Getting Prep, Step Two

Timothy Kincaid

December 6th, 2015

truvadaSince late October I have been trying to get a prescription for Truvada to be used as pre-exposure prophylaxis (PrEP) to prevent the possible contraction of HIV. It has not been an easy process and has involved being dumped by my primary physician and a complicated search for a replacement.

But finally I found care through APLA’s Gleicher / Chen Health Center and two weeks ago I went in for a series of tests, both general health and sexual health. On Thursday I returned for my results.

I was happy (though not very surprised) to learn that I did not test positive for HIV, gonorrhea, chlamydia, or syphilis. Blood pressure was fine. My triglycerides are just slightly high, but so is my “good” cholesterol. In general, I’m a healthy man.

Except one test wasn’t present. Although the clinic had requested the usual full analysis, the lab hadn’t run the tests necessary to evaluate my liver. And testing liver function is absolutely necessary to issuing a prescription for PrEP.

So the wait goes on.

On Monday, I’ll take the trip back to the clinic to draw more blood. And at some point on Tuesday I should know whether my liver is functioning properly and, assuming that all is well, I should be able to start the program.

Joe Beckmann

December 7th, 2015

Two questions:

1. Historically (since the approach has been around for nearly 20 years) there was some concern that long term PrEP would or could reduce the effect by the body adapting to Truvada, and diminishing it’s impact. Has that been disproven?

2. The same treatment with the same drug for three to seven days after a high risk encounter (known since 1985 or so as Post-Exposure Prophylaxis or PEP), has long been considered just as effective as pre-exposure treatments. Why would that treatment not (a) cost lots less money, and (b) reduce the probability of diminished impact?

Timothy Kincaid

December 7th, 2015


PEP is not a three to seven day treatment. Per the CDC, “Two to three drugs are usually prescribed, and they must be taken for 28 days.”


December 7th, 2015

Some attempts at responses to Joe’s questions…

1. I’m not sure what the 20-year time frame is that you’re referring to. Truvada was approved for use as PrEP by the FDA in 2012. The earliest PrEP research in humans started less than 15 years ago, and the first study which showed that Truvada was effective started in 2007 and published its first findings at the end of 2010.

I’m also not sure I understand what your concern is about the body adapting to Truvada and diminishing its effectiveness. In my understanding, Truvada protects against HIV infection by targeting HIV at a specific point in its replication cycle, that action is independent of any effects the drugs have on one’s body (or vice versa).

Are you perhaps thinking of the development of resistance by the virus? There has been some concern that inconsistent use of Truvada could lead to the development of more cases of resistant viruses (if a person using PrEP is already HIV positive or acquires HIV while taking PrEP its possible for their virus to develop resistance), but so far this has not been a problem in practice.

This article goes into some detail about the issue of resistance and PrEP use and discusses a recent study which suggests the development of resistance is rare and (since PrEP is so effective) the greatest risk comes from an undiagnosed infection when starting PrEP.

That’s why testing before starting PrEP and quarterly testing while using PrEP are central parts of the CDC’s guidelines. If someone does become infected it’s crucial to diagnose them as quickly as possible to minimise the chance that the virus will develop resistance (the FDA was very attentive to this when approving Truvada for use as PrEP).

I’m not sure if that addresses your question, as I mentioned, I didn’t entirely understand the concern you raised.

2. As Timothy wrote, PEP must be started within 3 days of a possible exposure and continued for 28 days!

In the case of PEP for HIV, we’re not exactly sure how effective it is because it’s difficult to design a study that could ethically provide a control group. Based on observational studies it’s thought to be at least around 85% effective. Truvada as PrEP has been studies much more rigorously and we know that when it’s taken as directed it reduces the risk of infection by at least 99%. That’s essentially as good as it gets in medicine.

