PrEP Checklist: What You Should Know

PrEP Checklist: What You Should Know

PrEP is one of those things that is just everywhere in my news and Facebook feeds, which is why I've written about it so often here. The debate that surrounds it astonishes me to no end as this is a life-changing drug for gay men, and yet the vitriol against it is unflatteringly similar to climate change deniers, complete with everything from distorted half-truths to flat-out lies and scare tactics.

All of the factual data you could want about Truvada as PrEP to dismiss the fear and bogus claims are everywhere...which is part of the problem: they're everywhere. It's really, REALLY hard to track down a place where the data is collected in a single location, so I figure I'd collect a chunk of it myself in an easy-to-read rundown of some of the most common questions and criticisms. Sources are linked in each section so you know where the data is coming from, so if you take issue with some of the conclusions, take it up with the scientists. Enjoy!

Can you still seroconvert while on PrEP?

Not if you take your pills as directed. In the results of the iPrEx OLE study participants that took between 4 and 7 pills per week had zero seroconversions. Now, there are always exceptions for everything in medical science, and it would not be surprising if someone, somewhere who took his pills daily still seroconverted...but there are people who always use a condom every time who seroconvert as well. Those are unfortunate exceptions, not the rule, and the likelihood that an individual has just the right biology and just the right exposure to still seroconvert is virtually nonexistent.

Aren't condoms more effective?

Not always. Ideally, condoms act as a perfect barrier, but realistically they have their own problems and drawbacks that seem to get overlooked. For starters, as many as 2.6% of condoms allow for some virus penetration. Then, between 5% and 12% break during intercourse.

Also, depending on the study cited, the overall efficacy ranges from just 69% to as high as 95%, which is a really broad range, and that high end mandates consistent usage, while the trend is roughly 50% of men will have unprotected anal sex at least once within the past year.

Plus, condoms are not approved by the FDA for anal intercourse.

They're still a better barrier than none at all, of course, and should be a part of a person's safer sex toolkit as most condom failures are due to incorrect use rather than product failure, but they're far from flawless.

People will use PrEP as an excuse to bareback

What kind of picture would you expect me to use? My mother reads this blog.

What kind of picture would you expect me to use? My mother reads this blog.

Some will, yes, but in the iPrEx OLE study no significant amount of "risk compensation" was observed in the over 1,600 participants. Participants were even tested for syphilis as a marker for sexual risk behavior and the incidence between the two groups - those on PrEP and those not - was comparable. 

The way things stand, it appears that people who already engage in riskier behavior are the ones most interested in PrEP, so what we have is at-risk people trying to make themselves safer, not safe people becoming more reckless.

PrEP causes bone density loss, liver damage, kidney damage, and lipodystrophy

In the initial iPrEx trial, bone mineral density loss ranged between -.04% and -1% across total hip, spine, femoral neck, and trochanter, and the largest impact happened when 13% of participants on PrEP lost 5% of spinal bone mineral density. However, there was no notable difference in incidents of fractures between the PrEP and placebo groups, and bone mineral density returned to normal when treatment stopped.

Liver toxicity is not considered to be one of the side effects of PrEP, nor does PrEP harm the kidneys. Lipodystrophy problems are associated with d4T (stavudine or Zerit) and Ritonavir (Norvir), not PrEP, though given that Truvada contains nucleoside reverse transcriptase inhibitors (NRTIs) it could cause increased fat levels.

PrEP is too expensive. My insurance won't cover PrEP.

Technically a subjective judgment, but yeah, PrEP is too expensive on its own for most people. Fortunately, most insurance companies cover it as they realize it's cheaper for them to cover the cost of prevention than the cost of ongoing chronic treatment (and if yours doesn't, change insurance providers), and Gilead offers financial assistance as well. Still, your mileage will vary depending on your own financial circumstances and insurance plans.

Anecdotally, I know of people who pay virtually nothing for their testing and prescriptions. Myself? My doctor wanted to run $4k worth of tests before he'd sign off, and my present insurance plan covered virtually none of it. As for the pills themselves, even with Gilead's assistance I would have been paying $300-$400 per month.

Speak with your insurance provider to figure out all of your specific circumstances. Truvada's patent expires in 2017 as well, so expect the market to be flooded with much cheaper generics when that happens.

HIV can become resistant to Tenofovir and Emtricitabine (FTC)

It can happen, and it did in the iPrEx study. However, that resistance only occurred within participants who had acute HIV infections when they started the trial, which is why your doctor will test your HIV status before prescribing PrEP. Of the participants who seroconverted during the study, none had FTC- or tenofovir-selected resistance mutations or reduced phenotypic susceptibility to these drugs.

PrEP is a replacement for condoms

Absolutely not. As has been pointed out in various places all over the internet, PrEP does nothing to prevent someone from potentially contracting a whole host of other STIs, and no one in any position of authority on the subject has even implied that PrEP is a replacement for condoms. PrEP is an additional tool to be used for protection against HIV only, and whether one uses it in conjunction with or in place of other methods such as condoms is a personal decision that they make for themselves.