PrEP: One Essential Tool in the HIV Prevention Toolkit
June 27 is National HIV Testing Day. The Centers for Disease Control and Prevention recommend that all patients seen in healthcare settings be tested for HIV, and that people at highest risk should be screened for HIV at least annually. These recommendations are intended to help people who don’t know they have HIV get treatment. For those who are screened and test negative there are different things they can do to stay HIV negative. Steven Shoptaw, PhD, describes one method that may be useful for those at highest risk.
By Steven Shoptaw, PhD (Center for HIV Identification, Prevention, and Treatment Services (CHIPTS), UCLA)
For those who are at high risk for HIV infection, there’s a medical approach that reduces risks of contracting HIV dramatically. It’s called pre-exposure prophylaxis or PrEP. PrEP uses antiretroviral medication (usually Truvada™, a two-drug combination of tenofovir and emtricitabine) to help HIV-negative people stay negative, even if they have sex without a condom with partners whose HIV status is either positive or unknown.
In this case, “high risk” is defined as having one or more sexual partners known to have HIV. It can also mean having sex where there is a high prevalence of HIV plus one or more of these risks:
Inconsistent or no condom use
Having sexual transmitted infections
Exchanging sex for money, food, shelter, drugs
Illicit drug use or alcohol dependence
Partners of unknown HIV status with any of the above risks.
PrEP using Truvada™ is approved for men who have sex with men, transgender individuals, for adult heterosexually active men and women and for injection drug users at substantial risk of HIV acquisition.
This is a significant advance in protecting the health of gay and bisexual men, men who have sex with men but don’t identify as gay, and transgender individuals. It brings sexual health for men into the domain of primary healthcare.
If you’re taking PrEP, it’s totally under your control—you don’t have to rely on someone else to put on a condom or to be truthful about his status. It echoes the ways that putting oral contraceptives into women’s hands brought women’s sexual health into primary healthcare.
For men who take PrEP as prescribed (daily or at least more than 4 doses per week), the risk for HIV infection decreases by more than 90%! But some people forget to take their medicine, raising the question, “What happens when a dose or two is missed?” One or two missed doses are not a big problem as long as you regularly take 4 or more doses each week. No infections have been reported for men who take 4 or more doses per week.
One possible exception was recently reported: A gay man who was taking oral daily Truvada™ became HIV infected because one of his partners was HIV-positive and was inconsistent with his own HIV antiretroviral therapy. Because the partner wasn’t following his PrEP regimen as instructed, the virus mutated and became resistant to several anti-HIV medications, including Truvada™. This happens very rarely, but it does confirm clinicians’ fears that not taking HIV medications as instructed can cause development of HIV that is resistant even to Truvada™. Consistency is key when it comes to PrEP.
Many, maybe even most, men at risk of HIV can take Truvada™ as recommended. But there are some important barriers that interfere with taking PrEP consistently.
Not having a regular place to live. Taking a pill every day requires consistent access to the essentials of good health, including a regular place to sleep and eating regular meals.
Lack of healthcare access. You have to go to a clinic or see a physician to get PrEP. Men—especially men of color—are not encouraged to seek healthcare, and in some parts of the United States, it is hard to get healthcare.
Stigma. Physicians may feel uncomfortable discussing sexual behavior, especially when it comes to men having sex with other men. Some may be unwilling to prescribe PrEP to men because they don’t approve of sex between men. Others may refuse to prescribe Truvada™ for HIV-negative men because its original use was to treat people with HIV. For some considering whether or not to take PrEP, concerns over embarrassment or harsh judgment from others can be a barrier.
Side effects. All medications have side effects; common ones for Truvada™ include mild gastrointestinal upset, nausea, and bloating. These usually go away once your body gets used to the drug. But there are also uncommon side effects that may be serious, including kidney damage. That’s why men starting PrEP with Truvada™ should have their kidney function tested before taking any pills. Truvada™ also causes bone mineral density loss, but this does not increase your risk for broken bones and it is reversed when you stop taking the drug. While risks for side effects are mild, it’s useful to discuss your own personal benefits relative to the risks with your medical provider.
Are you thinking about starting PrEP? Consult your physician and other people you trust. The decision to take PrEP should balance the risks of taking it against its benefits. For instance, most men don’t live their lives consistently having sex without a condom with multiple partners whose HIV status they don’t know. Instead, many men experience “seasons of risk” in their sexual lives, when the potential for encountering HIV during sex is higher at some times and lower at others.
During periods of low or no risk, men might stop taking PrEP. One drawback to this common behavior is that you can’t always anticipate when sex without a condom will happen. If you do have unexpected condomless sex, you can start post exposure prophylaxis. This is a 28-day regimen of antiretroviral medications after possible HIV exposure. But for PrEP to work before you engage in sex, you have to take it for at least a week for the medication to start protecting you. PrEP is not for everyone at risk for HIV infection, but it does offer a lot of promise to men who are willing to use it to help them to stay HIV negative. Over time, as more men and transgender individuals at risk use it, PrEP could help turn the tide of growing HIV infections – improving the health and welfare of countless others.
The American Psychological Association recognizes the importance of PrEP, and supports combined biomedical and behavioral approaches to optimize HIV prevention. You can also find out more about taking PrEP at Whatisprep.org. For more information about APA’s work on HIV, please visit the APA Office on AIDS website.
Steve Shoptaw, PhD, is a licensed psychologist and Professor in the UCLA Departments of Family Medicine and Psychiatry and Biobehavioral Sciences. Dr. Shoptaw joined the Department of Family Medicine as full professor in 2005. Prior to this, Dr. Shoptaw was a Research Psychologist with the Integrated Substance Abuse Program in the Dept. of Psychiatry & Behavioral Science since 2003. Dr. Shoptaw earned his BA (1982) in Psychology and MA (1985) and Ph.D. (1990) in Psychology at UCLA. His dissertation was nominated for the Gingerelli Award for Excellence in the Department of Psychology. Dr. Shoptaw completed his postdoctoral training in Psychophysiology at the UCLA NPI/VAMC in Sepulveda, CA in 1991.
Following that, Dr. Shoptaw worked for 10 years as a Principal Investigator with Friends Research Institute, Inc., during which time, his program of clinical research with substance abusers supported opening several treatment research clinics in Rancho Cucamonga, Hollywood, South Los Angeles, and West Hollywood. Dr. Shoptaw received the FRI Daniel Mendelsohn Young Investigator Award in 1996 and a mentoring award in 2000. In 1996, Dr. Shoptaw opened Safe House, a 24 bed facility that provides emergency, transitional and permanent housing to persons living with HIV/AIDS, chemical dependency, transitional and permanent housing to persons living with HIV/AIDS, chemical dependency, and mental illness who are homeless or at risk for homelessness. He continues with this program as a volunteer Executive Director. These linkages of clinical research and community collaboration have led Dr. Shoptaw’s work to influence practice guidelines in intervening with substance abusers, especially those at high risk for HIV transmission, locally, nationally and in emerging international epidemics.