Switch On Your HIV Smarts.

Promiscuous Gay Nerd: No Magic Bullet, Redux—Why Treatment as Prevention Isn’t Just a “Biomedical” Intervention

, by Jake Sobo

PGNerd2As I sat waiting for Hillary Clinton to deliver her much-ballyhooed address to the International AIDS Conference last year in Washington, DC, I found myself anxious. Clinton is a hero of mine, but could she seriously be counted on to say something right about HIV? When she got to the podium, she gave an impassioned speech that the media declared a “blueprint” for the first “AIDS-free generation.” The concept was a novel (if slightly confusing) reflection of the growing mountain of science indicating that treating HIV early could be a powerful tool for preventing new infections—a strategy generally known as “treatment as prevention.” Preventing HIV from accelerating to AIDS with treatment improved not just individual patients’ lives, but also mitigated the spread of the virus.

The end of AIDS, we were told, was so tantalizingly close that we should all be able to taste it. I won’t rehash all the evidence here. The most important piece of evidence in this vast puzzle are the findings heralded by Science as the “breakthrough” of 2011 that early treatment reduced the risk of heterosexual transmission by 96%. The context for this evidence cannot be understated. If you’ve stepped foot in any critical HIV prevention meeting in the past decade, you undoubtedly heard critics loudly proclaiming the failure of so-called “behavioral interventions” and the great need for “biomedical interventions” that many believed to be the only way forward. Condoms out, drugs in.

In this column, I have to ask: Are we in HIV prevention doomed to repeat our mistakes time and time again? You may be confused by my question, so let me explain. Last month, I penned a column suggesting that we needed new HIV prevention efforts to help educate gay men on how to navigate sexual risk. One commenter, someone I greatly respect for his longtime work in HIV, disagreed with my suggestion that we needed new “campaigns.” I don’t mean to single him out, but his comments reflect the trend I have described above. He says, “The biomedical interventions, such as PrEP, treatment as prevention, PEP, circumcision work. We need to redouble our efforts to keep HIV-negative men negative, but the choices are slim in terms of ways to do this beyond the drugs discussed in this article.”

This seems so undeniably true that it is hard to see the assumptions underlying it that make such a statement completely false. I turn to social historian Allan Brandt, whose important work, No Magic Bullet, helps to untangle the mess in which we’ve again found ourselves. I quote at length:

Perhaps more than any other single theme, twentieth-century medicine has been characterized by the search for “magic bullets”—specific treatments to root out and destroy microorganisms. This biomedical model has come to define the role and nature of the medical enterprise. In this paradigm, individuals become infected with a parasite that causes dysfunction of some sort; disease is defined as deviation from biological norm. Social conditions, environmental phenomena, and other variables are generally discounted as causes of disease. The physician dispenses “magic bullets” that restore the patient to health. (p. 4)

Here we are again, searching for a “magic bullet” to end HIV. I understand the desire to find some magical tool that will single-handedly end HIV transmission. But the idea that “biomedical interventions” exist somehow apart from “behavioral interventions” is a farce.

To understand why this is so, you needn’t look any further than the “treatment cascade.” Treatment for HIV is available either through private health insurance or the AIDS Drug Assistance Program. But of the more than one million Americans infected with HIV, only 36% are estimated to be receiving treatment and only 28% are estimated to have a low viral load. See the handy chart below:


Source: US Department of Health and Human Services

What does this tell us? Getting pills in peoples’ mouths isn’t exactly easy. It requires a massive amount of resources and socio-structural factors that facilitate its deployment. Primary care doctors. Health clinics. Social support for people on treatment. Case management. A safe home environment in which taking pills prescribed to treat HIV is feasible. Does this all sound like “biomedicine”? The answer is clearly no. This is behavior. It is also infrastructure. And stigma. And community support. And family life. In short, it requires a whole host of factors that cannot and must not be reduced to biomedicine.

The truth is that there is no such thing as a purely “biomedical intervention,” and there is no such thing as a purely “behavioral intervention.” For Pete’s sake, condoms are lumped under the term “behavioral,” and clearly we understand that they’re a technological intervention. They don’t even exist on a continuum. The distinction is entirely in our heads.

