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HIV Prevention

Edmonton Snapshot

In 2013, the Edmonton Zone had the highest rate of HIV in the Province with 112 cases reported and a rate of 8.8 per 100,000  persons, representing a 30% increase in cases reported since 2010.
In 2013, 50% of male cases were amongst men who have sex with men (MSM).

We’ve all heard about condoms, right? That’s good. Condoms remain one of the most effective ways to protect yourself against HIV and other STIs. That said, we know from the Edmonton Sex Now data that a significant portion of guys in our community are not using condoms consistently.

In some cases, like oral sex, that’s probably not so troubling. The truth is, the risk of contracting HIV through oral sex is extremely low. There would have to be something out of the ordinary occurring, such as bleeding gums, or a cut or sore within the mouth for there to be any realistic risk of transmission. So unless you’ve just had dental work done (or are an intense brusher/flosser) you’re pretty much good to go. Keep in mind, though, that although HIV risk is extremely low for oral sex, you can catch bacterial STIs like syphilis, gonorrhea, and chlamydia through oral sex.

Now, if we change the conversation to frontal or anal sex, however, the risk of HIV transmission is much higher, particularly within the context of anal sex. And although the risk per act of anal sex is quite low (meaning there’s a higher likelihood of contracting HIV if you have bareback sex multiple times as opposed to once) you can still contract HIV after just one exposure. For receptive partners, or bottoms, the risk increases again!

So, what do you do to protect yourself if you don’t have a great history of consistent condom use or you want to add an additional level of protection, on top of using condoms, just to ease your nerves? Fortunately for you, there are more options for HIV prevention than ever before. We’re going to focus on three of them: Treatment as Prevention (TasP), Pre-Exposure Prophylaxis (PrEP), and Post-Exposure Prophylaxis (PEP).

Edmonton Snapshot:
  • Of the HIV-positive respondents more than 90% were on HIV medication
  • Of those on medication more than 95% had an undetectable viral load.

We should treat people living with HIV because they deserve to live long, healthy lives. And if that’s where the benefit ends, good enough! However, it doesn’t.

We now know that when people who are living with HIV adhere to their HIV medication, many of them achieve an undetectable viral load. This doesn’t mean they are cured. But it does mean that the amount of HIV in their bloodstream is so low that current HIV tests cannot detect it (less than 40 copies/ml of blood in Alberta). So, what does that mean in terms of HIV transmission?

We’ve known for a long time that an undetectable viral load significantly decreases the chances of HIV transmission. However, over the past year, the scientific consensus has shifted even further. Therefore, the EMHC, alongside many of the leading organizations and medical professionals working in HIV across the globe, whole-heartedly endorses the Prevention Access Campaign consensus statement on the “Risk of Sexual Transmission from a Person Living with HIV who has an Undetectable Viral Load”:

People living with HIV on ART with an undetectable viral load in their blood have a negligible risk of sexual transmission of HIV.  Depending on the drugs employed it may take as long as six months for the viral load to become undetectable. Continued and reliable HIV suppression requires selection of appropriate agents and excellent adherence to treatment. HIV viral suppression should be monitored to assure both personal health and public health benefits.

In simpler terms, this means that people who are undetectable will not transmit HIV to their partners sexually. Or in the words of the “U=U” campaign, “Undetectable=Untransmittable.”

This shift in understanding regarding the impact of an undetectable viral load on the sexual transmission of HIV is significant in that it helps to combat HIV stigma by declaring that people who are undetectable no longer pose a “risk” of transmitting HIV to their partners sexually. It also alleviates the stress experienced by many people living with HIV by clearly stating that if they take their medication as prescribed and achieve and maintain an undetectable viral load, they are in control of their HIV and can stop it from being passed on to others sexually.

There are some caveats to this, however:

As the Prevention Access Campaign notes, an undetectable viral load only prevents transmission of HIV to sexual partners and may not be effective at preventing transmission through other means, such as sharing injection equipment (i.e. needles).

