Like us, you’ve heard and read the accounts of guys testing positive for HIV while taking PrEP. Their stories are told inside bars and clubs, spread from person to person, but most of all, posted on the internet for all to see. They make sure to tell us that not only have they tested poz while using this medication, but they also know of “lots of other guys” that have had the exact same experience. These stories are told with such emotion and conviction that the casual recipient of this information believes it without a shred of doubt. But there is one big problem with their tales; they are lies. Each and every single one of them are liars. Yeah, we said it!

Since PrEP was announced as a medication to prevent the spread of HIV it has lived in a home built of controversy and fear mongering. Truvada whores were our newest community villains, just shy of those horrid Barebackers. PrEP detractors consider those who take this medication to be lazy party bois who want to have as much condomless sex as possible. The theory, which did essentially prove to be correct, is that the STD infection rate within our community would rise.

In reality, PrEP is most prescribed and recommended for those guys who already are known to have high risk sex, including a lack of condom usage and multiple partners. Their usage of PrEP leads to an increase in overall STD testing as well as treatment, which could explain the rise of infections reported.

The plain truth of the matter is PrEP works! It is 99% effective in stopping HIV infection through sexual intercourse. Anyone who tells you differently is a pure and simple dirty, lying, liar, that lies. This is not to say that there are not those who have contracted HIV while using PrEP or that there are not some who honestly believe that they fall into this category.

When it comes to PrEP failure, there are two reasonings. The first, and the most common, is user error. The second, which concerns most people, but is so rare that it should not, is PrEP failure.

So, let’s talk about what’s going on.

What is PrEP?

By now you really should know what PrEP is and how it works, but if you don’t, click here for more information. For this article the most important information you need to know is about the two medications that make up the formula for PrEP. These would be emtricitabine and tenofovir. Together they are more commonly known under the brand name Truvada. In 2012, it became the first drug to be approved by the Food and Drug Administration for use in preventing HIV-negative people from contracting HIV through sexual intercourse. These medications have been used separately and together to fight HIV infection in those living with the virus for much longer. So, no, PrEP is not a new medication and it has been highly tested and proven, over and over again, by multiple agencies across the globe.

User Error

Humans are imperfect creatures that make mistakes and errors. Sometimes these are small and easily corrected and sometimes they have a much larger footprint. Once we agree that guys are human and will make mistakes when prescribed PrEP, failure on this medication makes more sense.

The most common dosing for PrEP is once daily, but so-called On Demand Dosing, where the individual takes the medication before and after sexual contact, is growing in popularity. Both have the same amount of effectiveness in preventing HIV infection. The differences are more about diminishing user error as well as addressing possible side-effects and cost concerns.

To be very clear, PrEP is just like any medication. If you do not take it EXACTLY as prescribed by your doctor, you will not receive the full benefits of the product as the manufacturers intended and tested for. This would not be the fault of PrEP but of the guy using it. This is the case with almost every single person who has contracted HIV while “on PrEP”.

Along with individual user error, is something we call “systemic breakdown”. This is when the error occurs not just possibly with the user but also with the established protocols for insuring the person being prescribed PrEP is the correct candidate as well as follow-up prescribing and testing is conducted. In effect, the doctors can fuck up too.

Systemic Breakdown

Because HIV is not like any virus we have encountered, our methods of treatment and prevention must also be new and innovative. PrEP is designed to prevent HIV from entering into healthy cells. But, to work efficiently, those cells must be free of HIV in the first place. To address this need, protocols have been created to reduce cases of ineffective treatment as well as drug resistance.

The CDC has developed guidance for providing PrEP to those most at risk for HIV infection. (SPOILER ALERT: THIS IS INCLUDES YOU).

I. Screening

Screening is the first phase in the delivery of PrEP. The screening phase includes the steps engagement, navigation, and an initial clinical evaluation. Screening is often the most time-intensive phase within the PrEP Care System.

  • Engagement includes an HIV risk assessment to identify persons who may benefit from PrEP. It also includes education about PrEP basics, including how PrEP works, the importance of medication adherence, and medication side effects.
  • Navigation services should be offered at the time of PrEP engagement to guide persons in need of PrEP to clinical services and insurance options that will pay for PrEP. If the client does not have insurance, navigators or clinic staff should assist the client in obtaining insurance or access to medication assistance programs.
  • The initial clinical evaluation is the final step in the screening phase and is performed by a medical provider. It occurs before prescribing PrEP and includes a brief history, including signs or symptoms of acute HIV or sexually transmitted diseases (STDs), history of kidney disease, a medication review and an assessment of indications for PrEP. The provider also should conduct an HIV blood test, evaluate kidney function, check hepatitis B virus (HBV) and hepatitis C virus (HCV) serology,and test for STDs.