Ending HIV is no easy task, and if we pretend we can do it tomorrow we’re just going to wind up feeling pretty miserable when we fail. Even if a vaccine is developed, do we seriously imagine that it will be an apolitical decision to distribute it widely? Look at HPV! Or shingles. As seductive as the idea can be, magic bullets are just another form of magical thinking.

I believe there is a role in prevention for innovation that includes pharmaceuticals, but that cannot be our endgame. We cannot abandon our responsibility to give those at risk of infection the tools to navigate their sexual lives in ways that reduce their risk and maximize their pleasure. Prevention for HIV-negative people is not passé. It is not yesterday’s news. It must be an important part of our arsenal moving forward, and it must not pretend to simply be a matter of drugs or behavior. There is so much more at stake.

What do you think about treatment as prevention? As always, leave a comment or shoot me a note at mylifeonprep@gmail.com.

Jake Sobo is a pen name used for anonymity. Jake has worked in the world of HIV prevention for nearly a decade. He previously published a 19-part series documenting his experiences on pre-exposure prophylaxis (PrEP), “My Life on PrEP,” for Positive Frontiers magazine, which was picked up by Manhunt, translated into French, and widely read in the HIV prevention world. He has spent the better part of his adult life having as much sex as possible while trying to avoid contracting HIV.


6 Responses to Promiscuous Gay Nerd: No Magic Bullet, Redux—Why Treatment as Prevention Isn’t Just a “Biomedical” Intervention

  1. Gus Cairns says:

    In the UK, the “treatment cascade” ends up with 53% of people with HIV being on ART and undetectable, not 28%. Same in France. Healthcare system reform would have a huge influence (as would tracing patients lost to care: there’s some evidence the 28% is an udnerestimate, because it doesn’t take acount of patients who have in fact just moved to another provider). Having said this, Jake is right: even in the UK, our 53% undetectable, hasn’t resulted in HIV incidence in gay men going down. Rather the reverse.

    • Jake Sobo says:

      Thanks for adding the international perspective, Gus! I’m terribly US-centric.

      I know in Australia the figures are even higher. But actually, as you say, I think these variations are just evidence of the same point: socio-structural conditions frame the context in which treatment is deployed.

  2. Don Barrett says:

    Thank you for noting that focusing on treatment misses all of the other diseases. An argument can be made that a key problem dates back to the gay movement’s having stopped too soon. Rather than continue a sex-positive focus on exploring sexual expression, we stopped with the freedom to express an identity. Though there was some sex-positive work in the 80’s that focused on healthy, sexual-need reducing alternative means of sexual expression, current campaigns seem to be stuck on penetration and ‘cover it,’ rather than opening the discourse on finding other healthy, fun ways to meet sexual needs.

  3. John Hamiga says:

    I really enjoyed reading this article.

    Jake, you have a good perspective outlining the case for “bio-behavioral” prevention approaches!


  4. Lesley Doyal says:

    Dear Jake,

    I very much enjoyed the ‘punch’ of the article and its clarity in exposing some of the obvious contradictions still inherent in so much HIV discourse. I would want to add to Gus’s point that we need to stretch much further in our international comparisons beyond the ‘rich’ world (UK/US) to those places where the obstacles inherent in negotiating the cascade are so much more difficult to to grapple with.
    I hope you will not mind me engaging in a little self promotion since my recently published book covers much of this territory from a very similar perspective to your own. You can see the details at

    best wishes Lesley

  5. Andy says:

    The increase in new infection among MSM is on treatment as prevention’s report card. The AIDS mafia can make all the graphs and conjectures they want but the proof is in the pudding. I’ll defer to Elizabeth Pisani-
    “In gay men, you’ve got quite a dramatic rise of new infections starting in the years since treatments became widely available. This means that the combined effect of being less worried [about HIV], and having more virus out there in the population — more people living longer, healthier lives, more likely to be getting laid, with HIV — is outweighing the [beneficial] effects of lower viral load.”