Category: PrEP

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PrEP: What is the HIV prevention drug and how effective is it?

— PrEP has been hailed by sexual health experts as crucial in bringing the HIV epidemic to an end, but studies show that only 20 per cent of the British public even know it exists.

BY CONOR CLARK

Taking PrEP (pre-exposure prophylaxis) is one of the most effective ways to reduce the risk of getting HIV, but knowledge about it among the British public remains scarce. In fact, just 20 per cent of people in the UK know it exists, according to research conducted by YouGov on behalf of Terrence Higgins Trust, the country’s leading sexual health charity. A staggering 77 per cent were also unaware that England can end new cases of HIV by 2030, which sexual health experts have said PrEP is key to making a reality. So, what is the drug, how effective is it at preventing HIV and where can you get it?

What is PrEP?

PrEP (sometimes known as Truvada) is a medicine that drastically reduces the risk of getting HIV from sex or injection drug use when taken effectively. It typically comes in the form of a tablet containing tenofovir disoproxil and emtricitabine, both of which are used to treat HIV. Once there’s enough of the drug inside you, it works by blocking HIV from getting into the body and replicating itself.

Long-acting injectable PrEP also exists and has been approved by the Food and Drug Administration (FDA) in the US, though is not yet available in the UK. It can also exist as a vaginal ring, though this is also not yet available in the UK.

PrEP does not protect you against any other sexually transmitted infections (STIs).

How effective is it at preventing HIV?

When taken effectively, PrEP reduces the risk of getting HIV from sex by 99 per cent. When taking it daily, PrEP needs to be taken for seven days until it becomes fully effective.

The PrEP Impact Trial, which involved more than 24,000 participants across 157 sexual health services from October 2017 to July 2020, proved the real-world effectiveness of the drug and concluded that it should be used more widely to prevent the spread of HIV. John Stewart, National Director for Specialised Commissioning at NHS England and co-Chair of the PrEP Impact Trial Oversight Board, said: “Not only did the trial directly prevent many cases of HIV, help normalise the use of PrEP, remove stigma and pave the way for a routinely commissioned clinically and cost-effective PrEP service; but it also made a very real contribution towards our goal of ending new cases of HIV by 2030.”

How often should I take it?

Most people take it orally in the form of a tablet, either regularly (one a day) or ‘event-based’ (two tablets two to 24 hours before sex, then one 24 hours after sex and a further one 48 hours after).

Those who were assigned female at birth and trans people using hormone treatment are recommended to take PrEP daily due to the lack of data available in supporting other dosing options. More information about this is available here.

Do I still need to test for HIV if I’m on PrEP?

The short answer is yes. Sam, a doctor at the Dean Street sexual health clinics in London, which are world-famous for their services to LGBTQIA+ people, said: “PrEP is the most effective way of protecting yourself from HIV. However, mistakes can happen with taking your PrEP, so we still advise testing every three to four months for HIV and all the other STIs.”

Kidney tests are done before you begin taking PrEP and continue routinely while you are on it. This is because it can sometimes affect your kidneys, though this is incredibly rare and typically only happens in those aged 50 and older or those who already have kidney problems.

Are there any side effects?

Not everyone gets side effects from PrEP and those who do usually see them go away after the first few weeks of taking it. “This is one of the number one reasons for people not wanting to take PrEP, but actually only about one in 10 people get side effects from PrEP and these tend to be quite mild and not very severe,” Sam told GAY TIMES.

According to the NHS, the most common side effects some people experience are:

  • Headache
  • Nausea and/or vomiting
  • Diarrhoea
  • Feeling dizzy and/or weak
  • Trouble sleeping
  • Bloating and/or indigestion

Clinicians recommend that anyone experiencing side effects seek medical advice if they persist.

Complete Article ↪HERE↩!

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PrEP

— The small blue pill helping end HIV transmission

Pre-Exposure Prophylaxis (PrEP) is used to prevent HIV transmission

By James W Kelly

Access to a preventative drug has led to a fall in the number of gay and bisexual men diagnosed with HIV, a leading sexual health clinic has said.

Health Security Agency (HSA) figures for London show the number of first diagnoses had fallen in this group by 3% from 2021 to 2022.

Pre-Exposure Prophylaxis (PrEP) is a “powerful tool” in ending transmission, 56 Dean Street clinic said.

However there was a rise of 17% in new HIV diagnoses in the capital.

The treatment which has been free on the NHS in England since 2020, involves taking the PrEP pill containing the drugs tenofovir and emtricitabine before having sex.

Uptake of the drug has been greatest in gay and bisexual men, the clinic said.

Consultant Dr Alan McOwan said: “Everyone should know about PrEP and its potential for preventing HIV.”

Dr Alan McOwan

Dr McOwan said it’s “really simple” to access PrEP

He encouraged anyone considered at higher risk of HIV to enquire about it at their local sexual health clinic.

