Not so long ago, the only way to prevent HIV exposure was by using condoms. So the decision was pretty clear. If you didn’t want to be exposed to HIV, you used a condom. End of story.
But the story continues. Now we have pre-exposure prophylaxis, or PrEP. For couples, PrEP may open up a whole new chapter in your relationship. Are you ready?
PrEP is a game-changer in more ways than one. I have had many clients talk to me about PrEP. Along with the issues that are coming up for them. Issues like: Going on a daily medication for the foreseeable future. Being stigmatized as someone who has a lot of random hookups. The level of risk from exposure that still might be present. Whether it is covered by insurance, along with the co-pays.
Some of my clients are single, and others are in relationships. And making the PrEP decision when you are in a relationship can be especially difficult. You have to consider not only your needs and expectations, but those of your partner. Two people. Twice as many considerations.
Here are a few examples that illustrate the kinds of questions couples are facing as they consider PrEP.
A client I’ll call Tom is HIV-negative and partnered with Daniel, who is HIV-positive. Tom has been comfortable using condoms and thought Daniel was as well. Recently, Daniel expressed the desire to have bareback sex and has requested that Tom go on PrEP so they can. “I’m not sure if I’m ready to have sex without a condom,” Tom said. “Daniel says I’ll be fine, since he’s undetectable. But he’s not the one taking the risk. I am.”
Mike and Roberto, who are both HIV-negative, are also considering PrEP. Mike has been wanting to open up the relationship and have sex with other men, and he views PrEP as a way to do that without placing Roberto at risk. “Talking about PrEP has opened the door to also talking about monogamy,” Mike said. “I’m not sure if we want to risk where this conversation might lead. I sure don’t want Roberto to think I’m ‘PrEPping’ for the end of our relationship.”
Melissa is HIV-negative and is partnered with Lonnie, a man who is positive. She wants to go on PrEP to feel more certain that she is protecting herself against HIV exposure. She doesn’t want to make this decision on her own and certainly doesn’t want to start the medication without informing him. “The truth is, I have always worried that a condom could break,” she said. “But I don’t want to make him feel like damaged goods. We went through that when we first got together. So it’s a real can of worms.”
Making the PrEP decision means having conversations about some topics that might be pretty uncomfortable. And they all revolve around a single word: Trust. Trusting yourself to stay within the boundaries you and your partner have agreed on, trusting your partner to do the same. Trusting that your partner won’t be hurt or offended by introducing PrEP into your relationship. And trusting your understanding of how PrEP works to ensure you and your partner are protected from HIV exposure. Conversations about PrEP can be difficult, and downright scary. Your motives for going on PrEP — or for refusing to go on PrEP — will need to be exposed to the light of day.
Let’s face it: Talking about life after PrEP can feel like negotiating safe sex all over again.
So a question: Do you trust that your relationship has a strong enough foundation to survive whatever might come up when you have this discussion?
I’m assuming that somebody is going to take the lead in getting the PrEP conversation started. Here are some steps to kicking it off and keeping it moving forward:
Start with a reminder: I love you. When you’re having a conversation about your relationship, start with reconfirming your foundation. After all, you’re together because you love each other.
State your intention. This isn’t the time to be a wimp about why you’re starting this conversation. But that also doesn’t mean you’re here to lay down the law. So how about making it clear that this is a decision for you and your partner to make together? You might say something like: “I’ve been thinking about PrEP and what it might mean for us. I want to talk to you about your thoughts. Is that OK?” If your partner isn’t ready to have the discussion, you may need to drop it for now and bring it up again when he/she is ready.
Let your partner talk first. You might already be aware of your partner’s feelings about PrEP. Or maybe not. Either way, give your partner a chance to express their opinion first. This approach can help your partner to feel like this really is a conversation and not only an opportunity for you to express your opinion or state the decision you have already made on your own. “I’m really interested to know what you think about PrEP.”
Listen. Early and often. Conversations are an interchange between two people. You take turns talking and listening. So when your partner talks, really listen to what they’re saying — instead of thinking about what you want to say next and waiting for them to take a breath so you can jump in. If you aren’t feeling listened to, gently ask your partner to do the same. It might help to state what you just heard your partner say, in your own words, to make sure you understand: “So you are saying ______.” Listening is one of the best ways to honor another person.
Offer to team up on getting informed. Make this an opportunity to look for information together. Share what you learn. Make a list of questions to get more information on. You might also want to meet as a couple with your doctor to talk about PrEP. To kick off the information-gathering: “How about if we get on the Internet and do some research? Where do you want to start?”
Get to the why question. OK, here goes what might be the hard part. At some point in the discussion, you’re going to need to clearly state why you want to consider going on PrEP, why you want your partner to, or why you won’t. Since you kicked off the conversation, your partner will at some point ask you the “why” question. Again, this is no time for talking around the issue. “Here’s why I think PrEP would be a good idea for me/you/us.” Or, “here’s why I don’t think it’s a good idea.” And then state why.
Keep listening. The conversation may go smoothly. Your partner may also have been thinking about PrEP and welcome the opportunity to talk about it. On the other hand, some elephants may have been wandering around your living room (one of them named “Trust”) that need to be identified and discussed. This could get uncomfortable. If so, listen with an open mind. Try to understand your partner’s concerns without being defensive: “I really want to know how you are feeling about this.” Again, it might help to restate what you think you just heard: “So what I think you are saying is _________.” Keep your head in the game even when you’d rather tune out.
Get clear on life with PrEP. PrEP may not make much of a difference at all beyond providing an additional barrier against HIV exposure. But it may also mean renegotiating some boundaries, or at least being up-front about boundaries that you have kind of been avoiding talking about. As the saying goes, put your cards on the table. Get specific with each other about what your relationship would be like with PrEP.
Consider this conversation a work in progress. You may need to consider the PrEP decision from a variety of angles before you come to a decision that you can both be comfortable with. Remember: Patience is a virtue. Give your partner time and space to work through his/her concerns on their own as well as with you. Keep the conversation going.
Talking about PrEP. This may be one of the most important conversations you and your partner have had so far. Approach the PrEP conversation with honesty and with an open mind. Hear each other out. Share information. Try to understand each other’s concerns and expectations. Be patient and kind. Keep talking.