PREP First Quarter 2016

Do HIV-negative gay men need a condom if they are in PrEP? Here's what I tell my patients

Those of you who follow my blog know that I am in pre-exposure prophylaxis (PrEP) To reduce the risk of infection HIV. And more and more of my patients are also starting to take Truvada the pill combining antiretroviral drugs tenofovir e emtricitabine) as PrEP to prevent HIV infection. And of all my patients, they ask me for explanations for my recommendations, which are to use condoms even in the light of PrEP data.

If you ask most doctors, researchers, and public health officials, the usual answer is, "Well, you should continue to use condoms because, of course, Truvada does not protect against STIs."

The problem is that this is not really what my patients are asking!

Let's face the fact that everyone hates condoms! We hear a lot about gay men who do not use condoms today, but how to convince a lot of men heterosexual to use condoms with their female partners who are "in control" of the birth rate? Are many doctors advising that all their patients need to use a condom every time and in every situation, use condoms now and forever, is this feasible? You know they're not using it. But that was the only message we had for gay men over a long period of time. And it was a vital message on the days when we had no other tools, there were few reliable tests and the transmission was not well understood. It was a message that saved the lives of countless people. But now it's a message that pathologizes gay sex and fails to recognize that people are making reasonable and rational choices about risk. We now have PrEP and treatment as prevention (TasP).

People want to know if using PrEP could effectively allow them to have sex without condoms. They are looking for their doctors for guidance. If we want to get around the issue of talking about other STDs, we let (us, the US doctors) stay "experimenting so that each one finds his own way. PrEP opens the door to talk about situations where the risks of HIV infection are so low that they may transact without condoms, and this seems to be a reasonable choice for them. I will share with you the guidance I give my patients.

Seat belts in addition to airbags

If some people want to take PrEP and still use condoms, I welcome your choice. They will be safer between us. Some have compared this association to the use of belts and suspenders. I do not like this picture because it implies that those who choose such an option are a bunch of Nerds on Wheels (see Urkel). I prefer the analogy of using seat belts and airbags in cars. Both are there to protect us, but they work in different ways - and the results are better when we use both modes.

At this point, I think most people agree that those who are in a stable long-term monogamous relationship, where both partners are seroconvergent, there is no need to use condoms. (Translator's note: I translated literally and I want to make my position very clear here: Two people who are HIV-positive are two completely different "Viral Universes" and there is a risk that, if there is what I call " of a drug-resistant strain that you take and I do not need to be clearer than that) 🙁

Let's look at the numbers

If we look at a variety of different sexual encounter scenarios apart from long-term planning, in a stable monogamous relationship with partners of convergent seropositivity, we can see some areas where PrEP (Treatmens as prevention) and PrEP can reduce the risk in such a way that the choice not to use condoms may seem like a rational choice.

The Centers for Disease Control and Prevention (CDC) calculated Translate The risk of HIV transmission to sexual various exhibitions and other. The risks for passive (receptive) individuals in anal intercourse (percussion) are from 134 to 10.000 exposures. Just to be clear, from a public health point of view, this is a high risk.

The undetectable Partner

If one partner is HIV positive and is on medication with an undetectable viral load (viral load <40 copies / ml) in some tests and <20 copies / ml in others), then the opportunity to transmit HIV is reduced by 97% or as much (conservative).

That is, according to a number of studies - including the study PARTNER, which showed absence of transmission among more than 700 couples serodiscordant. Couples who were not using condoms and where the HIV positive partner was under suppressive ART and the negative partner was not under PrEP. If the negative partner it is under PrEP and take the medications reliably, so the risk of getting HIV is reduced, say, from 92% to 100% according to several studies. With these risk reductions (97% and 95%), the risk becomes something like 1 for each 50.000 encounter. If we use a PrEP figure with 99%, we would be in the 1 spectrum every 250.000 episodes. I think we can legitimately ask: what else in terms of reducing the risk of HIV infection we could get from the use of condoms in this situation?

