sex, especially as it not only protects against HIV, but also against a whole host of other infections. What are your main reasons for taking PrEP?
Before I took PrEP, I had been exposed to an unplanned risk of infection a few times. That happened to me in the gay sauna, for example. My head is switched off during sex and only my cock decides what happens. I regretted it afterwards and panicked a bit: What if something has actually gone wrong? I wanted to avoid such situations in future.
The other point is the physical sensation during sex. It doesn't make that much difference to me when I'm active, but it does when I'm passive. That's why I've been less passive when I've been single, because I just didn't like the rubber. When I do feel like it, I simply find it more pleasurable without it.
Safer sex is changing with PrEP
Have you discussed the pros and cons of PrEP with friends or have you discussed it with yourself?
On the one hand, I talked about it with the positive friend I mentioned earlier, and on the other hand, I also had people in my circle of friends who were also considering taking PrEP. I held back at first with the other friends because they always communicated the safer sex messages.
... the classic safer sex messages ...
That is indeed an important objection; the language must now also be adapted. Is PrEP now also safer sex? On PlanetRomeo, for example, I can choose between "always", "by arrangement" and "never" in my safer sex profile. What does PrEP actually fall under here? On Grindr, on the other hand, you can click on PrEP directly.
How did you get your medication? Regularly with a private prescription from the pharmacy round the corner?
No, I had a friend explain to me how to take a generic ...
... a cheaper copycat preparation ...
... from India, legally and also quality-assured. The delivery arrived within less than two weeks, my doctor gave me the go-ahead and then I started taking the tablets.
Was there a moment of uncertainty and hesitation beforehand? Or was it like Christmas, when you can't wait to finally unwrap the present? In this case, taking pills for three days and then finally being able to have sex in the sauna without a condom?
(laughs) The Christmas spirit is a good thing, but I didn't go to the sauna. Back then I had two fuckbuddies who both really wanted to do without the rubber.
Do you take PrEP Permanent or event-relatedthat is, always in good time before having condomless sex?
I take the medication permanently. I've never quite understood how occasion-based PrEP works, and it's a bit too complicated for me. I have sex relatively often and the intervals and breaks wouldn't be that long anyway. So I prefer to take PrEP regularly. Sometimes I'm away on business trips for longer periods. So if I know I'm going to be somewhere in the provinces and I'm pretty sure I won't be having sex, then I take a break from the medication. And if the opportunity arises unexpectedly, I just use a rubber.
When I'm back, of course, I also wait the appropriate amount of time until I've built up the right level of medication with the tablets before I have sex without a condom.
Is the cost-benefit ratio right?
Even if you buy the medication as a cheaper generic, it is still a fixed monthly cost and you need the self-discipline to take the tablets regularly and to attend the check-ups at the doctor. You have now had a few months' experience with PrEP. Do you feel that the financial and organisational costs are in proportion to the benefits you derive from it?
Yes, definitely! My sex has been much more relaxed since then. And swallowing a pill every morning is no problem for me. I have a box of 7-day tablets in the bathroom right next to my hair gel. Because I don't leave the house without having my hair done, I can't miss the pills. And if it does happen or I've unexpectedly spent the night away from home, my mobile phone reminds me to take my pills every morning at 10am. To be on the safe side, I always have one pill with me in my rucksack and another dangles from a fob on my key ring. A friend gave me this tip.
So it's no hassle for me, I haven't had any side effects so far and everything has been fine with the medical checks so far. The monthly ration currently costs me around 60 euros, which I can easily afford and is definitely worth it.
Some doctors are worried that they won't be able to bill the insurance companies for regular checks for sexually transmitted infections. Do you have any problems with your doctor?
As this is a specialised practice with a large number of gay patients who are tested every three months anyway, this is probably not a problem for him. I only had to pay for the kidney test myself, which should also be done quarterly for PrEP. That was around 10 euros. Last time, however, I didn't get an invoice for it. Maybe they've forgotten about it or they're now billing for it elsewhere.
The reactions are very different
You only involved very few people in your decision-making phase. How are things now? Do other people in your circle of friends now know that you are taking PrEP?
Yes, I make no secret of it. The reactions are very different. Some don't ask much, others want to know lots of details.
However, I get the most reactions on gay dating platforms. I sometimes get "You old bareback cunt" thrown at me - just because the word PrEP is in my profile text. Others, on the other hand, send you messages like "Great that you're taking PrEP like me".
But above all, there are a lot of questions. Some want to know when I do it with and when without. Others want to know how PrEP works and how I get the medication. Basically, they're now asking me for all the information I was looking for in forums back then. I'm also happy to provide information, but I always tell them that they shouldn't just order the tablets online. Taking the tablets without medical supervision and then perhaps irregularly is the worst thing you can do.
How do you communicate that you are taking PrEP on sex dates?
It's very different. I don't always say it straight away so as not to put the other person under unwanted pressure that I absolutely want to have sex without a condom. I usually decide beforehand whether a condom is important or not when we're dating online. Then there are situations like recently on holiday: I met someone, we ended up in my hotel room and made out. Later, the guy saw the box of tablets in my bathroom and I explained to him that I was on PrEP. His reaction was: "I wish you'd said that before!".
It always depends on the individual case and requires a bit of sensitivity. Some people also write to me during online dates: "I've seen that you're taking PrEP, but I'm still only doing it with a condom." That's ok for me too. It's not that I now only have sex without a condom.
What is your experience, especially when you're out and about on dating platforms: do most people now know what PrEP actually is?
During that time, I only had contact with maybe two or three men who had never heard of it or didn't know exactly how it really works. They often ask very interesting questions, such as "So you're protected against HIV, but I'm not?".
Do you think it would be right for health insurance companies to cover the costs of PrEP?
The question of access to medication is always an ethical one, and this also applies to PrEP. I am speaking here from the perspective of someone who is doing quite well financially and I ask myself: why should gay men get PrEP for free when in other countries, even in Europe, not even all HIV-positive people have access to HIV medication?
I don't have a definitive answer to this yet. On the one hand, we are a rich country with high surpluses in the health insurance funds, but on the other hand there are many serious illnesses whose treatment has to be financed by the health system. So why should I let the health insurance companies pay for my fun without a rubber when I can afford it myself?
Objectively speaking, it's a luxury problem. But I'm alive now, and maybe I'll soon be in a monogamous relationship again. At the moment, however, I'm having a lot of sex with different men and I enjoy it more when I leave the rubber off.
PrEP is not right for everyone
Should PrEP become the safer sex standard for gay men?
For me, PrEP is a nice to havethe condom, on the other hand, is a must-have, that everyone should use. And if they want to do without it, they should just take PrEP. However, it is important that people are well informed enough to make this decision. And: it is important that all sides are analysed.
I've also seen people fail to take PrEP because they didn't take the medication regularly or, in the case of event-related PrEP, didn't take it on time. If you party for three days straight or get high on alcohol and drugs every weekend, you might not necessarily remember to take your pills and PrEP might not be the right thing for you.
But I believe that PrEP can certainly help to reduce the number of new HIV transmissions in Germany in the long term. And probably also that of other STIs, because people on PrEP get checked more regularly than others - at least that's what a study from the USA that I read recently said.
*Name changed
Forums and websites with information on PrEP (selection)
In German:
http://www.lovelazers.org/de/prep-die-pillen-davor/
http://www.lovelazers.org/de/handbuch-prep-selbst-besorgen/
PlanetRomeo: Club PrEP-Info-DE
In English:
