quantifying exposure risk for guys on PreP.

[wood]

So I have a question about risk for guys on PrEP, or good knowledge about exposure risk. As most know the stats say it can be up to 99% effective if it is taken correctly, but my question is a bit more involved. It has also been proven that guys who are undetectable also have a much lower risk of transmission to their partners, regardless of their sexual role. While there is some controversy about it, its still accepted that bottoming carries a higher risk of infection than topping.

So here is the situation that I personally found myself in the other day. For the first time since I have been on PrEP, I ended up having unprotected sex with a man who is undetectable. We have a flip session where we both ejaculated in each other twice. For me, I am exact about when I take my PrEP meds, and the guy said he was clean and undetectable at his last checkup, so is there anyway to quantify my risk beyond what I'm guessing is very low? I'm asking this out of curiosity more than anything. I'm not freaked out by the situation, and this is one of the reasons I am glad I started PrEP, also I think i actually may like the guy, so I would be curious about long term risk also.

[Guest]

You're both on meds? Barring other complications, nearly impossibly remote. Less than 0.01% chance.

[fillmyholeftl]

I would guess that it's pretty close to abstinence in risk... let's hypothetically say 2 guys meet up. same scenario, flip fuck & shoot in each other twice. What's the perceived certainty, that they are or think they are negative.... hollywoodslut... it's as risk free as you can get. (I do HIV education & counseling)

[bearbandit]

I'd think you're taking a bigger risk crossing the road. Yes, you almost certainly acquired a few copies of the virus, but the truvada in your system will clobber them. Hell, even without the truvada, if he's undetectable his cum won't contain enough HIV to establish a successful infection, even though viral load in semen tends to lag behind blood VL. So you're in a belt and braces situation - double protection.

PrEP isn't licensed in the UK yet: they're just coming to the end of the preliminary study and then have a further 2 year full study to do before it can be licensed (why we can't just accept the word of the USA on this, I don't know). Even with my undetectable viral load I'm cagey about fucking non-poz guys (personal thing around over-cautiousness I'm working through). If he were on PrEP, I'd be okay about it. I'm another HIV educator...

[wood]

I'd think you're taking a bigger risk crossing the road. Yes, you almost certainly acquired a few copies of the virus, but the truvada in your system will clobber them. Hell, even without the truvada, if he's undetectable his cum won't contain enough HIV to establish a successful infection, even though viral load in semen tends to lag behind blood VL. So you're in a belt and braces situation - double protection.

PrEP isn't licensed in the UK yet: they're just coming to the end of the preliminary study and then have a further 2 year full study to do before it can be licensed (why we can't just accept the word of the USA on this, I don't know). Even with my undetectable viral load I'm cagey about fucking non-poz guys (personal thing around over-cautiousness I'm working through). If he were on PrEP, I'd be okay about it. I'm another HIV educator...

The overcautiousness stems from the fact that drugs can and do cause harm, sometimes after market introduction. Thalidomide, and Vioxx come to mind immediately. However, I agree that PrEP should be available sooner considering its already in use for HIV patients.

http://en.wikipedia.org/wiki/List_of_withdrawn_drugs

And I agree with you, IMO there always should be a good discussion in mixed status situations, especially when not using protection.

[Blueyedsoul]

Hollywood: May I ask which healthcare provider you have? I am looking at PrEP and many here in SoCal provide it however since you are the only one I am aware of who diligently adheres to the regiment, I am curious as to your insights. Any tips on providers here in SoCal?

[ffoz]

I'm in Sydney, Australia. Anyone can correct me, a University in Melbourne has money to trial PrEP. My name is down for the trial once the University Of New South Wales gets the go ahead and the money. (keep in mind I have been barebacking for a few months and just recently tested NEG. i'm only as Neg as my last blood test).

..

OINK

[bearbandit]

The overcautiousness stems from the fact that drugs can and do cause harm, sometimes after market introduction. Thalidomide, and Vioxx come to mind immediately. However, I agree that PrEP should be available sooner considering its already in use for HIV patients.

http://en.wikipedia.org/wiki/List_of_withdrawn_drugs

And I agree with you, IMO there always should be a good discussion in mixed status situations, especially when not using protection.

