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"Hold the condoms. I'm on PrEP now!" - (9/3/2019)

By Dr. Ron Gasbarro

Tim always ordered a particular brand of condoms from the pharmacist. He said they worked the best for him. The next time he came into the store, the pharmacist said, “I have your order ready for you.” “Change of plans, Doc,” Tim said. “I don't need condoms! I’m on PrEP now!"

PrEP stands for Pre-Exposure Prophylaxis. It is the first medication regimen that shields a person from being infected by the human immunodeficiency virus (HIV), the communicable agent that results in acquired immunodeficiency syndrome (AIDS). AIDS is the stage of HIV infection where a person's immune system is fully compromised, leaving the body open to a wide range of potentially deadly diseases known as opportunistic infections. Approved by the US Food and Drug Administration (FDA) and according to the Centers for Disease Control and Prevention (CDC), clinical studies have determined that PrEP is safe and 92% effective in preventing HIV infection.

An estimated 1.2 million Americans are currently infected with HIV and about 36.9 million people are living with HIV worldwide, states the CDC. More than 700,000 Americans with AIDS have died since the beginning of the epidemic in 1981. Globally, the HIV virus has infected 75 million people and about 32 million people have died of HIV, states the World Health Organization (WHO). 

How does PrEP work? Antiretroviral drugs inactivate HIV. They help control the ways the virus ravages the immune system, specifically the T-lymphocytes (T-cells) in those already infected with HIV. The PrEP regimen consists of two antiretrovirals: emtricitabine and tenofovir in a single tablet (marketed as Truvada®) taken once daily. The regimen shields the immune system from a viral invasion that can lead to AIDS. Several issues must be conveyed to the patient before starting PrEP: 1) One must be HIV-negative before starting PrEP. 2) One must have good kidney and liver function as determined through blood testing. 3) PrEP does not prevent pregnancy or other sexually transmitted infections (STIs) caused by bacteria, such as gonorrhea and chlamydia, rather than by a virus, such as HIV. 

The obvious question: If PrEP does not protect against all STIs, should one use a condom anyway? According to CDC guidelines, PrEP patients must be tested for STIs every 3 to 6 months and must have their negative HIV-status confirmed every 3 months or upon diagnosis of an STI. However, many men and most women with gonorrhea are asymptomatic. Chlamydial infections are usually sans symptoms in both men and women. Getting tested every 6 months is a long interval in that a person – even one on PrEP – could unknowingly spread STIs to others between STI testing appointments. 

However, a 2017 study showed that the use of the CDC PrEP guidelines could result in a significant decline in STI incidence among men who have sex with men (MSM), with 42% fewer gonorrhea infections and 40% fewer chlamydial infections over the decade after PrEP was initiated. As PrEP has no biological effect on bacterial STI risk, the incidence reduction was attributable only to the recommended ongoing screening and treatment of STIs as part of the broader PrEP intervention. Using condoms would reduce the chances of getting an STI to almost zero. It is a personal decision fraught with serious complications.

Just as Tim was about to exit the pharmacy, he turned to the pharmacist and said, “You know, Doc, I think I will take those condoms anyway – just as a precaution.” “Smart boy,” thought the pharmacist. 

Ron Gasbarro, PharmD, is a registered pharmacist, medical writer, and principal at Rx-Press.com. Read more at www.rx-press.com

 


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