Andrew Christian
11/11/13

Are you PrEP-ared? A gay man’s review of Pre-Exposure Prophylaxis.

If there were a pill that could be taken daily to help prevent HIV infection, would you use it? Should you take it?


Let’s shine some light on this topic.

This month in West Hollywood, CA, two separate community discussions were held to educate primarily gay men and start a public conversation about Pre-Exposure Prophylaxis (PrEP) focusing on the science behind drug, its effectiveness, and its accessibility to the public.

Truvada, a medication usually prescribed for the treatment of patients with HIV, is now being prescribed as a preventative method for HIV, known as Pre-Exposure Prophylaxis (PrEP). The FDA approved this drug for use as PrEP in 2012 but due to the lack of widespread information via advertising and/or marketing, many people especially within the gay community, remain unaware of this additional tool in the fight to prevent HIV.

This article is meant to educate readers based on my personal experience at two recent community discussions surrounding this current controversial topic.

Meeting 1:

On November 7, 2013 at the West Hollywood Public Library, the city of West Hollywood sponsored a community dialogue on PrEP along with APLA, Frontiers, Dr. Michael Gottlieb HIV/Aids Information Center, National Aids Council, Project Inform, and the Stigma Project including panelist physicians Dr. Tony Mills and Dr. David Hardy, along with Terry Smith, Associate Director of APLA, and The LA County PrEP Workgroup, and members of the LA Gay and Lesbian Center. There were also representatives from UCLA and USC, which are both currently conducting studies with regard to PrEP. 

At this meeting, almost everyone wanted to know what the numbers say with regard to PrEP’s efficacy rates. The doctor’s were able to reference multiple studies that have been completed with regard to PrEP, as well as studies still being done today.  Many people seemed confused by the range of percentages and numbers, but the experts broke it down by saying that PrEP, (which is a combination of two HIV suppressant drugs) has a 40% efficacy rate based on the number of human test subjects who seroconverted (became HIV Positive) during the study. However, the biggest challenge with test subjects revolves around adherence to the medication daily. The doctors made a point to say that PrEP can be as effective as 90% if taken correctly.

The panel pointed out that many of the test subjects in these studies, which included men who had sex with men (MSM), as well as heterosexual men and women, did not have measureable amounts of the Truvada in their blood.  This is a major factor that would affect the efficacy rate of PrEP.

Many PrEP advocates and several audience members discussed their HIV status as well as their personal experiences with using PrEP.  Side effects of PrEP seem to be very mild with only reports of increased nausea. Studies have shown that the medication is processed through the kidneys so the doctors recommend PrEP patients have access to healthcare and receive proper blood tests to ensure overall health. One thing that was continually pointed out is that all test subjects were also given access to condoms, monthly STD testing, and counseling. The tests indicated that the number of sexual partners and the practice of unprotected sex among participants actually went down during this study.
In my opinion, it is important to remember that choosing to take PrEP is a personal choice. This should be based on your self-assessment of risk and should be discussed with your medical provider. When using a combination of condoms and PrEP, it is thought to be 99% effective in preventing HIV infections.


Meeting 2:

On November 9, 2013 the Impulse Group LA held a discussion at the Hollywood Improv titled “The Truth About PrEP.” It included Dr. David Hardy, Dr. Michael Wohlfeiler, Aaron Laxton (HIV prevention advocate), and Michael Weinstein, (President of Aids Healthcare Foundation “AHF”) as panelists.

The Impulse Group LA, which is primarily funded by AHF, is a group of community volunteers who work to spread the message of knowing your status, staying sexy, and safe. This meeting started with the introduction of Impulse group’s newest video entitled, “Knowing,” to help people to start discussing their HIV status, knowing their status, getting tested, and having safer sex with the use of condoms.  Shortly after the focus changed and the topic at hand was introduced to include a panel discussion with regard to PrEP.

It is important to note that many participants who were in attendance at the previous PrEP discussion were in attendance. However, several people within the community had stated they were avoiding this meeting because there was a belief, based on AHF’s backing, that this would completely be an anti- PrEP discussion. That could not have been further from the truth in my opinion.

At this panel, the community was able to ask questions anonymously. Through the answers, I gained a lot of insight not only into PrEP but also AHF’s reluctance to stand behind the treatment.  First off, the audience was asked to raise their hand if they used condoms 100% of the time. Only four people in the overly crowded room raised their hands, revealing the sad truth that while condoms are a great tool for prevention, most of us aren’t always using them. With this in mind, Truvada has been shown to be highly effective in reducing HIV infections.

Surprisingly, Michael from AHF admitted that if Truvada (PrEP) is taken daily as prescribed, it greatly reduces the chance of HIV infection. However, he believes is that PrEP will not be successful on a community wide basis because of challenges with adherence. Basically the tests have shown that a large percentage of test subjects did not take their PrEP daily as prescribed and many had low or no traces of the PrEP in their blood. This raised the question of whether people were skipping doses or if their bodies processed the medication more quickly. Some of the tests referenced by the panel indicated a 44% efficacy rate because in one of the medical studies, 49% of the people had no measurable amounts of Truvada in the blood. This lead most of the experts to believe that subjects tend to lie and say they are taking the medication, when in fact they were missing their doses. Michael went on to say that condoms are 99% effective when used properly, but obviously if you miss using a condom you don’t have the ability to add it later. Whereas, with PrEP, the main point is that you take it daily.

