If you’re HIV negative, PrEP vastly reduces the likelihood you’ll acquire the virus. Unsurprisingly, it’s hugely popular with gay and bi men. Once you start taking the daily medication, you just keep taking it, right?
Well, actually, it’s not so straightforward. A study from Australia found that one in four PrEP users stopped taking their PrEP during the pandemic. Another 5% switched from daily dosing to on-demand dosing.
Queerty spoke with doctors from sexual health clinics in the US who reported similar findings.
It’s not just because some people were having less sex: Some patients felt less comfortable traveling to clinics whilst they were supposed to be staying home. Others didn’t take to telehealth services.
“There’s that digital divide,” says Dr. Maya Green, Medical Director for Howard Brown Health and Founder of HIV Real Talk, a community-based HIV screening and prevention project in high-risk communities in Chicago.
“There’s the access to care issues that a lot of people experience, and then certainly if you were in a community that has been marginalized, the access to care has some strains on it. The pandemic snapped the small strings holding that process together for a lot of clinics and a lot of PrEP access.”
However, things have definitely been returning to normal this year.
Jorge Roman is the Clinical Director of San Francisco AIDS Foundation. He noticed a big upswing in services since February. It’s now back to pre-pandemic levels. Talk of a “Hot Vax Summer,” with the newly-vaccinated throwing themselves back into dating, has seen many resume their sex life with gusto.
Because of this, if you have interrupted your normal PrEP routine, it’s very important to start again. Everyone we talked to said there are some things you should bear in mind.
1. Don’t stop straight after a sexual encounter
“If someone is taking PrEP daily and engages in unprotected sex with somebody, our recommendation is always to take PrEP for at least one month after that sexual encounter,” Roman told Queerty. “That would be the first place where people are putting themselves at risk if they start and stop it too suddenly.”
Like the Australian study, Roman says he knows of some men that have switched to taking PrEP on-demand during the pandemic.
This means taking a double dose 2-24 hours before sex. You then take a single dose 24 hours after that dose, and then another 24 hours later. Studies have found this to be as effective as taking PrEP daily.
However, it should be noted, the FDA in the US approved PrEP as a daily medication only.
On-demand dosing requires knowing in advance when you might be having sex and a certain amount of planning. Many people prefer the simplicity of taking a daily pill and knowing they’re always prepared for sex. This leads us to the next point….
2. Don’t stop unless you know for certain you won’t be putting yourself at risk
Roman says failure to take PrEP as prescribed can lead to people becoming HIV positive. He’s seen it.
“Over the last year, I would say it was individuals who had a prescription for PrEP and maybe not filled it or were thinking they weren’t at high risk so were going to utilize on-demand strategies, and just didn’t take those first two pills and thought, ‘I’ll just start taking it after the encounter and I’ll be OK.’
“So there have been many cases where the individuals had a prescription, knew what they had the option of doing, and unfortunately didn’t.”
“I have had a couple of patients who stopped taking PrEP as directed during the pandemic thinking that they were not going to be sexually active, then unexpectedly they engaged in sexual intercourse.
“Months down the line their HIV test came back reactive. The risk is there.”
3. If you stop, always take an HIV test before restarting PrEP
This is crucial. Again, those we spoke with said they’d known individuals who stopped taking PrEP, contracted HIV, and then wanted to start PrEP again without knowing they were positive.
“If someone was off PrEP and had a sexual encounter with someone who happened to be HIV-positive who wasn’t controlling their viral load, and then decides to re-start PrEP, the concern is they’re on a medication that prevents HIV but doesn’t control HIV,” says Roman.
“If they were to become HIV positive, and restart PrEP, there is the danger they’d develop resistance to the class of medications that PrEP – Truvada and Descovy – falls under. That is always the concern.”
In other words, if you’re HIV-positive and take PrEP, it can seriously screw up your treatment options further down the line.
Dr. Green remembers one such case of seroconversion.
“I’ve seen just one person,” she says. “They restarted PrEP without knowing they were HIV positive. Luckily that person came in, said ‘Hey, I need my labs.’ They had started PrEP again just a couple of days earlier. We were able to get that result and do what was needed for the patient.”
Always get tested for HIV before starting or restarting PrEP. If your insurance doesn’t already demand it, it’s also a good idea to get tested every three months for HIV and other STIs, and check your kidney function.
4. Remember to take PrEP for a few days before any risky sex
If resuming a daily dose of PrEP medication, also remember that it takes a few days to reach full effectiveness. Around a week for Truvada for anal sex, or 21 days for vaginal sex and injecting drug users who share needles.
5. Finally, if you struggle with a daily pill, stopping and starting may soon be less of an issue
The Covid pandemic has turned our lives upside down in many ways. Although PrEP is highly effective at protecting you from HIV, getting back into a routine can be hard. And some people, for whatever reason, will always struggle to take a daily pill.
Fortunately, further treatment options might soon be available. Two of the clinicians we spoke to expressed excitement about Cabotegravir. This injectable form of PrEP, which can be given by a doctor every couple of months, is expected to be approved for use by the FDA later this year or early next year.
“That’s going to be another really great medication in the toolbox for patients who want to take PrEP,” says Dr. Natalie Vanek of Legacy Health in Texas. “I think that’s going to be a game-changer. I’m really looking forward to that for our patients.”
Vanek also says the pandemic has had some unexpected benefits.
Although she works from a large clinic in Houston, the increased use of telehealth has seen a big increase in gay men accessing PrEP from more rural areas of her state.
“Maybe they weren’t so comfortable seeing providers in the more rural communities,” she says. “Now they can see us just by the click of a few buttons on their phone or computer, and they’re more comfortable coming to a facility like ours. We’ve gotten so many more patients on PrEP.”
Getting people on PrEP is one thing. Keeping them on it is another.
“People tend to go on and off PrEP for a variety of reasons,” says Vanek. “They may be in a relationship, or maybe that relationship has stopped and started, and that’s OK, but as long as someone thinks they might be at risk, we certainly want them to be on PrEP and stay on PrEP.”
Her sentiments are echoed by Jorge Roman.
“Right now, in San Francisco, we want to put the message out there that people get back into their normal routine with PrEP.
“Look at sexual health care as one of those routine things that they need to get back into, so going in every three months for a check-up. They can have conversations with people like myself who can help guide their sexual health plan to keep them HIV negative.”