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A New Year, A New Way to Take PrEP?

, by Jake Sobo

I recently packed up my life into a truck and moved across the country. I was ecstatic to be employed in a field where jobs are offensively scarce, but was sad to be putting even more distance between me and my boyfriend. We’d been a two-hour drive apart until then. Now it would take four hours on a plane to reunite.

I started taking PrEP daily before I ever met Tim, my boyfriend of just over a year. For two years, I’ve taken those little blue pills just about every day—save maybe a few misses here and there. My kidneys are in fine form. I take vitamin D and calcium supplements as a precaution against bone density loss. And side effects? What side effects?

By all accounts, me and PrEP make a great team.

But perhaps because of the stress of the move and a new job, my libido has waned. I’m in a new city with no regular tricks to rely on. And living in a neighborhood where most of the guys eager to fuck me within a 20-minute radius seem to be closeted married men in their 40s (nothing against them; it’s just not my scene). On top of that, I’ve got good dick waiting for me at home. I’m not going to hook up with just any schmuck. My standards have, unexpectedly, taken a turn for higher ground (maybe too high!).

A year ago, I was fucking a new guy every five days or so. Since I moved out west in August, though, I’ve had sex with exactly three people. And one of those doesn’t really count because I kicked him out of bed for being such a sloppy, frog-mouthed kisser. Yuck.

Of course, another of those three is my wonderful boyfriend. When we’re together—about a week out of every month—we have beautiful sex and we don’t use condoms. He’s undetectable. I’m on PrEP. We’re basically the future.

As we come to the beginning of a new year, and reflect on days gone by, I have to start wondering: Should I keep taking those little blue pills every day? There are lots of reasons to think twice. Along with the number of men in my bed, my risk for joining the poz club has gone way, way down. And those pills ain’t cheap: I’m gulping down at least $30 every night before bed. I may not be paying for it, but somebody is. And although I’m not experiencing any side effects now, there’s always the concern that somewhere down the line that might change.

On the other hand, I am hoping to have at least some rando-sex. Perhaps even with closeted married men, if I must. And although the risk with me and the boyfriend is astronomically low, I know PrEP makes us both feel a lot more comfortable breeding each other silly.

Maybe there’s a middle ground, though. We’re in the early days of PrEP where taking a pill a day is the only FDA-approved strategy. But there are other PrEP strategies on the horizon. They’re testing out whether we can develop an injectable PrEP that your doctor could administer every three months or so. There’s also a fair amount of chatter around “intermittent PrEP” or “PrEP on demand.” Instead of taking a pill every day, the idea is that you might only have to take it when you need it. Scientists want to find out if taking two pills 24 hours before sex, a pill every day while you’re sexually active and a pill for two days after your last fuck prevents HIV infection. The handy diagram below illustrates the intermittent PrEP dosage being tested by French Canadian scientists in a study known as “IPERGAY.”

Diagram from IPERGAY study

Diagram depicting the IPERGAY dosage protocol for intermittent PrEP. Source: Canadian HIV Trials Network, http://www.hivnet.ubc.ca/clinical-studies/canadian-hiv-trials-database/ctn268/


If you keep your nose in the PrEP science world, you might have heard that IPERGAY scientists announced in October that they were shutting down the study’s placebo arm because the initial results clearly showed that intermittent PrEP worked. With such clear-cut evidence to demonstrate effectiveness in hand, it was unethical to keep giving some people in the trial a placebo.

But although the scientists behind IPERGAY said intermittent worked, the real pickle is that they didn’t say precisely how well it worked. The study’s lead researcher let slip to the media a figure of “80%,” but the fact is we don’t really know. We will have firm figures soon, when they are announced at CROI (a big, annual HIV conference) in late February.

Looking toward the new year, I asked my doctor—a nationally renowned expert on PrEP—what he made of intermittent PrEP. He, of course, cautioned that we need to wait to know more, but he raised some interesting concerns. He noted that the IPERGAY data presented at AIDS 2014 showed that people in the study were taking, on average, about 15 pills a month. 15. Pills. A. Month. Some simple math reveals that this is the equivalent of taking PrEP every other day. Not so intermittent, eh?

Potentially more concerning is the 80% effectiveness figure casually cited by IPERGAY’s lead researcher. If it pans out, this would be a comparatively low figure for taking PrEP roughly every other day. Data from the iPrEx study showed that PrEP was 96% effective when it was taken only four times a week. A big question on many people’s minds is why isn’t IPERGAY’s 80% figure more similar to what iPrEx found? I think the answer lies in the complexity and unpredictability of our sexual lives. For PrEP to work—intermittent or daily—you need to have the drug in your body as soon as you are exposed to the virus. If you only start taking the drug after you have sex, that’s not PrEP at all—it’s what we call “post-exposure prophylaxis” or PEP. It can help protect you as well, but it’s not likely as effective as PrEP.

Of course, in order to have the drug in your body, you’ve got to plan ahead. In the IPERGAY trial, this meant taking two Truvada pills two to 24 hours before sex. Yet, part of the great joy of sex for many people it’s the very fact that it’s spontaneous, unplanned, and surprising. We can’t always predict when luck will strike. If you’re taking PrEP every day, then this isn’t much of an issue. But if you only take PrEP a few hours before sex, you’ve got to know when you’re getting lucky ahead of time.

