PrEP discussion

[readymade]

I'm surprised I can't already find this topic anywhere in the forums. Seems to be quite the hot-button issue.

I have multiple partners, often of unknown status. Over the years guys have become increasingly aggressive about wanting me to fuck them bareback. It's pretty hard to resist that in the heat of the moment. Plus, I've had issues with condoms coming off or breaking, and one time a guy shot in my eye. Basically, if you're having a lot of sex, condoms really aren't enough.

After reading up on it this summer, I decided this would be the responsible thing for me to do. I decided the "Truvada Whore" label was pretty much sour grapes. It took a while--my primary care doctor (at Kaiser Permanente) didn't know what it was. She contacted Infectious Diseases, who told me to come in. Between my doctor waiting to hear back from them and the appointment date, it took about a month. The doctor said I was a good candidate, did all the tests, and I've been on it a couple of weeks with no noticeable side effects. Except I feel more secure in my sexual encounters.

So, if you're a typical single gay man, having a varied sex life and not consistent with condom use (let's face it, most guys aren't), you should really consider it. My co-pay is $25, but Gilead has a card you can get and they'll pay that for you. So it's free. You do have to go back for periodic labs, but that's a good thing as well. I'll be getting HIV tested a lot more often than in the past.

I thought I'd like to open up the discussion on this, see who else is doing it.

 

[nafhoosier]

I'm surprised I can't already find this topic anywhere in the forums. Seems to be quite the hot-button issue.

I have multiple partners, often of unknown status. Over the years guys have become increasingly aggressive about wanting me to fuck them bareback. It's pretty hard to resist that in the heat of the moment. Plus, I've had issues with condoms coming off or breaking, and one time a guy shot in my eye. Basically, if you're having a lot of sex, condoms really aren't enough.

After reading up on it this summer, I decided this would be the responsible thing for me to do. I decided the "Truvada Whore" label was pretty much sour grapes. It took a while--my primary care doctor (at Kaiser Permanente) didn't know what it was. She contacted Infectious Diseases, who told me to come in. Between my doctor waiting to hear back from them and the appointment date, it took about a month. The doctor said I was a good candidate, did all the tests, and I've been on it a couple of weeks with no noticeable side effects. Except I feel more secure in my sexual encounters.

So, if you're a typical single gay man, having a varied sex life and not consistent with condom use (let's face it, most guys aren't), you should really consider it. My co-pay is $25, but Gilead has a card you can get and they'll pay that for you. So it's free. You do have to go back for periodic labs, but that's a good thing as well. I'll be getting HIV tested a lot more often than in the past.

I thought I'd like to open up the discussion on this, see who else is doing it.

You are free to bareback as much as you want, as it's a free country. But, I have issues with your post.

You need to be more specific and concrete with your statement when you say that most single gay men with varied sex lives are not consistent with condom use. Orally? Anally? There's a difference between the two and rates of condom use - and despite those statistics, it's certainly not "most" gay men that are inconsistent with condom use.

You seem to not want HIV. Why are you not consistent with your condom use then? Do you have sex when you are heavily under the influence of drugs and alcohol? The "heat of the moment" to me is never as important as the need to protect my health from living a very hard life with HIV. PrEP is actually supposed to be used in ADDITION to a condom (which is absurd in and of itself), which is why many people in the gay community think it's a ridiculous new method to be encouraged for HIV prevention. Condoms DO work when used consistently and correctly.

Here's another good point: Like condoms, you are supposed to use PrEP consistently and correctly ALL THE TIME in order to prevent getting HIV. If, like you say, most gay men with "varied sex lives" can't even use a condom that can save their lives consistently all the time, how can they be trusted to consistently take a pill that can save their lives all the time?

I hate to break it to you 'readymade', but if you don't want HIV, turn your life around (at least your sex life) and wear a condom ALL THE TIME, at least for anal sex. Feel free to also try PrEP. But trust me, if you can't handle the responsibility of protecting your health through wearing a condom, you won't consistently stick to your PrEP regiment.

So either wrap it up 100% of the time (in addition to taking those pills if you choose), start curbing your hookups and being far more selective with your sexual partners, or accept the fact that you will eventually get HIV, because that's the direction you are headed from the sound of it!

Again, your health is your responsibility - not anyone else's.