Remember I was dead set against PrEP at first because of my experience with tenofovir. Nearly dying does tend to focus the mind in particular directions! But when I started getting things into perspective, like the odds of Fanconi's syndrome being 100,000 to 1, and now with the new formulation of tenofovir having a lower side effect profile, I started changing my mind. The kicker was the number of guys here using PrEP without any problems. I might get dogmatic at times, but I can and do change my mind!

Vioxx wasn't used here much, but thalidomide is still occasionally used for men with HIV (I believe only in hospital settings), simply because it's the drug that works best. There was an anti-diabetes drug which was withdrawn because its side effect profile showed a doubling of the risk of heart problems, but in my book twice a small number is still a small number. For me, the regret about the withdrawal of this drug was the fact that it showed some activity towards reversing the effects of lipodystrophy. Personally, a small increase in the possibility of heart problems would be worth it if I could reverse even just some of the effects of lipodystrophy.

[wood]

Remember I was dead set against PrEP at first because of my experience with tenofovir. Nearly dying does tend to focus the mind in particular directions! But when I started getting things into perspective, like the odds of Fanconi's syndrome being 100,000 to 1, and now with the new formulation of tenofovir having a lower side effect profile, I started changing my mind. The kicker was the number of guys here using PrEP without any problems. I might get dogmatic at times, but I can and do change my mind!

Always a good thing to keep learning!

[wood]

Hollywood: May I ask which healthcare provider you have? I am looking at PrEP and many here in SoCal provide it however since you are the only one I am aware of who diligently adheres to the regiment, I am curious as to your insights. Any tips on providers here in SoCal?

Sent you a PM with some info. My broader throughts on PrEP are all over here, but I will summarize them.

PrEP is NOT a license to do whatever you want and never get sick or get HIV. However, it is IMO the best thing to come out to prevent HIV infection since the epidemic began. I say this because abstinence is not realistic, and neither is 100% condom use. IMO any sexually active gay man should be on PrEP right now unless they have a medical reason not to be, or they have never had any unprotected intercourse. That's a drastic line that I don't think a lot of guys in here would say, but it is my stance on the topic. The reason I say this is because people are now picking and choosing protection, with the mentality its okay to go raw with some guys but not others. Studies show that overtime that provides almost no protection against HIV, its just luck of the draw. I think that If more people were on PrEP, and used it correctly we would finally see a drop in the rate of new HIV infections, which have stagnated over the past 10 years. As far as adherence is concerned its damn easy for me. I keep an alarm set everyday on my phone at a time when I'm always up, and almost always have the medication on me.

Ideally I also would like to see a weekly option, or even monthly (maybe a shot or implant) But I don't think that's occurring anytime soon. If cost is an issue for you with PrEP, I would recommend using an online pharmacy and looking for Cipla's "tenvir-em" Cipla is the only other pharma company licensed to make Truvada, but Cipla's generic version can be found for about $400 for a six month supply online. I posted several links in the PrEP cost discussion.

[bearbandit]

If cost is an issue for you with PrEP, I would recommend using an online pharmacy and looking for Cipla's "tenvir-em" Cipla is the only other pharma company licensed to make Truvada, but Cipla's generic version can be found for about $400 for a six month supply online. I posted several links in the PrEP cost discussion.

While I don't want to pour cold water on this idea, it is essential to have regular blood work-ups, looking particularly at kidney function. While the makes claim that any adverse effects are reversed on cessation of the drug, that isn't necessarily always true. You don't want the 1 in 100,000 experience, so factor into that $400 price tag a couple of blood work-ups. What tenofovir can do if it bites your ass is to stop your kidneys from recycling minerals so instead of re-absorbing things like vitamin D and calcium, you piss them away, along with B-group vitamins and potassium, which not only regulates your heart beat, but also is essential for clear thinking as it and sodium are responsible for the proper firing of neurons. I was lucky: they got me into a hospital before I starved to death or had a heart attack.

Sorry to bang on about the problems tenofovir can cause, but if someone's taking it without medical supervision, then he needs a sympathetic doctor who will order the tests.

