People & PrEP are better at preventing HIV than we thought

Peter

Since its release, patients have been told that PrEP is an effective HIV prevention medication only if taken on the daily. However, new information has come to light. Less than a month ago, it was announced that the ongoing iPrEx OLE study found that PrEP was 100% effective at preventing HIV infection in patients who took at least four doses a week.

Cool, right? Needless to say, I kept reading about the findings. Of the study’s sample, over one-third of the participants adhered to at least four doses a week. Among the entire group, it was found that adherence generally decreased over time. But, if somebody was going to stop taking PrEP altogether, they were more likely to do it early on. The quicker someone dropped off their drug regiment, the higher their risk for developing an HIV infection. Being older was associated with greater adherence, as was a higher education level—suggesting potential adherence disparities among participants. Also, the more a person believed that the medication would work, the more likely they were to adhere to it. All in all, these were also very insightful findings, but not too surprising.

Being the all-knowing, young, public health specialist-in-training that I am, I was immediately skeptical of the studies big-release finding. How were they so sure that simply adhering to PrEP four times a week was the factor preventing HIV transmission? Didn’t they take into account that people who are goody-good pill-takers are probably less risky people overall? I was eagerly awaiting the caveat sentence that would read, “However, it was also found that participants who adhered to a higher-does drug regiment also participated in other HIV prevention methods, such as frequent condom use, testing, and serosorting.”

That sentence never came.

In fact, my assumption and ego were both rocked when I read the more surprising results. First, those who chose not to take PrEP at the beginning of the study had some of the lowest rates of engagement in risk behaviors for HIV infection. Furthermore, being given PrEP was not related to any change in participants’ risk behaviors. And substance use—that other stigmatized, risky behavior that (according to the usual public health talk) makes people do all the bad things, all the time—was also not related to adherence.

The higher a person perceived their personal HIV risk to be, the more likely they were to adhere to their high PrEP regimen. Yet, ever so against my predisposition, their level of adherence had no direct relation to their usual risk behavior. If people were “risky” to begin with, they stayed “risky,” but stuck more to their treatment. So what does this mean? According to Dr. Robert Grant, this means that people who are at greater risk for HIV transmission are actually pretty good at making decisions about preventing infection, given their own lifestyles. Therefore, we should trust patients to reasonably know which prevention methods are best for their own lives—a practice that is sometimes unfamiliar in the healthcare world.

This study provides several important breakthroughs. First off, it appears that people (and their health care providers) do not have to stress about taking PrEP every. single. day. for it to be effective. Moreover, this study gives us further insight into the idea that what puts people at risk for HIV infection is not their identity (such as identifying as gay), but their individual behaviors (such as having condomless anal intercourse). But a tag-on to this thought is that we must be careful not to assign people an identity based off those behaviors, either—such as thinking of men who engage in condomless anal intercourse as people who are completely “at-risk.” While some populations will undoubtedly always be at greater risk for different diseases, we must remember that risk changes from day-to-day, context-to-context, and that, when given the opportunity, people are able to make balanced decisions about their risk and health. It is these balanced decisions as to how to manage risk that allow people to live how they want, be healthy, and not let their risk-status define their individual identity.

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