"Undetectable" "PrEP" and new realities.

PrEP has become widely available in the US, and the reality that an “undetectable” viral load means that the person with HIV is unlikely to transmit HIV seems to be widely understood.  How what choices does an HIV negative person have to remain negative?   How can a positive guy integrate this into having responsible sex?

“Pre-exposure prophylaxis” means that an HIV-negative person takes Truvada to prevent infection.   PrEP is highly effective against HIV.  It offers no protection at all against other STDs, including Hepatitis C, syphilis,  gonorrhea, etc, and condoms do offer some protection against these.   Still, if a guy finds that he’s not using condoms consistently in high-risk situations, or even if he wants to be condom-free once in a while, it is a viable option. 

The downside of Truvada protection is that it is a medication that has side effects. Anyone taking it for long periods should be checked out, There have been reported cases already of men using PrEP getting hepatitis C, so it isn’t really a license just to let yourself go in all situations.   

What does “undetectable”  really mean?   In one study, the risk is statistically close to zero, and this is great news.   There are a couple of caveats, though.

In studies, patients are constantly reminded of safe sex practices.  Study populations are probably less likely to transmit HIV in the first place.  In this setting patients are carefully monitored for STDs, which might not be the case in the real world.   Real-world settings are probably less safe.

More importantly, ALL of the studies (and even the “Swiss Non-Study”) the majority of study subjects have been straight.  Even in PARTNERS, 60% of study subjects were straight, meaning much less (almost no) anal intercourse.    As anal sex is about 20 times more likely to transmit HIV than vaginal sex, it’s easy to make a case that we actually do not know the risks of unprotected anal sex when a positive partner has an undetectable viral load.   Is it lower?  I think we have to assume it is much lower, but not zero.

If you are a negative man, take charge of your health by reducing your risk of HIV infection by using condoms, PrEP, reducing numbers of partners, etc.   In the settings of hookups, baths, random encounters, I would never trust my health to someone saying “I’m negative,” or “I’m undetectable.”  In an encounter with a guy you know to be positive, I think you can be comfortable knowing that if he is undetectable, that it’s safer to be with him than with a person of unknown status, and in the setting of a relationship, unprotected sex may be negotiable, according to your own comfort level, but it the two of you seem to be at risk for other STDs, I’d make that decision very carefully…..

For Poz guys?.   You can know that you are far less likely to transmit HIV than before, and this is great.   I think that you should still disclose your status (perhaps mostly to scare away the idiots that don’t understand reality), and you need to protect yourself from other STDs, and Hepatitis C.  I do worry that with ever decreasing use of condoms, the setting is perfect for big increases in Hep C transmission.

So, it’s all better, but the song remains the same.   Protect yourself and others, and the best protection is still openly and intelligently discuss HIV status.