[wood]

While I don't want to pour cold water on this idea, it is essential to have regular blood work-ups, looking particularly at kidney function. While the makes claim that any adverse effects are reversed on cessation of the drug, that isn't necessarily always true. You don't want the 1 in 100,000 experience, so factor into that $400 price tag a couple of blood work-ups. What tenofovir can do if it bites your ass is to stop your kidneys from recycling minerals so instead of re-absorbing things like vitamin D and calcium, you piss them away, along with B-group vitamins and potassium, which not only regulates your heart beat, but also is essential for clear thinking as it and sodium are responsible for the proper firing of neurons. I was lucky: they got me into a hospital before I starved to death or had a heart attack.

Sorry to bang on about the problems tenofovir can cause, but if someone's taking it without medical supervision, then he needs a sympathetic doctor who will order the tests.

Oh I fully agree, Im just saying its a cheaper alternative, but everyone should still get every three month checkups.

[Guest beezee]

PrEP isn't licensed in the UK yet: they're just coming to the end of the preliminary study and then have a further 2 year full study to do before it can be licensed (why we can't just accept the word of the USA on this, I don't know)

Because in this country drugs are paid for out of the public pocket. How do you think your average Daily Mail reader is going to feel when he finds out he's paying taxes for healthy gay guys to have ~£10,000 of meds a year each, so that they can have unlimited crazy bareback sex? To get PrEP onto the NHS, someone is going to have to build a case for it being a worthwhile spend of taxpayer money (knowing that 80% ish of people don't take it as directed). This can't be calculated without more UK data.

Returning to OP...

So I have a question about risk for guys on PrEP, or good knowledge about exposure risk. As most know the stats say it can be up to 99% effective if it is taken correctly, but my question is a bit more involved.

There aren't any statistics for the scenario you describe. 90-whatever % refers to the reduction in risk acquiring HIV over a year. It's not the same as a per-act reduction. And no one knows what the per-act stats are for an undetectable partner, even without PrEP, so all you can do is guess. Anyone answering otherwise is making stuff up...

[wood]

Because in this country drugs are paid for out of the public pocket. How do you think your average Daily Mail reader is going to feel when he finds out he's paying taxes for healthy gay guys to have ~£10,000 of meds a year each, so that they can have unlimited crazy bareback sex? To get PrEP onto the NHS, someone is going to have to build a case for it being a worthwhile spend of taxpayer money (knowing that 80% ish of people don't take it as directed). This can't be calculated without more UK data.

Returning to OP...

It would only increase costs in the short term, it the long term it would reduce healthcare burden.

There aren't any statistics for the scenario you describe. 90-whatever % refers to the reduction in risk acquiring HIV over a year. It's not the same as a per-act reduction. And no one knows what the per-act stats are for an undetectable partner, even without PrEP, so all you can do is guess. Anyone answering otherwise is making stuff up...

Im well aware that there is not specific study like that, It would take years of research to compile reasonably accurate data. What is known is that when taken correctly PrEP is up to 99% effective.

[Guest beezee]

It would only increase costs in the short term, it the long term it would reduce healthcare burden.

That might be true but no one knows for sure. Some guys won't bother to take it, some guys will take it and won't be exposed to HIV, some guys will take it be exposed and avoid infection, some guys will take it and catch HIV anyway. Some percentage of guys will take it believing it to be "99%", use it as a license to have ludicrous amounts of risky sex and as a result be more likely or just as likely to catch HIV as if they didn't take PrEP in the first place. No one knows how many guys will be in each category. So no one can say (yet) that in the long term it'll be cheaper to hand out $13k/£10k of HIV drugs to healthy guys. Not even the experts know that yet.

In the UK the process of working out whether it's better to give out PrEP or spend taxpayers' money on other things is done by expert health economists. Not there so far.

In the US, the FDA has no role to play in assessing cost-effectiveness (my understanding is that it's prohibited from doing so). After it has said Truvada is safe & effective for PrEP, it's up to insurers.

Im well aware that there is not specific study like that, It would take years of research to compile reasonably accurate data.

Then why ask? The only stats out there are from the 1990's - we know it's something like 1:30 to 1:100 risk per-act bottoming for a HIV+ partner. You said your man's undetectable - there are no 1 in whatever per-act figures for undetectable tops. The only studies that have been reported are for heterosexual sex. If he's on meds and you're on PrEP then your odds are probably better than 1:30-100 each fuck but no one can reasonably say by how much (yet).