The Problems with PrEP
In 1978, just before Spring Break, a classmate of mine informed me that he was starting himself on penicillin before traveling to Florida for Spring Break. This was in order to prevent him from getting either gonorrhea or syphilis. As a 20-year-old naïve junior in college, this made sense to me. Within two years, the new sexually transmitted disease, or STD, was Herpes simplex two or HSV2. Unfortunately penicillin has no activity against HSV2.
When I was in my fellowship for infectious disease, a family friend, who was a vascular surgeon since World War II, shared some thoughts with me about STDs and birth control. He found that with the introduction of the birth control pills and the use of the diaphragm, he saw an increase in sexually transmitted diseases which he believed was directly due to a decreased use of condoms.
These were some of the thoughts that occurred to me when I first heard about PrEP about five years ago. PrEP, also known as pre-exposure prophylaxis with the use of Truvada, is being used to prevent the spread of HIV. My concern was, would PrEP lead to a false sense of security leading to an increase in STDs?
Unfortunately, my concerns are becoming reality. There are several studies coming out showing that with the introduction of PrEP, there is now an increase in STDs. According to researchers in Australia, patients that were at the greater risk of STDs tended to be younger and had used PrEP prior to the trial, and reported having higher number of anal sex partners and greater participation in group sex, compared to those who did not get infected. Another concern is that if unsafe practices continue, it may lead to the transmission of resistant HIV virus. My reasoning is based on that if people participating in PrEP are at risk of STD’s, could there be a compliance issue in taking Truvada. Sporadic compliance could potentially lead to the transmission of resistant virus.
PrEP is a valuable tool and can help in reducing the transmission of HIV. However, it is not an indestructible shield. In order for PrEP to be effective, you must practice safe sex. Patients that participate in PrEP still need to be prudent in their sexual judgment.
In my practice, I have several patients who do participate in the PrEP program. And I do inform my patients of my concerns with PrEP and share with them some of the stories I relayed above. Moving forward, it comes down to the individual to ensure themselves that they are protected to the best of their abilities in an ever-changing world.