Let's Talk About PrEP

What is PrEP?

For those of you who aren’t familiar with it, PrEP (tenofovir/emtricitabine), which is used as pre-exposure prophylaxis (PrEP) to prevent people from contracting HIV.

Why are we talking about it?

Let us preface our answer by saying that the advancements in HIV/AIDS prevention and treatment, including PrEP, have been overwhelmingly positive and we fully support the use of PrEP as an extra form of protection for those most at risk of contracting HIV including those within the Gay Community. Having said that, it has come to our attention that there is a not so positive conversation taking place in the Gay Community about PrEP and it revolves around a little concept called Risk Compensation, meaning people using PrEP may be prone to taking more risks with their sexual activities, such as not using condoms, due to the fact that they feel safe from HIV, which let’s face it, is the most serious STI.

How did we become aware of this conversation?

Well, members of the gay community started having it on our Facebook posts, which focused on the increasing rates of STIs such as Gonorrhoea and Syphilis in males, as highlighted in the Kirby Institute’s 2018 Annual Surveillance Report. Comments such as ‘blame PrEP’ began to appear so we decided to find out more.

So what is the concern about PrEP and is it warranted?

We need to start by saying that there is currently no evidence to suggest that PrEP is directly associated with increasing levels of any STI in any demographic in Australia. The PrEP trials that are being run are all relatively new and there is no data available yet that reports on the STI diagnoses during the period the trials have been running. However, overseas some trials have been running longer and we found that the concerns in the Australian gay community may, in fact, be warranted if you take cases such as Northern California in America into account as reported on here by Benjamin Ryan for Poz*.

The article reported that “the quarterly rates of rectal gonorrhoea and urethral chlamydia increased steadily and about doubled after one year” amongst people accessing PrEP from the Northern California health system.

The article also goes on to say that, “In a September 2015 analysis of Kaiser Permanente’s San Francisco clinic’s population of 600 men who have sex with men (MSM) on PrEP, researchers found that many of them were using condoms less since starting PrEP and that during their first year or partial year on PrEP half of them had contracted at least one STI.”

So even without local evidence to suggest PrEP use may be decreasing the use of condoms and potentially increasing the occurrence of other STIs, it seemed like there might be a conversation that needed to be had now, as the use of PrEP is increasing in Australia.

Currently New South Wales, Victoria, Queensland and the ACT all have PrEP Trials in progress and South Australia’s started this month as well. In January, The Victorian AIDS Council also announced an extra 100K in funding for the Victorian trial allowing an extra 600 gay and bi-sexual men to join it.

PrEP promises to play a key role in the federal government’s commitment to end HIV by 2020 and we’re all for that, but we think there needs to be more said about the fact that PrEP only prevents HIV, used alone it is not an adequate method to protect any person from STIs and whilst Gonorrhoea and Chlamydia might seem like small fries they should not just be overlooked.

We were lucky enough to gain the support of Daniel Ceh, a Sydney-based Marketing Strategist & concerned member of the Gay Community, in writing this article.

He says, “The negative impact (of PrEP) lies in the way it has been adopted socially in LGBTI culture, and the lack of care that has been taken in making sure the drug is not having a negative impact on the sexual behaviour of the individuals in the trial.

This has effectively led to the establishment of a sexual recklessness that I have recognised in both close friends and the wider gay community. The common mindset is ‘Sure, I can still contract other STIs, but they’re curable with a simple pill or shot. I’m protected from the dangerous one.’

PrEP should not be adopted as a security blanket. It is not a free pass to unprotected sex, and without communicating this we have a substantial problem.”

One such problem is the increase in antibiotic resistant strains of STIs such as Syphilis and Gonorrhoea.

Our Head Doctor, Dr Mitchell Tanner says, “Antibiotic resistance has become the greatest medical challenge facing the modern world according to the World Health Organisation and without being a fear monger it’s important for people to know that antibiotic-resistant bacteria, including Gonorrhoea and Syphilis, are likely to become much more common. Of particular concern is Gonorrhoea, Ceftriaxone-resistant Gonorrhoea has been identified overseas and there is large concern over this as there is no known treatment available. It is truly frightening what we may be looking at.”

Why is this happening? Dr Tanner cites a number of reasons including, “inappropriate and incorrect prescribing of antibiotics, incomplete courses of antibiotics being taken and excessive use of antibiotics in agriculture to increase yields.”

