This text was developed as a supportive material, a cheat sheet, which counselors and medical specialists in clinics and NGOs can use for PrEP counseling.
What is PrEP?
Pre-exposure prophylaxis (PrEP) is the use of the antiretroviral drugs by HIV-negative people in order to prevent HIV infection. Since 2015, the World Health Organization has recommended a combination of 300 mg of tenofovir (TDF) and 200 mg of emtricitabine (FTC) for PrEP, which has a high level of safety and proven efficacy as a means of preventing HIV infection. The drug “Truvada” and similar generic drugs contain this combination.
Similarly, tenofovir without emtricitabine can be used for PrEP. In the coming 1-2 years, new and more comfortable for use drugs will be proposed for PrEP.
For whom is PrEP recommended?
PrEP is recommended as an additional method of prevention to reinforce traditional prevention methods, such as using condoms, reducing the number of sexual partners, or prescribing ARV therapy immediately after a diagnosis of HIV infection (treatment as prevention).
The primary target groups for PrEP are people who engage in high-risk behavior. These include:
- sexual partners of HIV-positive people,
- MSM with more than 2 sexual partners a year and who do not use condoms during every sexual contact,
- people who inject drugs,
- sex workers.
How does PrEP work?
PrEP prevents the virus from taking hold and beginning to actively replicate in the body.
If a person engages in risky behavior, such as anal sex without a condom, he may become infected with HIV. After HIV enters the body, it enters the cells of the immune system, to which it introduces its genetic information. After this happens, the cells stop working as they should, and begin to produce new viruses, which, in turn, infect new cells.
However, if the body has the necessary levels of TDF/FTC, the virus will not be able to begin multiplying and will be destroyed by the immune system. It takes some time to destroy the virus once it has entered the body, so it is important not only to ensure that the body has the right concentration of TDF/FTC before risky sexual contact, but also to maintain this concentration for several days after the risk has occurred.
Effectiveness of PrEP
Many studies from various countries, from the USA and France to African and Southeast Asian countries, showed that PrEP using Truvada significantly reduces the risk of infection (by 92%).
The average risk of HIV infection during anal sex with no condom is 138 cases of infection per 10,000 contacts if the HIV+ partner is the “active” partner, and 11 cases of infection per 10,000 contacts if the HIV+ partner is the “passive” partner. Using PrEP, the risk in the first case is reduced to 14 cases per 10,000 contacts, and in the second case, to 1 case per 10,000 contacts.
At the beginning of 2019, there were more than 500,000 PrEP users worldwide. Since 2012, there have only been 5 registered cases of HIV transmission among people correctly and continuously using PrEP.
It is important to point out that only the correct use of PrEP has such effective results!
How to use PrEP correctly
There are two ways to take Truvada for PrEP.
The first is to take the drug daily, i.e. taking Truvada every 24 hours. The second method is the “on demand” regimen, according to which the drug is taken in anticipation of risky situations.
A daily intake is easier to understand and follow. The “on demand” regimen is cheaper, because fewer drugs are needed, but it may be more difficult in terms of adherence.
Studies showed that daily intake is more effective, but the difference is rather insignificant. Therefore, it can be said that the effectiveness of both regimens are approximately equal.
Taking PrEP “on demand”
In this case, you need to take a double dosage of the drug 24 hours before sex, and then take 1 pill every 24 hours for 2 days. For example, if you plan to have sex Friday night, then Thursday evening you need to take 2 Truvada pills. You have sex as planned. 24 hours after taking the first 2 pills, you need to take a third, and then 24 hours after that, you need to take a fourth pill.
If you have sex less than 48 hours after having sex the first time (before which you began taking PrEP), you should continue to take PrEP daily until 48 hours after the last sexual contact and 2 doses of PrEP are taken.
If you have risky sex unexpectedly, you need to contact a clinic or AIDS center for post-exposure prophylaxis.
Adherence to PrEP
Regardless of whether you use a daily intake of Truvada or an “on demand” regimen for PrEP, an important issue will be whether PrEP intake is continuous and correct (adherence to PrEP). It is necessary to discuss ways to ensure adherence with the client. The easiest way to ensure that the drug is taken on time is to use regular alarm clocks or specialized smartphone apps. If the client travels often or does not spend the night at home, it is worth recommending that he buy a pillbox so that he always has the drug with him.
It is important to discuss in detail how to regularly and correctly take PrEP with the client, taking into account the specificities of the client’s lifestyle: his daily routine, the environment at home and at work, his habits, etc.
Safety of Truvada as PrEP
As with any drug, Truvada has side effects. They occur in about 1 out of every 10 users of Truvada. They may include nausea, abdominal cramps, and headaches. Often, these side effects are only experienced during the first month of taking the drug.
1% of Truvada users may have decreased bone mineralization, but the decrease is not significant, so there are no increased risks of bone fractures. In addition, this change is reversible. Mineralization increases after stopping the use of Truvada.
1 out of 200 people taking Truvada may have increased levels of creatinine. Often, this increase is reversible and the level of creatinine decreases after stopping Truvada.
What does a PrEP program include?
Pre-exposure prophylaxis is a range of complementary actions, which include the following components:
- taking drugs that prevent the reproduction of the virus (Truvada or analogous generic drugs),
- HIV testing before and during the administration of PrEP (PrEP is intended only for HIV prevention. If the client is HIV-positive, he will need to take full-fledged ARV therapy),
- testing for hepatitis B before starting PrEP, and vaccination if the client does not have hepatitis B,
- regular STI testing (Truvada protects against HIV, but the risk of other STIs will be high if condoms are not used),
- monitoring kidney functions, in order to stop taking the drug in time if there are side effects,
- regular counseling about the sexual behavior of the client to help improve the client’s ability to understand and discuss their sexual life, including analyzing and planning actions to reduce risks to their sexual life.
Only with all these actions is it possible to achieve such a significant reduction in the risk of infection (92%).
PrEP and hepatitis В
In theory, hepatitis B is not a barrier to PrEP using Truvada (TDF/FTC). However, if the client has hepatitis B, it is important to refer him to a hepatologist and emphasize that, in his case, it is important to ensure a high level of adherence to PrEP, so that the hepatitis virus does not develop a resistance to Truvada, which is used to treat hepatitis B.
However, there are different rules in different countries. Therefore, it is necessary to study national guidelines and protocols regulating PrEP in order to answer the question “Can people with hepatitis B take PrEP?”. If there are no such protocols, you can make a request to specialized virological institutes or to the World Health Organization.
In any case, if the client does not have hepatitis B, he should be recommended to have a hepatitis B vaccination.
If the client takes PrEP on their own and not as part of a program
In countries where there are no PrEP programs or where official PrEP programs are very expensive, some people decide to take PrEP for prevention on their own initiative and buy the drug through online pharmacies.
By doing so, these people protect their own health and help fight the HIV epidemic in their country, so it is important that they can find high-quality counseling support.
It is important that independent users understand that:
- PrEP should only be taken by HIV-negative people and that PrEP is useless for HIV-positive people,
- you need to be tested regularly (once every 3 months) for HIV, in order to start ARV therapy in time if infection does occur (see above),
- you need to know the symptoms of STIs and be tested regularly (if there are no symptoms, then at least 2 times a year) for STIs,
- you need to check kidney functioning before starting PrEP, and then regularly afterwards (every 6 months),
- you need to find an experienced counselor (doctor or NGO employee), with whom you can regularly (2-4 times a year) discuss the goals and results of PrEP and your health condition: what goals do they have when starting PrEP; what, in addition to PrEP, can help to protect their sexual health; where can they find help and support, etc.