Unprepared: The Difficulty of Getting a Prescription for a Drug That Effectively Prevents HIV Infection

I’m sitting on the examining table at Student Health in Iowa City, digging a nail into the cuticle of my right thumb, waiting for Robin, the physician’s assistant. Over the course of my grad school career, she’s walked me through a half dozen of these STI checks—swabbed my throat and rectum, handled my urine, drawn liters of blood, and sat patiently to answer my many questions.

She opens the door and sighs. “I’ve got good news and bad news.”

I hold my breath. My ex-boyfriend, Zac, has been my only partner since the last test a few months back, at the beginning of summer, while I was still in New York City. We both tested negative and always used condoms, but I’m remembering a conversation we had while eating in bed about a guy he’d gone on a couple of dates with a few months earlier. Zac was staring at the TV and fumbling with his hands.

“We were starting to hook up, and he told me that he’s HIV-positive.”

I’d dropped my samosa. “What?”

“No, no, no. He told me before anything happened. He said that him and his boyfriend had a threesome once, and the condom broke.”

A threesome and the condom broke.

I look down at my hand. At this point, I’m digging my nail into my knuckle.

“The good news is the tests came back negative.”

I exhale.

“The bad news is I can’t prescribe you Truvada.”

There is no rational reason for me to think I have HIV. I would have avoided this stress altogether if I weren’t interested in Truvada, a pill approved in 2012 to help prevent the contraction of HIV, also known as Pre-Exposure Prophylaxis, or PrEP. I’d heard about the drug at a party in New York and immediately looked it up on my phone. Of the 657 San Francisco residents the study followed for 32 months, zero tested positive for HIV.

“I want to prescribe it,” Robin says, pulling out a prescription pad, “believe me, but the doctor I work under won’t allow it, not until we have the right protocols.” She writes down a name and hands me the paper: “Try Dr. Nisly at River Landing. She runs an LGBT clinic on Tuesday nights.” In the past three years, she’s never referred me to the LGBT clinic, never even mentioned that there was one. As I fold the paper, I remember the first time I met Robin, right after I’d moved to this Midwestern college town from New York. I’d been on guard when she asked if I had sex with men or women or both. “Men,” I said, scanning her face for twitches, her voice for stutters. I waited for a loaded question or curt tone. They never came.

* * *

Later that week, I’m in a coffee shop, pressing my fingers to my temples where I’ve had headaches almost daily since I was eight. I extend my leg, lean toward it, and feel the satisfying soreness from deadlifting the day before. I’m reading the autobiography of Glenn Burke, a centerfielder with the Dodgers who died in 1995. “Before I found out I was positive for AIDS,” he writes, “I had many of the symptoms that go along with the disease in its initial stages. Headaches, sore muscles, fevers, throat paints, and diarrhea. I had them all.” I stop reading.

How could Burke not have known he was infected until he had full-blown AIDS? I search the internet. HIV can stay inert in the body for up to ten years, I learn, much longer than, say, SARS or Chickenpox, which stay dormant for fewer than three weeks. Patients are still contagious when they’re asymptomatic, though, which is why the epidemic began in the ’80s even though the virus entered the U.S. as early as 1969.

I think back to the HIV tests I’ve had before: all oral swabs. I learn that these have a window period of up to three months before they can detect the antibody. I remember that Robin drew blood for mine but read that even the most advanced blood tests, which detect the RNA of the virus, can miss an infection more recent than nine days. I stare at the statistics. One in five HIV-positive patients is unaware of his status. Despite being four percent of the population, men who have sex with men, an umbrella term that includes men who don’t identify as gay or bisexual, account for over half of the 50,000 new cases reported each year. I close my computer.

I’m not a hypochondriac. I don’t wipe down machines at the gym or wear flip-flops in the showers. I don’t wash my hands after using my phone or grabbing the handrails on the subway. I never suspected I had Ebola, Bird Flu, or MRSA. But there’s something different about HIV, something that feels simultaneously out of my control but also exclusively my responsibility.