Risk assessment was emphasized in both discussions. Aaron Laxton spoke saying that when taken daily that PrEP is up to 99% effective. AHF seems to be focusing on the one third of gay men who do not use condoms and the underlying belief that new HIV infections are coming from people who don’t know they are infected and are not using safer sex practices. Dr. Hardy made it a point to say that since large populations of gay men are currently not using condoms, the infection rate could be significantly reduced if members of this group tested negative and were given PrEP. Each expert provided a multitude of numbers during the discussion, ranging from 44% to 99% based on your personal risk assessment.

Michael’s position was basically that PrEP is not good for the gay community at large because most people won’t take their medicine religiously. He stated that if taken regularly it is a good means of prevention in addition to current methods.  He fears people will consider it a free pass, believing that they are no longer at risk for HIV infection. Michael said if PrEP could somehow be administered monthly or a higher adherence rate could and we could be guaranteed, he would support it on a larger scale. The lack of adherence is his major pushback.

Michael’s argument for his position regarding PrEP is based on study results that show that only about 20% of test participants take the medications regularly and correctly. So, the bottom line here is that PrEP is the best new tool on the market to help prevent the spread of HIV, but it is not foolproof. There are a lot of outlying variables that have to be taken into account before the world’s largest HIV organization could publicly back such a medication.

Some facts from the discussion were that if a person is HIV positive and taking their medication daily as prescribed, they are 96% less infectious, leaving only a 4% chance of spreading the infection. Also, if a person currently has a sexual transmitted infection, their rate of contracting HIV is higher.

The question of Truvada resistance was asked and the doctors addressed it by saying that the risk person of drug resistance is low as long as the patient is negative when they start the treatment. Michal chimed in stating that AHF wanted the FDA to require mandatory HIV testing in order to qualify for PrEP because if an individual is in the process of seroconverting and starts PrEP, they may develop a Truvada resistance. All the experts on the panel agreed that it is vital to make sure PrEP candidates are HIV negative through blood tests etc., before beginning treatment and suggested regular visits to a health care provider approximately every 3 months to make sure no side effects have occurred.

One audience member asked about the use of PrEP with regard to being in a serodiscordant relationship (where one partner is HIV positive and one partner is HIV negative) and wanted to know if his partner was compliant with his medication, and if he was on PrEP, should he continue to wear condoms. Dr Wohlfeiler replied that as a medical professional he will always recommend the use of condoms but that on a personal level he felt that the likelihood of transmitting HIV to the negative partner would be extremely low and that would be a personal choice the couple should make together.

The question was asked, what is better PrEP or PEP (post exposure prophylaxis)? The doctors said that prevention is always better than treatment and suggested that PrEP has advantages by avoiding the risk of the virus replicating inside one’s body and having to aggressively attack it after the fact.

Overall it seems as if everyone agreed that PrEP is one of the best most exciting things available now to help in the prevention of HIV. People need to remember that abandoning condoms still puts them at a higher risk category and that is a personal choice that needs be accepted by the individual. PrEP is only effective in helping to prevent the spread of HIV but not other sexually transmitted infections.

It is important to note that several other medically based studies are currently being performed to test ways to improve medication adherence, as well as to learn how the medication is being stored in the body’s tissues.

So let’s face it, we know that condoms can be very effective in protecting people from HIV and other STD’s/STI’s when used correctly and used 100% of the time. However, the simple fact is that not everyone uses condoms, approximately 50% of the gay male population admits to not wearing condoms 100% of the time and it is probably rare that many people are using condoms for oral sex. So with that in mind, it is important to think about PrEP in addition to our HIV prevention tool kit. We know that using condoms, using lube, getting tested, and even abstinence can be helpful in the reduction of HIV. Also it is important to access your risk based on your sexual preference. A Top (insertive partner) is at less risk than a Bottom (receptive partner). Simply put because the rectal area has only one layer of protective cells and if HIV is deposited in this area, there is a much higher rate of infection possibility. So this brings up a question of self-assessment of your risk factors and explains why the effectiveness of PrEP has a wide range of numbers. If you are a Top on PrEP and adhere to the medication daily, it may be possible to have up to 99% protection against HIV. If you are a Bottom, the risk is higher. However, by having levels of Truvada in your blood, you greatly reduce the possibility of becoming infected.

The thing to remember is that PrEP is NOT a license to go wild. If you are using condoms consistently, this may not be a needed addition to your daily regimen. However, for the large percentage of men who are not using condoms or requiring their partners to use condoms, PrEP is an added layer of protection and it is the best thing we have on the market currently. According to HIV prevention advocates, during the studies of gay men, there are people who have converted during the studies, but none of them had a measurable amount of Truvada in their bloodstream. Basically, if you aren’t adhering to the daily dosage, your protection levels drop.  Your level of protection from HIV while using PrEP is entirely based on your level of adherence to the medication. This has been shown because the test subjects who had a measurable amount of Truvada in their blood remained negative. This is why researchers have been willing to give figures over 90% and even as high as 99%. If you choose to take PrEP and only take it 50% of the time, you can expect 50% of the maximum coverage. If you take PrEP every day, you will get the maximum level protection from HIV.

