PEP, PrEP, and TasP

[T-Plus 26 Days... Almost a month!] 

26 days and 26 pills into my first prescription for PrEP. I can't believe it's been nearly a month already! Sure, it was rough at first, but it's been great for the past couple weeks now. There have been some really interesting social side-effects to getting on it that I didn't expect, though.

The first of these is that many people seem to feel a lot more entitled to ask me questions about my sex life. That isn't a problem for me, since a lot of my work involves talking about different aspects of human sexuality, but it's still surprising. A lot of those sorts of questions ultimately come down to asking me why I'm getting on PrEP: do I have an HIV-positive partner? (I don't, but I could!) Do I want to have sex bareback? (Sure, sometimes, but that's not really why I'm on PrEP.) How risky am I, exactly? (Depends on a lot of things.)

The other thing that I've found is a lot of confusion about PrEP versus other medication-based prevention methods (when people have even heard of them). There are a lot of ways to prevent HIV transmission, but there are really only three major types that use medications at the moment: PEP, PrEP, and TasP. To make these a little easier to tell apart, I made a chart, which you can take a look at below (I'll describe the three prevention methods in more detail in a moment).

PEP, PrEP, and TasP - Three Medication-Based HIV Prevention Methods.

Alright, so the one thing that all three of these prevention methods have in common is that they all involve getting a prescription for one or more HIV medications (anti-retroviral therapies/medications, or ART's). The medications work exactly the same way inside the body no matter why a person is taking them, though different medications prevent the virus' activity in lots of different ways. Each method is intended for a different stage in HIV's "life-cycle".

Please forgive me in advance, but for the sake of making these prevention methods a little easier to understand, I'm going to use the analogy of hormonal birth control. I know it's drastically over-simplifying things, and I'm not trying to compare pregnancy to illness except very, very loosely. Okay...


PEP - Post-Exposure Prophylaxis - PEP is a method of HIV prevention for emergencies; a person who believes they're HIV-negative (a doctor will confirm this before prescribing PEP) and thinks or knows that they've just been exposed to HIV can get a prescription for one or two ART meds to stop the infection from taking hold before it can get started. PEP is a short-term prescription, normally lasting for about a month. PEP is usually prescribed by an emergency room doctor (because it has to be prescribed within 72 hours of the suspected exposure), but it can be prescribed by a Primary Care Provider as well.

You can think of PEP as being like the morning-after pill for HIV: you get it right after sex (or blood contact, in the case of PEP) to stop things right after the fact.

Strict adherence to a PEP regimen is necessary to ensure it is most effective.


PrEP - Pre-Exposure Prophylaxis - PrEP is a medium- to long-term prevention strategy that involves getting a prescription for a single, daily ART pill (presently Truvada, which contains two medications - tenofovir disoproxil fumarate and emtricitabine) in order to prevent HIV infection in people that are confirmed to be HIV negative. Going on PrEP is a commitment, because as with PEP, strict adherence ensures that PrEP is most effective, but taken regularly and on time, taking PrEP can prevent HIV infection even through repeated exposures over an extended time.

People get on PrEP for a lot of reasons: yes, some because they absolutely hate condoms; but also for some because they have an HIV-positive partner (or might not want HIV to stand in the way of possible future partners); because they use IV drugs or have a lot of anonymous sex; or because they simply want to reduce their risk for contracting HIV. Most people take PrEP for some months to years during periods of higher risk for HIV infection.

You might think of PrEP as being a bit like going on the pill - it's a daily dose of a medication that, if taken properly, stops things in advance.


TasP - Treatment as Prevention - TasP refers to people who are HIV-positive, who are adherent to their HAART regimen and virally suppressed (the amount of active virus in the person is "undetectable" - so little that it's virtually missing when a doctor looks at their blood). A person who's HIV is undetectable has a much, much lower chance of transmitting their virus to a partner regardless of any other prevention methods. Yes, you read that right - an HIV-positive person whose virus is well-managed can theoretically have unprotected sex, even repeatedly, and not pass on the virus to their partner. This doesn't mean a condoms shouldn't be part of the equation, too (that goes for PrEP as well), but it means that with good medical care, safe and active sex-lives are possible for and with poz folks.

The birth control metaphor kind of falls apart here. A better analogy for TasP might be taking medication to treat herpes - it's a lifelong regimen, but while on it, the risk of transmission is reduced.

As with PEP and PrEP, strict adherence to a HAART regimen is necessary to ensure the greatest risk reduction.

