HIV PrEP

PrEP (Pre-Exposure Prophylaxis Against HIV) 

What is PrEP (Pre-Exposure Prophylaxis)?

PrEP is a daily medication to reduce the risk of getting infected with HIV and used to prevent HIV in high-risk individuals. PrEP means Pre-Exposure Prophylaxis which is a drug taken once a day before contact with any high-risk HIV exposure.

It is approved for use by the CDC (Control of Disease Center) if you frequently engage in high-risk behaviour, unsafe sex or used by medical personnel with a high risk of exposure with HIV and sex workers.​​​

What is high-risk behavior?

    • Unsafe sex without a condom

    • Sex parties

    • Multiple sexual partners

    • Sex while high on drugs

    • Sharing needles

    • History of STD / STI currently and in the past

    • Usual sexual practices

      • BDSM – insertion of foreign objects into the urethra (hard cock plug) or anus (hard anal plugs) which may damage the mucosa.

      • Necrophilia Sex – People who have sex with dead bodies. (contact with blood)

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PrEP (Pre-Exposure Prophylaxis Against HIV) 

What is PrEP (Pre-Exposure Prophylaxis)?

PrEP is a daily medication to reduce the risk of getting infected with HIV and used to prevent HIV in high-risk individuals. PrEP means Pre-Exposure Prophylaxis which is a drug taken once a day before contact with any high-risk HIV exposure.

It is approved for use by the CDC (Control of Disease Center) if you frequently engage in high-risk behaviour, unsafe sex or used by medical personnel with a high risk of exposure with HIV and sex workers.​​​

What is high-risk behavior?

    • Unsafe sex without a condom

    • Sex parties

    • Multiple sexual partners

    • Sex while high on drugs

    • Sharing needles

    • History of STD / STI currently and in the past

    • Usual sexual practices

      • BDSM – insertion of foreign objects into the urethra (hard cock plug) or anus (hard anal plugs) which may damage the mucosa.

      • Necrophilia Sex – People who have sex with dead bodies. (contact with blood)

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What is high-risk behavior?

​​Yes. Medical personnel does not belong to the high-risk group however medical personnel often deal with high-risk patients therefore they can consider PrEP. Even medical personnel dealing with violent psychiatric patients who are HIV positive can accidentally poke the medical personnel with an infected needle during blood taking or during medication administration. PrEP is an additional barrier in these risky situations and work.

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Who is suitable for PrEP (pre-exposure prophylaxis?

Sometimes you may not know are you suitable to start on PrEP but you can always discuss with a doctor who is skilled and certified to do PrEP. In my practice I will look at the patient’s full history:

  • safe or unsafe sex (any unsafe sex history is a red flag to start PrEP)

  • frequency of sexual contact

    • I advocate for PrEP if the person has sexual contact at least once a month

    • I do not advocate for people to be on PrEP if they have SAFE sex once every 2-3months. Infrequent safe sexual contact put the person at low risk.

  • occupation

    • sex worker

    • massage boys or massage girls with sexual services

    • medical professionals dealing with aggressive patients on unknown HIV status or aggressive HIV patients (as there is a risk of occupational needle stick injury)

  • type of fetishes

    • Orgies (multiple sexual partners in one time can cause an increased risk of HIV transmission)

    • Bareback (condomless sex)

    • Chemical Fun sex (sex while on illicit drugs can dull a person inhibitions, therefore, increase the chance of unsafe sexual practices)

    • Extreme BDSM or rough sex can cause injury and expose wounds which becomes a portal of HIV entry.​

  • history of other sexually transmitted diseases increase the risk of HIV transmission

    • in men to men sex: 8 times higher risk to transmit HIV if any one of the partners has any sexually transmitted disease

    • in men to women sex: 1.5 times higher risk to transmit HIV if any one of the partners has any sexually transmitted disease

    • marital status

    • in an open relationship means that the couple are together but they are still having other sexual partners need to be considered to be given PrEP.

    • a married couple needs to be considered for PrEP if they are sexually active with other partners.

    • a married couple when one is HIV positive and the other is HIV negative.

    • if one of the couples has HIV with unknown VIRAL LOAD, then PrEP needs to be considered if they practice unsafe sex or at risk of condom failure (condom tearing).

  • compliance with medication

    • I will never start my patients with PrEP if they are not compliant to medications. PrEP needs to be taken on a daily basis and if patients cannot comply to it then it is pointless to start them on PrEP.

  • allergies

    • history of PrEP allergies prior to the current visit.

As we look at the overall sexual history, you can begin to see a pattern. Patients need to be educated about PrEP. PrEP is not a drug to be taken lightly. PrEP should only be given to people who need it and to those who are compliant to medication. Your doctor needs to assess the risk and possibility of acquiring HIV and other sexually transmitted diseases.

Discuss with your doctor before starting with PrEP and you can read further about in our blog : “Is PrEP for me?” as you can easily relate more to stories and questions faced by our patients.​​

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When I am on PrEP can I have sex without condoms?