 

[KaraBulut]

There was a discussion a while back in one of the forums- probably Hot Topics- about PrEP.

There aren't research studies that support use of PrEP in gay men who choose to have unsafe sex. The original studies were of monogamous heterosexual couples where one partner was HIV+ and the other HIV-(discordant couples) and the studies looked at whether PrEP would prevent infections and perhaps allow the couples to conceive children. These couples were encouraged to use condoms if they were not attempting to get pregnant. These studies found that there were very few cases where the HIV- partner seroconverted.

There were also some studies in countries outside the US of men who have sex with men (MSM) who were given PrEP. Several participants in the study contracted HIV and it was unclear whether they contracted HIV because they weren't consistently taking the medication or whether the medication was ineffective for preventing HIV transmission from anal sex.

The manufacturer of Truvada has been putting out press releases citing studies saying that "Truvada can reduce HIV transmission" but they do not make it clear that there aren't studies supporting use of the drug in MSM who are choosing to have unsafe sex with multiple partners. There interest in finding a new market for a drug that must be taken daily for years and costs upwards of $1,000 per month has led to a situation where its effectiveness is being tested in the market of gay men who can find a provider who will write a prescription for them.

It's been interesting to see how this has rolled out. The CDC released guidelines in May, 2014 about PrEP and they were very specific about who should receive it. Older activists accused Gilead of milking profits off unsuspecting gay men by overselling a drug that has side effects and hasn't been proven to prevent HIV infection in gay men who are having unsafe sex. Younger activists accused the older activists of being out of step and out of touch.

Here's how this will probably play out:

1. There will be reports of HIV- men who seroconvert while on Truvada.
2. Minority activists will question why the drug is not available to MSM of color where the infection rates are as high as 50% in some urban communities. They will also question why their prevention programs are grossly underfunded.
3. There will be studies that confirm that missing even a single dose can result in an established infection.
4. There will be studies that determine that the drug doesn't prevent HIV infection in those who have unprotected anal sex with multiple partners of unknown status. The studies will determie that Truvada just prevents the infection from getting established and that this group of HIV+ men must take the drug for life.
5. Insurance companies will tire of paying the cost of the drug and they will put out guidelines that say they will only pay for the drug under certain circumstances.
6. The side effects of the drug will become an issue for some of the people taking the drug and they will stop taking it.
7. Many of the people taking the drug will tire of taking it every day or they will no longer be able to afford it. The virus will mutate and will develop resistance to one or more of the antiretrovirals in the drug.
8. Older activities will say "we told you so". Younger activists will accuse the older activists of being sex negative and out of touch.

 

[readymade]

Wow, Naf, you make a lot of unwarranted assumptions about me.

I don't drink or do drugs. At all.

I have NO trouble maintaining the 1-a-day regimen. I've been taking other 1-a-day pills for years.

My statement about reduced condom usage IS supported. In a 2012 study, the largest of its kind:

According to the study’s findings, one in three acts of anal intercourse between men are condom protected in the U.S.

So even if we assume that some of those acts are within committed relationships--still a lot.
[https://newsdesk.gmu.edu/2012/02/ne...e-u-s-among-gay-and-bisexual-men-ages-18-87/]

Kara: the original IPREX study argues against your point that "there aren't research studies that support use of PrEP in gay men who choose to have unsafe sex." From the study:

At screening, the average number of sexual partners reported by trial subjects in the past three months was 18. Sixty per cent reported any unprotected anal intercourse (UAI) in the last three months, 77.5% reported UAI with a partner of unknown HIV status in the last six months and 2.5% with a partner known to have HIV.

While condoms were handed out, there was no knowledge of actual usage. Considering subjects' prior behaviors, it seems likely they continued earlier behavior patterns. Among those who actually adhered to usage protocols and had the corresponding amount of drug in their systems, effectiveness was calculated at 92%. This is better than with condoms. (This study, by the way, was international and included 2500 subjects, including Americans.)
[http://www.aidsmap.com/The-iPrEx-study/page/1746640/]

I do not know any men who use condoms with oral sex. That contains a definite element of risk, though low. Condoms also break. They come off. (I've experience both personally.) Guys rub their dicks over holes before putting on the condoms. That can cause infection. So I would say that the reactionary, automatic reliance on condoms as a panacaea needs re-examination. People just think that if a condom is involved, they're protected. Not really.

