Ask the Doc: The Pros and Cons of PrEP

Q: Dear Doc, some of the guy's I've been hooking up with have suggested I go on PrEP to prevent getting HIV. Should I?

A: Truvada taken daily was approved by the FDA in July 2012 as Pre-Exposure Prophylaxis (PrEP) to prevent HIV transmission. Various studies have reported efficacies ranging from 44 to 75 percent. Efficacy seems to be in large part related to consistent daily dosing. But unless you have been living under a rock in Waziristan, the chances are that you are well aware that consistent use of condoms also reduces the risk of HIV transmission by about 80 percent.

For discordant couples (one positive, one negative), who have decided that a fully intimate latex-free sex life is a clear choice, then PrEP would seem to be a clear choice.

Additionally, assuming the positive partner is on suppressive ART, the risk of transmission can decrease from 60-96 percent. So, if both partners are on medications, transmission may approach a statistical improbability, much like being struck by lightning on a clear day.

Sex workers, who may have no choice in condom use, are likewise a seemingly clear choice for PrEP. For sexual compulsives who have no current intent of changing behaviors, Truvada is also a winner.

But most of my patients who are currently inquiring about or requesting prescriptions for Truvada do not fall into the above categories. They are gay men who simply like having sex and are not thrilled with condoms (which even if used, oftentimes break). So it is here that a discussion with your own physician who knows you best is key.

Q: Is barebacking safe on PrEP or are there risks I should know about?

A. Lighting has been known to strike on a clear day. PrEP is not a guarantee of prevention and it may lead to an increase in risky behavior. (Studies to date do not give a clear answer.) There are lots of other diseases that can also be acquired through unprotected sex. And over the course of decades, should one take PreP for that long (and in the absence of a vaccine breakthrough for prevention), side effects of medication may become more telling.

These might include bone mineral loss (osteopenia or osteoporosis) and some degree of kidney compromise and fat redistribution. There is also always the possibility of aggressive new recombinant strains of HIV as recently reported in West Africa, which may yet have unanticipated resistance profiles.

Population studies, mathematical models and cohort analysis do not answer the question of whether to take PrEP or not for the individual patient. As part of a national prevention strategy decreasing the pool of HIV transmissibility it is now clearly a prevention modality as is immediate treatment of HIV at diagnosis.

The benefits and risks for you and your health should be assessed in the patient-doctor setting with personalized advice from your physician to make the best choice(s) going forward.

Called "more than a doctor, a trusted friend" by his patients, Dr. Howard Scheiner is a true native New Yorker. He was born in the Bronx, he attended the esteemed Bronx High School of Science and City University of New York before receiving his medical education at The Mount Sinai School of Medicine. Truly a Renaissance man, in addition to his lifelong service to the medical profession, Dr. Scheiner is a published author, playwright and musical composer. Combining all his loves, he is perhaps most proud of founding "The Brent Varner Project, Inc." a charity that provides free HIV services to those in need through the Actors Fund of America.

This story is part of our special report: "Ask the Doc". Want to read more? Here's the full list.

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