In my sex life, there are some variables I can predict. I fly east once a month to see my partner. I can just about schedule our sex life. That’s one of the big bummers about being so far away: Being spontaneous is just about impossible. Outside of the relationship, however, predicting when I’ll manage to find a guy online that I think is fuckable (and who is similarly into me) and that is available at the same time I am is not exactly easy where I live now. Unfortunately, it’s the tricks who are most likely to infect me—not my boyfriend. In other words, the sex for which I most need to be “PrEPared” is also the sex that is most unpredictable.

2014 was big year for PrEP. As we start 2015, we look towards the future of PrEP and all eyes will be on CROI in February to see how the data finally shake out. At least where I sit, if the final data show that taking intermittent PrEP an average of 15 times a month is only 80% effective, I can’t see how complicating your PrEP regimen by having to predict when you’re going to hook up would make much sense for anyone currently taking it daily. I’d rather continue my daily regimen, rather than risk screwing it all up by not starting it far enough in advance—much less saying no to potentially great sex because I hadn’t taken my pills yet!

Perhaps intermittent PrEP will still make sense for some people who cannot or will not take it daily—or for people in very particular situations (e.g. where the bulk of their sex is concentrated in predictable time periods, such as business trips)—and maybe having an alternative to a daily dose will get more people on PrEP. That remains to be seen.

Have you considered changing your PrEP regimen? As always, leave me a comment or shoot an email to mylifeonprep@gmail.com. Happy New Year!

Jake Sobo is a pen name used for anonymity. Jake has worked in the world of HIV prevention for nearly a decade. He previously published a 19-part series documenting his experiences on pre-exposure prophylaxis (PrEP), “My Life on PrEP,” for Positive Frontiersmagazine, which was picked up by Manhunt, translated into French, and widely read in the HIV prevention world. He has spent the better part of his adult life having as much sex as possible while trying to avoid contracting HIV.

The opinions expressed in this article are those of the author alone. They do not reflect the opinions or positions of BETA Blog or of San Francisco AIDS Foundation. BETA Blog serves as a resource on new developments in HIV prevention, evolving approaches to HIV treatment, and strategies for living well with HIV. Our goal is to inform, empower, and inspire conversation.


3 Responses to A New Year, A New Way to Take PrEP?

  1. Tom C. says:

    Hello, I am/was a participant in the IPERGAY Prep study here in Paris for almost 3 years. I can explain from my personal experience and from others who I know who are in it. (We are also starting our own PrEP promotion group in Jan.). There are a lot of things that you leave out from your interpretation that needs to be said. First of all, intermittent PrEP, as PrEP itself, is not for everyone. It will be a choice (once it gets scientifically proven, and approved for public use) that people will have it open to them in the near future. It is not the ultimate solution, it is one that will possibly lead to other better solutions, in the future, (you mention injectables). People have to realize that PrEP is not just a pill taking experience. It is about going to a sexual health clinic regularly for HIv and IST testing and speaking to well-informed pros about the best prevention mesures to take into account in our ever changing sexual lives. You mention an un-official efficiency figure for the IPERGAY study, and use it as an example that it may not work. Well, don’t jump the gun here. Wait for the official report to be out before concluding anything. I think that the results will be as good as those in the IPREX study for those who really were taking TRUVADA. It was announced in the IAS meeting last Summer that a surprising number of men were adhering to the protocol. That is due to the counselling in the clinic that we get. Which proves that if this approach is legalized that it should only be made available in like circumstances as we got in the IPERGAY trial. PrEP is no magic bullet. It needs to be taken with careful medical guidance. Not everyone will like that, so they should choose to use condoms, and getting regularly tested. The idea of intermittent PrEP is one of reducing the risk to long term side effects, by reducing the amount of the drug in the body in the times with no sex. It is less expensive as well, less pills are consumed. But it can be used everyday if needed, and that depends on your lifestyle.

  2. Scott R. says:

    Jake, thank you for sharing your experience in 2014! I’m a long time listener, first time caller. I was wondering if you might elaborate on this: “those pills ain’t cheap: I’m gulping down at least $30 every night before bed. I may not be paying for it, but somebody is.”

    Do you believe that potential Prep patients should consider the “real” cost of the drug in making a decision about whether or not to take it? I bring it up, and feel a bit sensitive about it because my doctor at Kaiser who I appreciate for managing the trial program in SF, was very direct and dare I say judgmental in communicating the $1,300 (or whatever it is) a month cost of the drug.

    I wonder who was discouraged from starting Prep after meeting with this doctor. Maybe they felt that their risk for HIV just wasn’t worthy enough to justify the cost. Maybe they were led to believe that if they just got better at using condoms, they wouldn’t need Prep after all and they could save everyone, especially Poor Kaiser, some money. I think this is the intent behind the cost conversation during the lengthy lengthy process of getting on the drug through Kaiser SF and I’m not sure I ethically agree. I realize that we are being encouraged to consider “seasons of risk” in our own lives, but I’m not sure that the real cost of the drug should be a part of decision making process. Nevermind that my riskiest season of risk was during the time I was moving through the process of actually being prescribed the drug for the first time.

    What is the real cost of the drug? Of any drug? How do we even begin to answer these questions when our healthcare system in the US and the pharmaceutical companies we rely on are so perversely mismanaged and corrupt? Why should patients be the ones to consider the “real cost” when they are insured and have access to low cost meds- as all people should be.