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Dr. Wohl and Truvada
Aug 4, 2014

Dr. Wohl- I've noticed in statements you've made that Truvada can alone only be used as PrEP. I'm just wondering how you can draw that conclusion based on the lack of data we have about PrEP itself (besides the recent studies that are themselves controversial) and PEP and drugs that suffice for usage as PEP. To my knowledge, the AZT study for occupational exposures is the definitive study for PEP usage-- and that was one drug. We really don't know what the best combo is for PEP, but many medical providers will suggest a 3 drug regimen "just in case" or for a high risk exposure. If anything, do we not have more info available for Truvada as PEP instead? (I know the guidelines are now for Truvada as PrEP, but guidelines are obviously just the best recommendations based on research available in the here and now.)

I'm sure not all HIV specialists agree on everything, but I topped someone for 30 seconds without a condom last weekend and sought PEP at a community health clinic in Chicago that caters to the LGBT community, with big PrEP and PEP programs. The docs didn't even want to give me meds given my low risk (I don't know the status of my partner), but after insisting, they gave me Truvada. I began the med at 8 hours post-exposure. The pharmacist almost agreed that my risk was very low and with the Truvada it is almost negligible.

What are your thoughts on the above? No one wants HIV, but I think sometimes thebody tends to be very very conservative and a bit on the fear mongering side when it comes to alleviating concerns and doling out advice. I work with HIV in developing countries-- while it only takes one encounter to become infected, the vast majority of infections arise from receptive anal and vaginal sex. Why can't we be clear about facts instead of making folks worry about 0.06 percent chances? Of course, we should be vigilant about testing for HIV, getting poz folks to UD levels, and ending AIDS. Sexually active folks should regularly get tested, but to act like HIV is a disease that's relatively "easy" to get combined with issues regarding shame and mental health of the vulnerable populations at the highest risk (MSM, women, drug users, those from cultures where they cannot ask or make their partner to wear protection)-- I just think the "bedside manner" on this website could be a bit more friendly and less damning.

Thank you for your help.

Response from Dr. Wohl

I agree with you that there is a perception that HIV is easy to catch and thousands of keystrokes I have typed on this site to combat that notion. However, we do not see eye to eye about how to deal with sexual risk.

Despite the biological challenges of transmission, tens of thousands here in the US, and many more elsewhere, continue to get infected each year. New infection rates here have gone down but that may be because of the effects of HIV therapy on lowering viral load and thus transmissibility more than anything else.

While PrEP and PEP are not the answer to reducing transmission to zero, they can be important tools.

Truvada alone does work as PrEP. The iPrEX study clearly demonstrates this for men who have sex with men and the Partners PrEP trial for heterosexuals. Animal studies also show that this is an effective way to protect against infection when condoms are not used. PrEP is not for everyone but it is now an option that folks can decide for themselves whether to use or not.

As far as PEP, Truvada alone likely works. The issue is whether an additional agent confers more protection. Most experts believe it does. Here there are less data as this is a much harder thing to study. However, there are the considerations of compartments and resistance. Different drugs get into different compartments of the body differently. A combination of medications may be more protective in more places. Moreover, there is drug resistance. 10-20% of transmitted virus is resistant to at least one HIV medication. Therefore, some people may become infected with a strain of HIV that is is less susceptible to the agents in Truvada. Further, if infection were to occur despite the PEP, replicating virus in the face of Truvada alone would carry a high risk of leading to drug resistance among the newly established population of HIV. For these reasons, adding a well tolerated third drug (now Isentress) for 4 weeks seems prudent.

Prudence is what this is all about. We take vaccines for diseases we have a very low risk of ever encountering, and submit to colonoscopies at age 50 even though the vast majority of us will never get colon cancer. This site (and I) are responding to an epidemic that has devastated countless lives and communities and despite major advances still rages. I understand your points and respect them, but I would rather be what you would term "conservative" and prevent one single infection than to be more caviler and have someone lower their guard and acquire this virus.

DW



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