Should I Take Prep?

Should I take PrEP (Truvada)?

NOTE: When weighing the fear of possible side effects, long and short term, with the usage of PrEP, you should also think about your overall risk factors for contracting HIV and if you believe your risk is worth the protection. Only you can make this decision for yourself.

This is the million-dollar question, which we and no one else can answer for you, but we can provide some information to assist you. First off, if you are HIV positive, Truvada is one of many choices you have to treat your infection but not as PrEP. If you are unsure of your HIV status, we strongly recommend getting tested before making any decisions, as the outcome will greatly affect your choices. A proper physician will test you for the HIV virus before prescribing PrEP, and will continue testing you, every three (3) months, to make sure that you are still HIV negative.

PrEP is for those guys that are known to be HIV negative, and generally considered to be in a “high risk group for HIV infection”, as defined by the CDC. This is a very large net that includes all sexually active gay males. Unless you practice an abstinence only policy, PrEP is a possible medication for you. Contrary to much of the (mis)information published about PrEP on the web and in the media, we at GMJ believe that the final decision about this medication should be made by you alone, with the support of your treating physician. We can not say this enough.

Many news outlets, gay and straight, continue to publish articles about the inherent dangers associated with allowing gay males to choose to take a medication that relies upon strict adherence and is “extremely toxic”. Tom Myers of US News and World Reports, wrote a scathing article that PrEP “will do more harm than good” because we will not take the medication as prescribed, and will give many “a false sense of security”.

Larry Kramer, one of the founders of New York City’s, Gay Men’s Health Crisis (GMHC) stated in an article for the New York Times, “there’s something to me cowardly about taking Truvada instead of using a condom. You’re taking a drug that is poison to you, and it has lessened your energy to fight, to get involved, to do anything”.

And of course, you will remember David Duran, the HIV positive gay man who published a piece in the Huffington Post coining the phrase “Truvada whore”. Three year later, he, like Kramer has changed his tune. Stating,”when I first heard about PrEP, I wasn’t convinced. I was also, at the time, a slut-shaming, sexually introverted and rather judgmental human being. So when I penned the once famous “Truvada Whore” opinion piece that haunts me to this day, I was coming from a place of not really understanding why anyone would need or want to take this pill when condoms where so readily available.” Mr. Kramer, now calls PrEP “an essential tool”.

It should be stated that none of these men are medical doctors or policy experts, specializing in gay male health or specialists in the field of modern HIV treatment or prevention. And like them, none of your friends on Facebook, or those who write comments on gay news sites, are either. Strangers on the Internet are much more likely to be like Mr. Duran and coming from his place of personal trauma and bullshit, than someone looking out for your individual benefit.

But we want you to take a moment and think about these three (3) men and all of the harm they have created. All of the fear they have stoked as well as the misinformation they have spread. How many guys have contracted HIV while listening to them? How many at-risk men are now living with HIV and MUST TAKE TRUVADA FOR LIFE, instead of as a preventative measure, because they followed the advice of a pillar in our community, an uninformed writer for a magazine and a self-described “slut shaming, sexually introverted, judgmental” blogger?

Now, think about all of the gay men in your life that still continue to repeat the words of these men. The ones that know better than you what you should do, because they have a friend, who knows this guys, that went out with a guy on PrEP who is now…

The science is clear, but the choice is yours.

These guys are not alone in their negative opinions about what other consenting gay men do with their bodies and of the gay male community’s inability to take a medication regularly that can potentially keep us from contracting HIV…and thus NEEDING to take the very same medications for life.

But, here is a list of questions you should ask yourself before speaking with your doctor about PrEP. This is, of course not a complete list, but the basics. Along the way, think about your life, your actual life, not the one you project:

1. Am I HIV negative?

2. Am I sexually active?

3. Am I concerned about contracting HIV?

4. Am I sexually active with partners that are, or may be, HIV positive?

5. Am I in a relationship with someone who is HIV positive?

6. Have I tested positive for STDs other than HIV?

7. Am I a recreational drug user?

8. Am I a heavy alcohol drinker?

9. Do I enjoy multiple sex partners?

10. Do I use condoms properly and correctly, with every sexual partner, every time…no matter what?

And one of the most important questions: Am I willing and responsible enough to take PrEP, as directed by my attending doctor, and follow the medical guidelines for follow-up, which include:

A. Three (3) month visits for blood work to check for possible HIV infection, kidney function, other STD infections as well as other negative side effects.

B. Understanding the usage of PrEP does not provide protection against any other STDs and condom usage is still recommended to provide another level of protection against those diseases as well as HIV.

