On the pill: A male sex worker’s
Brandon Gacheru* (25) makes a living by having sex with people he hardly knows. He specialises in intercourse with other men. “I’m not always able to use a condom. And when I do, they sometimes burst,” he says. “Because I have multiple partners, I know I’m at risk of getting sexually transmitted infections.”
Gacheru lives in Kenya’s capital city, Nairobi. Sex work is illegal in his country. Yet in 2012, the East African country had 200 000 commercial sex workers, of whom 15 000 were men, according to a survey by the National Aids and Sexually Transmitted Infections Control Programme and other partners.
Gacheru has oral and anal sex with his clients. Kenya’s strategic Aids framework for 2014-2015 to 20182019 says only about three-quarters of men reported using a condom the last time they had anal sex with a male partner. Anal intercourse without a condom makes men who have sex with men particularly vulnerable to contracting HIV: studies have shown it’s the riskiest type of sex for HIV transmission.
A 2010 study in the International Journal of Epidemiology suggests that the per-act probability or risk of HIV infection from unprotected anal sex is about 18 times higher than that of unprotected vaginal sex.
It’s possible for either partner — the insertive partner or the receptive partner — to get HIV, but it is much riskier for an HIV-negative partner to be the receptive partner.
Because of his job, Gacheru is often a receptive anal sex partner. “You can unfortunately not negotiate your way out of all risks,” he says. “Worse still, you can be raped.”
Gacheru, who is HIV negative, is a peer educator at LVCT Health, a nongovernmental organisation that provides sexual health services and conducts research on preventing HIV. Here, he has learned about a pill called Truvada that he can take to reduce his chances of contracting HIV.
Truvada contains two ingredients, emtricitabine and tenofovir, which are used in antiretroviral medication that HIV-infected people take. Studies have shown that, when the pill is taken once a day by an HIVnegative person, it can decrease the person’s chances of contracting the virus by more than 90%.
Late last year, Kenya became the second African country, after South Africa, to approve the use of Truvada as a form of HIV prevention, which is known as pre-exposure prophylaxis (PrEP). PrEP is particularly useful to people who are at higher risk than the general population of contracting HIV. The World Health Organisation has identified three such groups: men who have sex with men, young women (15- to 24-yearolds) and sex workers.
Organisations in Kenya are running demonstration studies to investigatie how best to deliver PrEP treatment to people who need it.
Gacheru is part of one such study, run by LVCT Health. This way, he gets his PrEP pills for free. The study is following 2 100 PrEP users across Kenya for a year to find out, among other things, whether they’re taking their pills correctly: each day at more or less the same time. The less often a PrEP user takes Truvada, the less effective it becomes. The pill also works better when it’s taken at a specific time each day.
Gacheru is one of the 250 male trial participants who have sex with men in Nairobi. He finds it difficult to take his pill at the same time every day. “I take my medication at 11pm each night. But sometimes I am out clubbing during that time and don’t have a pill with me,” he says. “I rarely