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ASK THE DOC- PrEP: A Brief Review

Written by Dr. Jason Goldman, M.D.

The transmission of HIV can be prevented if proper steps are taken. The disease is well understood and the methods of transmission have been extensively studied. The importance of understanding prevention is that once HIV is contracted, there is no current cure. While the disease can be treated and life extended, it is better to not get infected in the first place. As a brief review, HIV is transmitted through blood and bodily fluids. The most at risk behaviors are those that lead to transmission of those fluids. During sexual intercourse, the partner who’s is receiving bodily fluids is at higher risk but the virus can still be transmitted to the other partner. Anal receptive is the highest risk. The presence of other sexually transmitted diseases can lead to breakdown in the skin and tissue which leads to a greater chance of infection. Intravenous drug users, especially when sharing used needles also have great risk of contracting the disease. The most obvious method of prevention is not to be exposed to blood or bodily fluids. Abstinence and not using intravenous drugs are the first and most obvious ways to prevent infection. Barring that, I will discuss some important prevention practices.

 

One of the most effective and proven methods of preventing HIV has been condoms. If used correctly, condoms significantly reduce the chances of not only getting HIV but also other sexually transmitted diseases. Condoms must be applied before any penetration occurs or else there is a chance of infection. While condoms have always been the mainstay of prevention, a new option has been proven to work that warrants discussion. This article will focus on PrEP.

 

Many studies have been conducted looking at if a patient who is positive for HIV but on treatment with an undetectable viral load can transmit the virus. Studies have also looked at if patients without HIV who take certain medications can become infected. The results are very promising in that a viral load consistently under 200 seems to prevent transmission. This assumes that the infected individual is consistently on medications and always has a viral load below 200. A person should not necessarily rely on the fact that a partner’s viral load is below 200 as the sole determinant of which protective measure to use. Conversely, a patient with a viral load below 200 should still inform the partner of the status and potential risk. An undetectable viral load does not abdicate the responsibility to the partner to be open and honest about HIV status. Any decision regarding prevention needs to be made with all the facts. The other side of the equation is pre exposure prophylaxis or PrEP. This involves taking a medication known as Truvada to prevent infection.

 

The drug has been around for many years and has been shown to be effective against HIV. PrEP is only for someone who does not yet have HIV. It must be taken every day in order to be effective. If you miss a dose, your risk of infection goes up. The important factors to know are how quickly PrEP will work, how effective it is and what are the downsides.

 

Truvada can be over 90% effective in preventing the acquisition of HIV. The drug needs at least 7 days of use for anal receptive sex, while both vaginal sex and intravenous drug use need at least 20 days. While the drug is generally tolerated, side effects could range from nausea and upset stomach to headaches, dizziness and strange dreams. It can also cause lipodystrophy, which is abnormal deposition of body fat. Patients can get a collection of fat in the upper back area that may need surgical removal. In some cases, Hepatitis B infections can get worse.

 

The real question is if PrEP is right for you as a patient. That is an individual question that requires a person to really examine his or her lifestyle, risk factors and goals of treatment. For example, an individual may want to consider PrEP if that person has multiple sex partners or intercourse with a known HIV positive individual. It is up to that person to decide how many forms of protection should be used. Condom use and PrEP offer even more protection against HIV then PrEP alone. It is also important to remember that PrEP does not protect against any other form of sexually transmitted disease.

 

In conclusion, PrEP is a very effective form of prevention of HIV when used correctly, but is not the only viable option. Multiple forms of protection should be considered when acting responsibly in the prevention of HIV. While PrEP is generally safe, side effects can occur and should be understood before taking the medications. If you think PrEP is the right decision for you, a discussion should be had with your doctor to make sure you fully understand all the risks and benefits of taking the medication.

 

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