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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.

Did you know that a pill can prevent HIV? PrEP is the use of HIV medication by someone who is HIV-negative in advance of an exposure to HIV to help precent infection. When taken daily as prescribed, PrEP is nearly 100% effective at preventing HIV infection. To learn more about this, click on the logo above to access the EMHC’s new online PrEP resource.

 

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.