Across England however, among gay and bisexual men, the overall reduced HIV transmission is not reflected across all ethnic groups.

Tarun Shah, who was diagnosed with HIV four years ago while trying to access PrEP, said the results were encouraging but more work was needed to target more at-risk people in accessing the drug.

He told BBC News: “A few months after enquiring about the PrEP trial, I ended up getting quite ill and it came out that I was HIV positive.”

Tarun said his experience accessing PrEP before his HIV diagnosis was “frustrating”

At the time, PrEP was only available on the NHS to a limited number of people during its trial and Tarun said he was unable to get onto it and could not afford the drugs privately.

He said he found it “frustrating” to think about his situation but added: “I’ve now been quite healthy ever since and it’s great to see that PrEP is now widely available to everyone.”

‘Many not being talked to’

The data for England shows new diagnoses fell by 17% from 2021-22 for white gay and bisexual men, while rises were observed among men of Asian (17%) and mixed or other ethnicity (25%).

Tarun, who is South Asian, said: “There are a lot of groups who don’t feel like they are being talked to in these conversations.

“The more people we can include, the better and I think it will be great that everyone has access to PrEP.”

While effective HIV treatment eliminates the possibility of transmission, Tarun said his partner taking PrEP provide them with a “double zero kind of safety”.

Complete Article ↪HERE↩!

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A New Way to Prevent S.T.I.s

— A Pill After Sex

By Apoorva Mandavilli

In a bid to stem the resurgence of sexually transmitted infections, the Centers for Disease Control and Prevention plans to recommend doxycycline, a widely used antibiotic, for use after an unprotected sexual encounter.

The antibiotic would be taken only by gay and bisexual men and transgender women who have had an S.T.I. within the previous year or who may be at risk for one. The scientific evidence is too limited to recommend the strategy, called doxy-PEP, to all people who might be exposed to infection-causing bacteria during sex.

The agency released draft guidelines on Monday and plans to finalize them after a 45-day public comment period.

A close-up view of a bottle of the antibiotic doxycycline, held by a hand in a pharmacy.
“We need game-changing innovations to turn the S.T.I. epidemic around, and this is a major step in the right direction,” an official with the Centers for Disease Control and Prevention said.

Why It Matters: Rates of S.T.I.s are skyrocketing.

In 2021, there were 1.6 million cases of chlamydia, more than 700,000 cases of gonorrhea and nearly 177,000 cases of syphilis in the United States, together tallying up to $1.1 billion in direct medical costs. (Rates of babies born with syphilis also soared that year, with nearly 3,000 affected.)

All three S.T.I.s are caused by bacteria and are easily treated with antibiotics. But the closure of sexual health clinics across the country and a drop in public awareness has contributed to a sharp rise in infections.

Gonorrhea cases have increased 118 percent since a historical low in 2009, according to the C.D.C. Syphilis was nearly eliminated in the United States about 20 years ago, but cases have risen 74 percent since 2017.

On any given day in 2018, about one in five Americans had an S.T.I., the C.D.C. has estimated.

“We need game-changing innovations to turn the S.T.I. epidemic around, and this is a major step in the right direction,” Dr. Jonathan Mermin, director of the agency’s National Center for H.I.V., Viral Hepatitis, S.T.D. and TB Prevention, said in an emailed statement.

The C.D.C.’s guidelines are based on studies that show that a single dose of doxycycline taken within 72 hours of unprotected sex dramatically cuts the risk of the infections.

Evidence from emerging research was compelling enough that clinics in some cities, such as San Francisco, have been offering doxy-PEP to those at high risk of infection for months. Generally, patients are given a supply of pills and told to take one within three days of an encounter during which they might have become infected.

But rates of S.T.I.s are highest among Black people and Native Americans, who are often those with the least access to health care. “No prevention tool — no matter how powerful — will change the S.T.I. epidemic if it doesn’t reach the people who need it most,” Dr. Mermin said.

Doxycycline has been in use for decades, and there are few indications that bacteria have become resistant to it. Syphilis and chlamydia do not often develop resistance, but gonorrhea is another question: Those bacteria have become resistant to multiple classes of antibiotics.

Still, the picture may change depending on how many people take doxy-PEP and how often, some experts cautioned.

“At the population level, that does worry me,” said Antón Castellanos Usigli, a sexual health expert who is an adjunct lecturer at the Columbia Mailman School of Health.

In places like his native Mexico, Dr. Castellanos Usigli said, indiscriminate use of antibiotics has fueled the rise of drug-resistant bacteria, which can alter a person’s gut microbiome.

What Happens Next: The C.D.C. will finalize new guidelines.

Evidence so far supports doxy-PEP’s use only in men who have sex with men and in transgender women. In those groups, the antibiotic cut rates of syphilis and chlamydia by about 90 percent and gonorrhea by about 55 percent.

Men who have sex with men account for nearly half of reported syphilis cases, according to the C.D.C. If studies show the approach to be effective in heterosexual cisgender men and cisgender women, the guidelines may be expanded.

The agency said doctors should prescribe doxy-PEP as part of a comprehensive sexual health program that includes counseling, screening and treatment for the infections and for H.I.V.

“Doxy-PEP will be a good option for some patients,” Dr. Castellanos Usigli said. “But we will have to do a lot of education with medical providers and patients so that we target the best candidates and prevent misuse and overuse.”

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A new morning-after pill to stop STDs could also make the problem worse

The CDC is considering recommending the antibiotic doxycycline to be used after sex to prevent syphilis, gonorrhea and chlamydia.

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Public health officials are deploying a powerful new weapon in the war against rising sexually transmitted infections: a common antibiotic that works as a morning-after pill.

It is the latest advancement as the sexual health field shifts to preventive medicine — not just condoms, abstinence and tests — as the best hope for quashing the pathogens that can spread during sex.

For the past decade, people have been able to have unprotected sex with a low risk of contracting HIV thanks to daily pills known as PrEP, or pre-exposure prophylaxis. But they were still susceptible to bacterial bugs, including the recent spike in syphilis, gonorrhea and chlamydia — until now.

Recent studies show the antibiotic doxycycline taken after sexual encounters works as a post-exposure prophylaxis to prevent those infections. But experts are also worried about unintended consequences. The Centers for Disease Control and Prevention plans to release guidelines later this summer for deploying the treatment, known as DoxyPEP, in hopes of addressing fears among medical professionals that preventive use would fuel antibiotic resistance — and the rise of drug-resistant superbugs.

“It’s the first major intervention we’ve had for STIs since the vaccine for human papillomavirus,” nearly two decades ago, said Jonathan Mermin, who leads STI prevention for the CDC. “But it is a new intervention, and because of that, there are potential benefits and potential risks.”

Doctors, public health officials and sexual health clinics have embraced preventive pills as a realistic way to curb STIs because they preserve pleasure while protecting partners. Some doctors have started prescribing it to a narrow segment of the gay community considered at elevated risk for STIs.

“Just like PrEP was a game changer, this empowers individuals to make choices about their sexual health,” said Jorge Roman, senior director of clinical services at the San Francisco AIDS Foundation, one of the first to widely distribute DoxyPEP. “It doesn’t always have to be about condoms.”

Doxycycline is already used as a front line antibiotic treatment for chlamydia and occasionally for syphilis and gonorrhea. But its use for prevention has drawn concerns that it would no longer be effective in patients who use it regularly and that it may facilitate the evolution of antibiotic resistant strains of the pathogens.

The drug’s proponents say these concerns are overblown because the criteria for eligibility are often narrow: Transgender women and men who have sex with men — and only if they have condomless sex and contracted an STI in the preceding year.

Those were the demographics recruited for a study of 500 patients in San Francisco and Seattle that found DoxyPEP effective. The study found a roughly 65 percent reduction in syphilis, gonorrhea and chlamydia cases in those who used the antibiotic between 2019 and 2022, mirroring similar results from European studies.

Another study of DoxyPEP use by cisgender women in Kenya between 2020 and 2022 did not find the treatment effective, a result that surprised and stumped researchers. Anatomical differences could play a role, but health officials say other studies suggest doxycycline becomes concentrated enough in vaginal fluid to confer protection against STIs.

Experts say it’s too early to conclude that DoxyPEP won’t work for women and more research is needed. Another possible explanation is women enrolled in the Kenyan study may not have consistently used doxycycline after sex. Researchers note early studies that found PrEP ineffective in protecting African women from HIV were eventually explained by poor adherence to the drug regimen rather than biological differences.

Researchers studying DoxyPEP are scrutinizing whether it could also render antibiotic treatments less effective. The U.S. study found a slight increase in antibacterial resistance, which the study’s authors said merits long-term attention. But they also said the finding should be tempered by the fact doctors would also be administering fewer antibiotics if people avoid catching and spreading STIs.

David Hyun, director of the Antibiotic Resistance Project at The Pew Charitable Trusts, said he was concerned by patients in the study using DoxyPEP as frequently as 20 times a month. More data is needed to understand the long-term effects — for individuals as well as broader communities, he said.

“If you keep exposing a patient to antibiotics like doxycycline, you are raising the risk of that patient being colonized or infected with a resistant strain sometime in the future,” Hyun said.

Some LGBTQ+ health providers suspect doctors may be using antibiotic resistance concerns to mask discomfort with condomless gay sex. They note that syphilis has yet to become resistant to penicillin since the antibiotic became the front-line treatment for the STI in the 1940s. And they point out doxycycline is widely used for other reasons, including long-term acne treatment and malaria prevention.

“We have used doxycycline for multiple other things,” Shira Heisler, medical director of the Detroit Public Health STD Clinic, said during a May conference of the National Coalition of STD Directors. “And I think specifically now being like, ‘We are not going to do it because of antimicrobial resistance’ when it’s specifically related to STIs is a good time to call out, ‘This is what stigma is. This is what bias is.’”