Hoping he’ll give me some perspective, I turn back to Burke, who dictated the book from his deathbed, where he had a space heater on one side and a fan on the other, never able to keep a comfortable temperature. Over several months, his weight dropped from 190 to 135 pounds. He couldn’t be interviewed for longer than 15 minutes without breaking down crying. “I’m so sick right now that I’m ready to die,” he says. “I want the pain to end.”

I stop reading and feel the lymph nodes in my neck: swollen, perhaps, but not engorged. I consider tucking my hand discretely under my shirt sleeve to check the ones in my armpits. Instead, I pack my backpack and leave the coffee shop.

* * *

Back at home, I email Dr. Wittich, the director of Student Health. “I was disappointed to learn that the Wellness Center is refusing to prescribe Truvada,” I write. “When the pill was first introduced, AIDS Healthcare Foundation President Michael Weinstein called the medication a ‘party drug’ that would encourage unprotected sex. I sincerely hope that that kind of counter-productive rationale is not at work at the University of Iowa. Other doctors in the area are prescribing Truvada, but the earliest appointment I could get with them was six weeks out, at the end of October — a wait that feels both pointless and discriminatory.”

The next morning, Dr. Wittich calls as I’m walking to the bus. After reassuring me that of course Student Health values HIV-prevention, she explains the delay is for our safety, to assure that the clinicians develop and implement the protocols uniformly. She asks when my appointment is at River Landing. “I don’t know for sure, but we might be prescribing it before then, so be sure to check back in,” she says sweetly. I thank her for her time, and she holds me on the line: “You said you’re a grad student. What are you studying?” I tell her writing. “That’s great. You’ll have to invite me to one of your readings when you’re a famous author.” We both laugh.

Five weeks later, I borrow my best friend’s car and drive to the university hospital. On my appointment reminder, I’d noticed that Dr. Xu was my doctor, but when I’d called, the receptionist had reassured me that Dr. Nisly would still be attending. Once there, I find out that Dr. Nisly’s called in sick for the first time since anyone can remember. Dr. Xu stares at me blank-faced when I ask for Truvada. For a half hour, I read in the examining room while she consults with the other physicians. “I’m sorry,” she says when she returns, another doctor beside her, smiling and shrugging her shoulders. “We don’t have the necessary protocols. You’ll have to come back later.”

The earliest appointment with Dr. Nisly is another six weeks out, Deb in scheduling says, “but I can get you in to see Dr. Edmond in Infectious Disease two Fridays from now.” Though a visiting writer is giving a master’s class that day—”Dr. Edmond only works Friday afternoons”—I take the slot.

The email to Dr. Wittich is drafted in my head before I’m even home. “Obviously, this isn’t the fault of any one person,” I write after recounting what happened at the appointment, “but I’m still dismayed that Dr. Nisly is the only person who seems capable or interested in prescribing a preventative drug. Again, the message to me is that this is not a priority; it is, instead, something that can be taken care of over there, off-site, at the LGBT clinic.”

I wait a week for Dr. Wittich’s response and then call her from my classroom before the students show up. “I didn’t know whether your email was meant to inform or a call to action,” she tells me, the enthusiasm drained from her voice. I tell her I don’t know either. “We’re also not affiliated with the University hospital,” she reminds me. “Student Health develops its own protocols.” I ask when she expects to be ready. The cheeriness creeps back into her voice: “A team of providers made a presentation to the rest of the staff this week.”

* * *

The next week I’m in my room with my best friend. “I took your car for that oil change,” I say, handing him the key ring that also has a spare key to my room.

“Thanks,” he says. “How much was it?”

“Don’t worry about it.”

“No, dude,” he says and pulls out his wallet. “How much?”

“It’s fine,” I say, shaking my head. “I’ve been borrowing your car a ton lately. I appreciate it.”

