PrEP is an Effective Weapon in the Fight Against HIV

HIV is in the news again, but many of the headlines are more promising than in previous years. Major media outlets and members of the LGBT community are buzzing about PrEP, a very effective tool that’s helping stop the spread of HIV.

HIV-negative individuals now have the option of using PrEP (short for pre-exposure prophylaxis), a combination of antiretroviral drugs, in order to prevent HIV infection. Currently there’s only one medication FDA approved for PrEP: Truvada, a daily medication that combines two antiretroviral medications in one tablet. It becomes effective after seven days and must be taken daily for full effectiveness. In the largest clinical study of PrEP to date, there were zero new cases of HIV infection among men using Truvada over 32 months, researchers at Kaiser Permanente reported.

PrEP was recently a plot point in the racy ABC drama How to Get Away With Murder — one of the first times it’s been featured on network television. It’s also gaining popularity in cities like San Francisco and Washington, DC, where One Medical patients are routinely asking their providers about the drug.

“We definitely encourage our high-risk patients to consider PrEP, and already have many patients using it,” says Malcolm Thaler, MD. “Of course, patients have to be reliable with follow-ups and remember that PrEP does not protect against other STDs — safe sexual practices are still essential.”

Many experts are putting their faith in PrEP as a potential game-changer in the realm of HIV, but new research also highlights the limitations of the treatment and the need for ongoing screening and safe sex practices, even while taking Truvada.

According to the Kaiser study, there were no new infections among patients during more than 2.5 years of observation. Over the course of the 32-month study, researchers recorded over 1,000 referrals for PrEP and more than 650 people who began using the regimen. The vast majority (99 percent) of the users were men who have sex with men, and their average age was 37.

Researchers went a step further with their investigation, asking 143 patients about their behavior changes after 6 months on PrEP. While 74 percent reported that their number of sexual partners hadn’t changed, 15 percent reported a decrease, and 11 percent reported an increase.

San Francisco public health officials are hailing PrEP as one of the big reasons for the drop in new cases of HIV in the city. Since 2012, when Truvada first became available, new HIV infections have dropped by 30 percent. And the rate of HIV deaths and new cases fell 17 percent from 2013 to 2014.

City health officials just announced they’re spending another $1.2 million each year to help make Truvada more widely available. Their goal is to cut the number of HIV deaths and new infections in San Francisco to 0.

As positive as the news is on PrEP, it does present some new health challenges. While 56 percent of PrEP users in the study kept using condoms as before, a significant number — 41 percent — started using condoms less often, with only 3 percent reporting an increase.

The study also highlighted another important limitation of the PrEP regimen: 6 months after starting it, 30 percent of users had been diagnosed with at least one sexually transmitted infection (STI), and after 12 months, this number had climbed to 50 percent (with about one third infected with a rectal STI, one-third infected with chlamydia, over a quarter with gonorrhea, and just over 5 percent with syphilis).

“PrEP is working, and we have to continue learning what needs to be done to keep it working,” says Bruce Olschmeid, MD, an HIV specialist in One Medical’s Beverly Hills office. “We’re seeing much lower rates of HIV transmission, but we’re seeing a lot more cases of gonorrhea, chlamydia, and syphilis. Ongoing testing is not only important for HIV, but for other STIs, especially if patients are choosing to use Truvada as their only means of protection.”

According to the study’s authors, takeaways from the research include the importance of regular testing for STIs and HIV is vital for people using PrEP, and so are safe sex practices like wearing condoms. These recommendations apply to anyone using PrEP, not just men who have sex with men, as observed in the study; transgender individuals, heterosexual men and women, and people using injection drugs should continue working closely with their healthcare providers to monitor their risk of infection from all STIs, not just HIV.

One Medical Group providers encourage high-risk patients to consider PrEP but to keep in mind that the regimen does not protect against other STIs and that safe sexual practices are still an essential part of staying healthy.

Greg Sauers, a physician assistant in San Francisco agrees, noting that he’s seen a rise in patient interest about the regimen firsthand. “Personally, I have seen an increase in the number of patients on PrEP and/or interested in it over the last 12 months,” he says. “The points that I stress to my patients on PrEP are that they need to take the medication every day and that the drug was approved for use in conjunction with condoms, not in place of them.”

Washington DC nurse practitioner Amy Stulman also points out that it’s important for anyone interested in PrEP to carefully evaluate whether the regimen is right for them and to have a conversation with a healthcare provider about sexual practices, partners, and safer sex habits.

“PrEP is a great option for individuals at high risk for HIV,” she says, noting that not all gay men are “high risk,” even if they have multiple partners. “However, it does require a certain commitment to testing and follow up, and is not without risks or costs.”

Along with pre-exposure prophylaxis, safer sex strategies include condom use, frequent STI testing, vaccinations, reducing drugs and alcohol as relates to sex, and clear communication with potential partners, says Stulman.

Sauers also adds that other health measures may be worth taking once a patient decides on PrEP. “There are also some lesser-known side effects of Truvada including bone density loss, so I usually have guys supplement with over-the-counter Vitamin D,” he says.

If you’re interested in learning more about PrEP, schedule an appointment with your healthcare provider. He or she will be able to share more information about the risks and benefits of using PrEP and do preliminary testing to confirm it’s safe for you to start taking the medication.

• PrEP Facts
• Centers for Disease Control and Prevention (CDC)
• Aids.gov
• Project Inform: Is taking PrEP the right choice for you?
• Project Inform: PrEP and working through a difficult doctor visit
• Truvada