Is it important for PrEP programs to talk about sex and pleasure, not just prevention?
A recent review article published in Current Opinion in HIV and AIDS discusses the “collateral” benefits—i.e., benefits other than HIV-prevention—reported by PrEP users. The HIV prevention strategy, which includes HIV-negative people taking a daily pill, is highly effective at preventing HIV and demand continues to grow. However, PrEP programs that divorce themselves from issues related to sex, pleasure and other social and sexual goals could undermine progress, argue Robert M. Grant, MD, of the Gladstone Institutes, the University of California at San Francisco and chief medical officer of San Francisco AIDS Foundation, and Kimberly Koester, MA, director of qualitative research at the Center for AIDS Prevention Studies. Here’s what they say researchers, clinicians, advocates and others should know about what people want—and get—from PrEP.
People want to know it’s effective
Users and prospective users want to know that PrEP works well to prevent HIV. “Providing information that ‘PrEP works when taken’ was pivotal for fostering demand and adherence,” the authors say.
Pleasure should not be ignored
Grant and Koester call attention to the tendency for HIV prevention research to discount or marginalize the role that pleasure has in sex—and ultimately stigmatize the sexual practices people enjoy and reduce them to a source of HIV risk. For some users, PrEP increases pleasure during sex by affecting intimacy, bonding, spontaneity and adventure. “PrEP users have reported that PrEP enhances sexual pleasure, and that this is sufficient motivation for their using PrEP.”
PrEP is about planning ahead
Condoms are recommended to be used with PrEP, but condom use—with PrEP and without PrEP—is often inconsistent. Because the decision to take PrEP is made in advance—as opposed to ‘in the moment,’—users are more likely to think ahead about future sexual situations. PrEP includes regular HIV and STI screenings, which may help people think more often and be more aware of their risk.
Emotional benefits of PrEP: Less fear, more empowerment
Many people report that HIV fear has manifested as anxiety during and after sex. PrEP use is reported to mitigate this fear for many. “This benefit of PrEP may be valued more highly than PrEP’s actual capacity to prevent HIV infection, although the two are related,” say Grant and Koester.
PrEP also allows HIV-negative partners to be in control over their own HIV status and health. PrEP users do not have to rely on their partners to use condoms, or maintain an undetectable HIV viral load. “PrEP is one of the only prevention interventions that is controlled by the receptive partners,” and can be used without the knowledge of sexual partners.
Less HIV stigma
PrEP bridges the divide between HIV-negative and HIV-positive people and enables serodiscordant people to have safer sexual interactions. “Such interactions lead to increased sensitivity to HIV issues, and greater inclusion of HIV-positive people in social networks that were previously exclusionary.”
PrEP offers a safer way for serodiscordant heterosexual couples to get pregnant. While there are other options that serodiscordant couples can use to conceive, such as sperm washing and in-vitro fertilization, they are not available in many locations and can be expensive. PrEP, along with timed condomless intercourse, has been successfully used by serodiscordant couples to conceive.
People desire HIV prevention strategies that fit into their life, and many realize that they experience “seasons of HIV risk” rather than life-long continued risk. PrEP can be taken daily for certain periods of time when people feel they will be at risk—and then discontinued, under their provider’s guidance, when it is no longer needed. For men who have sex with men, it takes seven days of daily dosing with Truvada (the drug used for PrEP) to reach protective levels in the body. PrEP is currently only approved in the U.S. for daily use.
Grant, R. M. & Koester, K. A. What people want from sex and preexposure prophylaxis. Current Opinion in HIV and AIDS. November, 2015.