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23 Oct 2014

Around 50 people — mostly gay men — gathered at the upstairs bar of the Colombian Hotel in Sydney’s Oxford Street. They were there with a panel of experts discussing PrEP. Proceedings began with the basics.

PrEP stands for pre-exposure prophylaxis (“prophylaxis” means to prevent or control the spread of an infection or disease). PrEP is recommended for people who are HIV negative and who are at substantial risk of HIV infection. PrEP involves taking a single pill — Truvada — every day to protect against HIV.

Then came the science. Truvada is a dual combination pill used to treat HIV. It contains tenofovir and emtricitabine which block important pathways that HIV uses to initiate infection. The presence of these medicines in the bloodstream stops HIV from taking hold and spreading in the body.

If taken daily, trials have found Truvada to be upwards of 92% effective in protecting against HIV. Indeed, in one analysis, the drug was shown to reduce the risk of HIV transmission by 99%. As an HIV-prevention method, PrEP, we learned, is as effective as condoms.

But, said the speaker — and it was a BIG but — in order for PrEP to significantly reduce the risk of HIV, strict adherence is required. Truvada is not a party pill to be taken before a night out, or the morning after. PrEP is only effective in protecting against HIV if taken every day — regardless of whether you have sex or not.

From the science, the panel moved on to address PrEP’s social implications.

Since Truvada’s release for PrEP use in the US in 2012 it has polarised the gay community. Some see it as an additional method (alongside condoms) of protecting against HIV — especially if the condom breaks or, for whatever reason, there is an episode of condomless sex. There are others who fear PrEP will provide an opportunity for risky sexual behaviour that will in turn lead to an explosion of other STIs such as gonorrhea and syphilis.

The American experience shows that far fewer gay men have embraced PrEP as experts had anticiapated. There are many reasons for this: confusion, lack of education and the stigmatisation of PrEP users by other gay men (the term "Truvada whore" has long been bandied about on social media networks). 

A Q&A followed the panel discussion and it was clear from the questions asked that there are many concerns:

“What are the side effects?” Short-term effects include headaches and stomach aches, weight loss, nausea and diarrhoea. Kidney health may be compromised; decreases in bone density may also be noted.

 “What does taking PrEP involve?” At first you will be counselled and tested for HIV, hepatitis B, kidney function and STIs. If all is OK, and you're thought to fit the “at risk” criteria, you will be prescribed PrEP. You will need to take the medication strictly as prescribed (orally, once a day). Once on PrEP, you will need to be tested regularly for HIV (at least every three months); you’ll need to be regularly tested for STIs; and your kidney health will need to be regularly assessed.

“How long does Truvada take to become effective?” No-one knows for sure, but five to seven days seems to be the conservative consensus.

“Where can I get it?” Truvada is currently only licensed in Australia as a component of existing HIV treatments. It is not licensed here for use as PrEP. However, a number of trials are underway. One — the PRELUDE Study — is designed to look into how clinics can provide PrEP in NSW. It will study whether people will find it agreeable to take PrEP every day, why they take it, what it’s like to take it, and whether it changes how the participants have sex.

“Isn’t there a chance PrEP will discourage condom use?” Studies conducted in the US have not found any evidence to suggest participants had deserted condoms en masse and engaged in risky behaviour. What PrEP was found to lead to was decreased stress, fear and guilt around HIV.

No doubt, in the months ahead, the questions will keep on coming. But at least a community dialogue has begun.