Proponents of DoxyPEP said it offers a long-needed solution to a spike in STIs. The CDC recorded more than 2.5 million cases of syphilis, gonorrhea and chlamydia in 2021, up from 1.8 million in 2011.

In 2021, 36 percent of syphilis and gonorrhea cases were in men who have sex with men, according to the CDC. The CDC says these disparities cannot be explained by differences in sexual behavior alone. When people have a smaller pool of potential sexual partners with higher rates of STIs, they are more likely to have sex with someone with an infection. Cases in cisgender women and heterosexual men have also been rising.

Experts say everyone would benefit from DoxyPEP being limited to those most at risk because that would break chains of transmission early and reduce the likelihood of infections spreading more broadly.

Some physicians say allowing people to have worry-free sex is a worthy goal on its own.

“My goal as a physician is to make sure my patients are able to have whatever type of sex they want and however much sex they want as safely as possible,” said Boghuma Kabisen Titanji, an infectious diseases specialist in Atlanta. “And if DoxyPEP would allow them to do it, then I have no problem offering it.”

Nick, a 35-year-old resident of Lafayette, Ind., said he recently started taking DoxyPEP for peace of mind, knowing he would be less likely to get an infection as he has frequent condomless sex.

HIV was no longer a concern because he has been taking PrEP for a decade, said Nick, who spoke on the condition that his last name not be used to candidly discuss his sex life. But he has endured uncomfortable bouts of syphilis and chlamydia.

“If you are taking HIV PrEP, why not take another extra kind of safeguard too?” he said. “It’s like a security blanket.”

As the country considers how widely to distribute DoxyPEP, public health officials and activists are worried it will be the latest medical advancement to roll out in an inequitable way, following similar racial gaps seen with PrEP and mpox vaccinations. Federal officials say PrEP users are disproportionately White even though most new HIV cases are in Black and Latino people. The CDC estimates that most mpox cases have been in Black and Latino men, but only a third of vaccine doses have gone to them.

LGBTQ+ health providers are already reporting disparities, with White patients more likely to ask about DoxyPEP and Black and Latino patients less likely to be familiar with it.

During a discussion about DoxyPEP at the STD conference, one state health official noted that those who can afford to travel to Puerto Vallarta, a popular vacation destination among some gay Americans, can buy doxycycline to stockpile for themselves and their friends because the antibiotic is available over the counter in Mexico. But experts say concerns about antibiotic resistance would make it difficult for over-the-counter sales to occur in the United States.

Mermin, the CDC official, said equity is a top concern as the agency crafts its guidance for the use of DoxyPEP. It would be essential to ensure the medication is available in clinics serving people at the highest risk for STIs, he said, and to raise awareness outside of medical settings, such as on dating apps.

In London, Joey Knock said he started buying DoxyPEP outside of official channels, a common practice among some gay Europeans, last winter after regular bouts of gonorrhea.

But he limits his use to higher-risk nights, such as when he has unprotected sex in dark rooms with strangers.

“I’m someone who was averaging an STI a month,” said Knock, 33. “I’ve done the risk analysis for me, but it also benefits other people if me taking DoxyPEP means I don’t get chlamydia, then I don’t pass chlamydia around.”

In San Francisco, the first major jurisdiction where public health officials recommended DoxyPEP, providers noticed patients taking a similar approach: Using it after higher-risk sexual encounters rather than every encounter.

“We need to do more analysis to see if that could be making DoxyPEP less effective or if perhaps people are making really good decisions about when to use it,” said Stephanie Cohen, who leads STI prevention for the San Francisco Department of Public Health.

The San Francisco AIDS Foundation, which says it has connected more than 1,800 people to DoxyPEP, does not limit the antibiotic to people who have recently contracted a sexually transmitted infection, but counsels patients on the unknown risks of antibiotic resistance.

Anu Hazra, co-medical director of the Howard Brown Health, an LGBTQ+ health provider in Chicago, said antimicrobial resistance is “probably the largest public health threat we have” but doxycycline for a small group of people pales in comparison to the rampant use of antibiotics in the meat industry and other sectors.

He and other experts say vaccines to prevent STIs could be another game changer that does not carry the same baggage as antibiotics. A recent study showing that a vaccine for meningitis can also reduce the likelihood of contracting gonorrhea offers promise on that front. But DoxyPEP offers an immediate solution to an ongoing problem and could be pared back if antibiotic resistance emerges, Hazra said.

“We are seeing rising rates of STIs across the board for nearly a decade now. What we are doing now is not working,” Hazra said. “We need to try something new.”

Complete Article ↪HERE↩!

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Sex After 60?

— You Need to Know About STD Prevention

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Coming this fall to your TV screen: “The Golden Bachelor.” That’s right, reality television fans, seniors are finally getting their shot at this (somewhat unscripted) love connection. The suspenseful rose ceremonies and extravagant date nights are likely. But will there be an overnight in the fantasy suite?