The fact is that guys are having sex without condoms. A lot. ANY tool that will help reduce HIV transmission should be welcomed. Instead there are these strange, almost puritanical responses highly reminiscent of abstinence-only sex education. You know, I recall when condoms became the first line of defense in AIDS prevention, there were similar reactions insisting that it wasn't enough, and that men needed to all settle down in stable monogamous relationships. Well, sure, that's effective (to a certain extent--guys do cheat). But that's a lifestyle option, not a tool. It's quite telling that Naf ends by telling me to "curb my hookups" and "be far more selective." (Not to mention the pompous, preachy admonition to "Turn your life around.") I really think this sexually conservative attitude is actually holding us back from addressing the issue and lowering infection rates.

Let me just say to anyone else who might read this: go look at these studies for yourself. That's what I did. I read lots of commentary on both sides, and went back and looked at the science. I talked it over with an infectious disease doctor. There's a lot of misinformation out there of the type that you see in these responses to my post, and I think I've countered them fairly well here. Yes, this is still pretty new, and who knows what the future holds, but I think it's a must for guys like myself who find that it's becoming increasingly difficult to maintain 100% condom usage in anal sex. Even if you're using condoms a lot, you can protect against accidents.

Here are a couple of good articles:
http://gawker.com/what-is-safe-sex-the-raw-and-uncomfortable-truth-about-1535583252
And be sure to read his followup where he discovers his initial problems were NOT about Truvada:
http://gawker.com/truvada-its-time-to-take-the-fucking-pill-1612386701

 

[KaraBulut]

Kara: the original IPREX study argues against your point that "there aren't research studies that support use of PrEP in gay men who choose to have unsafe sex." From the study:

While condoms were handed out, there was no knowledge of actual usage...

In my earlier comments and general cynicism, I had the iPrEx study in mind.

The study would have never been done in the US because it was a double blind study that weighed Truvada vs Placebo. Condoms were offered. Medication compliance was an issue. The population risk was not possible to evaluate because unlike the discordant couples studies, the HIV status of the study's sexual partners was unknown. The study size was relatively small but even with the condoms and the Truvada, there was about 5% of the study group that seroconverted and the reduction in the Truvada group was about 50% less than in the placebo group. Even in the highest compliance group- with condoms- with an unknown number of HIV exposures- there were still HIV infections.

That's a pretty pitiful result from a pretty meager study.

Yet, Truvada is being marketed as "prophylaxis".

I do not know any men who use condoms with oral sex. That contains a definite element of risk, though low. Condoms also break. They come off. (I've experience both personally.) Guys rub their dicks over holes before putting on the condoms. That can cause infection. So I would say that the reactionary, automatic reliance on condoms as a panacaea needs re-examination. People just think that if a condom is involved, they're protected. Not really.

Seat belts break. Seat belts can cause injury. People think they're protected when they use seat belts, but they're not really. So, why encourage people to use seat belts?

That sentence seems a bit absurd, especially when one compares the data from mortality and morbidity between the seatbelt vs no-seatbelt populations.

What we're talking about is risk reduction. We acknowledge that people need to drive cars. We acknowledge that people will have car accidents. However, we still encourage seatbelt use because we have the hard evidence to support that they reduce severity of injury and can save lives.

Somehow that same rational common sense approach to HIV risk reduction- which was demonstrably effective in the period from 1986 to present - seems to have been supplanted by the belief that antivirals are an adequate replacement. The research doesn't support that conclusion.

The fact is that guys are having sex without condoms. A lot. ANY tool that will help reduce HIV transmission should be welcomed.

And this is where the argument falls apart. It's true that condom compliance has historically been inconsistent. So, does anyone believe that compliance will be any better with a $40 per day pill versus a 50 cent condom?

Most ID guys who have been around for a while have seen what has happened over time with antibiotic resistance. The organism always outsmarts the drug. The same is true with antiretrovirals. The virus will evolve and become resistant. The more infections, the more intermittent the exposure to antiretrovirals, the more resistant strains.

We've had success with viral load reduction in HIV+ men on antiretrovirals. This has reduced exposures with serodiscordant partners- the studies support that. Unfortunately, this extension of antiretrovirals as "prophylaxis" and particularly as a substitute for more effective and proven countermeasures like condoms has never been a recommendation supported by public health experts.