I hope this post has been helpful for some people. You're more than welcome to share the image above, as long as you don't crop or edit it in any way. You can find a shareable post - including the chart - on Truvotter PrEP's Facebook page.

Dating on PrEP

[T-Plus 22 Days.]

So, I'm closing in on nearly a month on PrEP now, and the side effects have all but completely faded; add to that the snow day that I ended up with today, and I figured it was time to update my online dating profile. Mostly that involved tidying up bits that were old and outdated, like where I'm working, what my big goals are, that sort of thing. But I decided to add something to my profile that I hadn't had there before: my PrEP status. Check out the paragraph I added below (click the picture for a larger view):

I spent a lot of time thinking about it before I decided to do this; knowing the stigma around PrEP, I worried (I still worry, a little) that it might turn some people off of my profile. Across the community, there's still a really persistent myth that people on PrEP are promiscuous, unfaithful, irresponsible, etc.,... not things I want people to think about me when I'm looking for a date.

Except that picture is the furthest thing from the truth. If you've been reading the blog for a while, you've heard me say this before: I'm not an especially big risk-taker when it comes to my sex life. I've had plenty of partners, but I'm not spending all day every day on Grindr or SCRUFF, or out at the bar or bathhouse. To me, taking PrEP (and telling people that I'm on it on my dating profiles) is a really important part of NOT being risky. Sure it means that I can explore my sexual tastes and fantasies a little more freely, because I don't have to fear that I'm exposing myself to a very serious virus in the process, but it also means that I'm taking the fullest control of my safety and that of my partners that I possibly can. I think that's a really important thing to tell potential dates/partners/spouses: I care about my health, I care about your health, and I'm willing to be honest, even though that means being pretty vulnerable. I don't know about anyone else, but to me, that's the core of any good relationship.

So yeah, I put it up on my okCupid profile. Already, some people have responded, including one cute guy who happily even mentioned that he had no problem with me being on PrEP, and that he'd been thinking of getting on it himself.

Cheers, friends!

Calculating Risk

[T-Plus 13 Days!]

Normally I save these sorts of things for Truvotter PrEP School's Facebook page, and in fact it's up there too, but the tool I'm linking to below is really worth a look.

Gaily Grind Sexual Exposure Calculator

What is it? It's a calculator that estimates the number of people you've been sexually exposed to in your life. Remember, most partners that most people have been with have themselves been with some number of people before them. It's not shameful, it's a fact of human sexuality! It's an important thing to be aware of, though, because it says something about sexual safety and risk; namely, the more partners you've had, and the more partners they've had, the more likely you are to have been exposed to sexually transmitted infections.

All this doesn't necessarily mean that you have to have fewer partners! You can have as many happy and consenting partners as you'd like, as long as you're taking the appropriate precautions for the level of risk you're taking. In general, if you're engaging in riskier behaviors and/or with more partners, it's best to use more layers of protection - whatever options work best for you (and your partner). Regular testing should always be part of the equation, but beyond that, it's up to you.

This was a big part of my decision to go on PrEP, but also a big aspect of the stigma that's still attached to both HIV and PrEP, especially among the gay community. Many of you may have heard the term "Truvada whore" - a gay guy whose supposed sole goal for getting on PrEP is to go completely nuts and f*ck every guy he can find with no condoms. I'm a generally pretty quiet guy, but more than a few people have asked me outright if some version of that is why I got on PrEP.

The reality is that sure, there are probably a few people who get on PrEP mainly so they can spend all day at the bathhouse without packing a stack of rubbers. But so what? Sure, it's not the smartest move - PrEP only prevents HIV transmission, it doesn't touch syphilis or herpes or gonorrhea - but that person is still taking some responsibility for their sexual health and that of their partners. If they're being adherent to their Truvada, and getting their regular tests, then they can be pretty darn sure they aren't becoming positive, and that means that their partners aren't either.

Besides all that, though, the reality (at least that I can say anecdotally) is that the majority of people who get on PrEP are already looking out for their sexual health in one way or another, and are simply looking for a greater degree of security. I personally don't take a whole lot of risk in my sex life (I've had plenty of partners, but I generally insist on condoms, I talk about safety with them, etc.,) but for me, PrEP is still important. The risk of becoming HIV+ is a reality in the world today, especially for sexually active folks. I chose to get on PrEP because to my mind, my level of risk was enough to make it worth it. Given that it's free (for me, so far), and that there's work still to be done before we reach a cure, I feel an obligation to take this level of responsibility to look out for myself and whoever I sleep with.