After I insist again, he puts away his wallet, and eventually the conversation transitions to what we’ve talked about nightly for the past month: his ex-girlfriend and why he still feels so sad. He’s next to me on the couch, our bare knees touching, the closest our bodies have been since the break-up. The conversation lags for a second, and he leans over and puts his head in his hands. I rub his back. He inches closer and sits up. His eyes, aqua blue, are six inches from mine. Neither of us blinks. I cup his cheek with my hand and pull his face closer. The scruff feels prickly on the pads of my fingers.

* * *

It’s November 6th, and Dr. Edmond is running through my HIV risk assessment. “How many sexual partners have you had in the past six weeks?”

“Zero.” He checks a box. “Wait,” I say. I remember the night with my best friend, after we’d moved to the bed and I’d asked him the question I always ask: “When was the last time you were tested?”

“Uh,” he’d said, fumbling with his fly, “it’s been a while.”

“Does oral sex count?” I ask Dr. Edmond.

“Yes.”

“One.”

“Are you having any symptoms?”

“No.”

“Nothing? Does it burn when you pee?”

“No.”

“Do you ever have transactional sex?”

“What does that mean?”

“Sex for drugs or money or anything else you need?”

“No.”

“And you use condoms…”

“Always.”

“Have you recently had sexual contact with someone known to have AIDS?”

I consider saying Zac but realize how ludicrous that sounds. “No.”

“Well,” he says, ticking the final box, “I would consider you low risk.” I notice he doesn’t say lowest risk. “Why is it that you want a prescription for Truvada?”

This is the question I’m most nervous about because, as Dr. Edmond confirmed, I’m low risk. If he wants to follow the CDC’s guidelines, it’ll depend on whether he reads them as exclusive  (“PrEP is only for people without HIV who are at substantial risk”) or inclusive (“PrEP is most recommended for people without HIV who are at substantial risk”). The federal guidelines lend themselves to either reading, unlike those of several states. For example, Massachusetts’ Department of Public Health recommends against prescribing to “persons who are successfully and consistently using other prevention methods,” presumably to start treating them for HIV once their prevention methods become unsuccessful or inconsistent.

I’d wondered why the guidelines were so exclusive, but the only explanation I could find is that researchers worry about drug resistance.  Because Truvada’s used in tandem with other antiretrovirals for HIV-positive patients, recently infected patients who lack the identifying antigens and those who don’t take the pill daily and contract the disease could develop a tolerance — and possibly infect others with the drug-resistant strain. “We’ve learned from other infectious diseases that a poor quality program is worse than no program at all,” said Dr. Timothy Mastro in a 2012 article in The Atlantic. Mastro oversaw HIV/AIDS prevention at the CDC for over a decade.

In a field study in Kenya and Uganda, two researchers from UCSF found that recently infected patients and those forgetting to take the pill daily did pose a risk. However, for every case of drug resistance, the doctors estimated that Truvada prevented 25 infections, leading them to conclude that, “Attempting to restrict access to PrEP is expected to foster intermittent dosing, hoarding of medications, sharing among friends and partners, and other unsupervised use. Fomenting fear of drug resistance is misguided if it distracts us from fear of HIV itself, by far the greater threat to human health.”

Still, I was confused by the guidelines. “Low risk” individuals, the ones always using condoms, seem most likely to take Truvada as recommended and least likely to already be infected, so why disqualify them? The more I read, the less it makes sense. In April of 2015, the U.S. Public Health Service published its survey of 324 members of the American Academy of HIV Medicine. Of the respondents, ninety percent of whom work directly with patients, many as HIV-specialists, seventy percent were not “very likely” to prescribe to someone who always uses condoms. The highest risk groups didn’t fare much better. More than half the physicians were not “very likely” to prescribe Truvada to an IV drug user or a heterosexual with high risk factors, and twenty-one percent felt the same about prescribing to a man with an HIV-positive partner.

I look at Dr. Edmond and give the speech I’ve rehearsed: “I’m nervous about contracting HIV, and if there’s something I can do, I want to do it. I want more autonomy over my body.”

“Okay.” He nods his head sympathetically. “Wait — are you not having sex because of this anxiety?”