How effective is PrEP?

Ah, another tricky question. As we stated above, Truvada has been on the market since 2004, effectively treating HIV in those that are infected. Logic dictates that if something can treat an actual infection, it will be successful in protecting against potential infection. But, there is a catch…of course. When someone is diagnosed with the HIV virus, they are given a talk about the necessity of taking their meds, as directed and usually at the same time of day, every day. The sheer weight of an HIV positive result is known to be a great motivator for some to do as prescribed. It is literally the difference between life and death. But others still have issues following these directions and thus gaining the golden ticked of becoming “Undetectable”.

Just like any preventative tool, not everyone will do as recommended. Take, for example, flossing. We all know that one of the best ways to prevent cavities is to floss at least once, but probably twice daily. Do you floss twice a day? This is the reason that PrEP is not right for everyone, as taking it as directed will determine the overall effectiveness of the medication. So, let’s look at two studies regarding PrEP usage and the effects. One is based on a daily routine, the other for as little as four (4) times a week.


The San Francisco Study

This is considered the first “real world” study to follow sexually active gay males and the effects of PrEP in preventing HIV infection. Following 657 people, 99% who were men who have sex with men, with an average age of 37, for 32 months. All of the participants considered themselves to be sexually active, and not all used condoms. Study co-author, Julia Marcus states “74 percent of participants said there was no change in the number of sexual partners they had while taking the drug, and only 11 percent said they had more sexual partners. Also, 41 percent said they decreased their use of condoms, while 51 percent said their condom use was unchanged.” 0% of the study participants contracted the HIV virus! The results were published in the journal for Clinical Infections Diseases in September of 2015.


The IPrEx OLE Study

“Based on the findings in this study, the researchers estimate that taking Truvada four or more days a week is 100 percent effective at preventing HIV. The combined estimate range of four to six days a week dosing and daily dosing is 86 percent to 100 percent efficacy.  That means that, according to this trial, four or more days a week of PrEP reduces the risk of contracting HIV by at least 86 percent, but that figure may indeed be as high as 100 percent.

By comparison, the original iPrEx study showed a 92 percent risk reduction among those who had any Truvada in their systems, with an estimate range of 40 to 99 percent efficacy. A subsequent study of the iPrEx data used statistical modeling to estimate that four doses a week reduced the risk of HIV by 95 percent, with a 90 percent to more than 99 percent estimate range, and that daily dosing reduced the risk by 99 percent, with an estimate range of 96 to more than 99 percent.”

What does all of this mean?

The simple answer is that PrEP is a viable option to place in your tool box for HIV prevention, depending on your risk levels and adherence to the regiment. Some of the major ground rules for determining if Truvada is right for you depends greatly on your ability to take the medication as directed, attend regular check-ups with your doctor and take this choice seriously. Luckily, Truvada, for those that are HIV negative can be stopped and started again at a later date, as long as you remain negative during the gap. You may choose to use PrEP for a year, for example, stop, and then begin again. One of the greatest things about being a gay male is our ability to change our minds. Taking Truvada as PrEP does not have to be a permanent choice. As your life changes, so can your options.

But, what about drug resistance?

First off, if you are taking PrEP as prescribed, you should not contract HIV, so medication resistance will not be an issue. For those that are not able to completely comply, some interesting facts have come from recent studies.

Dr. Robert Grant, MD, MPH of the Gladstone Institutes, the University of California at San Francisco, and San Francisco AIDS Foundation, and Teri Liegler also of University of California, conclude that “Seroconversions on PrEP are more likely to occur during penile/vaginal sex than during anal sex, which helps explain why drug resistance developing during PrEP hasn’t been observed in groups of MSM who have seroconverted after receiving PrEP.”

Further, “we showed that the highest risk of resistance comes from those who start—or restart—PrEP during unrecognized infection,” says Dara Lehman, PhD, of the Fred Hutchinson Cancer Research Center, and lead author of the study of drug resistance and PrEP published in the Journal of Infectious Diseases. “Standard HIV tests detect antibodies and those are not present immediately after infection. So if you use a standard HIV test to screen someone and then put them on PrEP, there’s a chance that they were actually infected at the time of the test. It is important to work to improve that.”

Finally, even if, by some rare chance, you become infected with HIV while on PrEP, and also develop a resistance to Truvada, this does not mean that you are out of treatment options for HIV. There is a long list of other medications available for your consideration. A resistance to one medication does not mean a resistance to all HIV medications.