Some places prescribe only Truvada as PEP, but most use Truvada plus another drug. This is thought to increase its efficacy, but also increases the chance of side effects (although it’s also important to note that current PEP regimens are much better tolerated and easier to stick to than what was used 5 or 10 years ago).

Off the top of my head I can think of two other reasons that PrEP might be preferable to PEP for prevention. One is that because of the tight window for accessing treatment, a lot of people aren’t able to easily get PEP in time after a possible exposure. Being on PrEP means you’re protected in advance.

The other reason is that people have a hard time accurately judging their level of risk and tend to err on the side of underestimating it. Again, with PrEP you don’t have to think “was this worth the effort to go get PEP?” you’re just protected.

I do think that PEP is underutilised and still has a lot more potential, but to realise that potential will require making it a lot easier to access (things like this PP clinic will help a lot in that regard) and making more people aware of how and when they should use it (not to mention addressing the shame that a lot of people feel around using PEP).

Personally I’d rather get PrEP and be able to schedule my clinic appointments based on when it’s convenient, not when I’m panicking in an emergency. Other folks might see PrEP as more than they need or want to use, and that’s fine too. PEP and PrEP are both useful and effective ways to prevent HIV and people should be able to choose what works best for themselves.


December 7th, 2015

Joe, I would add to werdna’s list of reasons one should do PEP over PrEP the concern of constant risky exposure. A sex worker or a +/- couple would pretty much be constantly on PEP. Someone who only occasionally has sex, and chooses other precautions may employ PEP if a condom failed, for example. But for everybody else in between, werdna’s right: how do they judge what is risky? If you are non-monagamous, with frequent, multiple partners, then PrEP is probably far better (cheaper and easier) than PEP. PEP is like the morning-after pill – why would you use it regularly when you can just take the Pill and use a condom? With one, you are in a panic, with the other, you are in control.


December 7th, 2015

Usage as PEP in the way PrEP is used would also not take long to make the drug treatment obsolete in the long run, which is precisely why the CDC in its FAQ points out that PrEP is the treatment you should look at for prolonged consumption.

It’s also why it’s a good way to piss off your prescribing doctor to stop antibiotics before their full course, just like not taking PrEP as prescribed is also going to annoy your doctor.


December 8th, 2015

This was posted earlier today earlier at JoeMyGod,not sure if you’ve read it at all Timothy, but I thought it germane.

Last night a group of noted AIDS activists including Peter Staley and Larry Kramer met in the very apartment where the Gay Men’s Health Crisis was formed 33 years ago to denounce the “abusive pricing” and “profiteering” which continues to put cost of PrEP beyond the means of much of the world. The group has issued a statement:

“We – AIDS activists, new and old, aged 24 to 80 – have just broken bread in the same apartment where GMHC was formed, coming together for a lively discussion on how to reduce HIV infections among gay men and trans women. Although we may not see eye-to-eye on every issue we debated tonight, we all agree that Pre-Exposure Prophylaxis (PrEP) is highly effective at protecting a person from HIV infection. While PrEP isn’t for everyone, any individual who thinks they are at risk of getting HIV should have easy access to it, without judgement.

We are fed up with Gilead’s abusive pricing of its near monopolies in drugs that treat and prevent HIV. Truvada as PrEP was not their idea, and came to market based on research they didn’t pay for. Gilead’s PrEP profiteering must end. Full access to lifesaving drugs has been a hallmark of our movement, and we will join with AIDS activists across America and around the world to double-down on this push for health equity.

PrEP, along with condoms, TasP (Treatment as Prevention), and better access to healthcare, are now essential public health tools in lowering HIV infections among gay men and trans women. We must use every tool necessary to help them – and to help all those at risk – stop this virus, once and for all. ACT UP, Fight Back, Fight AIDS. – Larry Kramer, Jim Eigo, Matt Ebert, James Krellenstein, and Peter Staley.”

Timothy Kincaid

December 9th, 2015

Thanks, Byron.

It is, indeed, germane. I may post something on this later today.

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