Prepping for PrEP
I was frisky and bisexual, but careful, when I was the age my daughter is now. We were more worried about herpes then. HIV was just hitting the scene, and I was merely lucky not to have been infected. The majority of my generation were not.
I recently cornered Jesse Ehrenfeld, M.D., Director of The Vanderbilt Program for LGBTQI Health at the program’s recent symposium. With my daughter (and my past) in mind, I asked him to explain to me the PrEP strategy for the prevention of HIV infection.
You can never know enough about this subject when you have a teen in your household, or if you are a sexually active member of the community.
Let's assume here that my teen has admitted to following in my footsteps and is asking for practical advice about staying safe from HIV. What would you suggest I tell her?
First, in this type of situation, it is wonderful that a teen is willing to have a conversation with a parent about staying healthy, their sexuality and their activity, because many teens do not have this kind of relationship with their parents, so that would put you ahead of the game.
The key is to figure out what you can do to best support them as they are making decisions about how they want to stay safe and to stay healthy. PrEP (Pre-Exposure Prophylaxis) is certainly a very reasonable choice for higher risk youth to stay HIV negative.
Now one of the challenges is that we have limited data in adolescents around the use of PrEP, particularly because it’s not approved for anyone under eighteen. There are plenty of providers that are using it, and plenty of clinics that think it’s the right thing to do, and so that’s again a very personal decision for any one individual to make. But I think it’s great that your child would (potentially) be thinking “What is the right thing for me?”
It comes down to balancing risk and benefit. We know that PrEP is highly effective at preventing transmission of HIV, and so ... if they think it’s the right thing to do, then I certainly encourage them to consider going on it. One of the challenges is that it is important to be consistent with taking the drug, as much as one can be with taking any medication.
In layman’s terms, how does PrEP work?
PrEP is an antiretroviral drug strategy. Simply put, it allows one’s body to not acquire the HIV virus. It’s the same medication that we use to treat HIV infections, and it prevents viral replication if someone has been exposed to HIV.
Is it sort of like a flu shot then?
It’s not really like a flu shot in that the mechanism [of prevention] is actually quite different, but it is like a flu shot in that it is something you do in advance of exposure to prevent illness. Now, the good news is that PrEP is much more effective than the flu shot, which this year is only covering about a third of the strain that is running around. It is one of the best tools we think we have in reducing the spread of HIV.
Ok, in my 1980’s era mind, I remember it being drilled into my head that viruses are living things and can mutate into different forms in order to stay alive. Am I out of line if I am worried that HIV may one day mutate into something that PrEP cannot handle, down the road?
That’s a great question. There are concerns about the long-term effectiveness of the drug, and there is active surveillance going on to understand how the drug and the virus interact our in the community. As of right now, we do not see [any such mutations] happening.
The use of PrEP as a tool to prevent HIV has science behind it as a technique, and it’s a strategy that most credible and reputable medical organizations support to prevent HIV infections. The American Medical Association is fully behind the use of PrEP: Pediatrics isn’t there yet because the data isn’t there for the adolescent population as of yet.
If someone is trying to decide if they are going to use condoms every time reliably and consistently, even if they may be in an impaired state out late at night, or they can take a pill at lunch every day and know that they are good, that’s a personal decision. There are people who know they cannot reliably use condoms and it’s just not something that is likely to be a successful strategy for them in preventing infection by HIV. That’s a group of people that I would always point to PrEP, because we know that it is a strategy that can be highly effective in preventing transmission.
Is PrEP generally intended for people who are considered to be more sexually active?
The guidelines right now recommend prescribing to people who are considered high risk. There are lots of high risk groups out there, but particularly anyone in the LGBTQ+ community we would consider to be high risk for the potential acquisition of HIV.
Does PrEP prevent the acquisition or transmission of other sexually transmitted infections (STI’s)?
No, it does not. One of the challenges around acceptability of PrEP from a public health standpoint is the concern that people will take PrEP but will not use condoms and risk exposing themselves to all the other STI’s out there. PrEP does not prevent someone from getting infected by other STI’s. You should use condoms along with PrEP every time you have sex, but we also know that most people do not do that.
For the record here, just how important do you consider condom usage to be in preventing the transmission of STI’s?
Very important. I always encourage the use of condoms. We know there are a lot of other STI’s out there, and we have tremendous problems with syphilis, particularly in the South.
Condoms should always be the first line of defense, but we know that people are not always consistent and fail to use them appropriately or effectively. Remember, condoms can break too. There are lots of reasons why condom use has not reduced the epidemic the way that they could if they worked 100% of the time.
So, I would always tell anyone to whom we are prescribing PrEP that the best scenario is to use it with a condom consistently every time, but at a minimum being on PrEP is likely to prevent transmission of the HIV virus.
How would you deal with a parent who expresses concern that PrEP may encourage risky sexual behaviour?
Respectfully. We have the same kind of issue primarily in our adolescent clinics with parents who are against birth control and access to condoms.
While remembering that anyone over the age of eighteen can make this type of decision on their own, and keeping in mind the potential financial costs that might be incurred for some of these measures, we are constantly navigating these issues amongst our 15-17 year old patients around access to contraception in general as well as preventative measures around the transmission of STI’s.
Any last word for a parent like me with a teenager who recently entered high school?
PrEP is a great tool. It is underutilized, and it is definitely worth having the conversation with your doctor about whether it is right for [you or your] loved ones.
Julie Chase is the pen name for a local trans woman.