Fully PrEP'd?

PrEP is a fantastic tool in the fight against HIV, but not a silver bullet.

By Justin Lehmiller

By now, you have probably heard about the latest HIV-prevention tool, Pre-exposure Prophylaxis (or PrEP for short). PrEP is a medication regimen for HIV-negative individuals that involves taking the antiretroviral drug Truvada once daily in order to reduce the risk of contracting HIV. Studies have found that, when taken as instructed, PrEP can lower the risk of HIV transmission by 90 percent or more. The tremendous success of PrEP has generated great interest and media attention, and rightly so—but it remains widely misunderstood. The purpose of this article is to correct a few of the most pervasive misconceptions about PrEP in the LGBT community.

Perhaps the biggest false belief about PrEP is that if you are on it, condoms are no longer necessary. Consistent with this line of thinking, some porn producers have even citedPrEP in their decision to abandon condom use altogether in their films. It is not particularly surprising that so many people leap to conclusions about the need for condoms when confronted with the statistics about how effective PrEP is. However, this reflects a fundamental misunderstanding about the sexual health of men who have sex with men, which is that HIV is the only sexually transmitted infection (STI) that matters.

Condoms provide protection against a wide range of STIs, including HPV, syphilis, and gonorrhea—PrEP does not. Protecting against those other infections does matter and should be taken seriously, especially in light of growing evidence that HPV is linked to cancers of the throat and anus. It is not just that, though. We are also seeing a growing number of STIs that are resistant to our primary treatment methods. It is not a question of if, but rather when we will be confronted with a sexually transmitted “superbug” that resists all known antibiotics. When that happens, condoms will be our best line of defense against it.

It is for these reasons that physicians recommend that persons on PrEP continue to use condoms. PrEP therefore should not be viewed as a replacement for condoms, but rather as an additional layer of protection against one specific sexual infection: HIV.

Another major misunderstanding of PrEP is that all men who have sex with men should be on it. Indeed, many of my friends and acquaintances have taken to social media in recent months declaring something to this effect. While I certainly share the sentiment about wanting to stop the spread of HIV, we need to be careful about saying that all gay or bisexual men should be taking this drug and we need to recognize that giving PrEP to all men who have sex with men is not a practical solution.

PrEP therefore should not be viewed as a replacement for condoms, but rather as an additional layer of protection against one specific sexual infection: HIV.

First, the decision to start PrEP (or any other medication for that matter) is a deeply personal one and not for anyone else to dictate. Moreover, some would argue that it is unwise to imply that being a gay or bisexual man automatically necessitates any kind of prescription.

Second, few people realize the financial cost of PrEP, which is currently about $1,300 per person per month, which translates to $15,600 over the course of a year. Even if you conservatively estimate the percentage of the population that consists of adult non-heterosexual men, this would result in a cost of tens of billions of dollars per year. This does not take into account all of the extra healthcare utilization that such widespread implementation would entail, such as routine physician visits every few months to check for potential drug side effects (the most serious of which is that PrEP can impair kidney functioning in rare cases—another factor that makes the decision to start this medication a very personal one).

Because we have limited healthcare dollars and resources, PrEP is most effectively used in a very targeted way, directed primarily toward those gay and bisexual men who are at the highest risk of contracting HIV (e.g., those in an ongoing relationship with an HIV-positive partner, as well as those who have multiple partners and who use condoms inconsistently during anal sex).

All of that said, PrEP is most certainly a welcome addition to the fight against HIV, and there is no doubt that its usage will help many in the LGBT community to live longer and healthier lives. However, PrEP is a tool that we must all take the time to better understand and, above all else, use wisely.

Dr. Justin Lehmiller is a social psychologist and author of the popular blog, Sex and Psychology (http://sexandpsychology.com). He conducts research on casual sex and safer-sex practices, and has authored a sexuality textbook that is used in college classrooms around the world. Learn more and receive updates on the latest sex research by following him on Facebook (facebook.com/psychologyofsex) or Twitter (@JustinLehmiller).