Are you PrEPared - By Eric Paul Leue, Mr. Los Angeles Leather 2014
Recently there have been many news reports about promising new developments in HIV research. Besides studies that have confirmed the efficacy of “Treatment as Prevention,” the U.S. public health departments are now also rolling out PrEP (Pre-Exposure Prophylaxis) under the recent guidelines of the CDC. What is already approved in the U.S. is still in studies in Europe: IPERGAY in France and PROUD in the UK.
With all that is going on in the news, it is hard to keep up. Many reports seem to contradict each other and oftentimes the mass of information is overwhelming.
My name is Eric Paul Leue. I am Mr. Los Angeles Leather, a bear, a pup and a 28-year-old German, HIV-negative, gay man. I have been involved with HIV education, care and outreach for about a decade in Berlin, London and now LA. Over the coming weeks and months I will be writing about HIV & STIs with a special focus on the hot-topic—PrEP.
STIs (Sexually Transmitted Infections) used to be known as STDs (Sexually Transmitted Diseases). Since not every infection shows signs of a disease and the word “disease” can trigger negative emotions, this change in wording has gained broad acceptance. The most commonly discussed STIs are bacterial infections like gonorrhea, chlamydia and syphilis, and viral infections like HIV, herpes, HPV and hepatitis B. Most STIs can be contracted through vaginal/anal/oral intercourse and some even through kissing. I have personally had chlamydia and gonorrhea in my throat.
HIV is often referred to as the only STI that can’t be cured. While there are other incurable infections like HSV (herpes), specific types of hepatitis, and HPV (human papillomavirus), untreated HIV remains to be the most fatal.
We have all heard about HIV at some point, but what is it really? HIV is a retrovirus that can be transmitted in blood, semen, vaginal fluids, and breast milk. Transmission is most common during unprotected sex. Once in a person, HIV weakens the immune system because it reproduces by infecting and basically killing vital CD4 T cells. Today, a variety of antiretroviral drugs (ARVs) are able to suppress an HIV infection until a person basically is undetectable, meaning the person living with HIV has less than “X” number of viral copies per milliliter of blood. Generally a person with less than 50 copies/ml is considered undetectable. ARVs intervene with the viral reproduction. Fusion/Entry Inhibitors block HIV from getting into CD4 cells, and NRTIs/NNRTIs, integrase inhibitors and protease inhibitors all interfere with enzymes that the virus needs to make copies. If a person with an HIV infection is not treated, the virus will overwhelm the immune system within 9-11 years and the final stage of the infection, known as AIDS (acquired immunodeficiency syndrome) will set in. A person is generally diagnosed with AIDS when the CD4 T-cell counts drops below 200 per microliter of blood, or HIV-related diseases set in.
In the US, the STI prevention toolkit consists of regular testing, condoms, PEP, TasP, PrEP, sero-sorting and abstinence. Sero-sorting and abstinence are prevention methods that are based on behavior.Regular testing (at intervals of 1-3 months) enables patients to discover and treat possible STI infections. Successful treatment of the found infection then breaks the transmission cycle and thereby prevents further infections in others.
Condoms are a physical barrier and recommended for vaginal/anal intercourse. It is widely recognized that they are not very popular during oral sex. PEP (Post-Exposure Prophylaxis) is a biomedical HIV transmission prevention. The U.S. FDA approved first ARVs for use as PEP in 1996. It is prescribed for 28 days within 72 hours after a possible exposure to HIV to prevent the virus from manifesting in a person.
TasP (Treatment as Prevention) is a biomedical HIV transmission prevention. It is based on the minimal chance of transmission (0.14%) if a person with HIV has a suppressed/undetectable viral load.PrEP is also a biomedical HIV transmission prevention. The U.S. FDA approved Truvada for use as PrEP in 2012. It is an oral dose that is taken daily before a possible exposure to HIV. The U.S. CDC guidelines specify that PrEP needs to be taken continuously for seven days to prevent transmission in rectal tissue, and 20 days to prevent transmission in cervicovaginal tissue.
The HIV prevalence rate in the United States is about 2.4 times higher than in the United Kingdom. Whereas the population of the U.S. is only five times larger than the population of the UK, there are 12 times as many people living with HIV in the US. The HIV “Treatment Cascade” indicates how effective a country’s public health policies are in regards to HIV. In light of TasP’s efficacy, the treatment cascades are especially interesting.
The graph shows us that while the UK has a higher percentage of undiagnosed HIV infections, the percentage of people with a suppressed viral load by far exceeds the efforts in the US. It is to be noted that the UK statistics identify a suppressed viral load as less then 50 viral copies/ml, whereas the U.S. statistics already consider less than 200 viral copies/ml as undetectable.
We often hear that if everyone would use a condom every time they had sex we wouldn’t have to deal with all these STIs. While this thought is not entirely wrong, it is also not entirely true.
During the 2013 Conference on Retroviruses and Opportunistic Infections (CROI 2013), the efficacy of consistent condom use was determined to be 70% based on two studies (EXPLORE and VAX004). It was established that out of more than 7,000 men, only 16.4% self-reported to have used condoms during every anal/vaginal intercourse and that intermittent condom use basically has 0% efficacy.
PrEP is prescribed as daily oral doses of Truvada. This drug is a combination of two active agents, Tenofovir (TDF) and Emtricitabine (FTC) and was first FDA-approved for HIV treatment in 2004.
During the initial studies (iPrex, Partner, TDF2 and Bangkok Tenofovir) efficacy rates of Pre-Exposure Prophylaxis were established. A regression model calculation based on the iPrex study identified daily PrEP to prevent 99% of HIV transmissions. At the 2014 AIDS conference in Melbourne, the results of the follow-up study (iPrex OLE) showed PrEP’s efficacy in gay men who adhered to four or more doses per week at 100%. Other forms of PrEP, like long-term injectable options, are currently being studied and show great promise.
Since neither abstinence, sero-sorting, TasP nor condoms are the sole solution in regards to HIV prevention, is PrEP our best bet? Again, while this thought is not entirely wrong, it is also not entirely true.
The prevention toolkit offers multiple options for people to choose from. Some people have difficulties with taking medication; others do not use condoms every time. PrEP is the best HIV transmission prevention to date, but sexual health is a very personal topic and, as such, a personal choice. Only you know what will work best for you.
Look out for future editorials to learn more about PrEP, its side effects, drug resistance and other key points.
If you have any questions about PrEP pease email Eric, at eric@bearworldmagazine.com
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