Thanks for humoring my little soapbox here - I knew the myths surrounding PrEP going in to this process, but it's been fascinating and a little frustrating sometimes to encounter them face to face.

Cheers, folks!

PrEP Is For Women, Too

[T-Minus 20 Days.]

Normally, I would write a long-form post, but I really think this article encapsulates the idea better than I could: women need to be a part of the equation when discussing PrEP!

HIV is not gender-specific. Nor is PrEP.

If the link above doesn't work, you can also find the article here: http://www.thedailybeast.com/articles/2015/12/19/the-hiv-drug-half-a-million-women-need.html

Weighing the Risks - Side Effects and Such

[T-Minus 26 Days.]

There are risks to starting any medication. Of course there are. Starting any new medication means facing down potential side effects, not to mention adding a new routine to one's day or week or month. It means adding another visit to the pharmacist, and everything that entails (including potentially awkward conversations with the pharmacist about this medication or that). It means more frequent visits to the doctor.

I want to say that I spent a lot of time considering the side effects of PrEP, and other issues mentioned above, but I didn't. From the outset, Truvada (PrEP) was described to me as incredibly safe and reliable - even a couple of years ago, there was substantial evidence that PrEP was extremely effective. Besides, I already take a couple medications regularly, so adding another to the mix really isn't going to change my routine that much. The pharmacist still makes me a little uncomfortable, but not because of PrEP - it's just always felt like picking up or discussing medications should be a more private thing (but I deal with it). And I like my doctor, not to mention I enjoy being healthy in a general sense, so having a good reminder to check in more often isn't exactly a bad thing. And I'm fortunate to have good insurance and a good job, so the cost of the extra appointments and things isn't as big a deal for me as it might be for some.

As I've gotten a bit closer to starting PrEP, I have gotten a little more anxious about side effects though, so I did a little research into the specifics. Check out a section from Gilead's prescriber's guide for Truvada for PrEP below, as well as the company's website for individuals interested in PrEP.

For those taking Truvada for PrEP, the most common side effects were "headache, abdominal pain and decreased weight," and the incidence was incredibly low. It really seems pretty damn safe. I can deal with a headache or an upset stomach for a bit (in my experience, side effects from meds don't tend to stick with me for very long). Decreased weight is maybe something to consider, but of course I'll be going to the doctor every few months while I'm on PrEP anyway, so I can always talk about diet if my doctor or I ever feel like I'm losing too much weight - not likely!

Of course, there's a cost aspect to taking PrEP, too. I'm choosing to voluntarily take a daily medication that even on my decent insurance is a bit pricey. Still, relative to a lifetime of medical care for HIV, I think PrEP wins financially, too. Besides, there are programs all over that can potentially help subsidize the cost of Truvada for PrEP. I'll talk more about this in an upcoming post, but if you need cost assistance now, Gilead has a fantastic copay and prescription assistance program.

Ultimately, my decision to take PrEP has been about deciding how much risk (physical, social, financial, etc.,) I'm willing to accept in taking it, versus my risk for HIV infection. It's no small thing - taking it or not, either could have a major impact on my life.

For me, the choice feels easy (I feel that in my case, it's a fairly cheap and very effective way to enhance my protection against HIV,) but for you reading this, maybe that's not the case. That's okay, too! There are loads of other prevention options, if PrEP isn't right for you. If it is, and you're just not sure how to talk about it (or a bit scared to,) there are lots of fantastic resources to help start that conversation - and lots of great doctors that are willing to have it, too!

For resources about PrEP, HIV/Testing, and HIV/AIDS in general, click on the Resources tab near the top of the page.

More soon. Happy Winter Holidays, folks!

Layers of Protection - Condoms (and PrEP)

Condoms are a really big issue, no matter one's sexuality. They certainly have been for me, though not always in the best ways.

I think the first time I really thought about condoms was early in high school, during one of those really awkward, way-too-late "birds and the bees" conversations that we're stereotypically expected to have as kids. One frigid morning in the middle of winter (probably late January), my dad got me up reeeeeally early in the morning. He told me we should go for a drive (cue teenage apprehension). We got on the road, and got going a ways, before my dad tossed out the (basically expected) reason we were going for a drive. He asked me if I had any questions about sex (I didn't), and then told me if I ever needed condoms and was too embarrassed to buy them, to let him know. I got really nervous and mumbled some sort of thank you. To that point, I had never really thought about condoms at all - I was a nerdy kid who wasn't dating, and besides, was struggling to accept his sexuality.