Overall, sex is healthy, it should be fun, and people need to be aware of their protection options. Many people choose to take PrEP to help alleviate the anxiety around having sex so they can enjoy it, whereas others are taking PrEP simply to increase their protection level. Some of the big pushback on the topic of PrEP comes because this really is the men’s sexual liberation, just as was birth control for women. This is giving men a choice on what prevention tools they are comfortable with using and is starting a discussion of self-assessment of risks for HIV and other sexually transmitted infections.
In 2013, it is time to self-assess our own personal risk for HIV and determine if a once-daily medication is something that you believe would help to protect yourself or not. My suggestion is to continue to educate yourself and ask your medical providers for more information. Private insurance currently covers PrEP as a preventative treatment and Gilead (the pharmaceutical creator of Truvada) offers a co-pay assistance program to help offset the cost. If you do not have insurance, you can research PrEP research studies in you area. In Los Angeles there are several groups that can help connect you with PrEP, including UCLA, USC, The Los Angeles PrEP Workgroup, and the Los Angeles Gay & Lesbian Center. Starting the discussion itself is just the beginning.  Love yourself. Protect yourself. Accept the risks you are willing to take, and make the right choices for you.

J Travis Walters
Additional Resources:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6223a2.htm

- J Travis Walters is a registered marriage and family therapist intern (IMF #69485) working toward licensure and a certified lifecoach in West Hollywood, CA who focuses on positive psychology in order to improve self-image and sexual expression. J Travis Walters is currently participating in a PrEP study provided through UCLA, reviewing the effectiveness of text messaging to improve medication adherenc


13 comments:

  1. Very nice article/

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  2. Very comprehensive article that I will share within all of my networks!

    ReplyDelete
    Replies
    1. Not comprehensive at all. This site is a bunch of jealous ass haters

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  3. This is very biased. The author is a participant in a PrEP study. I think this type of whitewashing of PrEP's risks only makes people more skeptical.

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  4. This piece is quite slanted and doesn't broach the original intent of such medications: namely, to be used mainly in serodiscordant relationships and in at-risk professions (e.g., medical, police, etc.). If 50% of gay men are supposedly not using condoms, as the article purports, human behavior clearly suggests eventual easing of traditional safe sex measures as people think they have protection in their bloodstream, which does absolutely for other STI's (e.g., HPV, HSV, syphilis, etc.). Similar trends occurred when birth control pills became available to women, as other STI's became rampant as rubbers were left unused. Wait till these guys start getting anal/colorectal cancers in their 50's. Finally, has the potential for a morphing superstrain of HIV even been broached in these meetings? The drug companies are trying to sell a drug till a vaccine is available. If use of this drug leads to strain-morphing, vaccines will take longer to develop and the drug companies will just make more money on protease inhibitors, etc. Think down the road before jumping on the Truvada bandwagon. There's a reason this type of medication has been quietly available for years already. Scientists know the risks of other infections and how it could deter vaccine efforts in the long-run.

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  5. This piece is hardly slanted. All we did was report on what we saw this week accurately. We are certainly not on the bandwagon. We are simply relaying what went down. If you can find better coverage of PREP week here in WeHo please feel free to share it with the rest of us.

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  6. Condoms are free and take about 1 second to put on. I dont get you queens.

    ReplyDelete
    Replies
    1. I don't get you queens who think because you like condoms then we all should wear them. Some men enjoy the intimacy of skin on skin, are educated about the risks, are honest about their hiv status, and accept responsibility for their behavior. Get over it.

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    2. i dont like them... but i enjoy living and my health and they are pretty cheap and easy. (kinda like u!)

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  7. No, this article did not seem biased in the least. It gave clear info, pro's and con's, and most importantly, told the reader to talk to their healthcare provider and make their own decision, if interested.

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  8. I think we can all make our own decisions. I am choosing not to get on PREP because it makes me physically ill. I also think that our bodies are capable of becoming immune to the type of protection that PREP claims to provide. This is a new frontier for all of us & I thank AHF & Impulse for their efforts to start a healthy dialogue.

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  9. Gays are gonna think this a cure-all and will run around participating in risky behavior. This is a shitstorm waiting to happen. It seems gay sex has been reduced to nothing but "taking loads." All barebackers can talk about is how many loads they can take or shot inside of someone. Its pretty disgusting. I also hate the people who make bad decisions and don't want to be accountable when they contract HIV and the meds are so expensive/have horrible side effects. You made the choice, live with the consequences. It's no different than drinking and driving. You may contract HIV, you may get arrested for DUI or get in an accident and kill someone or kill yourself. In the end you made the decision, you pay the price.

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  10. HIV is a Fraud

    http://www.youtube.com/watch?v=NZll-t1BIaQ

    ReplyDelete

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