Why safe sex still matters, even if you're on PrEP

Updated June 4, 2021.

Thirty years ago, an HIV diagnosis was often considered a death sentence. Today, the human immunodeficiency virus that causes AIDS is not only thought of as manageable, but almost entirely preventable.

The golden child of this innovative era is PrEP (short for pre-exposure prophylaxis treatment), a combination of antiretroviral drugs intended to prevent HIV. Experts are hailing it as a revolutionary tool, but they’re also transparent about its limitations and inability to prevent other forms of sexually transmitted diseases (STDs, sometimes referred to as sexually transmitted infections or STIs). “We’re seeing a lot of people stop using condoms when they go on PrEP, have unprotected sex with multiple partners, and just keep spreading diseases around,” says Carol Grim, a San Francisco registered nurse. Regardless of your orientation, if you’re considering or taking PrEP (or know someone who is), you’ll want to understand why safety still matters.

According to the Centers for Disease Control and Prevention (CDC), STD rates have risen each year. From 2015 to 2019, syphilis rates increased by 74 percent, and gonorrhea and chlamydia climbed by 56 percent and 19 percent, respectively.

And while Truvada (Emtricitabine / Tenofovir) and Descovy (emtricitabine & tenofovir alafenamide), the only combination drugs currently approved for PrEP, have made a significant impact, its popularity may be distorting perception of its abilities: studies suggest some people who use PrEP utilize condoms with less regularity. One San Francisco study found a 30 percent increase in STDs among PrEP users after six months. When asked about condom use, 56 percent said they used them at the same rate after starting PrEP, 41 percent used them less, and 3 percent used them more. After one year, half had an infection like chlamydia, gonorrhea, or syphilis. However, the study did not include a control group to compare participants’ behaviors and outcomes.

“PrEP is like birth control in that it protects you from something you want protection from but it doesn’t protect against other things like STIs,” says Heather Boerner, author of Positively Negative: Love, Pregnancy, and Science’s Surprising Victory Over HIV. “When you have other infections, it increases the likelihood of getting HIV because of inflammation in the system. If you’re taking PrEP to prevent against HIV, it’s just good sexual health self care to protect yourself in all ways.”

While condoms are still considered the most effective way to prevent STDs, using them is an individual choice. “Anyone making a decision about whether to use Truvada for PrEP will also ideally be sure to get educated about STIs,” says Bruce Olmscheid, a provider in Beverly Hills. “The decision about whether to use condoms remains their individual decision. I’m here to help and to be sure that they know some of the downstream risks and that their first knowledge about syphilis or gonorrhea doesn’t happen at the time they’re diagnosed with it.”

Condoms can be helpful, but they’re not the only option. “Those on PrEP who don’t use condoms consistently can reduce their risk through other means, such as not combining sex with drugs or alcohol and reducing their number of sexual partners,” says Amy Stulman, a provider in Washington D.C.

Contracting an STD isn’t the end of the world, but repeated infections and treatments do pose risks. “Fortunately gonorrhea, chlamydia, and syphilis can be treated with antibiotics, but some of these infections can cause complications,” Stulman says. “And antibiotics themselves aren’t without harms.” Just like all medications, antibiotics carry the risk of side effects, and they aren’t meant to be taken repeatedly.

According to the CDC, simply using antibiotics creates resistance. Gonorrhea specifically has developed resistance to drugs prescribed to treat it, and has forced us to use stronger doses of antibiotics to counter it. While these powerful drugs are important tools for managing infections, using them repeatedly for preventable infections is dangerous.

“If we keep treating the same infection multiple times each year, the drugs are going to stop working,” Grim says. “Antibiotics are precious and finite resources and drug companies have stopped manufacturing new ones, so we only have a handful left at our disposal. When they stop working, we won’t have very many options.”

The good news is education seems to make a difference. Studies have shown that simply informing patients of the risks associated with repeated antibiotic courses can potentially lower the demand for the drugs and help prevent resistance down the road.

“You can have a great time and swing from the chandeliers and you can still have a conversation before the swinging from chandeliers begins.” — Heather Boerner

PrEP is promising but not a surefire solution. To be maximally effective, it must be taken every day and it requires consistent screening and follow-up.

“While I’m amazed and grateful that we have a medication that’s working to prevent HIV, I…continue to require my patients to be monitored every three months to be sure it’s still working,” Olmscheid says. “I only dispense a 90-day supply of Truvada in exchange for a newly updated negative HIV test.”

Even when taken correctly, PrEP is 92 to 93 percent effective in reducing HIV risk. While that’s significant, the possibility of infection still exists. In 2018, researchers reported the first documented case of Truvada’s failure: a 43-year-old man contracted HIV despite two years of successful use.

And even if you’re using PrEP by the book, how do you know your partners are? “If you have multiple partners, many will tell you they are on PrEP, but you have no way of knowing for sure how adherent they are to taking it every day,” Olmscheid says.

The bottom line is that PrEP is groundbreaking, but it has limitations. Continuing to prioritize safety, protection, and honest communication is key.

“Most people taking PrEP are not using it as carte blanche to be wild and crazy,” Boerner says, pointing to a 2010 landmark study that showed most PrEP users are more mindful of their health and often end up being more selective about partners. “But you can totally be wild and crazy and still be safe. You can have a great time and swing from the chandeliers and you can still have a conversation before the swinging from chandeliers begins.”