Pre-exposure prophylaxis (PrEP) against HIV infection utilizing tenofovir/emtricitabine (Truvada) has been nothing short of revolutionary in changing the landscape of HIV prevention. What has been less discussed are the enormous secondary benefits that have followed the introduction of PrEP.
- Frank discussions about sex and risk.
- Increased attention to screening, prevention and treatment of sexually transmitted infections (STIs).
- New attention to fighting HIV stigma.
- Discussions about pregnancy in mixed-status heterosexual couples.
- Encouraging people, especially young people, to seek primary care.
So first, because it's the one that makes most people, especially providers, nervous: Let's talk about sex.
Over the last 20 or more years we have witnessed the systematic destruction of adequate sex education for young people and a corresponding resurgence of a neo-Victorian morality that makes sex dirty. At the same time, we are bombarded by messages encouraging us to have sex. This has created a dynamic that encourages young people to be very sexually active, even at very young ages, but then prevents them from talking about it frankly and openly.
In addition, we have allowed too many providers to shirk their duty to provide STI testing as part of primary care. Patients frequently come to me from other providers after having been told "we don't do that here" or "we don't know how to do that." Would we ever allow providers to say "we don't know how to do an EKG" or "we don't test blood pressures here?" We need to educate all providers to do this testing.
If We Don't Ask, Patients Won't Tell
When a patient comes to me requesting PrEP, I try to get an understanding of exactly what they are doing sexually. We talk about what kind of sex they are having (oral, anal, vaginal), how they are doing it, how often they are using condoms (or not), who they are doing it with, what fetishes they may have -- as detailed a discussion as possible. I ask all of these questions in a nonjudgmental way.
I realized a long time ago that if I don't ask, most people won't just offer the information, and if I ask it the right way, people are usually very glad to be honest. And then they begin to ask questions. It is amazing how many questions have gone unanswered for so long for sexually-active people!
With a clear understanding of the actual risk people have, I can advise them much better about PrEP. While we are talking about risk, let me say that I think one of the big mistakes that has been made in the early rollout of PrEP is to link it to those with "high risk behavior." If someone has had one episode of condomless intercourse or needed post-exposure prophylaxis even once, PrEP should be discussed.
PrEP is also appropriate for the person who is using condoms all the time but remains scared of sex because of HIV. What a wonder to watch people lose that fear, justified or not, when they start PrEP.
And what about in the sero-opposite relationship, where the HIV-positive partner is often so worried about passing on HIV (even though he or she has an undetectable viral load and may be more than 97-98% less likely to do so) and the HIV-negative partner may be afraid every time they have sex as well, reasonable or not?
A well-rounded PrEP program encourages more frequent testing for STIs. Some recommendations are for every six months, but this recommendation needs to be individualized. Given the high levels of STIs we have experienced for the last several years, I recommend testing every three months at a minimum and more if indicated. Of course this recommendation needs to be individualized. If I have a patient who is on PrEP and in a truly monogamous relationship (perhaps someone in a sero-opposite relationship), then yearly testing is probably adequate. And if a patient never has anal intercourse and never receives oral-anal sex (rimming), there is no need to test that particular site.
I am frequently asked if I am seeing an uptick in STI incidence with PrEP. I am not sure. What I do know is that I was seeing a steep rise in infection rates over the last few years before PrEP was introduced. The majority of infections were oral and urethral. I saw some anal infections as clearly condom use was falling off, echoing some studies.
I believe we are seeing more anal infections now as some people are engaging in condomless intercourse, often in entirely appropriate and safe ways, but I am not sure that the overall incidence of STIs is increased. In addition, we are testing far more people far more frequently and I believe this is leading to increased numbers. These findings are similar to what was reported in the large Kaiser cohort recently reported from San Francisco.
I believe that one of the most important benefits of PrEP could be a return to something we have not seen since the 1970s, when sexually active people were encouraged to get frequent STI testing,: Community-based efforts to provide this in a nonthreatening and nonjudgmental (and often even fun) atmosphere, and where there was no stigma about having an STI and getting it treated.
Repairing the Serostatus Divide
HIV treatment has become more and more convenient and effective. When people have undetectable viral loads, they are highly unlikely to transmit the virus. In multiple studies, there has been no transmission from positive to negative partners where therapy was administered. This has led some of us to say that someone with HIV who is on meds and undetectable may be the safest person to have sex with. That person is aware of his or her status and doing something about it. That is far safer than the person whose last HIV test was two or five or 10 years ago.
At the same time, however, HIV stigma has been on the rise. How often in the last few years I have heard young people especially say, "Oh I would never have sex with someone who is HIV positive." One of the amazing changes I am seeing is the number of young people who are negative and on PrEP who are suddenly comfortable having sex with sero-opposite (HIV-positive) partners. I think there is a real chance that PrEP can end separation based on HIV status.
PrEP may also provide an answer to the prayers of couples where HIV has prevented them from feeling comfortable enough to have children. Many cannot afford the exorbitantly-priced option of sperm washing and in vitro fertilization that has been used to deliver healthy babies. Anecdotal reports are already being received of women whose partners are HIV positive and undetectable who have started PrEP and are conceiving in the old-fashioned way. It is vital that studies begin to test this as an option for those people willing to pursue this. We should at least be collecting data.
A Bridge to Primary Care
Finally, and perhaps most importantly in the long run, PrEP is encouraging young people to seek primary care. With the lower-cost options of the Affordable Care Act, many more have the ability to obtain insurance, but previously it was difficult to get young, healthy people to establish care. Now we, as providers, have a chance to more actively engage on topics such as sexual health, use of alcohol and drugs, smoking, domestic violence, bullying, and nutrition at a much earlier age. By encouraging self-respect and healthy behavior in younger people, especially in the LGBT community, we may finally be able to really fight back against so many of the health problems that have plagued our community.
Having a powerful tool like PrEP for people who are HIV negative added to improving treatment and access for those who are HIV positive is finally giving us real hope of eliminating new infections and eventually ending the HIV epidemic. The secondary benefits of a PrEP program, if done the right way, can also lead to more use of primary care and better long-term health outcomes across our communities.