The fight for PrEP access in Ireland
by Patrick Flynn
Samuel Delany’s Times Square Red, Times Square Blue stands out to me as one of the most memorable portrayals of gay male life before and during the emergence of HIV.
Better known as a science fiction novelist, the Marxist Delany’s work – part memoir, part sociological essay - painted a timeless picture of queer New York from the 1970s to the 1990s centred around his sexual experiences in Times Square’s gay cinemas and venues, capturing with fondness but without mawkishness a queer community lost to both the scourge of HIV and to the gentrification which took hold in Times Square from the Koch to the Guiliani eras. Above all, Delany mourned the loss of the interactions in Times Square’s queer venues, which were inter-class, casual, and more unpredictable than those that followed gentrification and, while not thinking it possible to return to the pre-HIV era, he called for the re-establishment of institutions that could serve the same social functions, providing opportunities for consensual gay sex with others. It’s a story that speaks not just to Delany’s experience, but to gay communities elsewhere in the period. [1]
“The story of the queer communities’ fightback against the HIV crisis is a central part of the fight for queer liberation over the past few decades.”
The story of the queer communities’ fightback against the HIV crisis, through groups like the AIDS Coalition to Unleash Power (ACT UP), founded in the United States in 1987, is a central part of the fight for queer liberation over the past few decades. A raft of films in recent years have documented the devastation of HIV on LGBTQ communities in the 1980s and 1990s. Films like 2015’s Pride, (its protagonist, Irish Young Communist League member and Gays and Lesbians Support the Miners founder Mark Ashton, died from HIV) and 2017’s 120 BPM (about the activism of Act Up in early 90s France), also showed how queer communities across the world fought back against the conscious inaction of governments as the virus spread.
The threat of HIV has not gone away. Ireland had the highest rate of HIV diagnosis in Western Europe last year, with only Estonia and Cyprus having worse rates of infection. It was most pronounced among men who have sex with men, but rates are rising also among women and non-binary people.[2] There are similar increases in other sexually transmitted diseases such as gonorrhoea and chlamydia among both straight and LGBT populations.[3] Yet the resources exist – both in terms of education, and in the emergence of the extremely effective Pre-Exposure Prophylaxis (PreP) drug, to comprehensively tackle HIV and allow gay and bi men and others to enjoy a sex life unfettered by its dangers. The question is why both education and the availability of PreP have not been more widely rolled out in Ireland.
Sex Education, or the lack thereof
The answer to the former issue lies, most obviously, in the Catholic roots of our education system. Instead of providing a holistic programme of sex education which would help students approach sex and relationships in a healthy and consent-based way, the Catholic education system’s ethos has hobbled how sex was addressed in Irish schools – on the occasions the s-word is acknowledged at all.
I recall Cura, the now defunct ‘crisis pregnancy’ agency affiliated to the Catholic Bishops Conference, visiting our school in Transition Year in the mid-2000s; needless to say, the ethos of this ‘sex education’ was entirely heterosexual in vision, and within this abstinence was emphasised with condom use not mentioned.
“Even when it strayed away from an exclusively Catholic focus, the Irish education system’s treatment of sex was just plain weird.”
Even when it strayed away from an exclusively Catholic focus, the Irish education system’s treatment of sex was just plain weird. My only memory of HIV being dealt with, for instance, was when our teachers arranged a school assembly as part of our SPHE programme in my Leaving Cert year where, to the visible discomfort of students present, a Canadian man, weeping, hunched over and looking distraught and dishevelled, told us his story of how he had contracted the virus from his girlfriend and how it had destroyed his life. It was only in the final moments of his presentation that he broke character, snapped upright and dispassionately informed us that he was an actor, and part of an educational programme promoting awareness of HIV among secondary school students, making me, at least, feel somewhat manipulated.
When I later related this story to friends in college everyone would look at me in disbelief; lest anyone think this was a late-2000s fever dream on my part, several Reddit posts testify to the fact this same actor visited schools around the country throughout the period. The actor himself claimed in one comment thread that his ‘show’ reached 300,000 students.[4] I don’t know what long-term impression this experience had on my classmates, but I certainly doubt such theatrics would have been as effective as a secular, LGBTQ+-inclusive sex education policy incorporated into the curriculum itself, empowering students with actual facts rather than cheap shock tactics.
