On PrEP & the Problem of Access


Just this week, San Francisco startup, Nurx, launched a new service to provide prescriptions for pre-exposure prophylaxis (PrEP) via smartphone. In what seems an almost-expected next step for providing access to PrEP, co-founder Hans Gangeskar said the company is providing this service because ‘[PrEP is] not as widely available as [it] should be for the populations who need [it].’ Effectively, Nurx will streamline the process from health survey and blood sampling to prescription and delivery, by making all materials accessible through a simple mobile application. A new technology for an needing market. Check.

This new technology makes abundantly clear how the market is responding to our needs. And not only that, such technology almost buzzes in response to resolute anger concerning accessible medicine (both for sexual health and more generally) here in the UK. Just as well, this new access appears increasingly open; it purports to provide exponential networks of connection for many of the people in the ‘high-risk group’ regularly tied to PrEP. But let’s not chew our tongues with glee just yet.

The problems circumscribed in PrEP, not especially the moralistic onanisms, but rather issues of accessible economics, appear obfuscated within public discourse. A public discourse, that is, founded upon hundreds of hours of film, travelling photo exhibits, sex education workshops; protests, sit-ins, and marches; Twitter campaigns, rambling Facebook posts, and the occasional personal blog entry. In all this, I hear my fellow activists scream: The epidemic isn’t over. Indeed, the epidemic isn’t over, but who would know unless provoked to ask?

This is first to say, PrEP is tied up in a battle to understand whether or not we occupy a state of emergency.

I write, now, partly in anger that the NHS decided earlier this month that it will not commission PrEP for HIV prevention, contrary to an eighteen-month period of preparatory consultations with key clinicians, counsellors, and community advocates (see Mags Portman’s recent blog post). But even more than that, I shudder each time an article appears where access goes uncomplicated. In other words, UC San Fransisco Professor Robert Grant’s statement in the Nurx announcement went without mentioning the pitfalls in its potential accessible network.

“I like that Nurx makes PrEP available to people who may be afraid of doctors or may be afraid of the judgment that they’ve experienced from doctors. We need to work to make medical services as friendly as possible and try to eliminate the shaming that comes with going to the doctor.” -Robert Grant, University of California San Fransisco

Grant makes a key, and correct, claim: preventative medicine and privatised medicine in the United States need to address the psychological stress of visiting the clinic. Not only is it clear that clinicians aren’t always prepared to talk about the socio-economics of sex and its acts, the system, on the whole, is relatively unprepared to talk about ‘sex as a healthy act’ outside of monogamy. Hence, access to information is encrypted, sensitised, blocked, or opaque in the medical system. The shame to which Grant refers is none other than those repressive threads fed from our (hyper)unsexual medicalisation of the body.

Of course, medical care in the U.S. differs from the U.K. in that Americans subscribe to a highly privatised system based on emergency response. The issue is that a large number of needing people, with or without Obamacare, only receive satisfactory or suitable coverage for their needs. That there continue to be people in the U.S. without emergency coverage, let alone cyclical and meticulous coverage, reminds us of the messy state of the medical industry. That a medical mogul can steamroll Americans in favour of a 5,000% price increase says something about the relationship between Americans and the medical industry. And this is to say: The medical industry, not far from medical practice, dictates practice. Practice becomes catered to what sells; people become bound to profit. What happens when profit compounds profit, but those positioned low on the socio-economic ladder are unable to deal with escalating (mind-numbing) compounding profit? They lose.

In the U.S., and even greater in the U.K., the honest problem with PrEP is access. But there’s another form of access I want to address, and that’s access to societal change. PrEP is making waves. Indeed, PrEP will go so far as to revolutionise sexual potential in our era. PrEP will breathe relief into men most ‘at risk’ for contracting (or already having contracted) HIV. PrEP will mean gay men, in particular, can fear a little less a virus that has caused massive devastation in our time. PrEP will engender a new sexual future, one that is not a utopia but is full of desire and potential. PrEP, by all means, will enact societal change.

Regardless of the bubble of lives PrEP will inevitably save, however, our inability to use this medical technology to turn our attention to societal levels outside the middle-to-upper class means that we will continue to replicate medical oppressions of those who need PrEP most. PrEP will be lost to a class who, still much deserving, fails to recognise coalition, solidarity, and change across economic strata. Organisations like ACT UP London, PrEPster, and Positive East; grassroots efforts; and even Twitter campaigns do speak out against economic crisis that never left our community (in fact, through the devastation of the first epidemic, the distance between the queer impoverished and the rich could swallow the whole of England), but they are few in number. Too few of us outside these organisations, within extended and overlapping and social queer communities, who will end up on PrEP the moment it is institutionalised, will give a second thought about how PrEP can change a life.

Whose life could PrEP change for the better? PrEP could oversee the impending decriminalisation of sex work. A nationalised PrEP campaign (already sparsely undertaken by PrEPster) could explode the fight for re-funding massive cuts to HIV/AIDS services, particularly through the NHS. And, perhaps most importantly, PrEP, when incorporated into sex education workshops, could spell a movement towards a sex-positive future. Who knows? PrEP could be the impetus to push for change to sex ed in classrooms across the UK.

None of this matters if PrEP isn’t a mean as well as an end. PrEP can spell anger inasmuch as it can spell passion and pleasure. But we have to learn to care — if not again, so much more than our critics claim we do. We must care in two directons. If we can, we must dismantle our disposition against the political sphere in order to even start a cycle of growth. We must tell our lovers, amidst our acts of fiery love, that our love is still political, for loving means caring for others around us. Loving is a network of communication. Loving is endemic to queerness. We are bound to this claim.

If this is not an urge, it is in the least a plea to recognise which directions PrEP is pointing. In which ways will you access PrEP? In which ways can’t you? How can you help others access PrEP who might need it more than you? When and where can you talk about PrEP? How often do you talk about PrEP with gay men who don’t know what PrEP is or people who would otherwise not know about PrEP? How can you learn to care in the eternity that is this epidemic?

I want to end with a few truisms, which we all must reiterate, unpack, and expound upon in order to move toward a ‘sex-positive future’. Only by recognising what PrEP says can we begin to open up the implications for social change. Let’s begin:

[1] Until education practices concerning safe sex, condoms, and abstinence are revised, altered, or abandoned, PrEP will remain surrounded by myths, stereotypes, and stigma.

[2] Until it reaches the underrepresented populations that are most ‘at-risk’, especially those populations that cannot afford or are in no social situation to accept it, PrEP will remain a bourgeoise preventative medicine.

[3] PrEP is a bourgeoise preventative medicine until it caters to a full spectrum that purports to ‘access life’ in addition to ‘access pleasure’.

[4] To ‘access life’ entails reiterating that HIV ≠ death. Instead, HIV must equal life; but in doing so, HIV becomes a livable procurement of the medical system.

[5] Finally, we are all indebted to the medical system to some degree. To repay our debt, we can only: Act Up, Fight Back, Fight HIV and AIDS.

In order to fight, we must acknowledge there is a fight to be won. The epidemic is not over. The epidemic never was over. We live in an era of epidemic. Live now. And live with us.