Ask the Doc: PrEP Redux

In this week's "Ask the Doc" column, Dr. Howard Scheiner, MD/AAHIVS, once again addresses questions about PrEP via Truvada, including whether it can work in small doses, and why some people are against it.

He'll let you know whether a random handful of pills taken on the dance floor will do anything to prevent HIV infection, and will touch on the growing firestorm that has recently brought some vocal opponents of PrEP into the media spotlight.

Is PrEP a lifesaver, or does it contain hidden health consequences? Ask the doc, and find out.

Dance Dance Revolution

Q: Dear Doc, I have occasionally seen guys offering a pill of Truvada on the dance floor to prevent HIV. How effective would that be?

A: Ask for two and another two "to go." The IPERGAY study from France just reported "on demand" prevention utilizing two Truvada before -- one at 24 hours and one at 48 hours after sex, versus placebo. About 400 high-risk men who have sex with men (MSM) were randomized into two groups. One group received Truvada just prior to sexual intercourse and the other group a placebo. The results showed a significant difference in incidence between the two groups with a significant reduction in the "on demand" PrEP group. The percentage reduction seems to be at least better than the 49 percent reported in the 2010 IPREX study in MSM and transgender women. We will need to wait until next year for full results.

Remember that this preliminary analysis compares "on demand" to nothing. So, daily PrEP is still the only recommended way to go if PrEP is in your tool bag.

It looks likely that if you miss up to three doses in a week, it may still be effective. While the FDA approved Truvada taken daily in July 2012 as Pre-Exposure Prophylaxis (PrEP) to prevent HIV transmission, it now seems that possibly four doses a week may also be effective. This is based on data relating HIV incidence to the concentration of drug in the blood.

And if you are not taking PrEP, two tablets taken just before sex is a likely winner compared to nothing. But try to remember to take the next two days' daily doses, to conform to the study protocol.

Of course, all this is supposed to incorporate risk reduction programs and condom use. My guess is that you might be hard pressed to find either of these on that dance floor.

Is PrEP a Public Health Disaster in the Making?

Q: I read that the AIDS Healthcare Foundation is launching a national ad campaign against Truvada? Why, and what should I believe?

A: President Michael Weinstein of the LA-based organization is an outspoken opponent of PrEP, and that is why. It seems that he is worrying about a "public health disaster in the making" from the use of Truvada as PrEP.

My previous questioner gave some credence to Truvada as a "party drug," which also seems to be part of Weinstein's complaint. This lends itself to a moral stance that should have nothing to do with a medical advance. It harkens back to the hue and cry over birth control pills in the '60s.

There are always competing interests and views. From the public health standpoint, Truvada can be seen as a major achievement in controlling HIV transmission, especially in gay men. It certainly is possible that there will be health consequences. The obvious ones are transmitting other sexually transmitted diseases. Less obvious would be a theoretical risk of resistant virus developing.

From the personal health standpoint, it can be a necessary tool to aid in preventing HIV acquisition for a higher risk patient.

Whether a medication is right for you should be discussed with your personal physician, who should have your interests paramount. It should not be based on public policy, ad campaigns, or another's moral viewpoint.

Called "more than a doctor, a trusted friend" by his patients, Dr. Howard Scheiner is a true native New Yorker. He was born in the Bronx, he attended the esteemed Bronx High School of Science and City University of New York before receiving his medical education at The Mount Sinai School of Medicine. Truly a Renaissance man, in addition to his lifelong service to the medical profession, Dr. Scheiner is a published author, playwright and musical composer. Combining all his loves, he is perhaps most proud of founding "The Brent Varner Project, Inc." a charity that provides free HIV services to those in need through the Actors Fund of America.

This story is part of our special report: "Ask the Doc". Want to read more? Here's the full list.

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