A viral load test only measures a person’s viral load at the time their blood was taken. Once people achieve an undetectable viral load, if they continue to take their HIV medication as prescribed, they should maintain an undetectable viral load. However, if someone was stop taking their medication, their viral load could increase above an undetectable viral load, meaning that the risk of transmitting HIV to others sexually would increase.

An undetectable viral load only protects against the transmission of HIV. People should still consider the potential risk of transmission of other STIs and take precautions as deemed necessary, such as the use of barrier methods such as internal or external condoms.

Finally, the EMHC recognizes the many structural barriers which make obtaining an undetectable viral load more difficult for some people living with HIV. Although we celebrate the wide embrace of the science proving that undetectable individuals will not transmit HIV to their partners sexually, we also encourage all stakeholders engaged in HIV work to continue to work to remove barriers which discourage people from HIV testing, treatment, and obtaining an undetectable viral load and all of the associated health and prevention benefits that come with that.

PrEP-Info
What is it?

PrEP stands for Pre-Exposure Prophylaxis. It’s a new way for guys to have safer sex, and reduce their risk of getting HIV. It involves taking an HIV medication (Truvada) on a regular basis. One might consider it similar to the birth control pill, but for guys.

 

Who is it for?

PrEP is for HIV negative gay guys who are at a higher risk of catching HIV. You might be at a higher risk if:2

  • You have had condomless (bareback) sex with a partner who’s HIV status you weren’t absolutely sure about in the past 6 months
  • You have had sex with more than 3 guys in the past 6 months
  • You’ve exchanged money, gifts or drugs for sex in the last 6 months
  • You’ve had an STI in the past 6 months (Eg. Chlamidya or gonorrhea)
  • You’ve had condomless (bareback) sex with an HIV positive partner in the past 6 months

 

What can it do?

A recent study showed that PrEP can reduce the chance of catching HIV by up to 86%.3

In these studies, how much a guy was protected from HIV depended on how often they remembered to take their meds. If a guy took all their meds, their risk of catching HIV was down to almost zero percent.5 In fact, at this time, there’s only been one case of a person who caught HIV while taking their PrEP reliably every day.

It’s important to remember that PrEP won’t work if you don’t remember to take it!

 

What would I have to do?

You would have to take one pill (Truvada) every day, and see your doctor every 3 months for refills and some blood tests, including an HIV test. You also need to be tested for HIV and hepatitis before you start on PrEP.2

You don’t have to take PrEP forever – some guys only take it during periods in their life where they’re having lots of sex, then stop when they’re having sex with fewer people. (Eg. In a relationship)6

One ongoing study even said that guys might be able to take PrEP in a special way before and after they have high-risk sex, but we don’t know for sure if this works yet, so most guys take it every day.1

 

What does it not do, and what are the risks?

PrEP does not prevent you from getting other STI’s, like chlamydia, gonorrhea or syphilis. You should still try to use condoms as much as you can while you are on PrEP.

Some guys will get a bit of nausea or weight loss after starting PrEP. This usually goes away in a few weeks.2,6

Like with everything, there are some risks to PrEP that you should know about. Very rarely some guys will get abnormalities in their kidney or bone tests that go away after stopping the meds. There is a very small risk that if you do catch HIV while on PrEP, it may become resistant to the HIV medications in Truvada (tenofovir & emtricitabine).2,3,6

If you don’t have a private drug plan that covers the cost of Truvada, it can be very expensive – $800 – $1,100 per month.7 Very few drug plans in Alberta actually cover PrEP.6

 

How can I get it?

Although Truvada has been approved for use as PrEP in the US since 2012, the decision to approve Truvada for use as PrEP in Canada didn’t occur until February 2016.

Currently, public health plans in Canada are still deciding if, how, and to what extent they will cover PrEP. Depending on the decision Alberta Health makes, it could significantly impact people’s ability to access PrEP in this province. We are currently working with various stakeholders to ensure that this process renders a decision that will make PrEP affordable and accessible to all who need it.