“Young people should be empowered with education on consent, and knowledge that resources like PrEP exist and are available to access.”
People Before Profit-Solidarity’s Objective Sex Education Bill, which was put before the Oireachtas in 2018, was a serious attempt to challenge this embarrassing state of affairs and move towards a situation where students were seriously educated on consent and safe sex, different aspects of sexual and gender identity, methods of termination and reproductive rights. While the Bill passed the Dáil without government opposition – Fianna Fáil opposed the measure [5] - it is currently languishing in committee stage purgatory, and the establishment parties are in no mood to expedite it along. In the current climate, where the far-right are trying to engineer an anti-LGBT backlash in society (see Jess Spear’s interview with the coalition to defend our libraries in Issue 13) it is more imperative than ever that efforts like this are supported. Young people should be empowered with education on consent, and knowledge that resources like PrEP exist and are available to access.
What is PrEP?
PrEP, which stands for “Pre-Exposure Prophylaxis”, is a safe and effective means of prevention against HIV; when used correctly, it provides near complete protection. It stops the HIV virus from replicating in your body, meaning it cannot establish an infection – simply put, if you are taking PrEP properly and are exposed to HIV, you will remain HIV negative.
However, it is not a protection against other sexually transmitted infections, hence condom use and regular STI checking are still crucial alongside use of PrEP. PrEP can be taken daily if that is suitable for you, or if suitable it can be taken on demand when you know you will have sex in the next 24 hours – in which case you should take two pills between 2-24 hours before sex, one tablet 24 hours after that and one more pill 24 hours after that.
Man2man.ie is a good, practical guide aimed at men who have sex with men on accessing condoms and lube, PrEP and the Monkeybox vaccine in the South, also covering issues such as consent, while sexualwellbeing.ie has comprehensive information for men and trans women..rainbow-project.org has a similar guide for those in the Six Counties. PrEP can be accessed for free in the South through the Medical Card or the Drug Payment Scheme Card which is available through the HSE for anyone with a PPS number. HIV tests can be easily ordered through HIV Ireland at popular queer venues like Outhouse and The George, and also through Grindr.
The fight for PrEP access
In comparison with countries like Norway, which has provided PrEP free of charge since 2016,[6] Ireland has been much tardier. The issue was highlighted when, in a good example of international LGBT solidarity, Varadkar’s 2018 visit to the site of the Stonewall Inn in New York – the site of the famous uprising against police harassment of queer people in 1969 – was met by a protest by Act Up New York organised at two hours’ notice, who had been notified by Act Up in Dublin about the abysmal access to PrEP in Ireland. Varadkar himself barely commented on the topic during his time as Taoiseach.[7] While the HSE now provides PrEP through a programme initiated by 2019, reaching 3,802 people by the final quarter of 2023, the programme remains underfunded and understaffed, excluding clients from accessing the service. By the government’s own admission ‘many PrEP services are reaching (or have reached) capacity and service users are reporting challenges accessing appointments’. While appointments at the 13 public PrEP services are free of charge, the remaining 17 private providers charge for consultations.[8]
“By the government’s own admission ‘many PrEP services are reaching (or have reached) capacity and service users are reporting challenges accessing appointments’. ”
PrEP has been big business for big pharma, a fact which has also hindered access to the drug. Pharma giant Gilead – the Handmaid’s Tale references make themselves – has made more than 14 billion euros through PrEP, charging over €400 a month for its branded Truvada PrEP drug. Since its patent for PrEP expired in 2017, it has attempted in both the Irish and European courts to prevent cheaper versions of PrEP becoming widely available. Gilead has done this while calling itself as an ally of the LGBT+ community. The company, who have a factory in Cork, sponsored the local Pride parade, whose organisers defended the sponsorship when it understandably came under fire by local LGBT activists, arguing that it was a show of support for the company’s LGBT employees. This missed the point entirely and was entirely out of step with the activism of Act Up and others, from the 1980s to now, in standing against the state and big business to resist the HIV crisis.[9]
