The answer to who should take PrEP is simple. Anyone who is at recurrent risk of exposure to HIV.
In theory, this could include anyone who has condomless sex.
A comprehensive list follows.
Talk about it with your friends who might be at risk. Talk about it to anyone who might have sex without a condom. Talk about it at the water coolers. Talk about it in the office. Start removing the shame and the stigma that is associated with HIV and HIV prevention.
Dr. Raphael Landovitz – TEDxUCLA 2016
What does PrEP mean?
PrEP stands for pre-exposure prophylaxis.
What is prophylaxis? The definition of prophylaxis is the prevention of disease.
PrEP refers specifically to HIV pre-exposure prophylaxis.
STOP HIV BEFORE EXPOSURE.
Can men and women take PrEP?
In my Cape Town practice, there is a misconception that PrEP is only for men who have sex with men (MSM).
MSM currently make up about 50% of PrEP users worldwide. 1 This is most likely due to the awareness campaigns in this community.
However, the statistics reported by UNAIDS.ORG of new HIV infections in 2022 confirm that women are at high risk:
- “Of the 1.3 million new infections worldwide, women and girls accounted for 46%.“
- “In sub-Saharan Africa, adolescent girls and young women accounted for more than 77% of new infections among young people aged 15-24 years in 2022.”
- “In sub-Saharan Africa, adolescent girls and young women (aged 15-24 years) were more than three times as likely to acquire HIV than their male peers in 2022.”
Who should take PrEP?
Below is a comprehensive list of who should take PrEP by Caroline Reid for the Desmond Tutu Health Foundation.
The following criteria are sufficient to request PrEP:
- A sexual partner who is HIV positive, not on ART, or not yet virally suppressed.
- Sexually active in a high HIV prevalence population AND any of the following:
- Vaginal or anal intercourse without condoms with more than one partner, OR
- A sexual partner with one or more HIV risk factors, OR
- A history of an STI by lab testing or self-report or syndromic STI treatment, OR
- Any use of post-exposure prophylaxis (PEP), OR
- Injecting shared needles, OR
- Breastfeeding from an HIV-positive person OR
- Requesting PrEP.
This TED talk from 2016 is worth watching.
Dr Raphael Landovitz makes the point that we take medication to prevent heart attacks, pregnancy, and osteoporosis.
Why not take something daily to prevent HIV?
At the time of this talk, there were 4 million new cases a year worldwide. In 2022, it is down to 1.3 million.
Where can I access PrEP?
You need a doctor’s prescription to get PrEP.
- Ask your GP if they can help you with a script. Some medical colleagues are still not comfortable prescribing PrEP as they are not well-educated on the subject.
- In South Africa, there are government community clinics and non-government organizations (NGOs) where you can access PrEP.
You can call the South African National HIV/AIDS helpline on 0800 012 322 for information.
There needs to be a lot more education about what PrEP is and its availability. As mentioned, even doctors need to learn more.
Recently, university students and community clinic users were part of a study in South Africa.
“The study population was at high risk of HIV infection, with early age of sexual debut, multiple concurrent sexual partners and inconsistent condom usage.” 2
Only 12.3% of the group had a complete understanding of what PrEP was, and 15% knew that it was available at their local clinic. 2
What medication is PrEP?
PrEP is an antiretroviral (ARV) medication. These are medications that treat and prevent HIV infection.
Daily PrEP contains two active substances, emtricitabine (FTC) and tenofovir disoproxil (TDF). They are in one tablet. They have been used for years, are safe, and have few side effects.
When am I protected against HIV?
Generally, the guidelines for daily PrEP are
- MSM are safe in 7 days
- Women are safe after 21 days
More accurate descriptions are given by the Centers for Disease Control (CDC) in the below table.
| DAYS AFTER STARTING PrEP | |
|---|---|
| Receptive anal sex (bottoming) | Seven (7) |
| Receptive vaginal sex | Twenty-one (21) |
| Injection drug use | Twenty-one (21) |
| Insertive anal sex (topping) | No data |
| Insertive vaginal sex | No data |
How effective is PrEP?
PrEP is 99% effective against sexual HIV exposure when taken daily. 3
It is essential to understand that nothing is 100% safe.
Are the ARVs in PrEP safe to use?
Yes, these ARVs have treated HIV successfully for years.
They are well tolerated with a low side effect profile.
We know its safety profile. (PrEP) requires some blood test monitoring and some careful understanding of things to watch out for. But there aren’t any show stoppers that would make you say, “This isn’t safe, don’t do that.” Particularly for people who are at risk.
Dr. Landovitz
What tests will I need when starting PrEP?
You will need a 4th-generation HIV Ag/Ab combination test to make sure you are HIV-negative.
Your doctor will also do baseline tests for hepatitis B, kidney, and liver functions. Other tests might be necessary for your medical history, including STI screening.
What follow-up tests will I need?
HIV and kidney function every three months in most patients. Your doctor might request shorter intervals or add other tests at their discretion.
Can I stop and start PrEP?
Yes, you can.
You can stop and start PrEP as your risk situation changes.
Do this under a doctor’s supervision. You must do testing and follow-ups at the correct intervals.
How long must I take PrEP for?
Organizations give different advice. However, 3 out of 6, including the WHO, recommend continuing for 28 days from your last possible exposure. 1
I recommend my patients do HIV testing at four weeks and again at 12 weeks after their last HIV contact risk.
Do I have to take a pill every day? Aren’t there other options?
There are two other options depending on whether they are registered and accessible in your country.
On-demand PrEP
- It is only for men who have sex with men (MSM)
- This regime (2-1-1) uses the same tablets as daily PrEP.
- This ARV tablet is not registered to be used at this dose, so when prescribed, it is off-label. It is not approved by the Food and Drug Administration (FDA) or recommended by the CDC or the South African HIV Clinician Society (SAHCS).
- Discuss it with your prescribing doctor.
Injectible 2-monthly PrEP
- Cabotegravir is an ARV that is injected every two months into the buttock.
- It is available in some counties. Although it has been registered in South Africa, it is not readily available.
What else should I know?
- PrEP does not protect against other STIs.
- PrEP is not a contraceptive; it doesn’t prevent pregnancy.
- Be aware of signs and symptoms (S & S) of acute HIV infection, which is a flu-like illness. You may experience fever, sweats, sore muscles and joints, tiredness, headaches, mouth sores, or a rash. If you develop these while on PrEP, follow up with your doctor.
References
- Rutstein, S. E., Smith, D. K., Dalal, S., Baggaley, R. C., & Cohen, M. S. (2020). Initiation, discontinuation, and restarting HIV pre-exposure prophylaxis: ongoing implementation strategies. The Lancet. HIV, 7(10), e721–e730. https://doi.org/10.1016/S2352-3018(20)30203-4
- Haffejee, F., Fasanmi-Kana, O., Ally, F., Thandar, Y., & Basdav, J. (2023). Four years later: Do South Africans know what pre-exposure prophylaxis for HIV is? AIDS care, 35(4), 466–473. https://doi.org/10.1080/09540121.2022.2032573
- Centers for Disease Control and Prevention. (2022, June 17). Effective HIV prevention strategies. https://www.cdc.gov/hiv/risk/estimates/preventionstrategies.html#anchor_1562942347
