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Deciding to Start Pre-exposure Prophylaxis (PrEP)
As a gay male Infectious Disease fellow, I knew that PrEP was going to be a large part of my daily discussions with patients and peers. And although I scrupulously practice safe sex, I wondered if I should be on PrEP myself.
Then I took a step back and realized that I need to practice what I preach. I had a responsibility to openly talk about keeping oneself safe, keeping oneself healthy—and PrEP was going to be a large part of that. So, I called my primary care provider, and together we decided that I should start PrEP.
My Experience With Oral PrEP
The process was really simple. We had to review my other medications—I’m receiving medications for anxiety, depression, and obsessive-compulsive disorder—to determine whether there were any drug–drug interactions, and we discussed timing and dosing. I’ve had no issues: no interactions with medications and no adverse events whatsoever. I’m fortunate that in my workplace, I have a whole cadre of experts supporting me. I have infectious disease attendings, infectious disease pharmacists, and HIV pharmacists at my disposal for questions and advice.
Insurance approval for reimbursement also was very simple. At one point, I had to go from brand name to generic PrEP, but I’ve noticed no differences.
There is a commitment, though. For oral PrEP, you need to see your physician regularly to be screened for sexually transmitted infections and HIV and have your kidney function tested, and you need to take the medication every day. But it’s no harder than taking any other medication.
I know that some people take PrEP on demand, but for me, consistency is key. If I take it every single day, I’m more likely to adhere to it. I will admit to missing a day here and there, but I’ve never gone more than 2 days without remembering.
To me, the most important aspect of oral PrEP is the comfort of knowing that when you take it, it works. The evidence from many clinical trials is that it is highly effective in preventing transmission of HIV. At the same time, you still have to be safe and cognizant of your sexual practices. You still need to practice safe sex to prevent other sexually transmitted infections—and you have to take your meds.
Thoughts About Long-Acting Injectable PrEP
The idea of a newer medication—a long-acting injectable—is exciting to me. I think it is groundbreaking to have an every-2-month medication. It takes away the stress of remembering to take a once-daily pill. Your medication visit could be combined with your screening visit. In addition, things might really be simplified when PrEP moves even more into the primary care provider realm and PrEP appointments can be combined with other regular appointments.
I think that having a long-acting injectable takes a lot of stress, anxiety, and worry out of the equation, and I would pursue the long-acting injectable for myself for many reasons. At the same time, when I think about the injectable, many questions come to mind: In the future, can I do this injection from home? Will my health insurance cover it? Are there any preexisting conditions that would prevent me from having this medication? Are there any adverse events? Do I know anybody else who’s on it? These are questions I have had that I am sure my patients will have, as well.
There also are practicalities that may be issues with this medication. Even finding the right place to get the injection every 2 months may be an issue. Will I be able to be there when they’re open? If I am not able to get it on the appointed day, will that affect the therapeutic level of the drug? Will that affect its potency? What happens if I’m out of state or the country and unable to get it? I mentioned how important consistency in taking oral PrEP is to me; a 2-month span between doses may affect my ability to be adherent.
The other issue is disclosure. With oral PrEP, I go to a pharmacy, pick up my medications, pay, and leave. Oral PrEP is private in that I do it on my own time. I take it, and I move on with my day—nobody sees it. But if you’re getting an injectable, you have to sit in a chair in a waiting room. You get pulled into an exam room to get the injection. People may get nervous or anxious in that setting. They see other people at the pharmacy or clinic, or other site where you are going for injections. In 2022, HIV stigma is not what it used to be, but it still exists.
These medication questions, practical questions, and disclosure concerns are my own experience, but it all makes me realize that these are likely to be the same concerns that other patients might have, and we need to explore them with each patient considering this new prevention strategy.
In your practice, are patients interested in long-acting injectable PrEP? Join the discussion by posting a comment sharing your experiences, and then learn about other key decisions in HIV.