If this is, in fact, reality, then there should be. Physical intimacy important — sex even has health benefits. Yes, even for those in their twilight years. Shining a light on sex after 60 may be just what the doctor ordered. But seniors also need to know how to protect themselves from sexually transmitted diseases (STDs).

STD Rates Rise Along with Sex After 60

Sexual health may not be a topic older adults are keen on discussing — even with their care providers. “Unfortunately, this reluctance to talk about sex is putting newly single seniors at risk for sexually transmitted infections,” says Laurie Archbald-Pannone, MD, a geriatrician with UVA Health. As a geriatrician, she specializes in primary care for older adults.

One analysis showed that in adults over age 60, diagnosis rates for STDs (also known as sexually transmitted infections or STIs) increased 23% in 3 years.

That’s more than double the increase seen in the rest of the population, which saw a rise of just 11% in diagnoses of STDs. The main STDS are gonorrhea, chlamydia, and herpes simplex.

Why the STD Boom Among Boomers?

The rise is likely due to “a lack of awareness among this age group about STI prevalence and prevention,” says Archbald-Pannone.

“A common scenario is when someone older in life suddenly rejoins the dating scene after a decades-long monogamous relationship. This person may not have a history of STI education, so may not be aware of appropriate prevention or STI signs and symptoms,” she says.

With increased availability of medications for menopausal symptoms and erectile dysfunction, sex after 60 is more common. But older adults are also more susceptible to infections due to age-related changes in immune function. For women, postmenopausal vaginal dryness can increase the risk for tears in the vaginal wall, which can accelerate the spread of infection.

Let’s Talk About Sex After 60

Unfortunately, says Archbald-Pannone, many clinicians are missing an opportunity to educate this population about STD prevention, including the use of condoms and the importance of screening.

“In terms of sexual health, we as providers readily talk about STI prevention with younger patients,” she says. “Among older adults, however, studies show clinicians are not having the same conversations. Often it’s because the provider is uncomfortable bringing up the topic. At any age, it’s difficult to discuss sensitive topics. But, as providers, we can have a big impact by talking to our patients about sexual practices, sexual health and STI prevention.

“We have to make sure that, as clinicians, we’re well educated on these topics so we can be a resource for our patients,” adds Archbald-Pannone. “We also have to create a judgment-free, open environment so patients feel comfortable having those conversations.”

4 Tips for STD Prevention

For anyone entering a sexual relationship, Archbald-Pannone has the following advice:

Talk to Your Partner

Be aware of your partner’s sexual history and STD risk factors before being intimate.

Use Protection

Condoms or other barrier methods used during intercourse prevent infections.

Looking for Senior Healthcare?

UVA Health geriatricians are experts in senior care.

Get Screened & Encourage Partners to Do the Same

If you are sexually active — either with a new partner, with several partners, or if your partner has recently had sex with others — you should have an annual STD screening. There is no age cutoff for screening.

Know STD Symptoms

If you’re having sex after 60 or any age, educate yourself on the signs and symptoms of gonorrhea, chlamydia, and herpes simplex. Some of the most common include:

  • Bumps, sores, or lesions around the genitals
  • Discharge from the penis or vagina
  • Painful urination

Get Treated

If you experience any unusual symptoms after engaging in sexual intercourse, don’t delay treatment. The condition can get worse.

Be sure to discuss your diagnosis with your partner so that they can get treatment as well.

Talk to Your Doctor

Your sexual health is an important part of your overall well-being. So don’t hesitate to discuss your questions and concerns with a clinician. Make your doctor aware of changes in your sexual practices to ensure you’re making safe choices when having sex after 60 or any age.

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Gay social and sexual norms are shifting in the PrEP era

By Krishen Samuel

While cost remains the biggest barrier to accessing PrEP for gay and bisexual men in Canada, they also felt pressure to take PrEP and have sex without condoms, with younger men tending to feel less anxious about HIV transmission. This reflects shifting social and sexual norms in the era of PrEP and U=U, according to recent qualitative research.

While pre-exposure prophylaxis for HIV (PrEP) has been approved in Canada since 2016, implementation has been impeded by cost challenges. Certain provincial health insurance plans, including British Columbia’s, fully cover PrEP for gay and bisexual men who meet the guidelines. However, this is not the case in other provinces, such as Ontario, where PrEP is fully covered until the age of 25, over the age of 65, and for those receiving disability grants and social assistance. Across Canada, eligible Indigenous people, members of the armed forces and military veterans can access PrEP.

The study

Dr Mark Gaspar from the University of Toronto aimed to better understand PrEP-decision making among HIV-negative gay, bisexual and queer men. Drawing on the PrEP Cascade, which considers readiness for PrEP, seeking PrEP out and discussing it with a healthcare provider, he and colleagues conducted 45 in-depth one-on-one interviews between March and October 2020 (all but one were over Zoom) with men in Ontario and British Columbia.

