Those of you who have read my blog know that I am on pre-exposure prophylaxis (PrEP) to reduce my risk for HIV infection. And more and more of my patients are also beginning to take Truvada (a pill combining the antiretroviral drugs tenofovir and emtricitabine) as PrEP to prevent HIV infection. And all of my patients are asking me what my recommendations are for condom use in light of the data on PrEP.
If you ask most clinicians, researchers and public health officials, the usual answer is: "Well, you should continue to use condoms because, of course, Truvada does not protect against STIs (sexually transmitted infections)."
The problem is THAT IS NOT THE QUESTION PATIENTS ARE ASKING!
Let's face the fact that everyone hates condoms! We hear a lot about gay men not using condoms these days, but how many heterosexual men are using them if their female partners are on birth control? Are doctors counseling that all of their straight patients need to use a condom every time in every situation, now and forever? You know they're not. But that's the only message we've had for gay men for a long time. It's a message that was vital in the days when we had no other tools, had unreliable testing and did not understand transmission well. It's a message that saved countless lives. But now it's a message that pathologizes gay sex and fails to recognize that people are making reasonable and rational choices about risk. Now we have PrEP and treatment as prevention (TasP).
People want to know if using PrEP could actually allow them to go without condoms. They are looking to their doctors for guidance. If we sidestep the question by talking about STIs, then we leave people fumbling around to find their own way. PrEP opens the door to talking about situations where the risk of HIV infection will be so low that perhaps going without condoms is a reasonable choice. I will share with you the guidance I give my patients.
Seat Belts Plus Airbags
If some people want to take PrEP and still use condoms, I salute their choice. They will be the safest among us. Some have likened this to using a belt and suspenders to hold up one's pants. I don't like this image because it implies that those who choose it are a bunch of nerds (see Urkel). I prefer the analogy of the use of seat belts and airbags in cars. Both are there to protect us, but they work in different ways to do so -- and outcomes are best when we use both modalities.
At this point, I think most people would agree that those in a long-term, stable monogamous relationship where both partners are the same serostatus do not need to use condoms.
Let's Look at the Numbers
If we look at several different scenarios for sexual encounters outside of a long-term, stable monogamous relationship with partners of like serostatus, we can see some areas where PrEP and TasP can reduce risk so much that choosing not to use condoms can be a rational choice.
The U.S. Centers for Disease Control and Prevention (CDC) has calculated the risk of HIV transmission for multiple sexual and other exposures. The risk for receptive anal intercourse (bottoming) is 134 for 10,000 exposures. Just to be clear, from a public health standpoint, this is a high risk.
If one partner is HIV positive and is undetectable on medication (viral load <40 copies/mL on some tests and <20 copies/mL on others), then the chance of passing HIV is reduced by 97% or so (conservatively).
This is according to a number of studies -- including the PARTNER study, which showed no transmission among over 700 serodiscordant couples who were not using condoms and where the HIV-positive partner was on suppressive antiretroviral therapy and the negative partner was not on PrEP. If the negative partner is on PrEP, and taking the medications reliably, then that person's risk of acquiring HIV is reduced by, let's say, 92% to 100% according to various studies. With these reductions in risk (97% and then 95%), the risk becomes something like 1 out of 50,000 encounters. If we use a 99% figure for PrEP, we're looking at 1 per 250,000 episodes. I think we can reasonably ask: What more HIV risk reduction we can get from using condoms in this situation?
Both Partners Negative, Both on PrEP
If both partners are negative and on PrEP, then both are being seen by medical providers. And if those providers are following protocol, then the patients are getting tested every three months for HIV and STIs and taking their meds and should reliably be negative. What does a condom add to HIV risk reduction in this scenario?
Both Partners Say They're Negative, One on PrEP
If one partner who claims to be negative is on PrEP and the other is not, then it becomes a bit more complicated. If you are the person on PrEP, you need to ask yourself how well you know the other person. Do you trust that the person is really negative? Do you know when the individual last got tested? Do you know the individual's sexual history? And finally, are you comfortable enough with what you know and with Truvada's ability to prevent HIV infection to not use a condom with this person? A more difficult choice to be sure, but one where knowledge of your partner can help to reduce risk.
The Unknown Partner Scenario
That leaves the unknown partner, someone whose serostatus you cannot know for sure. I ask my patients to consider this scenario: You're on PrEP and a really hot guy comes up to you and says, "I really want to have sex with you, but you should know I recently became positive for HIV and I'm not on any medications yet and my viral load is pretty high." Would you have unprotected sex with this man?
- Most of my patients immediately answer no (unfortunately too many would not even have sex with him, despite the fact that condoms would protect them, but we'll leave stigma to another discussion).
- Some people say they aren't sure. A few have said they would only top that person without a condom (the risk from a single episode of insertive anal intercourse is 11 in 10,000 encounters -- you do the math).
- A small number who are strong believers in the power of PrEP to protect them say they would still have unprotected sex, including receptive anal intercourse.
So we talk about these choices.
To those who say they would use a condom, I say that is the way they then need to handle every unknown hookup.
For those who say they would still have unprotected sex, I first say that I hope that PrEP will be as effective in this scenario as it was in studies overall. I then caution them that the data we have from studies have not proven that is true. The studies of PrEP have not looked at the HIV status and viral load levels of every partner of the study participants. We cannot say for sure that PrEP will work as well overall if one is constantly encountering partners with very high HIV viral loads. That is not to say for sure that it won't work, but we just don't know. People who are on PrEP and not using condoms with strangers are, in fact, experimenting with their own bodies. I am not saying that they are wrong or stupid or ill-informed, but they need to be aware that we do not know for sure that this will be safe.
The STI Issue
Of course, there is always the STI issue as well. If someone has an infection in the urethra with a discharge and burning, most would assume that person would not be having sex with others. Unfortunately, most anal infections (and oral ones too) are asymptomatic. So people are unaware that they are infected and will continue to have sexual encounters. Using a condom for intercourse when you're hooking up with people will definitely reduce your risk of acquiring an STI.
Moving the Message
PrEP is a game-changer in so many ways. I think one of the biggest changes is that we can reasonably start looking at risk in various types of sexual encounters. With real data, we can help people to begin to think about their risk in very clear ways. Perhaps, if our message moves from "you have to use a condom in every situation now and forever" to "there are definitely times when using a condom will work to reduce your risk in significant ways, but there are situations where not using a condom is a reasonable choice," we may be able to improve outcomes, improve sexual decision-making and lower new infection rates.
Howard Grossman, M.D., is the director of AlphaBetterCare, an LGBT-friendly primary care provider serving New York City and New Jersey. An HIV physician and researcher for more than 20 years, Grossman is also a senior attending physician at Mount Sinai Roosevelt Hospital.