In the meantime, some private insurers offer coverage for PrEP. If you think that PrEP is right for you, ask your doctor about it. If your doctor doesn’t know enough about PrEP to feel comfortable prescribing it to you, you can ask to speak to a physician at the Edmonton STI Clinic about it.

If you are interested in taking PrEP and are having difficulty obtaining a prescription or insurance coverage for it, someone from HIV Edmonton can help you: brook.b@hivedmonton.com.

  1. Molina J. M. et al. On Demand PrEP With Oral TDF-FTC in MSM: Results of the ANRS Ipergay Trial. (2015) Conference on Retroviruses and Opportunistic Infections (CROI), Seattle, USA, abstract 23LB, 2015.
  2. Grant, R. M. et al. Pre-exposure chemoprophylaxis for HIV prevention in men who have sex with men. (IPrEx) New England Journal of Medicine (2015) 363;27 2587-2599
  3. McCormak, S. et al. Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomized trial Lancet (2015) pii: S0140-6736(15)00056-2
  4. World Health Organization (WHO) Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV (2015)
  5. Anderson, P. L. et al. Emtricitibine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men Science Translational Medicine (2012) 4;151 1 – 8
  6. Spinner, C.D. et al. HIV pre-exposure prophylaxis (PrEP): a review of current knowledge of oral systemic HIV PrEP in humans Infection (2015) 1 – 8
  7. http://www.actoronto.org/home.nsf/pages/act.docs.2293

Just like the name indicates, Post (after), Exposure (an encounter that carries a risk of HIV infection), Prophylaxis (Prevention) is a prevention option for HIV-negative guys that can be taken after a possible exposure to HIV in order to prevent infection.

PEP is a combination of anti-viral or “anti-HIV” medications that are taken for 28 days. For it to be most effective, you should start PEP 1-4 hours after your exposure but no longer than 72 hours afterward. If taken quickly and as directed, PEP can reduce the risk of HIV transmission by >80 per cent.

So how do you know if you need it?

Firstly, you need to have been engaged in a high-risk sexual or drug-sharing activity with someone who you know is HIV-positive or whose HIV status unknown. Keep in mind that poz guys with undetectable viral loads have an extremely low possibility of transmitting the virus (link). If the HIV-positive guy in question has consistently tested undetectable then it is unlikely that you are at a high risk of HIV infection and PEP may not be recommended.

Some activities that could put you at a higher risk for HIV exposure are condomless anal or frontal sex, especially when the HIV-positive partner is not undetectable and the HIV-negative individual is not on PrEP. Sharing needles is also an activity associated with a higher-risk of HIV-infection.

You can access PEP by going to any Edmonton-area Emergency Department to be assessed by a physician, or you can also call the Edmonton STI Clinic to discuss it with a nurse. Whether or not you can go on PEP, though, depends on a number of factors—it is not recommended in every situation.

In general, PEP may be recommended if: you had sex with a known HIV-positive person without a condom or the condom broke; you had condomless anal or frontal sex with someone who had HIV but they didn’t tell you until afterward; you were sexually assaulted by someone who has HIV or who’s HIV status is unknown; or you shared needles or drug equipment with someone who had HIV or who’s HIV status is unknown. These are just broad examples and other factors will be considered by the assessing physician before putting you on it.

If you do go on PEP, you will need to have some blood work taken to check your present HIV status, as well as for syphilis, Hepatitis C, and some other tests to make sure your body remains healthy while you’re on the medication. Testing for other STIs will also be recommended. You will then see a specialist at a later date for an appointment for follow-up.

To recap: To access PEP, you must have had a high-risk exposure that has the potential to pass HIV on to you; the decision to start you on PEP is dependent upon a number of factors and based on a physician’s assessment; and it should be started as soon as possible, 1-4 hours after a potential exposure but no longer than 72 hours after.