Forty percent of the men were aged 30-39, while just under a third were between 20-29. Most men identified as cisgender (91%), and gay (87%), while 38% were White, 16% East Asian and 13% Black. Thirty-seven of the 45 men were taking or had taken PrEP. Thirty-eight percent lived in the greater Toronto area, while 33% resided in Vancouver.

The costs of accessing PrEP

The cost of PrEP presented the biggest access barrier, particularly in Ontario.  Some participants said they felt PrEP was “only for rich people” as access to PrEP often depended on having a job with private health insurance and being able to paying the co-pay associated with PrEP. For men participating in the ‘gig economy’ or for those changing jobs and insurance plans, consistent access to PrEP presented a challenge.

While many participants acknowledged that if they wanted to access PrEP, they could do so, they were aware of the effort involved in getting PrEP consistently, including transportation costs and taking time off work to go to medical appointments. Thus, in addition to viewing themselves as at risk for HIV, they also needed to feel that PrEP’s value outweighed all associated costs. For some men, despite seeing themselves as being at a high risk for HIV and needing to access PrEP, cost presented too prohibitive a barrier. For those who could afford PrEP, other barriers were seen as less significant.

Health concerns related to PrEP

Men who were hesitant about taking PrEP tended to voice the strongest concerns about side effects, contracting other STIs and the effectiveness of PrEP. In general, participants agreed that PrEP was highly effective at preventing HIV. Some participants expressed concerns regarding the fact that PrEP contains anti-HIV drugs, and its effects on their kidneys, bones and liver, although none of the interviewees had themselves experienced such problems:

“I don’t have a concern with [immediate, short-term] side-effects. I just haven’t seen what it does to the body. We have to see what it does to the body after five to ten years, or three years, you know?”

One user shared that he would often pause his PrEP due to concern over side effects. However, most men viewed side effects as temporary, or easily reversible if PrEP was stopped.

Another concern related to contracting STIs other than HIV; the necessity of PrEP was questioned if one could simply use condoms to prevent all STIs: 

“Yes, [I am concerned with] side effects and also what’s the . . . if I still need to wear a condom—so a condom is supposed to prevent HIV and other STIs. If you take PrEP it’s going to protect you against HIV but not everything else. So then taking PrEP and using a condom I think is overdoing it. So just use a condom and get it over with. That’s my simple-minded thinking. And I don’t like condoms. So that’s why I would end up with the unsafe sex situation [on PrEP].”

PrEP’s impact on sex

Participants shared varied experiences regarding the effects PrEP had had on their sex lives. Several had more sex and used condoms less. In some relationships, PrEP opened the door to exploring non-monogamy. However, there were some men who stated that their sex life had remained unchanged and questioned whether they needed PrEP. According to one participant: “Like I’m wasting it. Like I’m taking it but I’m still not that [sexually] active, you know?” However, one participant stated that he was glad that he kept taking PrEP, despite not thinking that he needed it at one point. This challenges the notion of risk as fixed and instead indicates that it fluctuates over time, with PrEP being more necessary at some points than at others. Additionally, some men start PrEP not because they see themselves as being at high risk, but rather to try it out and see how it fits in with their sex lives.

“Previously a man could be accused of being promiscuous for taking PrEP, now he was viewed as responsible for doing so.”

Linked to this, many PrEP users shared how they stopped, paused and restarted PrEP at different points. Men spoke about using event-based dosing or planning sex around PrEP dosing, but stated that it was difficult to find accurate information on using PrEP episodically:

“I guess even if someone asks me, oh do you want to have sex and I say yes, if I’m not on PrEP at that time I’ll usually kind of set a date with them a week from now or more than a week so I have time to ramp up the PrEP again.”

PrEP contributed to how men planned both their immediate and future sex lives. One participant stated that he hoped to be in a long-term monogamous relationship once he turned 25, as PrEP would no longer be covered by provincial insurance in Ontario at that age:

“I want to finally settle down, and be with someone exclusively and not have to worry about hooking up and stuff.”

Changing social and sexual norms

Men stated that norms around sex had changed because of PrEP, especially regarding condom use and notions of ‘safe sex’.

“There are some people that just don’t want to use condoms and if you want to have sex with them, that’s kind of where you’re gonna be.”

For some participants, this had a distinct racial element to it, with PrEP being seen as something associated with White gay men. This association meant that some Black gay men would not take it unless other men they knew were taking it, or they could risk being seen to cater to the whims of White men.

“If my Black friends aren’t taking it then I’m obviously not going to take it.”

Glossary

stigma

Social attitudes that suggest that having a particular illness or being in a particular situation is something to be ashamed of. Stigma can be questioned and challenged.