I force a laugh, as if the idea’s preposterous. “Of course not.”

“Alright,” he says, gesturing toward the examining table. “Hop up.”

My grey hospital gown crinkles as I lie down. Dr. Edmond checks the glands in my neck and my armpits. He presses down around my groin and examines my testicles. I flip onto my side, and he inspects my anus.

“Okay,” he says, taking off his gloves, “everything looks normal. You can go ahead and change.”

We sit down again, him in front of the computer, me in a chair facing him. “So here’s what’s going to happen,” he tells me. “We’ll test you for HIV now, and if you test negative” — if, not when — “I’ll call in the prescription that day. Does that sound good?”

“Actually, I just tested negative,” I tell him, fingering the pages of a notebook I’ve brought along to take notes.

“Have you had sexual contact since then?”

I remember the scruff, prickly on my fingers. “Yes.”

“Regardless, this time around we’ll use the RNA test.”

“And what about the other protocols? Can we do them today?”

Dr. Edmond squints. “What other protocols?”

“I’m not sure. At Student Health, they said that — ”

He shakes his head. “They just aren’t that big of a deal. After we get your blood sample, we’ll test your kidneys and vitamin D levels. A small percentage of patients have decreased kidney function and bone mineral density. In three months, you’ll come in, we’ll test you for HIV again, and talk about if you had any side effects.”

“Oh,” I say, closing the notebook and putting down my pen. “Is that it?”

“Yeah. You just have to make sure you take the pill every night. Does that sound like something you can do?”

“I take a vitamin every night, so yes.”

“Perfect. They’re also looking at — and don’t do this, it’s just a thought — that maybe at some point you’ll be able to take Truvada right before you have sex and then right after, and that’s it.”

“Oh, so I’d still take it every night?”

That’s the joke I’ll make later in my head as I’m replaying the conversation for a fifth, sixth, seventh time. Instead, I shake his hand and walk down the hall to have my blood drawn.

That Sunday night, I’m watching “How to Get away with Murder.” Connor, the promiscuous law student who mostly uses condoms but forgets here and there, is cajoled into getting tested for HIV by his nerdy on-again, off-again boyfriend. After a tense couple of hours, he learns he’s clean and goes to Oliver’s apartment to celebrate. In the dark, wrapped in blankets, and choking back tears, Oliver says he lied over the phone about his results. He didn’t want to scare Connor.

I assumed the co-star of an ABC family drama would never contract HIV, but when Oliver reveals his diagnosis, adrenaline hits my chest, right above my sternum. It creeps toward my neck, blossoms outward, and pulses in sync with my frenetic heartbeat. It’s the same jolt I used to get in college dive-team meets, from three meters up, when I’d hit the bottom of my press and start to throw myself upward and backward and two and a half times around.

Lying in bed that night, I picture myself spitting into the sink after hooking up with my best friend — was there blood from a cut in my mouth? I mentally examine every razor, towel, and toothbrush we’ve shared. I scan my memory for glimpses of the trashcan in Zac’s bedroom and any broken condoms it might’ve held. My test in September could’ve missed an infection I got during July and August. As I track possibilities, the thoughts become more delusional. The nurse who drew my blood looked young — too young, inexperienced. Did she even open the packaging for a fresh needle? Did she swab my skin? Did she use the right labels?

The next morning, a Monday morning, I drag myself through ten hours of teaching and attending class, comforted by the distraction. Otherwise, my mind wanders back to Glenn Burke’s deathbed. I’m so sick right now that I’m ready to die. I want the pain to end. Checking my lymph nodes has become a nervous tic. I take ten Ibuprofen a day for the headaches. For the first time in years, my chin and forehead are covered in acne.

Stress and lack of sleep produce the same flu-like symptoms as HIV, and my self-diagnosis fits perfectly with my penchant for melodrama. The relationship with my best friend has imploded in exactly the same way it did two years earlier: the same girlfriend, the same lull in the relationship. This time, he slept with me on Wednesday and Thursday and then with her on Friday. If he’s capable of that, I reason, he’s capable of anything, certainly lying about his HIV status. Obsessing is how I refract my anger, the way I can blame him and blame myself for something more tragic than making the same mistake twice. But even recognizing the paranoia, the consequence for being wrong — and the guilt for being complacent and naive — is too intense to ignore.

