Ask the Doc: Dangers of PrEP-Only Prevention
In this installment of the popular Ask the Doc series, Dr. Howard Scheiner looks again at PrEP with Truvada, the pros and cons of the regimen, and other risks that come with unprotected sex, like anogenital warts, anal cancer, HPV, STDs and Hepatitis C. Learn how safer sex and regular testing can help keep you healthier.
Q: Dear Doc, I just read a quote from Larry Kramer, in The New York Times, referring to PrEP. He said that "Anybody who voluntarily takes an anti-viral every day has got to have rocks in their heads." What do you think about that?
A: For those of you who may not know Larry Kramer, watch the recently released HBO film of his play, "The Normal Heart." As a co-founder of both GMHC and ACT UP, clearly the lens through which he views HIV/AIDS is unique. His perspective is shaped by his own illness and personal struggles and his fight to give voice and visibility to the anguish and suffering of a once ignored and shunned generation, along with his fight for accelerated approval of AIDS drugs.
It seems from my reading that he views PrEP medication as a "poison" to the body. And while this or any medication may have side effects or long-term consequences, for those who choose to decrease the risk of transmission with this approach, it can be a useful tool. PrEP can be stopped at any time, should one come to agree with him or find this tool is no longer necessary or if side effects occur; HIV once acquired cannot be stopped so easily.
It should be noted that Truvada was approved as PrEP to be used as part of a comprehensive prevention strategy that includes safer-sex practices with condom use. In my experience, this is not always the situation in the real world, where PrEP is used as the only strategy. Of course, regular testing for other sexually transmitted diseases -- some of which facilitate HIV transmission -- must still be done.
Add Screenings, If Using Only PrEP
Q: I have started Truvada as prevention for HIV. I don't use condoms. I know it won't prevent gonorrhea or syphilis, but are there other diseases I also need to be checked for?
A: HPV (Human Papilloma Virus) is the most common sexually transmitted disease in the US. A recent study determined that 69 percent of sexually active American adults are infected. Some types of HPV can cause anal cancer. Other types cause anogenital warts. If you have had anal warts you are at increased risk for getting anal cancer. Vaccination before initial sexual exposure can reduce the risk of anal cancer. Recommendations on who should get an anal Pap smear are evolving as there is no clear consensus yet.
The NYS Department of Health AIDS Institute suggests it yearly for HIV-positive men. For HIV-negative Men who have Sex with Men (MSM) and women who have anal sex, it probably is reasonable to do it every 1-3 years. If you have unprotected sex utilizing a Truvada prevention strategy, I would suggest yearly anal Pap testing.
Since 2000, there has been a rising incidence of acute Hepatitis C in HIV-infected MSM. The reported infections climbed from 7 percent in 2000 to 24 percent in 2010. While the findings support sexual transmission of Hepatitis C in MSM, there may be other factors related to higher-risk sexual practices and drug use. It would seem reasonable to add a yearly Hepatitis C screening test if you are having unprotected sex on a Truvada prevention strategy.