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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 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?

One study that looked at the impact of an undetectable viral load on HIV transmission is the Partner Study. The Partner Study started in September 2010. They released preliminary results in 2014 which covered the time period from the beginning of the study up until November 2013.

The preliminary results were based off of 767 serodiscordant couples. A serodiscordant couple is a couple where one partner is HIV-positive and the other is HIV-negative. 282 of the couples in the study were same-sex male couples.

In order to participate in the study, the couples had to meet several criteria. Firstly, they had to report condomless sex. Also, the HIV-negative partner couldn’t use PrEP or PEP. This is key as it allowed the Partner study to test the effectiveness of TasP alone as opposed to in combination with other prevention methods. In addition to this, the HIV-positive partner was on HIV medication and had an undetectable viral load (less than 200 copies/ml of blood for this study).

Over the three years reported on for the preliminary results, approximately 44,000 condomless sex acts occurred, both vaginal and anal. In some cases the HIV-positive partner was the insertive partner and in others the HIV-positive partner was the receptive partner. At the end of three years, how many infections do you think occurred between the couples in the study?

Zero

Based on their data, the researchers concluded that the risk per act of condomless anal sex when the HIV-positive partner has an undetectable viral load is:

  • 0.05% for receptive anal sex (the negative partner is the bottom)
  • 0.033% for insertive anal sex (the positive partner is the bottom)

Over ten years the risk would be:

  • 17.9% for receptive anal sex
  • 12.8% for insertive anal sex

Now, those numbers for the ten year risk look a little high, right? Well, what’s important to understand is that these numbers are upper confidence limits. For example, when you look at the 10 year risk for receptive anal sex, what the number is actually saying is that the true risk is extremely likely to be somewhere between 0% and 17.9%.

The partner study is still ongoing. As they enroll more same-sex male couples and have data related to anal sex, as long as the number of transmissions between partners remains at zero, the upper confident limit will decrease. In the meantime, it’s important to note that when one of the researchers from the Partner Study was publicly asked to give their best estimate for what the true risk of HIV transmission is when the HIV-positive partner is undetectable, their answer was “zero.”

So what does that mean for you? Well, it continues to reaffirm the understanding that poz guys, when they adhere to their HIV medication have an extremely low chance of transmitting HIV to others. This doesn’t mean that you throw the condoms out the window. In fact, if a serodiscordant couple has sex and the poz partner is undetectable AND they use a condom then that decreases the likelihood of transmission even more. However, if you as a consenting adult read the data and decide condomless sex is important to you and you’re comfortable with the risk, then that’s okay too. It’s really about understanding what sex you want to have and what amount of risk you are or are not comfortable with.

There is one final consideration, however. Someone’s viral load is directly linked to their HIV medication adherence. If someone was to stop taking their medication, their viral load, and thus the risk of HIV transmission, could increase very quickly. So, if you are using TasP as a prevention method, especially without the use of additional prevention measures, it is important to ensure you are taking your HIV medication daily, as prescribed.

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, PrEP is going through a process called the Common Drug Review. Once this occurs, the Alberta Ministry of Health will make a decision as to how PrEP is listed on public plans in Alberta-determining how and for whom the government will cover the cost of PrEP. It is anticipated that some of these decisions will occur as early as the end of December 2016 but may take longer.

In the meantime, it is likely that more insurers will begin covering Truvada for use as PrEP over the coming months.If you think that PrEP is right for you, ask your doctor about it. There aren’t specific guidelines or policies in Alberta as it relates to PrEP. Chances are that your doctor won’t know much about it and you’ll need to be referred to a specialist or speak with someone at the Edmonton STI Clinic.

A group of HIV specialists from across the country are currently working on developing national PrEP guidelines. In the meantime, if you are interested in accessing PrEP and having difficulty navigating the system, someone from HIV Edmonton can help you: [email protected]

  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.