In the end, it's become a means to an end for a population that wants to indulge in risky behavior and now have been sold the idea that taking a $1300 per month drug will allow them to do so without risk.

 

[readymade]

The study would have never been done in the US because it was a double blind study that weighed Truvada vs Placebo. Condoms were offered. Medication compliance was an issue. The population risk was not possible to evaluate because unlike the discordant couples studies, the HIV status of the study's sexual partners was unknown. The study size was relatively small but even with the condoms and the Truvada, there was about 5% of the study group that seroconverted and the reduction in the Truvada group was about 50% less than in the placebo group. Even in the highest compliance group- with condoms- with an unknown number of HIV exposures- there were still HIV infections.

That's a pretty pitiful result from a pretty meager study.

Wow. This is a willful misreading of the evidence. First, there WAS an American cohort in the study. Second, 2500 is NOT a small number for this kind of study. Third, you don’t have to know the serostatus of all their partners to see that the placebo group had far higher infection rates. Fourth, nothing in the study says that the “highest compliance group-with condoms” still had HIV infections.

What we're talking about is risk reduction. We acknowledge that people need to drive cars. We acknowledge that people will have car accidents. However, we still encourage seatbelt use because we have the hard evidence to support that they reduce severity of injury and can save lives.

Sure, but why can’t PrEP be like airbags? Why can’t we have both? Extend your metaphor: you’re arguing that because seatbelts are pretty effective, we shouldn’t invest in airbags; that there is only one way to drive safely. Safety can only rely on one method. Ridiculous.

So, does anyone believe that compliance will be any better with a $40 per day pill versus a 50 cent condom?

Well, obviously I do, and so do lots of other people who are taking it. If people can afford it, why not? Are you arguing that just because not everybody can or will use Truvada that nobody should?

Most ID guys who have been around for a while have seen what has happened over time with antibiotic resistance. The organism always outsmarts the drug. The same is true with antiretrovirals. The virus will evolve and become resistant. The more infections, the more intermittent the exposure to antiretrovirals, the more resistant strains.

Read the science. Truvada’s been around for a long time. There is no indication of problems with resistance in anything I’ve read.

Unfortunately, this extension of antiretrovirals as "prophylaxis" and particularly as a substitute for more effective and proven countermeasures like condoms has never been a recommendation supported by public health experts.

Wow. This shows woeful ignorance of reality. Not only has the FDA approved this (based on the science); but also, WHO has officially recommended that all gay men worldwide consider getting on PrEP.

In the end, it's become a means to an end for a population that wants to indulge in risky behavior and now have been sold the idea that taking a $1300 per month drug will allow them to do so without risk.

Gilead has engaged in ZERO marketing of PrEP. I defy you to show me an ad from them. All information has come from health professionals. None of the materials available focus on “indulging in risky behavior . . . without risk.” PrEP is covered by most insurance, and Gilead has a co-pay subsidy plan, so it's effectively free. Believe me, my HMO would not pay for it if it weren't going to be effective for them in the long run (e.g., reducing risk).

I encourage you to read up, starting with the articles I linked, which have numerous other links contained within.

 

[hotatlboi]

Unfortunately, this extension of antiretrovirals as "prophylaxis" and particularly as a substitute for more effective and proven countermeasures like condoms has never been a recommendation supported by public health experts.

I believe the first part of this statement is inaccurate, the CDC released their clinical recommendations for truvada for prophylactic use earlier this year.

http://www.cdc.gov/hiv/pdf/PrEPguidelines2014.pdf

Also, the WHO.

http://www.who.int/mediacentre/news/releases/2014/key-populations-to-hiv/en/

When PreP was first approved by the FDA in 2012, most public health agencies had not signed on to the logic of it yet, but most since have.

 

[hotatlboi]

Seems to be quite the hot-button issue.

It really seems to be a divide between older and younger guys.

Many older guys who lived through the AIDS crises have an extreme resistance to anything that could even possibly communicate the idea that a condom is not 100% required all the time. To many of these guys, their psyche was shaped by a powerful reality that not using a condom equals death, and that anyone who chooses not to use a condom therefore is a reckless freak with some kind of death wish.