On Tuesday night, the night before Dr. Edmond said I’d have my results back, I take two Ambien and try to sleep. I skip my 9 a.m. class. When I drop off an essay in the program lounge later that day and see the professor, a loving Jewish grandmother, she tells me I don’t look well. I consider closing the door of her office and telling her that I’m coming apart. In a program of anxious writers, I certainly wouldn’t be the first. But since I’ll find out my diagnosis later in the day, maybe it’s best to wait. I walk to teach my last class of the week and consider keeping my phone turned on. “One second,” I’ll shout to the undergrads as I rush out of the room when it rings. “This is important.” Instead, I bury it in my backpack. Dr. Edmond doesn’t call.

* * *

When he does call, I’m sitting in my kitchen and instantly feel the pulsing of my heart. “I’m calling to let you know that your labs all look good except for the creatinine, but maybe you were just a little dehydrated that day.”

“Doctor,” I say, pacing around my room. “What about the HIV test?”

“It’s negative,” he says as casually as if it were an afterthought.

My brain releases endorphins, and for the first time in almost a week, my neck and shoulders relax. I collapse onto the bed.

“I’ll call in the prescription today.”

A few minutes later, I drag myself to the bathroom. My eyes are puffy and ringed at the bottom as if bruised. Three large pimples sit above my left eyebrow and will stay visible until after the new year. I splash cold water on my face, rub my eyes, and exhale.

* * *

“Alright,” the pharmacist says, handing me the white paper bag with a month’s supply of Truvada, “that’ll be $370.32.” I hand her the laminated co-pay card from Gilead, the drug maker. After I’d confirmed that I was a U.S. resident and wasn’t receiving any government assistance for prescriptions—the two main criteria for admission—I’d entered my contact information online. It’d taken about three minutes, and six business days later, an unmarked white envelope had arrived at my apartment. “$0.00” flashes on the screen. Gilead caps my benefits at $3,600 a year, so if I keep the same insurance after I graduate, I’ll accrue $843.84 in Truvada costs by the end of the year. I decide to kick that can down the line and sign the electronic pad. “Do you have any questions?” Marissa asks. I ask if I have to take it at the same time every day. She pauses for a second. “I believe so.” Do I need to eat beforehand? She purses her lips. “Hmm, let me see.” She holds out her hand, and I put the bag in it. She takes out the bottle and scans the label. “No,” she says. “No, you don’t need to take it with food.”

“What about alcohol?”

She stares at the bottle again. “Let’s check. I don’t prescribe this one a lot.” She opens up the thick, accordion-folded paper attached to the vial and reads through the six point font, clicking her nail on the plastic as she goes. “Does not react with alcohol,” she says, smiling.

* * *

The following weekend, my brother visits from Chicago and we go to the outdoor wrestling match. Afterward, we tailgate for the football game, and by 6 p.m., we’re both exhausted. We catch a cab to downtown and layer pizza on top of the Fireball cinnamon whiskey and beer sloshing around in our stomachs. Back in my apartment, I take a nap while my brother watches the Hawkeyes beat Minnesota. When I wake up, we look at each other, pale and glassy-eyed, and decide against going back out.

We put on “Trainwreck,” but halfway through, nausea hits. I start chugging water, but within a half hour I’m running to the bathroom. For the next two hours, my stomach empties, and then I dry heave so hard I worry I’ll pop a blood vessel in my eye. In between, I lie on my bed, one foot on the ground to control the spinning of the room. “Dude, are you alright?” my brother asks, haggard but nowhere near as debilitated. “It’s the fucking Truvada,” I groan. Every night for a week, the minimum time required for the drug to sufficiently build up in my body, I’ve been taking the light blue pill along with my multivitamin. I groan again, swallow my migraine medication, and pray I don’t throw it up. Two hours later, the last of the nausea passes, and I fall asleep.

