TO PrEP, OR NOT TO PrEP Safe sex and HIV prevention

To PrEP, or not to PrEP That is the question, says Christo Valentyn, when it comes to safe sex and HIV prevention. You may have noticed that a certain word is making its appearance more frequently in gay news and even on dating apps like Grindr: PrEP, or as some choose to use it, #PrEP. Since our very own government is still in two minds about whether HIV and AIDS exists or not, there is limited communication on the existence, usage and benefits of PrEP, or preexposure prophylaxis, in South Africa, which makes it even more revelatory to see more people embracing and proclaiming the use of it. Surely it’s a good thing that gay men, individually, are looking at modern day preventions to stay safe when it comes to sexual health?

My own reluctance regarding PrEP, from a research and usage perspective, may be based on personal perceptions, but in the same breath, I’ve always been a great supporter of safe sex initiatives. Science continues to make exceptional strides in its mission to curb the further spreading of HIV through various drugs, and I remain hopeful every time I read a story about how much closer scientists are to a cure. Most recently, for example, a team of international researchers led by Northwestern University has discovered that HIV continues to replicate new cells at low levels in the lymphoid tissue, even when it is undetectable in a patient’s blood. Although seemingly minute, this discovery could be the breakthrough that many scientists have been searching for to take the next step in HIV treatment and prevention, reports HIV Plus magazine.

Why? For the past decade, researchers have known that, although antiretroviral medication can suppress HIV in the blood, the virus remains in the body at the tissue level hiding in the body’s reservoirs. Scientists previously believed that these infected

cells were long-lived rather than newly formed, but with these findings, they now know that the virus is constantly replenished by low-level replication instead of older cells that have stayed in a resting state since a person seroconverted. “We now have a path to a cure,“ said corresponding author Dr. Steven Wolinsky, chief of infectious diseases at Northwestern University’s Feinberg School of Medicine. “The challenge is to deliver drugs at clinically effective concentrations to where the virus continues to replicate within the patient.“

Excellent news, yes, but I’ve been left wondering why I remain sceptical. For someone with an inquisitive mind and a penchant for penning his thoughts, this is a predicament. I’m also a bit of a conspiracy theorist and a certified bookworm, and I’ve read my fair share of fictional tales about viral threats and mutating viruses to believe that there’s more to the fiction than we think. Robin Cook made a name for himself writing about all kinds of deliciously harmful viruses, and just think of James Dashner’s bestselling Maze Runner series, in which a virus – called the Flare – mutated way beyond what the evil masterminds thought it would. Where there’s smoke, there is usually fire, so I certainly do believe that we can’t control everything, especially when it comes to something that requires controlled laboratories for in-depth analysis.

HIV, specifically, is known to mutate. We know there are different strains, and that different people react differently to it. When something becomes that uncontrollable, I see red flags everywhere. My mind tells me that because of this volatile nature, one drug – one, single thing – can’t possibly prevent all the known and unknown viral strains. This is, in a nutshell, and by no means interpreted in a medical or scientific manner, what PrEP sets out to do.

Pre-exposure prophylaxis is deemed to be one of the most effective ways to prevent the transmission of HIV among gay and bisexual men specifically, with clinical and real-world trials proving its efficacy at or near 100%. While the use of PrEP still leaves one susceptible to other sexually transmitted diseases, the U.S.A.’s authoritative Centers for Disease Control have officially endorsed it – in addition to condom use – as an HIV prevention strategy, as have the World Health Organisation.

However, and true to my sceptical nature, February this year saw the first documented case of a man contracting HIV while taking daily doses of Truvada as PrEP being reported at the 2016 Conference on Retroviruses and Opportunistic Infections (CROI) in Boston. The gentleman in question, aged 43, stuck to the PrEP regime religiously for two years before testing positive for HIV. So what went wrong?

Truvada consists of two drugs, tenofovir and emtricitabine. Research (apparently) shows that resistance to the latter drug is fairly common, while more mutations in HIV strains resistant to tenofovir have also started to emerge. The case in question is the first time a virus has been resistant to both drugs. Even more interestingly, tests on the gentleman indicated that he was infected very recently before being tested positive, but more shockingly, that his drug resistance had been transmitted from another person – it wasn’t a latent genetic resistance that only came to life after he was infected. To me, this is straight out of a Robin Cook

thriller; clear proof of just how much HIV has mutated over the decades, and great incentive to keep the condoms handy…

However, I have learned that just because I have an opinion doesn’t mean I’m right. I am not on the drug, so I can’t really present my opinion as gospel. To get some feedback from the proverbial horse’s mouth, I made extensive use of Grindr’s chat functionality whenever I saw “PrEP“ or “#PrEP“ on a profile – and I was surprised at how willing several total strangers were to talk about it, and how their feedback was so similar.

Marius (not his real name) is in an open relationship. On the odd occasion that he hooks up with someone other than his partner, he always feels guilty about possibility having contracted “something,“ followed by paranoia about whether he played it safely enough. It reached a point where he would take the condom out of the trash and fill it with water to see if it might have leaked. Having heard of PrEP, he consulted a virologist to find out more about it, and decided to start using it. He notes that the added level of “safety“ didn’t change his sexual behaviour initially, and especially not in the sense that he suddenly hooked up with other men more frequently.

While we may have many opinions on open relationships, one of the core aspects that make it work is trust, says Marius. Previously, neither he nor his partner engaged in unprotected sex, not even with each other. This remains one of the rules in their relationship – no unprotected sex with another person – but, as they are now both on PrEP, they have started enjoying unprotected sex with each other. For Marius, this is a huge step considering the angst and paranoia he experienced after sex before taking PrEP.

“For me it was a no-brainer,“ he says. “Here is a pill that offers the same level of protection as a condom, and has been tested and endorsed by all of the world’s biggest medical and health organisations. I truly believe that more people will start using PrEP as awareness around the drug and its benefits increase.“

Internationally, there appears to be a much stronger drive to educate gay and bisexual men specifically on PrEP and its benefits, and we’ll soon see the term become more commonplace on dating and hook-up apps. Scruff, which functions similarly to Grindr, have already added two new metadata fields to the app, one for sexual practices (top, bottom, oral, fetish, etc.), and one for safer sex practices like condoms, PrEP and TasP (treatment as prevention). Grindr, which is the most widely-used hook-up app in the world (two million daily users), is a bit more vague about similar in-app plans, but has partnered with Gilead Sciences, the company that created Truvada, on research and educational awareness.

I would be lying if I said that I do not have a tiny bit of scepticism left, but if I’m being honest, that remains rooted in my nature and is an entirely subjective position. Objectively, there is still no doubt in my mind that safe sex is the only sex to have, and I will remain a steadfast believer in condom usage as the first line of defence. There is an overwhelming amount of research that shows the efficacy and benefits of PrEP, and as so many men who are using it have told me, it really is a no-brainer to add this to your regime. Can we ever be fully protected from HIV? Time will tell, but we can certainly do our damnedest to prevent it.