To many younger guys, who grew up in an era where HIV was well controlled, where acquiring it does not equal death, and where transmission of it is markedly reduced due to treatment, they have a very different perception of the risks of not using condom and therefore seem more more open to alternative or additive treatment options like PreP.

 

[KaraBulut]

I believe the first part of this statement is inaccurate, the CDC released their clinical recommendations for truvada for prophylactic use earlier this year.

http://www.cdc.gov/hiv/pdf/PrEPguidelines2014.pdf

Also, the WHO.

http://www.who.int/mediacentre/news/releases/2014/key-populations-to-hiv/en/

When PreP was first approved by the FDA in 2012, most public health agencies had not signed on to the logic of it yet, but most since have.

Yes, I'm familiar with the guidelines. The statement on page 27 is the key:

When supporting consistent and correct condom use is feasible and the patient is motivated to achieve it, high levels of protection against both HIV and several STIs are afforded without the side effects or cost of medication. A clinician can support consistent condom use by providing brief clinical counseling ... by referring the patient to behavioral medicine or health education staff in the clinical setting, or by referring the patient to community based or local health department counseling and support services.

Therefore, unless the patient reports confidence that consistent condom use can be achieved, additional HIV prevention methods, including the consideration of PrEP should be provided while continuing to support condom.

The WHO HIV/AIDS Programme guidelines were much clearer:

All PrEP trials achieved results through combination prevention, with strong emphasis on increased and continued condom use. Providing PrEP while avoiding the displacement of existing condom use is crucially important.

It really seems to be a divide between older and younger guys.

Many older guys who lived through the AIDS crises have an extreme resistance to anything that could even possibly communicate the idea that a condom is not 100% required all the time.

It's much simpler. The very fact that "older guys" are around is a testament that behavior modification was successful. When one looks at recent trends- particularly in increases in hepatitis rates and HPV-associated oral/anorectal cancers in MSM- it's apparent that condom non-compliance has other ramifications.

The $18K per year price tag makes it out of the reach of a large percentage of high risk populations. Medi-Cal has recently agreed to cover the cost of PrEP without a TAR which removes some barriers but there hasn't been a significant increase in prescriptions- at least not to date.

 

[hotatlboi]

It's much simpler. The very fact that "older guys" are around is a testament that behavior modification was successful. When one looks at recent trends- particularly in increases in hepatitis rates and HPV-associated oral/anorectal cancers in MSM- it's apparent that condom non-compliance has other ramifications.

No one is suggesting that PreP is a magic pill that gives you a license to become a whore and go bareback with anyone and everyone any time you want. If you do that, you're an idiot and deserve whatever you get.

I've been sexually active for 10 years. I have for the most part used condoms, but not 100% of the time. There were a few times where I didn't use a condom and I was really stressed out and worried for the next 3 months. PreP is about eliminating those situations more than anything.

Rather than see the benefit this could have, many guys have just taken to condemning people that have not used a condom 100% of the time. To me, this is a self righteous almost fundamentalist attitude about sex that does not serve much benefit.

 

[medic1]

Alas, many younger gay guys do see it in this way. No longer terminal, just a chronic illness managed by pharmacology, such a false sense of security.
Guys do use PrEP in the believe that it is the magic bullet, they are wrong, As an emergency measure, yes.
As an alternative to condoms, no............

 

[kallipolis]

Alas, many younger gay guys do see it in this way. No longer terminal, just a chronic illness managed by pharmacology, such a false sense of security.
Guys do use PrEP in the believe that it is the magic bullet, they are wrong, As an emergency measure, yes.
As an alternative to condoms, no............

Well noted....

Condoms should be an essential ingredient in our wallet to be used...on every occasion.....

 

[hotatlboi]

Alas, many younger gay guys do see it in this way. No longer terminal, just a chronic illness managed by pharmacology, such a false sense of security.

That IS what HIV is today. Are you suggesting it is not? Assuming you take your meds the average life expectancy of people with HIV is almost up to that of the general population. It is no longer terminal and is simply a chronic condition.

Now, if you are simply suggesting that despite this people should not have a cavalier attitude about going bareback, then I fully agree with that.

 

[medic1]

Aids still accounts for thousands of deaths per year. Count yourself lucky you have access to ARV's.
I see patients who hold this sense of dodging the bullet because of PrEP, alas for some the bullet hit home.

You are correct about your assumption about my feeling of not using condoms...........