The next Friday, I’m at a bar celebrating the birthday of a friend, who orders a round of Fireball shots for the table. I stare at mine while someone makes a toast. I have my migraine medication and a roll of Tums in my pocket. I’m wondering how quickly I can get home if I have to when the shouts of “happy birthday” snap me back to attention. I look up and take the shot. The nausea, a potential side effect for the first week, never occurs again.

The next week, I meet with Cody Shafer, the HIV/AIDS health educator for Johnson County, expecting him to be surprised by my nine-week ordeal. He nods his head. “It seems almost too simple to be real, but for their entire medical career, any time the word ‘HIV’ came up these doctors sent the patient to a specialist. I have to shift that mindset that it’s HIV prevention, not care.”

Shafer evangelizes for Truvada “with anyone who’ll listen,” but the majority of his prevention work still focuses on condoms — a fact he tells me with a shrug. “As an HIV public health community, we recognize that thirty years of that messaging has been ineffective, especially now. People are less anxious about HIV.”

I feel a tiny punch under my sternum and ask why.

“I think people are pretty aware of the successes of HIV treatment and medication, of its management and their ability to live with it.” I ask if that really changes their behavior. He nods. “Plus, condoms are only effective when used correctly. I’m yet to have anyone in a college class who can demonstrate how to properly put a condom on — ” I roll my eyes: Midwesterners — “down to checking the packaging for tears or holes. . .”

I cock my head to the side and squint.

“. . . looking at the expiration date. . . ”

I purse my lips.

“. . .properly opening the package in a way that wouldn’t damage the condom. . .”

I picture myself holding one between my teeth and ripping.

“. . . and putting it on without having to flip it over, so then your genetic material’s on the outside of the condom.” I bite my lip and change the subject.

If advocating condoms is ineffective, how does Shafer help his clients, most of whom are underserved and more likely to abuse alcohol and drugs, smoke, and attempt suicide? “Next to HIV prevention, the single best thing about PrEP is that I’m getting people into primary care,” Shafer says. While his clients are waiting the twenty minutes for their test results, Shafer enrolls those without health insurance under the Affordable Care Act. And since they have to be re-tested every three months to refill their prescription, almost all are seeing a physician more regularly than they ever have. With insurance, “we’re also opening up the doors to mental health providers, to all these other services that they may never have accessed before.”

Shafer’s message only reaches so far. Of Iowa’s 99 counties, Johnson County is one of five that offer all three components of prevention, treatment, and care: counseling, testing, and referral sites, client service providers, and HIV/AIDS treatment facilities. More than half the counties don’t even border a county with testing services. For patients in rural communities who learn of Truvada, can afford it, and convince their providers to prescribe it, another barrier exists: “They’re really hesitant about going through their local pharmacy and having somebody know they’re taking it,” Shafer tells me.

After fifteen months of being lobbied, the Iowa State Health Department is drafting a letter to providers, urging them to prescribe PrEP, a move that Shafer hopes will be more effective than the messaging from the federal level. “The CDC guidelines are identifying the people who need it most,” Shafer says. “That’s commonly being misunderstood as if you don’t meet the criteria, I’m not going to give it to you.” I ask Shafer how he tries to convince reluctant providers. “I defer to research, essentially. Doing maintenance of PrEP for an individual for 10 years is going to be cheaper than treating them for one.” And what about those prescription guidelines?  “What I end up telling them is if somebody asks for it, you should give it to them.”

Local governments are starting to do just that. San Francisco’s City Clinic has its own PrEP coordinator. Washington State has prioritized Truvada for its End AIDS Campaign. In December of 2015, New York City inundated the subway with English and Spanish-language ads that target the groups most at risk (gay men, transgender women, and people of color) and encourage riders to “Play Sure” with PrEP and condoms. In the next year, municipally funded clinics will receive a free portable kit with condoms, lubricant, and eventually, a starter dose of Truvada for those who qualify. The $6.6 million initiative aims to reduce new HIV diagnoses in New York City from 3,000 a year to 750 by 2020.

