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PrEP'ing: Are You Ready? Doctors and Advocates Are Gearing Up to Bring Truvada PrEP to People at Greatest Risk of Infection

July/August 2012

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PrEP'ing: Are You Ready? Doctors and Advocates Are Gearing Up to Bring Truvada PrEP to People at Greatest Risk of Infection

Love it or hate it, it's coming: HIV prevention with the use of one pill, taken once a day.In May, the use of the HIV drug Truvada by HIV-negative people to prevent infection with the virus was recommended for FDA approval by the agency's Antiviral Drugs Advisory Committee (AVDAC).

"Today is an exciting day for HIV prevention," said Kenneth H. Mayer, M.D., Medical Research Director and Co-Chair of The Fenway Institute at Fenway Health in Boston, about the recommendation. "Although [Truvada] for PrEP [pre-exposure prophylaxis, or prevention] is not a panacea, this approach can prevent many new infections and could dramatically impact HIV transmission worldwide."

But for all of its promise, and all of its advocates, HIV prevention with Truvada has some concerned that it could be used incorrectly, creating a new set of potentially serious problems.

Many also worry that people on PrEP may stop using condoms or increase their risk in other ways, such as having sex with more partners. Doing so may negate the good that PrEP can do.

As well-intentioned as these people may be, they may be overlooking problems with condoms and HIV treatment, both of which if used and used correctly, are highly effective in preventing HIV transmission. Yet few come out against condoms or HIV therapy because of their potential for misuse and harm.

Even sex with condoms can be risky, and the promise of prevention for partners with HIV treatment is often unfulfilled due to lack of access -- the Centers for Disease Control and Prevention (CDC) estimates that only one in three people with HIV in the U.S. have controlled, or "undetectable," virus, and further, that one in five don't even know they're infected. People with HIV may also choose not to be on antiviral therapy for any number of reasons, and so remain more infectious to their sexual partners than if they were on treatment, especially in the absence of condoms. Never mind that those with undetectable virus in their blood may still be infectious.


At Risk

The week that the advisory committee made its decision, a young man in Chicago struggled with the symptoms of seroconverting, including nausea, diarrhea, and nightsweats, after having three episodes of unprotected sex with a presumably HIV-negative man in another city.

Chris had chatted with this man for months over the Internet, but it wasn't until after they had sex that he told Chris, "You know, there are some people out there who say that they're HIV-negative but they're positive and they're spreading the virus. My ex-boyfriend in L.A. is one of those guys."

"He even had a word for it, 'pozzing.' I never heard of that," said Chris.

Would taking Truvada every day have helped Chris, who was now in a state of panic?

"I definitely would be somebody who would take something like that," said Chris. "It sounds almost like a miracle drug, especially after all I've been through with my friends, watching some of them get infected and some of them die. I think the drug is exciting."

When Safer Sex Isn't

Truvada is not a morning-after pill as some believe.

When Mark (not his real name) worked in HIV services in Chicago more than a decade ago, he heard from several gay men that they were infected when their sex partner took his condom off while they were having sex, usually without their knowledge. He began spreading the word about this danger in his outreach and heard back from many men who told him, "That's my story."

"I would always tell people to reach around and feel to see that the condom was still on," said Mark. "People were shocked." He remembers most distinctly a handsome young man who stood up during one of his talks and tearfully thanked him. "He was angry at his infector," said Mark, "but I remember even more his anger and hurt at friends who didn't believe that this had happened to him."

In some cases, gay men who were "tops," or insertive anal sex partners, thought they were virtually risk-free. But while they were at lower risk than the "bottom" (receptive) partner, many of them became infected nonetheless.

He's also haunted by the experience of testing two young men who were a couple. The first boyfriend tested HIV-negative, but the second one tested positive. "Right in front of me out in the lobby, he said, 'I'm negative, let's go home.' And there was nothing I could do about it. They had to send me home that day because I was going out of my mind."

Afterwards he made it a point to tell people to ask to be in the same room when their partner gets an HIV test result, and that it's a red flag if the person refuses.

Like Chris and many other gay men, Mark struggled with the deception practiced on the Internet. "I don't know how many times guys told me, 'Oh my God, you're the first person to tell me you're positive' or 'You're the first person I've met who's positive.' No, I'm just probably the first guy who was honest. Others [who were HIV-positive] either lie or they don't know they're positive. If you put your life and your care in someone else's hands based on their word, you're putting yourself at risk." Even gay men who thought they were in safe, monogamous relationships became infected by the partner they trusted, he said.

Mark says that if PrEP protects one or two people, it's worth it. "I'm on the side of using all the options we can get."

Sexual Assault

Eight years ago, Vince (not his real name) went home with a man he'd just met. They made out, but Vince, drunk, fell asleep. He woke up with the man inside him. He fought back and got the guy off him, but there was no condom, which mystified him, since "the guy didn't know me." Having always practiced protected anal sex, Vince knows that this sexual assault is how he became infected.

He had only had unprotected sex one other time -- and he thought it was protected. "I know he had on a condom, I helped him put it on. But he let it come off inside me." Vince wondered what happened to the condom when he didn't see it after sex. Thinking back on that night in a bathhouse, he says he should have asked about it. (The condom came out later when he used the bathroom.) Vince waited six months to test for HIV (the recommendation at the time) and he was negative. He says he was lucky.

But that was then and this is now. Today once-daily prevention with Truvada is an option that can be added to condom use with an off-label prescription and is already available, even without official FDA approval.

"I absolutely would have taken it, even though I always played safe. You never know when something like that is going to happen. You do everything you can to prevent it and then you make one mistake and it changes your life forever. It sucks," said Vince. He says he would take Truvada PrEP today in a heartbeat, if he was still HIV-negative and at risk, knowing what he knows now.

"Having been through that [first] experience, it would have helped when I got infected," Vince said.

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This article was provided by Positively Aware. It is a part of the publication Positively Aware. Visit Positively Aware's website to find out more about the publication.
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