PrEP does not protect against other STDs

That is correct. Truvada is a medication formulated to combat the HIV virus, and only that virus. Just like the flu vaccine only protects against the flu and not the common cold, pneumonia or Chickenpox. Medical organizations around the world have concluded that, as effective as PrEP is, gay males that are sexually active should continue to utilize condoms to reduce the risk of infection from other sexually transmitted diseases. Even though latex is not a perfect product, it does assist in reducing your individual risk factors for contracting other STDs.

  •  We at GMJ have decided not to address the matter of condom usage in relationship to PrEP, so-called “barebacking” and other distractions because we understand that there are guys who do not like to use condoms for a myriad of reason which started long before Truvada hit the market. We have created a Piece on condoms, where we take up this topic.

What if my doctor will not prescribe PrEP for me?

GMJ has a Primer about how to find a proper doctor and the hurdles gay males have in obtaining one that is truly knowledgeable about our experiences. A recent study out of New York City found that 1 out of every 3 doctors did not have sufficient, if any, knowledge, about PrEP. For this very reason, the New York City Department of Health has created an outreach program to educate and promote PrEP amongst the medical profession as part of its “End AIDS by 2020” campaign. But, if you do not happen to live in New York City, this does not help you…you must learn to help yourself.

If you find that your doctor will not provide you with a prescription for PrEP, for whatever reason(s), this is definitely not the right practice for you. You know your life, and your potential risk factors for contracting HIV and other STDs, so you need a medical team that works with you in supporting your healthcare needs, not against you. The first step is getting yourself educated about Truvada and being willing to take a hard stance to get what you need to protect yourself and your sexual partner(s).

The ultimate decision about taking this medication is yours, not your friends’, your family members’, people on FaceBook, or your doctor. Man up!

I heard it is expensive. How do I pay for PrEP?

Truvada is paid for through healthcare plans through the Affordable Care Act (Obama Care), Medicaid, Medicare and ADAP programs around the country. Some Gay and Lesbian clinics will also provide the medication for free to those who cannot afford it. Co-pays may apply, so check with your insurance plan to see how much your yearly costs may be. We cannot give you an exact price because it will vary from plan to plan and even state to state. But most major cities have made providing PrEP a major concern and have created coverage plans to insure those most at risk are able to receive Truvada. Do your homework and don’t let others scare you away with stories about cost.

Finally, you must also weigh your personal risks factors of contracting HIV and the long-term monetary cost of having a life long chronic illness.

I heard that PrEP was toxic!

In the early days of the AIDS epidemic one of the first medications, AZT was known to be very aggressive in treating the illness, and thus causing serious physical damage to the patients, including death. Over time, other medications hit the market with varying degrees of intensity, which some Poz guys could tolerate but others could not. Medications for illnesses is a science which is always in progress. The makers of Truvada, for this very reason, have reformulated the drug to make it safer for longer-term use, without the major side effects of medications past. As of this date there are scores of HIV positive people around the world that have been taking Truvada since 2004, without damage to their bodies. To the contrary, they are doing very well on this medication. Further, like most medications, PrEP does not remain potent in the body for more than a few days without further dosing. It passes through the system rather quickly which is why daily treatment is necessary.

For some, letting go of the past is very hard. And for them, all HIV medications are toxic, or in the words of Larry Kramer “poison”. This is not true. A recent study by Noah Kojima and Jeffrey D. Klausner of the School of Medicine, University of California Los Angeles, was published in the Open Forum Infectious Diseases journal.

The researchers compared five major studies on the impact of PrEP to two of those on Aspirin safety, scoring them based on the likelihood of reported side-effects. They wrote: “The safety and effectiveness studies of [the drug] for HIV infection pre-exposure prophylaxis (PrEP) in men and women showed that daily use reduced the risk of HIV acquisition, but there still may concerns about safety.

“We conclude that FTC-TDF (Truvada) for PrEP for HIV infection favorably compares to aspirin in terms of user safety. While long-term studies are needed, providers should feel reassured about the safety of short- and medium-term PrEP for HIV infection with FTC-TDF.

  • One more thing…

Truvada is one of the “miracle drugs” which have brought people living with the HIV virus back to a point of great health, extending their life expectancy into the normal range. As a preventive medication PrEP has the ability to slow down and even halt the spread of this illness before it has the ability to take the lives or health of our brothers or ourselves. But, for some reason, just like with women and the birth control pill, there has been a great deal of opposition and misunderstanding about this medication.

From ugly terms such as “Truvada whore” and slut shaming for those who choose to take this medication, we are not doing our community a positive service.

Every life that is spared an HIV diagnosis is a good thing!