What is PrEP?
PrEP stands for Pre-Exposure Prophylaxis. PrEP is a medication, in the form of a tablet, which is taken once a day to prevent a person from contracting HIV. Pre-exposure means “before being exposed” and Prophylaxis means “to prevent infection” (1, 2).
What is HIV?
Human Immunodeficiency Virus (HIV) is a virus which is spread through unprotected sex or sharing needles during drug use. When someone contracts HIV they may develop a disease called Acquired Immunodeficiency Syndrome or AIDs. AIDS causes the immune system from working properly and may cause them to easily catch other infections and some cancers. It is a lifelong illness. People who have HIV, also called HIV-positive, can infect other people through unprotected sex and sharing needles during drug use.
Who Would Benefit From PrEP?
If you are HIV-negative and don’t always use condoms during sex, then PrEP could greatly reduce your risk of HIV. Some people are at higher risk of developing HIV than others. You are at a high risk of contracting HIV if you: • Have unprotected sex. • Have sex with a partner who is being treated for HIV. • Recently had a Sexually Transmitted Infection (STI), especially a rectal infection or syphilis. • Have previously used PEP or Post-Exposure Prophylaxis treatment. • Use recreational drugs for sex, also called Chem Sex • Inject recreational drugs. If you are ever unsure of what may put you at higher risk of developing HIV, talk to your doctor or one of our Meagher’s pharmacists on 01-8117781.
Who Should Not Take PrEP?
If you are HIV-positive, you should not take PrEP as it will affect your treatment. Some people are happy to and can always use condoms, as long as they use them effectively they may not need to use PrEP. However, it can be difficult to always use a condom. A person who is HIV negative but has a HIV positive partner having treatment, may also not need to use PrEP. This is so long as the HIV positive partner has an undetectable viral load and is no longer an infection risk to their HIV negative partner. If there is ever any doubt, always speak tp your doctor or ask a Meagher’s pharmacists advice
How Effective is PrEP?
PrEP is very effective at reducing the risk of HIV infection. It works extremely well when it is taken correctly. It can be compared to the contraceptive pill which is highly effective at preventing pregnancy as long as it is used correctly. Many studies have been performed on the use of PrEP in preventing HIV infection. Globally, out of tens of thousands of people taking PrEP, only three people have so far been reported to have been infected who were taking it correctly. Of these three people, two were due to a resistant strain of HIV, which is rare in the UK and Ireland. If you would like to read more about the studies, go to the following sub-heading.
PrEP has been shown in many studies to be highly effective at reducing the risk of HIV infection and works extremely well if taken correctly. The PROUD study carried out in several sexual health clinics in England, enrolled more than 500 gay and other men who have sex with men (MSM) and included some trans women. One group took daily PrEP as soon as they enrolled in the study (immediate group). The other group started PrEP after a year (delayed group). In October 2014, PROUD reported that PrEP dramatically reduced the risk of HIV infection (by 86%). Nearly all new HIV infections happened in people in the delayed PrEP group. The few infections that happened in the immediate PrEP group were in people who had not taken PrEP properly (3). The IPERGAY study, from France and Canada, also reported an 86% reduction in a similar high risk group of gay men and trans women. IPERGAY used event based dosing (EBD) rather than daily PrEP. A subsequent observational study of event based PrEP in IPERGAY participants found a 97% reduction in HIV risk. There is more information on event based dosing later in the leaflet (4). There are also good results from heterosexual studies. The Partners PrEP study in Africa reported a 96% reduction in new HIV infections in people taking PrEP correctly (5). In PrEP studies where HIV infections have happened, not taking the medication properly was the biggest factor for those who became HIV positive.
What are the side-effects of taking PrEP?
Most people taking PrEP will not notice any side effects. 1 in 10 people have reported mild nausea, diarrhoea, bloating and head ache during their first month of PrEP. These side effects often stop with continued use. Occasionally, PrEP can cause some serious side-effects. These can involve reduced kidney function and thinning of the bones. Frequent blood tests can spot these problems as they start to occur. These side-effects are only usually a problem if you have kidney problems or thin bones before starting PrEP. These side-effects reverse when you stop taking PrEP.
PrEP and drug resistance
If you take PrEP correctly, the chance of developing drug resistance is very low. Resistance relates to the HIV virus and not to the person. A HIV negative person can’t become resistant. Resistance is only a risk if you are HIV positive. Even then the risk is low. The risks of drug resistance developing are from: • Starting PrEP without knowing that you are already HIV positive. Therefore, a 4th generation HIV test is essential before starting PrEP. • Becoming HIV positive during a break from PrEP and then not having an HIV test before restarting. • Missing too many PrEP doses, so that drug levels are too low to prevent HIV infection. • Contact with drug-resistant HIV. This is very rare: globally, as of 2018, only two cases have been reported of PrEP not working because of drug-resistant HIV.
Will PrEP protect me from other STIs?