II. PrEP Initiation

Where the initial clinical evaluation is an assessment of indications for PrEP including an assessment of laboratory values, PrEP initiation refers to when the PrEP medication is prescribed.

For locations where laboratory testing results, including an HIV test, are available on the same day as drawn, the initiation phase may occur on the same day as the initial clinical evaluation. When it is not possible to rule out HIV and normal renal function on the same day as the initial clinical evaluation, it is recommended to initiate PrEP within seven days of the HIV test to minimize the risk of HIV acquisition between the time of HIV testing and PrEP initiation. The  U.S. Public Health Service’s Preexposure Prophylaxis for the Prevention of HIV Infection in the United States – 2017 Update pdf icon[PDF – 2 MB] provides additional instruction on ruling out HIV infection prior to starting PrEP.

At the time of PrEP initiation, PrEP basics are reviewed and PrEP medication is prescribed. Medication can be provided directly by the clinic or by providing a prescription to an outside pharmacy. Paying for PrEP is part of this phase. Some insurers may require a prior authorization to cover the cost of medication or services. Medication can be accessed through drug assistance programs, like Ready, Set, PrEPexternal iconReady, Set, PrEP provides medication for those without drug prescription coverage or insurance.

III. Follow-Up

According to PrEP clinical practice guidelines:

  • Every three months:
    • Conduct HIV blood test
    • Conduct a symptom review of STDs, acute HIV infection, and side effects
    • Conduct HIV risk behavior assessment
    • Screen for STDs in sexually active adults and adolescents with signs or symptoms of an STD and in men who have sex with men (MSM) at high risk, defined as those with a recent bacterial STD or those with multiple sex partners
    • Provide adherence counseling and answer questions
    • Provide a new 3-month prescription for PrEP
  • Every six months:
    • Screen for STDs in sexually active adults and adolescents who do not meet the criteria for more frequent screening
    • Assess kidney function

A systemic breakdown can occur at any point during the above practice guidelines but most often, if it occurs, it will happen during the screening process or one of the follow-up visits. Both will involve not discovering that the guy has been infected with HIV at some point before initial usage, or a self prescribed break in usage. For example, as published by The BodyPro, the case of a 34-year-old gay white man in the U.S. who received an HIV-negative result from an antigen/antibody test, which has an average window of 21-28 days.

Two months (or 62 days) after receiving these results, the man’s doctor gave him a 30-day prescription for tenofovir/emtricitabine, with 11 refills. No further confirmatory testing was conducted to ensure that the man had not acquired HIV during the unknown three-month window (November 2015-February 2016) or after initiating PrEP.

The man reported discontinuing use in May 2016 “due to perceived lack of risk,” then restarted on his own two months (61 days) later. At no point in this process was he ever tested for HIV, nor did he receive any monitoring from his provider. His HIV status and adherence patterns are undocumented during this entire seven-month period.

When PrEP does really fail

Nothing in life is perfect, including medications. For this reason, no doctor or scientist would ever claim that one is 100% effective. PrEP, when used correctly is as close as we will most likely ever get. But, let’s dive into that possible 1%.

PrEP overload?

Just like a car that overheats, scientists have found that there is actually a limit to PrEPs ability to fight off HIV infection. The bar is crazy high, but one guy did fly over it.

A man in Amsterdam contracted HIV despite reporting excellent adherence to daily oral pre-exposure prophylaxis (PrEP) using tenofovir/emtricitabine (TDF/FTC, Truvada), according to a study presented at CROI 2017 in Seattle.

“A 50-year-old MSM (man who has sex with men) who became HIV positive eight months after starting PrEP. The patient tested negative for HIV at the start of PrEP, and at one month, three months and six months.”

“The patient reported an average of about 50 anal sex partners per month before diagnosis. He also reported having condomless anal sex on about 50% of the days before diagnosis. The median number of sex partners per day with condomless anal sex ranged between two to five each month. Additionally, during his time on PrEP, the patient experienced two instances of rectal gonorrhea and one instance of rectal Chlamydia. He also reported using drugs during sex, including amphetamine, cocaine, mephedrone and ketamine.”

“The presence of an aberrant immune response under appropriate serum TDF levels raises the possibility that a very high HIV exposure, possibly in combination with inadequate TDF levels in gut mucosa may have led to infection,” the researchers hypothesize. However, it remains unknown why and how the patient seroconverted.”