Undetectable = Untransmittable (U=U)

U=U stands for Undetectable = Untransmittable. It means that when a person living with HIV is on regular treatment that lowers the amount of virus in their body to undetectable levels, there is zero risk of passing on HIV to their partners. The low level of virus is described as an undetectable viral load. 

safer sex

Sex in which the risk of HIV and STI transmission is reduced or is minimal. Describing this as ‘safer’ rather than ‘safe’ sex reflects the fact that some safer sex practices do not completely eliminate transmission risks. In the past, ‘safer sex’ primarily referred to the use of condoms during penetrative sex, as well as being sexual in non-penetrative ways. Modern definitions should also include the use of PrEP and the HIV-positive partner having an undetectable viral load. However, some people do continue to use the term as a synonym for condom use.

qualitative

Qualitative research is used to explore and understand people’s beliefs, experiences, attitudes or behaviours. It asks questions about how and why. Qualitative research might ask questions about why people find it hard to use HIV prevention methods. It wouldn’t ask how many people use them or collect data in the form of numbers. Qualitative research methods include interviews, focus groups and participant observation.

event based

In relation to pre-exposure prophylaxis (PrEP), this dosing schedule involves taking PrEP just before and after having sex. It is an alternative to daily dosing that is only recommended for people having anal sex, not vaginal sex. A double dose of PrEP should be taken 2-24 hours before anticipated sex, and then, if sex happens, additional pills 24 hours and 48 hours after the double dose. In the event of sex on several days in a row, one pill should be taken each day until 48 hours after the last sexual intercourse.
Participants also described an evolution of perceptions related to PrEP. Whereas previously a man could be accused of being promiscuous for taking it (“Truvada whores”), he was now viewed as responsible for doing so.

“I would get guys saying, ‘no thanks, I’m not interested’ and I’d be like oh ok, and they’d be like, ‘well you’re on PrEP and I don’t want to hook up because you’re obviously on a whore rampage.’ That’s been said to me a few times. Now it’s like, I talk to guys who aren’t on PrEP and I’m like, ‘what the fuck, you’re not on PrEP, are you crazy?’”

However, some men resisted the pressure to take PrEP. For them, it was either not seen as necessary to ensure sexual safety, or it was viewed as a way for pharmaceutical companies to make a profit from the sex lives of gay men.

While some men on PrEP had become more confident in having sex with men with an undetectable viral load, and there was an acknowledgement that it could make disclosure easier, there were some who still expressed stigma towards those living with HIV in the era of PrEP.

“I’m on PrEP, yeah I feel comfortable hooking up with undetectable people.”

“Nowadays, guys who are [HIV-] positive don’t even feel like they need to tell you that they’re positive. [. . .] I’m just like, I don’t want to do it [have sex with HIV-positive men]. It’s my body I can do whatever the hell I want. It doesn’t mean I don’t understand all the facts.”

Generational differences

There were distinct generational differences in PrEP perceptions. Men who were sexually active in the 80s and 90s viewed it very differently to younger men, who tended to feel less anxious regarding HIV transmission.

“I always assumed that not using a condom equated to AIDS.”

“I’m [in my 40s]. So when I was like 20, like there wasn’t, you know, HIV was still like a death sentence kind of a thing. So, these kinds of things [like PrEP] are exciting, but I guess I yeah . . . I’m not sure, I don’t know what my hesitation is in terms of wanting to take it fully or know more about it.”

“I’ve not had a lot of anxiety around [HIV] transmission, I think part of that was because of that . . . I think more recent medical advancements in the treatment of HIV.”

There was also a sense that all the progress made regarding behavioural interventions would be lost on the younger generation with the advent of PrEP.

“So now to say, yo, take this pill and don’t even think about it. I was like, ugh, fuck, all of those years of behaviour change work sort of scuttled out in one moment.”

“My identity as a queer person, a queer man, was so interlinked with the looming threat of HIV that whether I was conscious of it or not, my early reticence and scepticism around these other options [like PrEP] was almost comparable to that example of an old person going, ‘oh well, I grew up it was really hard and these [younger] motherfuckers have it too easy.’ Well we all should have it a little bit easier, right? And so yeah, I was like, we should all be free of this [fear of HIV].”

Conclusion

“In addition to pragmatic barriers and biomedical concerns, PrEP has significant social implications with its uptake altering sexual practices and sexuality in diverse and complex ways,” the authors conclude. “The more healthcare providers and health promotion experts are able to understand these shifts in sexuality, the better equipped they will be at producing education, soliciting questions, and refining their messages to clients to ensure that gay, bisexual and queer men are making informed choices about PrEP that effectively reduce their risks.”

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Should You Be on PrEP?

This medication can significantly lower your risk of HIV

As recently as the 1990s, it was unthinkable that medication could someday prevent the spread of HIV. But in 2012, the U.S. Food and Drug Administration (FDA) approved the first medication known as pre-exposure prophylaxis, or PrEP, which can prevent HIV from taking hold in your body.

Now, PrEP has become an important tool in combatting the spread of HIV. Internal medicine specialist James Hekman, MD, explains what PrEP is, how it works and whether it’s right for you.