Those outside of the gay metropolises will not be so lucky. Since the FDA approved Truvada for PrEP in July of 2012, about 80,000 people have started the regimen, over half of whom live in California, New York, Texas, Florida, or Illinois. This is far fewer than the number considered “high risk” (even by the CDC’s draconian standards), so why is this potentially life-saving drug so under-utilized? I was resolute, perhaps manic, in accessing Truvada. Yet, from my first meeting with Robin to the day Dr. Edmond called in my prescription, it took me 62 days  — four appointments at three separate locations and two blood tests. Five health professionals asked me whether I was a top or bottom, how many men I’d slept with in the past six months, and if I had sex for money, drugs, or anything else I needed. They never rolled their eyes or suggested I would be ineligible, but as a man who has sex with men in Iowa, I am most likely the exception, not the rule.

It’s easy to imagine that, beneath the concerns about protocols and side effects and drug resistance, is paternalism, the kind of moral cringing that leads Dr. Horberg, director of HIV and AIDS for Kaiser Permanente in California, to say that Truvada “is not a Saturday night special.” One of the original clinical trials found no additional risk-taking behavior among its participants, and considering the drug’s effectiveness at preventing HIV, these rationales feel more like excuses. Still, I’m not so quick to dismiss them. For all that Dr. Horberg and I don’t agree on, we do share the same anxiety.

It’s always been obvious that the burden for protecting myself is on me, not a stranger or a best friend or a provider at Student Health, so at our core, Dr. Horberg and I have the same fear — that people can’t be trusted: that they’ll stop wearing condoms, forget to take the pill, say they’ll get tested and never follow through. I empathize with Dr. Horberg, and I wish he would empathize back. The drug won’t treat any other STI, but when it comes to the big one, the one that can be managed but ultimately and unalterably is a death sentence, it’s effective, even more so than condoms. It isn’t a conversation where I have to trust that my partner is telling the truth and isn’t the one man in five who’s unaware of his positive status. It isn’t a thin piece of latex I hope is unexpired, applied correctly, and doesn’t break. It’s a pill I choose to take — with or without food, with or without alcohol, when I want, for as long as I can afford it.

* * *

After the semester ends in early December, I fly back to New York for winter break. There, I meet a man at the gym and ask him on a date. When he shows up to the bar, his hair’s styled how I like: buzzed short on the sides and left long on top. His plaid shirt is rolled up to the elbows, right above the muscles of his forearm. We order drinks and sit next to each other on an over-stuffed couch, our feet on the low table in front of us. After I come back with the second round, he turns his body and rests his knee on the couch, right next to mine. I put one hand on his leg and hold my glass with the other. When we finish, I ask if he wants another drink in my apartment.

I shut the door behind us, put my hand on his cheek, and kiss him. Hugging him from behind, we walk to the couch, where he straddles me and takes off his shirt. “I have to ask,” I say, appreciating the shadow in between his pecs, “When was the last time you were tested?”

“November,” he says. I raise an eyebrow. “Negative,” he adds. “And I’ve had sex with one other person since then.” I keep my eyebrow raised. “We used protection.” Without waiting for him to ask, I say I’m on Truvada. “Okay,” he shrugs. Then, he pauses and cocks his head. “Are you saying we shouldn’t use a condom?” I shake my head. No, no, no. His shoulders relax, and I lean up and kiss the right one.

“You’re not on it?” I ask, more accusatory than I mean.

“No” he says. “It’s just too new. They don’t know enough about it.”

For a second, I pause. If he’d never heard of it, I’d have thought him ignorant. If he’d been on it, I’d have wondered how consistently he took the pills. As it is, I think he’s naive — but these are casual thoughts now, products of an overactive imagination and three gin and tonics.

“Okay,” I say, taking off my shirt and pulling him closer. “Okay.”