“This underscores the importance of regular HIV testing in PrEP users and being aware of potential atypical patterns of seroconversion,” the study authors conclude.”

Dried blood spots were collected at month six and month eight, both of which showed adequate levels of tenofovir, suggesting good adherence to PrEP.

Unverified PrEP adherence

Contrary to PrEP detractors (READ: haters) there are many protocols in place to address issues of medication adherence, as well as procedures to quickly assist anyone who is believed to have contracted HIV while using the medication.

The SERO PrEP Initiative is a resource provided by Grant’s laboratory for people who may have become HIV infected after receiving PrEP, and it offers confirmatory lab tests and other services free of charge. At least 650,000 individuals are now using PrEP worldwide, according to the August 2020 Global PrEP Tracker report, and four incidents have been reported where individuals with verified adherence to the drug acquired HIV. A few additional cases have been reported with unconfirmed adherence, or are currently under investigation.

As discussed earlier, adherence to PrEP is very important to receive the greatest intended benefits and outcomes. But not everyone, for whatever reasons, are able to do so. When this happens, HIV infection can occur. That is not the end of the story though. Once infection has been confirmed, medical providers assess the situation and, if necessary, the individual’s full details and accounts will lead to greater study and research.

In the most basic terms, what this means is that if your friend, who claims to have contracted HIV while on PrEP had actually done so, while properly using the medication as directed, he would have become one of the very rare case studies presented to the world at one of the yearly Conferences on Retroviruses and Opportunistic Infections (CROI). If not, he was one of the guys who failed while on PreP, but was NOT failed BY PrEP.

Just like in every area of life, there are outliers and those who fall into a grey category. Regarding PrEP, these will be individuals who converted to HIV positive while using PrEP but their true adherence can neither be confirmed nor invalidated.

As of the beginning of 2021, there are a total of seven (7) cases in the entire world and history of PrEP usage that fall within this framework. You can read about them HERE. What they all have in common is the inability of doctors/scientist to pin-point either the exact period of infection, the amount of HIV within the user’s system at the time of infection and/or the veracity of the statements made by the user regarding his adherence to PrEP.

It should be noted that, also at this time, there are three (3) cases that were reported to have been due to PrEP failure informally that are either unconfirmed or under investigation.

Verified PrEP adherence

Yes, we know, this is the information you truly care about. Just how many millions of guys around the world have contracted HIV while on PrEP that the “lame stream media” refuses to report.

If you believe guys have been contracting HIV while using PrEP as prescribed, you are correct. But, these numbers are not being hidden by anyone. To the contrary, each year the numbers, if they exist, are reported in multiple outlets devoted to HIV infection and/or Infectious Diseases. It is important that these stories be told and that we as a community understand the truth about PrEP. To be crystal clear, as of this writing there have been a grand total of four (4) individuals in the entire world that have contracted HIV while having verified PrEP adherence. One of them, the gentleman from Amsterdam was discussed earlier. The other three fall into the “resistance” category.

What is PrEP Resistance ?

 A 43-year-old gay man in Toronto who was adherent to pre-exposure prophylaxis (PrEP). Presented at CROI 2016 on Feb. 25, this is the first documented case of “PrEP failure,”. As reported by The BodyPro.

PrEP did not prevent infection in this instance because the person was exposed to a strain of HIV that had become resistant to several antiretroviral medications. These medications included (but were not limited to) tenofovir and emtricitabine, the two antiretrovirals in Truvada, which is currently the only PrEP regimen approved in the U.S.

It is estimated that well below 1% of people living with HIV are resistant to these two medications; even fewer also have a detectable viral load. Even if a person had this rare strain, if their viral load were undetectable, it would be extremely unlikely — borderline impossible, research has found — that he or she could transmit the virus to anyone.

Amount of PrEP resistance around us

Fearmongers will have you believe that PrEP resistance is common, but they would be lying. As published by AIDSMAP:

A study presented at the recent 25th Conference on Retroviruses and Opportunistic Infections (CROI 2018) aims to quantify how many people with HIV there might be in the community who both have a detectable HIV viral load and also have significant resistance to tenofovir and emtricitabine, the two drugs currently used in pre-exposure prophylaxis (PrEP).

The researchers, from the University of Washington in Seattle, found that in King County, which contains Seattle, no more than 0.3% of the local HIV-positive population had viral loads over 10,000 copies/ml, and also high-level resistance to tenofovir and emtricitabine.