PrEP is only affective against HIV and so will not protect you from other STIs. STIs include chlamydia, gonorrhoea and syphilis. Condoms are the best way of preventing STIs Even though many STIs do not have symptoms and can be easily treated, some can have unpleasant and serious consequences, especially for those who are HIV-positive. To avoid this, regular STI checks are always a good idea.
Does PrEP interact with other medication?
PrEP is does not interact with most medicines. The exception is with anti-inflammatories (NSAIDs) such as ibuprofen (E.g. Nurofen) and diclofenac (E.g. Difene). Taking both together can cause kidney problems. It is important to always tell your doctor and pharmacist if you start any new medicines and if you are unsure about something, always ask your pharmacist. Never assume that a medicine is safe just because it can be bought over the counter. PrEP does not interact with hormonal contraceptives, nor does it interact with hormone therapy used by some trans and non-binary people.
Where Can I get PrEP?
PrEP is only available on prescription and through pharmacies. It is currently not covered by any drug scheme in Ireland such as medical card and the drug payment scheme (DPS). However, Meaghers Pharmacies, located in eight locations around Dublin, provide PrEP at the lowest prices in Ireland. If you are thinking of starting PrEP, talk to your doctor or call a sexual health clinic. If your doctor thinks PrEP is right for you, they may write a prescription which will allow you to access PrEP. In Ireland, it is illegal to access prescription medications such as PrEP online and so you should always visit a pharmacy.
What Should I do Before I Start PrEP?
Before you start PrEP, you must make sure you are not HIV positive. This can be done by taking a 4th generation HIV test. There are several HSE services which provide the test and advice on taking PrEP. These include the HSE HIV and Sexual Health helpline and STI clinics which offer HIV testing. If you had a risk of contracting HIV in the four weeks before starting PrEP, you should do another HIV test four weeks after starting, just to make sure the infection wasn’t risked. In addition, it is important to have hepatitis B test before starting PrEP. If you are negative, a Hepatitis A and B vaccine are always a good idea if you are suitable for them. During these tests, a routine Sexual Transmitted Infection (STI) check is always worthwhile. All Again, if you are ever unsure, talk to your Meagher’s pharmacist. All STI clinics offer HIV testing. To find your nearest clinic, click here.
What Should I do While Taking PrEP?
Once you have started PrEP, it is important to monitor how it is working for you. Every 3-4 months, it is important to: • Have a 4th generation HIV test. • Have a full STI check • Have a urine test to check for kidney function • If you have kidney problems or are over 40, a blood test to check kidney function. Every 12 months, it is important to: • Have a blood test to check for kidney function • A test for hepatitis C if you are a man who has sex with other men (MSM).
How do I Take PrEP?
PrEP is likely to be most effective when both PrEP drugs are at protective levels before you have sex. However, any PrEP, even if late, will be better than none. Your body takes time to absorb medicines. Therefore, PrEP should be taken both BEFORE sex (to let the levels build up) and AFTER sex (to keep levels high). To make sure the levels of PrEP are highest in your body when you are exposed to HIV, it can be taken in two ways, daily dosing (DD) or event-based dosing (EBD). Daily dosing involves taking PrEP every day, at the same time each day. Event based dosing involves taking PrEP before and after sex How you should take PrEP is dependent on your circumstances and how often you have sex.
Daily Dosing with PrEP: for anal and vaginal sex
For vaginal sex, you need to take daily PrEP at least six days each week. You also need to take PrEP for ideally a week to reach protective drug levels before having sex. This is because PrEP is absorbed differently in vaginal tissue compared to rectal tissue. So, for woman, transgender men and transgender woman having vaginal/frontal sex, daily dosing is best. Event-based dosing (EBD) is NOT suitable for women or transgender women having vaginal sex. EBD is NOT suitable for transgender men for vaginal/frontal sex. In all these cases, daily PrEP dosing is recommended. For anal sex, there is more evidence supporting daily PrEP. But event-based dosing was very effective for anal sex, which is explained next.
Event-Based Dosing: for anal sex only
You need to take two tablets of PrEP (double dose) between no later than 2 hours before and no earlier than 24 hours before anal sex. The before-sex dose is very important to make sure that there is enough medicine in the body when you have sex. You need to continue taking one pill every 24 hours for the days you are having condomless anal sex. After your last condomless anal sex, you need to take a single pill around 24 and 48 hours later, within a two hour window. If you think that there is even a possibility that you may have anal sex, it is best that you take the two tablets of PrEP beforehand as described. Important things to remember with Event-Based Dosing: • It is vital that you do not miss a dose if you are doing event-based dosing. • It is not suitable for any form of vaginal/frontal sex • It is not suitable if you have hepatitis B For men, whose only risk is insertive sex (vaginal or anal), on- demand dosing is likely to be okay, just that there is more data for daily PrEP. Please talk to your doctor about the best dose and timing that will be most suitable for you.