"Raw Sex" -- Are the Rules Changing?
December 5, 2013
What About PrEP?
One of the newest tools in the prevention toolbox, PrEP, got a lot of attention at the forum. An audience poll showed that 23% had either used PrEP or had a partner who had done so.
Hemming reviewed some data from major PrEP studies. The iPrEx study of men who have sex with men found that daily PrEP using Truvada (Gilead Science's tenofovir/emtricitabine combination pill) lowered HIV infection risk by more than 90% among participants who had blood drug levels indicating that they took it regularly.
Dr. Eveland stressed that Truvada "is not a morning-after pill" and must be taken every day. Studies are underway looking at intermittent PrEP taken before and after sex, but so far research only supports daily use with good adherence.
Scardina related that he first heard about PrEP after doing post-exposure prophylaxis, or PEP -- taking antiretrovirals after exposure to prevent HIV from establishing infection. He then enrolled in City Clinic's PrEP study, which provided him with a year's worth of Truvada.
"Truvada has worked really well for me," he said. "I haven't relied solely on PrEP and still use condoms depending on the situation."
Speaking from the audience, activist attorney David Waggoner said he started taking Truvada PrEP four years ago, long before it was approved by the FDA. He too had taken PEP multiple times after unprotected sex and asked his doctor if he could just stay on antiretrovirals for prevention.
As for why PrEP has not "caught on like wildfire," Hemming noted that it can be a challenge to take pills every day. In a majority of PrEP studies, many or most people did not take it as directed. Some people are also fearful about PrEP after seeing the debilitating side effects of older antiretroviral drugs. "People are scared of what it's going to do to their body," he said.
Truvada is generally well tolerated but can cause kidney problems and bone loss in some people. According to Dr. Eveland, the most common side effects are fatigue and gastrointestinal symptoms. But Scardina said he has had "barely any side effects," while Waggoner reported that he "never had any side effects at all."
The cost of Truvada -- about $1,000 per month -- is also a barrier. Guttirez brought up the issue of low-income people and people of color who may not have access to PrEP. Scardina just turned 26 and has to go off his parents' health plan. "I'm running out of pills and I don't have insurance," he lamented.
Even for people who are insured, Truvada for prevention may be hard to come by. Waggoner related that a friend seeking PrEP from Kaiser Permanente was required to go before a panel of doctors to be grilled about his sexual behavior and level of risk. Another audience member, however, said he was able to get Truvada PrEP through Kaiser with little difficulty. Waggoner also noted that Gilead offers a patient assistance program for people who cannot afford Truvada PrEP.
Several panelists and audience members brought up the issue of "slut-shaming," or moralistic objections to people who use PrEP or other risk-reduction strategies instead of using a condom every time they have sex.
"Science is still lower on the hierarchy than morality," said Waggoner. "Puritanical ideas are guiding social policy."
Guttirez and others raised the issue of discrimination on the basis of positive or negative status being replaced by discrimination based on viral load or PrEP use. "Where is the space for men with detectable viral load," he asked?
"As a positive person, I feel if said 'I love to take loads and give them' I'll be stigmatized. ... People will say 'Typhoid Mary is running around,'" Ramos declared. "I have to be more responsible [for HIV prevention] than a negative person. ... The onus on the positive person has been unfair for awhile, and it's good to see negative men now taking responsibility."
"Not having the trauma of losing all your friends has impacted the way [younger guys] have sex and the harm reduction strategies we employ," Guttirez acknowledged. "Shaming from elders with the intention of wanting to support comes off as a scare tactic that I don't think is successful."
"There's a lot of room for queer and trans people to grow together talking about HIV intergenerationally," he said. "We don't have to leave these conversations in the bedroom."
To connect with sexual health services, find out about clinical trials, and learn more about the safer-sex strategies discussed at the Real Talk forum, take advantage of these important resources.
Liz Highleyman is a freelance medical writer and editor-in-chief of HIVandHepatitis.com.
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