What does this mean for those who are putting themselves at risk of catching these STIs? “Having previously had an infection that has been treated doesn’t increase the individual’s risk of then developing a resistant STI. However, the more times a bacteria is treated with antibiotics, and perhaps not treated effectively, the more likely a resistant strain may develop and then go on to infect people in the community. The fact of the matter is having a cavalier attitude to any infection that poses a risk to your health and the health of others is irresponsible. Modern medicine has made us all feel safe in different ways, but bacteria will always fight back and we need to be aware that it is, particularly when it comes to Gonorrhoea and Syphilis.

The bottom line is they are infections and we should all be trying to avoid them, especially as the presence of other STIs has been shown to increase a person’s risk of contracting HIV.”

If you’re still wondering what all the fuss is about then let’s go back to Daniel. Amongst his concerns, Daniel cites the way PrEP was introduced to the Gay Community, he says, “I was introduced to the drug after seeing it on profiles on different popular gay dating/hookup apps. Predominantly it was used to market an individual’s sexual perks. Statements like “Into raw, on PrEP” were popping up left right and centre.

I began to question the way this preventative drug had been adopted recreationally. Surely the intention wasn’t for it to be used as an endorsement for raw sex, but the way PrEP was introduced into safe sexual health practice is reducing other forms of protection from necessary to optional.

What urged me into action was a recent discussion with an acquaintance of mine. His exact words were, “How great is PrEP?! I’ve taken so many poz loads without a problem”. I was shocked, and scared.

PrEP does not eliminate the risk of contracting HIV. It decreases the risk greatly, but it is not a failsafe.”

Dr Tanner says, “Daniel is correct that PrEP is not 100% effective. Some will argue that condoms aren’t 100% effective either, there’s always a risk, but inviting that risk by not using an extra form of protection when most people on PrEP are used to using condoms anyway is unnecessary.”

It’s still early days for Australia with PrEP and its positive contribution to the battle against HIV is far too important to overlook, but we felt this discussion needed to be had now and Daniel agreed with us, “as more results on PrEP’s success become apparent, naturally sexual health organisations will revel in it and encourage those at risk of contracting HIV to start taking it. I believe the more the success of the drug alone is talked about the more at ease people will be to use it and have unsafe sex. The way this drug is shaping sexual behaviour in the rainbow community does not have to be an issue though, providing that sexual health organisations begin campaigning about the importance of condoms and the need for protection from other STIs in addition to PrEP.”

So on that note here’s a final word from Dr Tanner,

“Women have The Pill to prevent one potentially unwanted outcome of unsafe sex, but not STIs. Of the Chlamydia diagnoses in 2015 between the ages of 15-29 more than half were in females. That might have nothing to do with The Pill or other forms of Birth Control, but it does suggest a lack of concern amongst the female community in the at-risk age group about STIs, whereas if they didn’t have access to The Pill the importance of using a condom may have far more meaning to them. In some ways PrEP is similar, its use drastically decreases the most serious outcome of unprotected sex for men who have sex with men. Unfortunately, like those using The Pill, people using PrEP need to be responsible for their sexual health as a whole and use PrEP for what it’s meant to be used for, to prevent HIV, along with condoms to prevent other STIs. I’d also urge PrEP users to get tested more regularly if they are going to engage in riskier sexual behaviour. Current guidelines for those at high-risk of contracting STIs are once every three months, but if you’re having unprotected sex with multiple partners the responsible thing to do is to get tested on a more regular basis. STIs like Chlamydia and Gonorrhoea are quickly detected and your early detection and treatment will help to stop the spread of these increasingly common STIs, which although treatable should not be underestimated. There are departments in every State Government dedicated to STI prevention and whilst HIV is still a valid major concern, Chlamydia and Gonorrhoea are being treated as increasingly important priorities so if they’re that concerned about them and I’m seriously concerned about them as a doctor then I think we all should be.”

So there you have it, take PrEP, use condoms. Let’s all be as safe as we can be.

One a closing note, we’d like to say a big thank you to Daniel for his openness and support in helping us address this sensitive subject. We have done so because we believe that as part of the sexual health community it is our duty to make sure people are taking every precaution.

As always, Be Safe Not Sorry and Get Tested Regularly.

*Data of the North California Study Participants was outlined by POZ as, “By and large, the study population was affluent, white, well educated, did not have a history of substance abuse and was presumed to consist almost entirely of men who have sex with men (MSM). A total of 97.9 percent were men. Their ages ranged from 18 to 68; the average age was 37. A total of 69.6 percent of them were white, 12.2 were Latino, 10.3 percent were Asian/Pacific Islander and 4.3 percent were Black. A total of 11.5 percent lacked a high school diploma. The median household income was $74,094.”