quantifying exposure risk for guys on PreP.

[wood]

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).

I ask because its about communication, and seeing who if anyone has updated info. There is nothing wrong with asking.

[bearbandit]

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.

Remember also that there are a number of heterosexuals in serodiscordant relationships who would also benefit, especially women over fifty who form one of the biggest core groups of Daily Mail readers, as well as one of the fastest growing groups of people with HIV in the UK. Yes, PrEP is expensive, but even more expensive is keeping someone hospitalised and using increasingly expensive drugs.

While I've come to accept PrEP, I still maintain that safer and cheaper alternate drugs need to be found, and that what we're calling PrEP today is really just a proof of concept - it'll do till something better comes along. "Knowing that 80% ish of people don't take it as directed"? and "This can't be calculated without more UK data." seem to be contradictory statements, especially when PrEP is only in stage 1 trial in the UK.

The thing that we're forgetting about in all the fuss about PrEP is TasP: treatment as protection. If someone's infectivity, as measured by viral load, is reduced to undetectable, the need for extra precautions reduces accordingly. The Swiss statement may have applied only to observations from heterosexuals, but the detectable limit has dropped considerably since then and it is not unusual for guys with HIV to start treatment earlier than recommended in order to get the viral load down and so protect their partners.

The mistake began thirty years ago when it was decided that the aim of HIV prevention was 0% sexual transmission, whereas for people injecting, a policy of harm reduction was set up, including the use of needle exchanges so that users no longer needed to share needles. The proof of the success of the harm reduction shows in the massive reduction of the numbers of (traditional) users with HIV. Policy hasn't budged from the 0% sexual transmissions target and has failed miserably. If the NHS are spending fuck knows how much money keeping me alive, that means the same money is keeping my viral load suppressed below the point of infectivity.

TasP requires more honesty than usual, but with the PwHIV's health on the line, adherence is going to be much better: it's always easier to medicate an existing condition than it is to offer prophylaxis against a possible condition. Yes there are risks to this concept, but what doesn't carry an element of risk, however small? I used to use my motorbike as an example of that risk, and I suppose it still holds true. Instead of a pleasant quiet ride home from the nearest shop (9 miles away) I hit the 1 in many thousands chance, lost control of my bike and snapped my ankle in such a way that it's unlike ever to heal properly. My life changed, probably forever, in a second or two. But I chose to take the risk...

[wood]

While I've come to accept PrEP, I still maintain that safer and cheaper alternate drugs need to be found, and that what we're calling PrEP today is really just a proof of concept - it'll do till something better comes along. "Knowing that 80% ish of people don't take it as directed"? and "This can't be calculated without more UK data." seem to be contradictory statements, especially when PrEP is only in stage 1 trial in the UK.

The thing that we're forgetting about in all the fuss about PrEP is TasP: treatment as protection. If someone's infectivity, as measured by viral load, is reduced to undetectable, the need for extra precautions reduces accordingly.

Heres my problem with the drug trials, While IMO they convey accurate scientific data, they dont always convey accurate data about general populations trends. For example in the iPrEX study as you said 80% of people didnt take the drug correctly. I want to know what is the reason for that, and is that aproblem that would occur in the broader population. Having worked with people who do investigational research, IMO the answer is no. The people that get recruited for drug trials unfortately tend to be from lower socioeconomic backgrounds, and often have other life complications, such as housing problems, other health issues, or substance abuse problems. This is simply because people don't want to be guinea pigs unless paid, and the pay is low, so they get people that need low amount of money, sometimes for basis subsistence.

I agree that cheaper drugs, and possibly once a week medications should be investigated for PrEP, but I dont think that should delay the introduction of PrEP on a wider audience now. Also i hold a view that is probably widely unpopular here, but i will say it anyway. Testing should be mandatory in all populations, hell in the US tie it to paying your taxes. Starting at about age 12, probably doing it at schools, they gradually moving it up to workplace locations. the reason I say this is because people need to know whether they like it or not. People need to know their status. This is the most basic rule in preventing any type of infection. After that people need to take the proper precautions. As you say for HIV+ populations, that's TASP. The studies are there. Anyone who tests positive should go on medication ASAP, and not wait for higher viral loads, or decreased T-cell counts, the sooner they get the viral load to almost nothing the less risk they are to others. For negative populations it means regular tests, condoms, education, and PrEP for high risk groups.