HIV infection is no longer the death sentence it was in the 1990s. Antiretroviral therapy--medication used to prevent replication and spread of the HIV virus--has transformed an incurable ailment into a chronic disease, just like asthma, diabetes or high cholesterol.
In fact, if HIV+ individuals quickly initiate antiretroviral therapy [ART] and maintain an undetectable viral load, they will live as long or even longer than individuals who are HIV negative (Samji et. al.). Wait, what? Yes. Appropriate management of HIV infection requires quarterly visits to the doctor to ensure that the viral load remains undetectable. An undetectable viral load means that no virus can be measured in the blood. If no virus is in the blood, the virus cannot be transmitted to another person (PARTNER study).
This regularly scheduled contact with the health system increases the likelihood that those living with HIV will receive preventive services, ranging from vaccinations to colonoscopies. And prevention produces longevity.
Of course, this is by no means a recommendation to become infected with HIV to increase your life expectancy, but rather a testament to the efficacy of antiretroviral therapy and the importance of preventive medicine.
New York City
More than 100,000 New Yorkers are living with HIV; this is over one percent of the city. However, it's estimated that 20% of New Yorkers who are HIV+ are unaware of their diagnosis (gmhc.org). These undiagnosed cases drive future infections.
In 2017, nearly 2,500 New Yorkers will be diagnosed with HIV.
Not all HIV tests are created equal; tests differ based on their window periods--the delay between HIV exposure and the test's ability to detect infection. Following a possible HIV exposure, a negative test result is only valid after waiting through the window period of the test.
Currently available tests measure three different targets: HIV RNA, HIV p24 and HIV antibodies.
HIV RNA, the genetic material of the virus, can be detected in the blood at 10 days. HIV p24, a protein component of the virus, can be detected at 14 days ["4th Generation Test"]. HIV antibodies, the body's immune response against the virus, can be detected at 21 days ["3rd Generation Test"].
Know Your Status
It's imperative to know your status; get tested regularly. Understand which HIV test you are getting and its associated window period. If you are positive, begin antiretroviral treatment immediately. If you are negative, stay negative.
I offer HIV testing from the privacy of your home or office.
HIV & Oral Sex
Reports of contracting HIV through oral sex are anecdotal at best. Acid from the stomach neutralizes bacteria and viruses; always make sure to drink a glass of water after performing oral sex. Do NOT perform oral sex if you have any form of oral ulcers, which could allow direct access into your bloodstream.
Among New York males who become infected, male-to-male sexual contact dominates the mode of transmission, with infection via injection drug use a distant second and heterosexual acts in third. Black males are nearly three times as likely as white males to be diagnosed with HIV (nyc.gov).
The racial disparity is even wider among females, with black women 13 times more likely to be living with HIV than their white counterparts (aidsvu.org). Women are most likely to contract the virus through heterosexual contact.
Pre or Post?
You've likely heard of PEP, or post-exposure prophylaxis, which is prescribed after possible exposure to HIV. PEP is a combination of three antiretroviral drugs taken for four weeks. If a nurse gets stuck with a needle, a woman gets raped or a man has unprotected sex, PEP significantly decreases the chance that the individual will contract HIV. PEP should be initiated as soon as possible following exposure and is most effective if started within 72 hours of exposure.
PrEP, or pre-exposure prophylaxis is taken before possible exposure to HIV. PrEP is a combination of two drugs: emtricatibine and tenofovir, known by the brand name Truvada. These antiviral drugs are commonly used to treat HIV. However, when an HIV- person takes Truvada, these medications serve to prevent HIV. PrEP blocks replication of the virus.
Taking PrEP everyday decreases the risk of HIV transmission by 99% (the STRAND trial).
Should You Take PrEP?
Consider taking PrEP if you are HIV negative and:
- Are a gay male having anal sex without condoms
- Are in a sexual relationship with someone who is HIV positive
- Have required multiple treatments with post-exposure prophylaxis [PEP]
- Have excessive anxiety about acquiring HIV, resulting in a diminished quality of sexual encounters
- Use injectable drugs
How To Get Started
- Schedule an appointment.
- Before you start PrEP, I will draw your blood to test for HIV, check kidney and liver function.
- Follow-up every three months to repeat lab testing and receive your next PrEP prescription.
How effective is PrEP?
If taken everyday, PrEP decreases the risk of HIV transmission by up to 99%. Here are four studies examining efficacy of PrEP in different segments of the population:
Homosexual Men: iPrEX: Grant RM, Lama JR, Anderson PL, et al; iPrEx Study Team. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med 2010;363(27):2587-99.
Heterosexuals: TDF2: Thigpen MC, Kebaabetswe PM, Paxton LA, et al; TDF2 Study Group. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. N Engl J Med 2012;367(5):423-34.
Women: Partners PrEP: Baeten JM, Donnell D, Ndase P, et al; Partners PrEP Study Team. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med 2012;367(5):399-410.
IV Drug Users: Bangkok Tenofovir Study: Choopanya K, Martin M, Suntharasamai P, et al; Bangkok Tenofovir Study Group. Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet 2013;381(9883):2083-90.
How long does PrEP take to start working?
Truvada must attain sufficient concentration in the blood and tissue in order to be effective. 7 days for men and 21 days for women.
Does PrEP cause side effects?
PrEP is a well tolerated medication. Some people experience mild nausea during the first month of taking Truvada.
what about long-term side effects associated with PrEP?
HIV- individuals have been taking PrEP for over five years, without any significant side effects (cdc.gov). In a small fraction of people Truvada may harm the kidneys; regular lab testing monitors the kidneys to ensure proper functioning. Truvada may cause a decrease in bone mineral density in certain individuals. Every treatment has benefits and risks. It's important to discuss possible benefits versus possible risks with your doctor before starting any form of treatment.
Can PrEP be stopped at any time?
Yes, taking PrEP is voluntary. However, as the concentration of Truvada in your body decreases so too will your protection against HIV.
If I stop taking PrEP will I be able to restart?
Yes. In order to restart, you will need to repeat the same blood work.
How much does PrEP cost?
PrEP is inexpensive or even free for most people. Insurance typically covers the majority of the cost and you pay a copay. Gilead, the manufacturer of Truvada, covers the copay for those who qualify, which brings the cost down to free. The online application can be found here: https://advancingaccessconsent.iassist.com
Do I have to take PrEP everyday?
Yes. In order to fully protect yourself Truvada should be taken everyday. E V E R Y D A Y. Missing doses decreases the concentration of the medication in your body thereby rendering the medication less effective. PrEP is not designed to be taken only before or immediately after sex without a condom. Do not start and stop PrEP based on your possible exposure to HIV.
Does taking PrEP mean that I don't have to use condoms?
Condoms should be used in addition to PrEP, not as a substitute. Although PrEP prevents HIV infection, Truvada does not protect against other sexually transmitted infections [STI] like gonorrhea, chlamydia, syphilis or herpes. Screening for STIs is part of routine laboratory work for taking PrEP.
Anderson et. al. "Emtricitabine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men." Sci Transl Med. 2012 Sep 12;4(151):151ra125.
Samji H et al. "Closing the gap: increases in life expectancy among treated HIV-positive individuals in the United States and Canada." PLOS ONE 8(12): e81355. Doi:10.1371/journal.pone.0081355. 2014.