 

[LuckysRevenge]

I'm with the older gays on this one.

I've seen many gay guys (friends included) who have seen PrEP as a substitute for condoms.

And they use "studies" and such like the ones posted here as evidence that they'll be fine.

They may not whore around with everyone in sight, but they still have bareback sex outside of monogamous relationships. I see this heading in a very depressing direction. I'm not sure why wearing condoms is so difficult for some people. IMO the continued praise of PrEP only further encourages those who already have an inclination to ditch condoms.

 

[mbamike]

I have just taken my first dosage of Truvada. I am still a bit anxious about this medication given all that has been said about it both pro and con, but I am looking at it as another layer of protection from HIV. BTW, I practice safer sex. I use condoms regularly.

I was also a bit apprehensive about "coming out" to the doctor. In general, I am not out. All I have said to the doctors up to this point was that I have sex with multiple sex partners. I was not specific that these sex partners were men and I was having "anal receptive sex."

I had my annual checkup last week with my primary care physician. I get my medical care through the VA system and had to get a referral from the primary care physician to the infectious disease (ID) clinic at the main VA hospital in the area.

The ID doctors were rather nonchalant about the whole ordeal. I think the first doctor was an intern and had to consult with the other doctor. After I "came out" and requested to be put on Truvada, he wanted to know my other medications, if I have a history of STDs, do I use condoms, do I use illegal drugs and if I ever had hepatitis. I have been vaccinated for hepatitis A and B.

I took copies of my lab results from the county health clinic to show that I get tested every 3-6 months for STDs and HIV. I was negative for both as of March 6.

I go back for a follow-up in three months. The ID doctor wrote the order so I can continue getting tested for STDs and HIV at the county health clinic since my local VA clinic is not really set up to test for STDs. I thought this was really nice of him. I just have the bring him a copy of the results.

I'm basically venting because of the anxiety. Anyone have any questions, I will try to answer them. Send me a PM if you like.

 

[KaraBulut]

I have just taken my first dosage of Truvada. I am still a bit anxious about this medication given all that has been said about it both pro and con, but I am looking at it as another layer of protection from HIV. BTW, I practice safer sex. I use condoms regularly.

Worth emphasis for those reading this thread: PrEP is not a replacement for condoms.

Hepatitis and syphilis rates have always been the marker that we track for MSM STD rates. A rise in hepatitis and syphilis are a good predictor of HIV infection rates in the future.

The CDC released their 2013 statistics on STDs at the end of 2014:

The rate of primary and secondary syphilis last year was the highest recorded since 1996 the Centers for Disease Control and Prevention (CDC) announced this week with the release of their 2013 STD Surveillance report. In 2013, there were 17,357 confirmed case of syphilis in the United States, a ten-percent increase over the previous year. Of those individuals diagnosed with syphilis, 91% percent were men and 75% were men who have sex with men (MSM).

The ID doctors were rather nonchalant about the whole ordeal. I think the first doctor was an intern and had to consult with the other doctor. After I "came out" and requested to be put on Truvada, he wanted to know my other medications, if I have a history of STDs, do I use condoms, do I use illegal drugs and if I ever had hepatitis. I have been vaccinated for hepatitis A and B.

All of the questions he asked are on the mark.

ID guys are pretty cool guys. They've been dealing with HIV now for 30 years, so most of them have a pretty blase' attitude. Since the CDC issued guidelines in favor of PrEP, the VA has to fall in line and provide Truvada to those who meet the CDC guideline.

 

[hotatlboi]

I have just taken my first dosage of Truvada. I am still a bit anxious about this medication given all that has been said about it both pro and con, but I am looking at it as another layer of protection from HIV.

I've been taking it for a few months. I will probably go off it at some point now that I have a bf, but I haven't had too many issues.

It made my stomach a little upset for the first week or so, especially if I took it at night. I switched to taking it in the morning and haven't had any problems.

 

[LuckysRevenge]

I've been taking it for a few months. I will probably go off it at some point now that I have a bf, but I haven't had too many issues.

It made my stomach a little upset for the first week or so, especially if I took it at night. I switched to taking it in the morning and haven't had any problems.

I'm curious. Did you take it in addition to using condoms?

 

[mbamike]

I'm curious. Did you take it in addition to using condoms?

Yes, I still use condoms.