Both negative partners, both under PrEP

If both partners are negative and under PrEP, then both are being seen by medical providers. And if these providers are following protocol, then patients are being tested every three months for HIV and STIs and seeing that their adherence to the medication is reliable should be negative. What can a condom add to reduce HIV risk in this setting?

dating-safe-and-dating-with-camsinha-300x224Both partners they say which are negative under PrEP

If one partner who claims to be negative and is under PrEP and the other is not, then this becomes a little more complicated. If you are the person under PrEP, you need to ask yourself how you can be certain that the other person is not misrepresenting facts. Do you trust that the person is really negative? Do you know when the individual was actually tested? Do you know the sexual history of the individual? And finally, are you comfortable enough with what you know about Truvada and its ability to prevent HIV infection so you can not use a condom with this person? A harder choice to be sure, but how would your partner's knowledge help reduce risk?

The unknown partner scenario

What to do about the unknown partner, someone whose HIV status you can not know for sure. I ask my patients to consider this scenario: You are in PrEP and a really hot guy comes to you and says "I really want to have sex with you but you should know I recently became HIV positive and I am not in use medications and my viral load is still quite high. "

Would you have unprotected sex with this man?

  • Most of my patients respond immediately that they do not (unfortunately many would not even want to have sex with him, despite the fact that condoms would protect, but let's leave Stigma for another discussion).

Editor's Note: There is a research done, I believe, by Datafolha where 33% of people would refuse to WORK AT WORK EVEN WITH A PERSON LIVING WITH HIV.

  • Some people say they are not sure. Some said they would just say top sex with the person without a condom (the risk from a single episode of anal insertive intercourse is 11 in 10.000 dating - you happen to be given statistics in evolution and analysis).
  • A small number of people who are strongly believers in the power of PrEP to protect them would say they would still have unprotected sex, including anal receptive coitus.

then we talk about these choices.

For those who say they would use a condom, I would say that this is the way they then need to deal with every fuck with a stranger.

For those who say they would still have unprotected sex, I must first say that I expect PrEP to be as effective in this setting as it was in general studies. I then prescribe caution to them, since the data available to us in the studies have not proved that they are truly definitive. In the PrEP studies we did not look at the HIV serological status and viral load levels of each partner of the study participants. We can not say for sure when PrEP will work well, how PrEP works, in general, if someone is constantly trading without condom with partners with very high HIV viral loads.

It is not possible to say with certainty that PrEP will not will work, we just do not know, whoever fucks without condoms with strangers is, in fact, practicing empirical experimentation with his own body. I'm not saying they are wrong or that they are stupid or misinformed, but they need to be aware that we do not know for certain that this person will be safe.

A issue of STDs

Of course, there is always the issue of STDs too! If someone had an infection in the urethra, such as a discharge tube that burns, most would assume that this person might not be having sex with other people. Unfortunately, most anal (and oral) infections are asymptomatic. So people are not aware that they are infected and will continue to have sexual encounters. When using a condom for intercourse when you have sex with everyone, it will almost certainly reduce your risk of getting an STD.

Move the message

PrEP is a game turn in many ways. I think one of the biggest changes is that one can begin to reasonably look at the risks in various types of sexual encounters. With real data, we can help people start thinking about the various ways they can manage the risks you discern and admit to accepting running in much clearer ways.

Maybe if we passed to transmit, in place of the assertive message that, from today, "You have to use condoms in every situation, now and always" to "there are times when definitely using the condom this will be safer, but there are situations where not being in a condom can be a reasonable choice"; perhaps this can improve outcomes and improve decision making in the care of your sex life, minimizing the occurrence of infections.

Howard Grossman, MD, is the director of AlphaBetterCare, an LGBT-friendly primary care provider who serves the city of New York and New Jersey. A physician and HIV researcher for more than twenty years, Grossman is also a senior physician at Mount Sinai Roosevelt Hospital.

Translated from original HIV-Negative Gay Men Need Condoms if They're on PrEP? Here's What I Tell My Patients written by Howard Grossman, MDA from for Claudio Souza and reviewed by Mara Macedo.


Claudio Souza

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