PrEP does not replace condoms in the role of the condom is as a first protective barrier. PrEP is considered as an adjunct to the use of condoms or as a second barrier of protection if condom fails.

 

We do not encourage a PrEP user to disregard the use of condoms with the illusion that PrEP on its own is enough to prevent HIV. Nevertheless, many people do not practice safe sex and they should be given PrEP since they do not use condoms at all.

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Can I use PrEP (pre-exposure prophylaxis) if I am pregnant or breastfeeding?

Yes. You can start on PrEP and the safety profile for PrEP is good for both pregnant and breastfeeding mothers. There are conditions when PrEP is warranted in pregnant or breastfeeding mothers:

  1. 1. Husband or partner is HIV positive (Serodiscordant Partner)

  2. 2. Risk like occupation as a sex worker or an escort

PrEP can be safely started in pregnant and breastfeeding women however it requires monitoring and vigilant compliance to medications.

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Can PrEP (pre-exposure prophylaxis) prevent other sexually transmitted diseases (STD)?

PrEP is licensed for the prevention of HIV but there are a few supporting evidence that it can be used to reduce the incidence of Herpes. PrEP does not prevent other sexually transmitted diseases like Syphilis, gonorrhoea and etc.

What should I know before starting PrEP (pre-exposure prophylaxis)?

These are a few questions your doctor should ask you to give you a full assessment:

  1. Sexual orientation

    • Heterosexual relationship means normal man to woman intercourse. Studies have shown a lower risk for a heterosexual relationship to acquire HIV however we must not assume that heterosexual partners are mostly safe. As the saying goes: Assumption is the mother of possibilities. I have had many patients who assume that they are safe and these are the ones whom I have diagnosed with HIV.

    • Homosexual relationship means single sex partners either gays (men to men) or lesbians (women to women) relationships. It is a known fact that when HIV was first known to the world; HIV had a different name called “Gay Related Immuno-Deficiency” (GRID). Incidence of HIV was seen more in men to men sexual partners therefore it was dubbed as GRID.

    • Bisexual relationship means the person can be interested in both men and women either 
       

  2. Frequency of sexual contact indicates the possibility of getting infected with HIV. The more frequent contacts mean that the chance of getting infected with HIV is proportionally higher.

  3. Type of sexual exposure like hand-jobs (assisted masturbation), blowjobs (oral fellatio), vaginal sex, anal sex changes the rates of infection. Starting from the highest risk to the lowest risk sexual exposure: Anal sex > vaginal sex > oral fellatio > assisted masturbation.

  4. Duration of sex. The longer the duration equals higher risk.

  5. Safe or unsafe sex. Safe sex basically means protected with condom which reduces the risk for HIV infection. If the condom breaks then it is possible that risk of getting infected with HIV is much higher because a person may have had penetration repeatedly causing damage to the inner tissues and wounds therefore small bleeding can have a higher chance of HIV transmission. Condom is not absolute protection and has been shown to give about 86 % protection because the possibility of the condom getting torn, improper wearing, condom slip off or even getting raped. In rape cases condom is already irrelevant.                                                                                       

  6. Chemical fun. You probably may never have heard about chemical fun. It is very common for people to mix drugs and sex. It is rather similar to the likes of cigarette and alcohol. Some people actually take methamphetamine or ‘ice’ and it has an amnestic effect therefore most people do not remember the incident or possibly high-risk contact, while on the drug. This situation causes one of the highest risk to acquire HIV.

  7. Fetish is sometimes a range of interesting to kinky processes which are not suitable to be discussed here. Be assured certain sexual practices may increase risk of contracting HIV to be 2-3 folds.

  8. Transmission of HIV may be influenced by an individual’s work. Like myself, I am a medical professional and I deal with potential HIV positive patients whose status is unknown to me. I personally am on PrEP not because of my work. It is also possible to start PrEP in sex workers, medical professionals and laboratory technicians only if they fit the criteria of PrEP commencement. This condition will require more consultation with your doctor and understanding about the personal risk to HIV.

  9. Marital Status or partnered. This status is important because I will want to protect your partner and other parties involved in your sexual life. Consideration about pregnancy and transmission to your partner and needs to be addressed with precision.

 


PrEP is not about starting a drug but more to maintaining the compliance of the drug to achieve optimal results. The commencement of PrEP is about counseling and traveling with your patient throughout the process.

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How effective is PrEP (pre-exposure prophylaxis)?

This drug can give you a reduction of risk of HIV transmission from 92% or more in unsafe sex (without condom or other forms of protective barriers) according to studies conducted regarding the efficacy of PrEP:

Condom is only 86% prevention. PrEP is considered an adjunct to condoms and other protective barriers, it should not be used as an excuse that PrEP is a replacement for the use of condoms and other protective barriers. When condoms and PrEP are combined prevention is almost close to 100% protection.

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What are the side effects of PrEP (pre-exposure prophylaxis)?