However, an even smaller proportion of newly diagnosed people – just three cases in ten years, or one in 606 of those diagnosed – had primary drug resistance, i.e. actually became infected with tenofovir/emtricitabine-resistant HIV, and this is more likely to reflect the maximum frequency of people who could acquire drug-resistant HIV from someone else despite being on PrEP.

Susan Buskin and colleagues from Public Health Seattle and the University of Washington searched through drug resistance test records from 2003 to the end of 2017 to establish the frequency of high- and low-level resistance to tenofovir and emtricitabine. They also did four rounds of tests in 2016 and 2017 to establish how many people had “substantial” blood viral loads (viraemia) of over 10,000 copies/ml and how many had low-level viraemia of 1000-10,000 copies/ml.

They then counted how many people had both viraemia and drug resistance together, and used sequential testing to see how many had persistent viraemia.

Out of 6963 people on King County’s database of people diagnosed with HIV, 3881 (56%) had had a drug resistance test. Out of these 246 (6%) had high-level tenofovir/emtricitabine resistance, while at the last round of viral load tests 310 had substantial viraemia, or roughly 5% of people diagnosed.More news from United States

However, only 12 people (0.3% of those with resistance tests, or one in 323 people) had both high-level resistance and substantial viraemia.

What about those who are undiagnosed with HIV?

If you are sexually active, it is very important for you to have regular tests for STDs, including, but not limited to HIV. We recommend every three months. In the United States, there is a significant portion of people living with HIV that are undiagnosed. These people do not know about their infection, so their ability to pass it on to others is very high, especially when they have been initially exposed. This is because HIV viral load counts are usually the highest, and thus most contagious, during this time frame because the body has not yet created antibodies to fight the virus.

About 1.2 million people are living with HIV in the US but about 240,000 don’t know they are infected. Each year, about 50,000 people get infected with HIV in the US.  As of 2017, the latest figures available and published by the CDC, 51% of those Americans known to be living with HIV DO NOT HAVE AN UNDETECTABLE VIRAL LOAD, and are thus still able to transmit the virus. These figures are significantly higher than in comparable first world nations.

Effectively, we are looking at three (3) issues, not one. First, those people who do not know that they are living with HIV, then those who do know but have not reached undetectable levels and finally, of the prior two categories, how likely are they to have a strain of the virus that is resistant to PrEP?

The bad news

We don’t know what we don’t know. We can not research those who refuse to be counted. This is why is it most imperative that, not only are we having the largest number and percentage of our community tested for HIV and others STDs as often as possible, but also making sure that those who do test positive are able to have proper access to care and treatment as to become undetectable as quickly as possible.

The good news

Just like in real estate, much of this information comes down to location, location, location. Whether you are in the United States, The European Union, Latin America or Asia, will dictate not only your possible exposure to HIV but your access to PrEP. More and more countries are finding ways to make the drug accessible and affordable to those most in need. Testing for HIV is increasing and so is the knowledge about Undetectable equals Uninfectious (U=U). All of these measures are beginning to effect the HIV rates around the world, but there is something new being researched about PrEP usage that is worth noting.

In a symposium at CROI 2019, Jean-Michele Molina, MD, presented on PrEP failures, highlighting elements of diagnosis, resistance and treatment.

“it’s an important issue to assess the relationship between PrEP failures and resistance. What we’ve learned from clinical trials is that the way to see a resistance emerging with PrEP is actually to stop PrEP in someone who has acute HIV infection.”

We also know that there is a major difference between someone developing resistance to PrEP while using it, and someone encountering a sexual partner that has a strain of the virus which is already resistant to the medications within PrEP. The former, has yet to be encountered. The latter is the form of infection we have seen.

Finally, every single person known to have contracted HIV while using PrEP, either verified or not, was placed on effective HIV treatment and are doing well. PrEP resistance does not result in those infected being without medication treatment options or positive outcomes.

Before you Go

On so many levels we have the ability to not only slow down the number of HIV infections but also the variant strains that are resistant to PrEP. Both of them involve getting tested regularly for HIV and, if positive, taking your medications properly and as directed. Mutations come from those who are not consistent with their regiments.

With all of this being said, the greatest power we have is spreading facts and not fear about HIV prevention, treatment, those who choose to take PrEP and those living with HIV. The lies and disinformation circulating might seem funny and harmless but 40 years of fighting this virus should teach us that they are not.

If you or your provider believe you have acquired HIV while adhering to PrEP, please contact the researchers at the SERO PrEP Project so they can learn more from your experience and offer their treatment advice. It also advisable for your doctor to report your case promptly to your country’s drug regulatory agency (in the U.S., the FDA) and to Gilead, the manufacturer of Truvada. The more people communicate, the more we will understand.

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