Gilead is not the only corporation active in manufacturing PrEP whose actions the queer community should be aware of. On being prescribed it, an Israeli brand, Teva, is often offered by pharmacies as the default. A UN human rights report recently cited by the Ireland Palestine Solidarity Campaign highlights Teva’s trading in illegal settlements in the Occupied Territories. Teva also exploits the captive Palestinian market through the dominant role of the Israeli pharmaceutical industry on the Palestinian market which has hobbled the development of pharmaceuticals in Palestine, profiting from the Israeli Ministry of Health’s regulations on drug registration in Israel and their enforcement on the Palestinian market. The irony is that this situation is taking place while the Israeli military actively targets Palestinian hospitals. The company paid the Israeli state $565 million in backdated taxes in 2023, going directly to a state committing genocide in occupied Palestine, and it is an increasing target of BDS protests internationally. The BDS movement lists Teva as a pressure target, calling for ‘pressure against these companies, including boycotts, if reasonable alternatives exist’.[10]
Thankfully, in seeking access to PrEP, it is straightforward in Ireland to find alternatives to Teva, such as the Mylan brand. While I was informed in a Boots in Galway City that they only had access to Teva, another conveniently located pharmacy was able to order Mylan in time to collect the next morning. In boycotting Teva, we stand alongside groups like Queers Against Israeli Apartheid, whose solidarity work with Palestinians and calling out of Israel’s facile attempts at ‘pinkwashing’ – using superficial pro-LGBTQ+ gestures to obscure its crimes by cynically portraying itself as a liberal bulwark – is more important than ever today.
This is an issue that goes well beyond the LGBT community. It is a modern day horror perpetuated by the capitalist system that, with modern antiretroviral treatments making HIV entirely untransmittable, and the extraordinary effectiveness of PrEP, we're at the level technologically where we can massively reduce the spread of the HIV virus in humans within a generation or so, but instead condoms, let alone PrEP, are difficult to obtain in many sub-Saharan African countries.[11]
“[W]e’re at the level technologically where we can massively reduce the spread of the HIV virus in humans within a generation or so, but instead condoms, let alone PrEP, are difficult to obtain in many sub-Saharan African countries.”
Conclusion
Whether it's PrEP, the abortion pill, or Hormone Replacement Therapy, there is a history in Ireland of fighting for access to healthcare for women and queer and trans communities, as we fight against a deep history of the paternalistic, patriarchal moralism in prevailing Catholic attitudes. Goretti Horgan has spoken in Rupture previously of how the campaign for reproductive rights in the 1980s was ‘about the right to have a sex life that wasn't linked to reproduction’. Similarly, PrEP allows gay and bisexual men and others to have a sex life free of the concern of HIV, in the emancipatory vision as advanced by Delany in the 1990s. In so doing, the drug needs to be taken out of the monopoly of for-profit corporations, but provided free to the people and communities who need it, for not only queer communities but all people who need it.
Notes
[1] Samuel R. Delany, Times Square Red, Times Square Blue (New York, 1999).
[2] https://www.irishtimes.com/health/2023/12/01/irish-rate-of-hiv-diagnoses-highest-in-western-europe/; https://www.independent.ie/irish-news/hiv-on-the-rise-among-women-and-transgender-people-in-ireland/a1941372555.html
[4] https://www.reddit.com/r/ireland/comments/1bfamqa/school_speaker_pretending_to_have_hiv/; https://www.reddit.com/r/ireland/comments/ipc01k/comment/g4k612e/
[5] https://www.rte.ie/news/politics/2018/0419/955733-sex-education/
[6] https://www.businessinsider.com/norway-offers-hiv-drug-prep-free-2016-10
[7] https://gcn.ie/act-new-york-protest-irelands-prep-costs-varadkars-stonewall-visit/
[8] https://www.oireachtas.ie/en/debates/question/2024-05-14/658/
[9] https://www.irishexaminer.com/news/arid-30859196.html
[10] https://www.ipsc.ie/campaigns/consumer-boycott; https://www.aljazeera.com/news/2019/2/12/israeli-firms-face-un-blacklist-for-settlement-business; https://www.whoprofits.org/companies/company/4212?teva-pharmaceutical-industries
[11] https://www.thejournal.ie/global-gag-order-malawi-4711902-Jul2019/