PrEP has some side effects and predominantly it varies from one person to another:

  1. One of the more famous side effects is called “Start-up Syndrome”. New users to PrEP can have some symptoms which appear during the first two weeks after commencement of PrEP. “Start-up Syndrome” basically can range from:

    • abdominal bloating

    • headache

    • nausea

    • dizziness

    • loose stool

      • Most of the symptoms are manageable can be also treated symptomatically. Other symptoms also can be associated with PrEP are insomnia and fatigue but described symptoms are rare. Based on my practice I have only come across 1 patient who had insomnia which resolved spontaneously after two weeks.

  2. Bone density loss can occur while they are on prolonged use of PrEP. Prolonged use of PrEP has been shown to cause loss of bone density and osteoporosis, however, it is our job to identify who is at risk and how to prevent osteoporosis. It is not necessary to stop PrEP if you are having a loss of bone density, your doctor needs to discuss with you the preventive and other treatments available to prevent osteoporosis.











     

  3. PrEP also requires monitoring of kidney function.

    • PrEP is excreted through the kidneys, therefore we should acquire a baseline for the kidney function before the commencement of PrEP.

    • The initial baseline is to detect possible underlying kidney dysfunction or disease prior to commencement of PrEP.

    • If you have underlying kidney impairment or usage of PrEP which may impair your kidney function; PrEP dosage can be adjusted based on your creatinine clearance. Kindly speak to you PrEP provider regarding the dose adjustment if necessary.

    • PrEP is relatively safe for the kidneys as multiple studies have shown that discontinuation of PrEP in case of kidney impairment can normal the kidney function back to normal.
       

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What are the steps before starting PrEP (pre-exposure prophylaxis)?

initiate PrEP you need to understand the methodology of initiation of PrEP. PrEP can only be started if you are HIV negative. PrEP must NEVER be started in a person who is infected with HIV or HIV naïve. Persons who are HIV naïve means that the person is infected with HIV but have not started treatment.

You need to ensure that you have had protected sex for a minimal of 2-3months before you test for HIV. HIV has a “window period” which can be negative on a test but HIV may already be in the body. My job is to ensure that it is safe to start you on PrEP. PrEP is not a drug you can get it like some sort of candy and run off like a happy child. You need to know how to start, how to be tested and how to stop PrEP. These are knowledge which you need to be equipped with and that is the job of your provider.

I use a 4th generation HIV test in my setting to give you better accuracy as the test is 99.7% accurate up to 2 weeks from last possible HIV contact. A daily PrEP pill needs to be started seven (7) days prior to safe or unsafe sexual contact.

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How to start and stop PrEP (pre-exposure prophylaxis)?

Once the doctor gives you the green light to start your PrEP; you need to know how to observe certain rules. PrEP needs to be taken daily to give you its maximal protection. There are two protocols to follow:

  1. MSM (Men sex Men) Start with 7 days of PrEP daily before any sexual or high-risk exposure then continue for another 7 days of PrEP after the last day of exposure.

  2. Women require a longer course of PrEP. Start with 7 days of PrEP daily before any sexual or high-risk exposure then continue for another 20 days of PrEP after the last day of exposure.

  3. PrEP needs to be monitored for liver, kidney function and HIV. Sometimes your doctor may also advise you to screen for other sexually transmitted diseases like hepatitis B, gonorrhoea, chlamydia, trichomonas and HPV.

Why do you need to screen for sexually transmitted diseases before initiation of PrEP (pre-exposure prophylaxis)?

It is recommended to perform a full test for sexually transmitted disease test which can be discussed with your doctor.

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Can I start on PrEP (pre-exposure prophylaxis) if I have Hepatitis B?

  1. ​Yes. You can start on PrEP if you have active Hepatitis B or chronic Hepatitis B. There have been many controversial arguments that chronic Hepatitis B, should not be started on PrEP because it can cause acute flaring of Hepatitis B.
  2. PrEP consists of Tenofovir + Emcitrabine (combination drug) for HIV prevention. Tenofovir is also used for the treatment of Hepatitis B and researchers were afraid that sudden withdrawal of Tenofovir can cause Hepatitis B to flare up.

  3. A study of patients on PrEP who are infected with Chronic Hepatitis B, have shown that patients have low Hepatitis B flare-ups after the withdrawal of PrEP. In this single study, patients who were suffering from acute Hepatitis B were given PrEP and after the withdrawal of PrEP the patient’s acute Hepatitis B started to seroconvert (forming antibodies against Hepatitis B). This condition finally resulted in full recovery from acute Hepatitis B and becoming naturally immuned to Hepatitis B.

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What are the sexually transmitted diseases which are required to test before starting PrEP (pre-exposure prophylaxis?

Compulsory tests before starting PrEP are important to ensure that you have a healthy sexual relationship or intimacy and they are:

    • HIV

    • Hepatitis A

    • Hepatitis B

    • Hepatitis C

    • Syphilis

Additional recommended test before commencement of PrEP:

    • Gonorrhea

    • Chlamydia

    • HPV (Human Papillomavirus)

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