HIV Pre-Exposure Prophylaxis (PrEP) is not for everyone

The Food and Drug Administration (FDA) recently approved the re-labeling of the HIV medication Truvada, which is a combination of tenofovir plus emtricitabine, for use as pre-exposure prophylaxis (PrEP) for HIV prevention.  PrEP involves the daily use of HIV antiretroviral medications HIV-uninfected individuals as a way of reducing their chances of becoming infected with the virus.  For many in the HIV prevention community the FDA approval was hailed as a milestone in the development of new biomedical HIV prevention strategies. For others, concerns remain regarding the potential for developing drug resistance among those who become infected while taking Truvada, and also the possibility of condom abandonment among PrEP adopters.  In order for PrEP to be effective in reducing new infections, it must first be accepted as a viable HIV prevention strategy by high-risk groups.

Several PrEP acceptability studies have indicated that men who have sex with men (MSM) are extremely enthusiastic about PrEP and would most likely use it.  However, the time these studies were done was before we even knew if PrEP would even work in preventing HIV infection.  Today a new reality exists for PrEP that may impact how MSM perceive of PrEP. This new reality includes the completion of multiple PrEP clinical trials, known efficacy levels of PrEP for different high-risk populations, safety information, drug resistance information, the Centers for Disease Control and Prevention’s (CDC) guidance for administering and monitoring PrEP use with MSM and, as mentioned, the FDA approval of Truvada for use as PrEP.  As a result of this new context for PrEP, the high levels of enthusiasm demonstrated in previous acceptability studies may be diminished given the true realities associated with PrEP adoption (e.g., only partially efficacious, required regular HIV testing, ongoing medical monitoring, side effects, toxicities, costs, unknown long-term side effects, etc.).  Today, the question remains, who will want and should use PrEP for HIV prevention.

PrEP is undoubtedly one of the most important contributions to our HIV prevention tool box in recent years; however, it is not a panacea and it is most definitely not for everyone.  There are particular segments of the MSM population that would most likely benefit from PrEP, such as MSM who must engage in sex work or survival sex, MSM who are unable to use condoms consistently, and HIV-negative MSM with HIV-positive partners.  For this last group, PrEP may be particularly beneficial.  HIV-negative individuals with HIV-positive partners have a continuous threat of exposure to the virus with every sexual encounter.  In a study we did with minority serodiscordant gay couples, Latino and African-American HIV-negative men told us why they would want to use PrEP:

“I am very positive about it. I think that if you are in a relationship where one partner is positive and the other isn’t, I think that to have the option to take something that has been proven to be effective is tremendous, I really do.”

“If I was prescribed the pill I would not negate condoms just because I was on the pill. I would still take that extra precaution, but just having that pill would give me just that much more assurance that I won’t contract the disease.”

“I would take it for better sex with my partner and not having the stress on my brain, worried about whether or not we did something wrong and did I contract the virus.”

For these men, PrEP would not only help prevent HIV infection, it would also help reduce the psychological distress associated with being in a relationship with someone who is HIV-positive.  There may be concerns with PrEP, and given the steps involved in accessing and using PrEP, we cannot predict if high-risk MSM will actually adopt PrEP, but to exclude it from our HIV prevention tool box, particularly for high-risk MSM noted here, would only place them at continued risk of becoming infected with HIV.  PrEP is not for everyone, nor was it intended to be, but there are certain high-risk MSM that would truly benefit from its availability.


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