Many of us don't think about condoms much, for a long time. Sure, we might hear about them awkwardly form our parents, or perhaps in Sex-Ed in school if we're lucky (I didn't, much), but in general discussing condoms is something we're really bad at in the United States. Worse, frequently when we do talk about them (at least among men), it's to rationalize why we should't/can't/won't wear them. I've had dozens of male friends who refuse to wear condoms for one reason or another. I'll admit (a little ashamedly) that all through my twenties I did that, too. I had a hard time finding ones that fit me, from the little bit I tried, and so pretty quickly I stopped bothering to even look. I just came up with excuses.

So yeah, for a long time, I didn't use condoms. Maybe the act "felt better", a little, but I didn't. Every time I had sex without a condom, I ended up going through a good week or two guilt period afterward. Sometimes that guilt would last even longer - until my next HIV/STI panel. Not knowing if you just got syphilis is not a happy place to be!

Working on stepping up my condom usage is something I've spent a lot of time on over the past few years or so. I started doing my research. I read articles, perused websites, but most importantly, I got small packs and samples of a bunch of different condoms and then tried I them on. Yep, I probably tried a dozen over the course of a few months, until I found a few brands and types that work really well for me.

Watch a really cute guy prove that you absolutely can't be too big for a condom.

I thought about a few big things - pros and cons, desired attributes, etc., - to condoms when I was making my decisions:

Risks and Rewards

Condoms aren't 100% fool-proof when used alone. They can break. They can come off. Other things can happen to them to make them unreliable (this is NO EXCUSE not to use them!)

Some people have latex allergies that make it difficult to wear typical condoms. Condoms made of natural materials can be more porous, and frequently only protect against pregnancy, but not HIV or other STI's.

Condoms need to be put on the moment you plan to start any sort of penetration. This is easily forgotten. And yeah, I get it, it's pretty gross to give a blow job on rubber (and sure, oral sex is less likely to transmit some Sexually Transmitted Infections,) but honestly, if you don't know your partner well, it's best to use a condom then, too.

Condoms can be really freaking hard to put on when drunk!

But on the flip side...

Condoms are pretty damn effective - they are among the cheapest and most effective forms of prevention against unwanted pregnancy and STI's around.

There are numerous alternative synthetic materials that condoms can be made of, ensuring that there is a safe, comfortable condom for nearly everyone.

Keeping a reasonable supply of non-expired condoms in different places (that aren't too hot or cold), such as by your bed, makes grabbing a condom easy.

For me, this one has become easy, since I've resolved to give up drinking for a while, but more importantly, if you're drunk (and particularly if your prospective partner is), you should probably reconsider having sex anyway, as consent can't be given by a drunk person.

Sizes and Shapes

Condoms come in a variety of shapes and sizes. I personally tend to need slightly smaller condoms for comfort and to make sure they fit snugly, but of course people are a variety of sizes, and ultimately the goal is to find a condom that fits properly and feels comfortable. According to some research, much of men's discomfort and trouble around wearing condoms may stem from using the wrong size on our... stems. For guys who are a bit larger, there are of course XL varieties of condom.

Where to Buy

I prefer to buy my condoms from Amazon (yes, Amazon sells condoms!) The advantage of Amazon is that you can buy from a variety of sellers, frequently in varying levels of bulk (and typically for very cheap), and if you're concerned about privacy, remember that your condoms will come in a smiling Amazon.com box. People are as likely to think you bought a new Blu Ray. I have Amazon Prime, so my condoms ship with free Two-Day Shipping, meaning if I get low, I can restock quickly and easily. It's super efficient!

Condoms and PrEP

As I move forward with starting a PrEP Truvada regimen, I absolutely have to continue my condom use. Just as condoms aren't 100% effective, nor is PrEP! Not to mention, PrEP only prevents HIV transmission, but not any of the other STI's out there. 

Just taking PrEP is NOT going to keep me from getting a nasty case of gonorrhea, or chlamydia, or syphilis. One major fear that many doctors still have in prescribing PrEP is that condom use will decline once patients are on it. Research is mixed (see here and here,) but in general, men seem to still continue to use condoms after beginning PrEP. There may be some decline, but condom use among men in the United States is drastically low to begin with - a much larger issue that needs to also be tackled.