What is PrEP?

Human immunodeficiency virus, or HIV, is a sexually transmitted disease that attacks your immune system, which can make it difficult for your body to fight off illness. The most common way people get HIV is through vaginal, oral or anal sex, but you can also get it by sharing needles to take drugs.

But taking PrEP can prevent you from contracting HIV by blocking the virus from taking hold within your body.

The name says it all: “Pre-exposure” means “before you get exposed,” and “prophylaxis” is a common medical word that refers to actions you take to prevent a disease from developing or spreading. PrEP, then, is medication you take to keep you safe from HIV — before you’ve ever been exposed to it.

Should you take PrEP?

“PrEP is for people who don’t have HIV but are at an increased risk of contracting it through sex or injection drug use,” Dr. Hekman explains.

Your doctor may recommend you go on PrEP if you:

  • Have a sexual partner with HIV.
  • Have sex without using condoms.
  • Have been diagnosed with a sexually transmitted disease in the last six months.
  • Inject drugs with someone who has HIV.
  • Inject drugs by sharing needles or syringes.
  • Have been exposed to HIV in the past and continue to engage in high-risk behavior.

How to take PrEP

PrEP isn’t a particular brand; rather, it’s a category. Right now, there are three types of PrEP:

  • Truvada® is a daily pill that combines two drugs called tenofovir disoproxil and emtricitabine. It’s for anyone who’s at risk of contracting HIV through sex or injection drug use, and it’s also available in generic form.
  • Descovy® is a daily pill that combines two drugs called tenofovir alafenamide and emtricitabine. It’s for sexually active cisgender men and transgender women who are at risk for HIV; it’s not for people who have vaginal sex. The generic form is not currently available in the U.S.
  • Apretude® is the brand name of medication called cabotegravir, which is an injection you receive every two months from your doctor. The FDA approved it for use in December 2021, and no generic form is currently available.

How long does it take for PrEP to work?

You should be on PrEP for one to three weeks in order for it to start working. But to maximize your protection from HIV, you have to be sure to take every dose. Simply put, Dr. Hekman says, “PrEP is incredibly effective, but only if you take it as prescribed.”

HIV.gov reports that when taken correctly, the pill forms of PrEP reduce the risk of getting HIV from sex by about 99%, and it reduces the risk of getting HIV from drug use by at least 74%. But the medication isn’t nearly as effective if it isn’t taken consistently, so be sure to set those daily reminders.

Side effects of taking PrEP

PrEP is considered safe, but you may experience some side effects at first. They should go away on their own, but talk to your doctor if you continue experiencing them:

  • Nausea.
  • Diarrhea.
  • Headache.
  • Fatigue.
  • Stomach pain.

If you have kidney disease or a history of hepatitis B, be sure to tell your doctor. It may impact whether you’re able to go on PrEP.

Does PrEP prevent STDs?

Condoms are just as important as they’ve always been. “PrEP does not prevent the spread of STDs,” Dr. Hekman says. You can (and should) pair PrEP with condom use for the best chances of reducing your risk.

Will PrEP interfere with hormone therapy?

If you’re on gender-affirming hormone therapy, you may be worried about whether and how PrEP will interfere.

Trans women have been reported to have lower levels of PrEP in their bloodstream than other people, Dr. Hekman says, but there’s not yet enough research to say why. And because the transgender population is at high risk for HIV, it’s important to work with a doctor who can ensure that you can remain on hormone therapy and guard yourself against HIV.

“We know that when trans women are under medical care, doctors can monitor their levels of both HIV control and hormones,” Dr. Hekman explains. “We can adjust doses to make sure that they achieve appropriate levels of gender-affirming hormone therapy while also remaining protected from HIV.”

Can you take PrEP after HIV exposure?

PrEP is a pre-exposure medication, which means that in order for it to do its job, you need to be taking it before you’re exposed to HIV. That means PrEP is not the right medication to take if you’ve been exposed to HIV and want to reduce your chance of infection.

If you’ve been exposed to HIV and aren’t already on PrEP, see a doctor — whether your primary care physician or at an emergency room or urgent care facility — within 72 hours. They can prescribe post-exposure prophylaxis (PEP), medication to prevent HIV after exposure. Unlike PrEP, PEP is used in emergency exposure situations.

Talking to your doctor about PrEP

PrEP is only available by prescription, so if you’re interested in starting it, make an appointment to speak with your doctor. “They’ll give you an HIV test and talk you through any concerns you have about going on PrEP,” Dr. Hekman says.

Looking for a healthcare provider who is trained in health issues specific to the LGBTQIA+ community? Many nationwide health services and state clinics are open and affirming, and there are other ways to find an LGBTQIA+ doctor’s office near you.

If you’re concerned about how to pay for PrEP, be sure to ask your doctor about that, too. Most insurance companies and state Medicare plans cover PrEP, and other options are available for those who qualify.

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