Difference Between "on-Demand" Vs. Daily Prep Use

[paris_student]

So today I went to my PrEP appointment at a hospital in Paris to finally get PrEP prescribed.

 

Everything went smoothly until we started discussing the PrEP usage that I'd prefer, with me boldly stating that I'd like to use it daily for maximum protection. However, the doctor felt that an "on-demand" protocol, whereby I'd be taking two pills before having sex, then one pill on the next day and another one on the day after, would suit my needs even better.

 

I guess that she was right in that I didn't have much sex in the last three months (because of me waiting for PrEP and because I don't like to use condoms anyway), however the thing I wanted to ask you all is whether you think that not using PrEP daily would have the same levels of protection as daily use.

 

Now the thing I didn't tell her is that I'm going on PrEP because I'd like to be more active sexually and attend local sex clubs with a "no loads refused" policy, with me being the bottom. And for some reason I feel that taking a pill before and after a bareback orgy is not enough to protect me from all the potential HIV that would be contained in the tops' cum...

 

I understand the doc's concern about Truvada being a "heavy" drug, but I'm willing to take the risk to take it daily as long as my kidneys are being monitored and checked regularly.

 

The funny thing is that at the end of my appointment I still got a box with 30 pills in it, which as I understand would be reniewed at my next appointment in a month's time (first check-up is in a month, then every three months), so the doctor's remark wasn't due to her wanting to "save money" on me, since as we all know Truvada is quite an expensive drug. In the end I guess I'll still be able to use it daily for at least a month anyway...

 

What do you guys think about this ? 

Edited March 23, 2016 by paris_student

[tallbtm]

In the U.S., daily dosing is the recommended protocol and that's what I do. Sex isn't always "planned" and you might not have the two pills with you to take in advance. If you (with help from your health plan or insurance) can afford it, I agree with you that daily dosing makes more sense.

The studies I'm aware of show Truvada-as-PrEP very effective through daily dosing. I'm not aware that it has yet been proven to work just as well in "on-demand" use. I hope it will be (for people who can't afford daily use or for people who have infreqent sexual encounters) but would want to wait for that to be definitely shown and approved.

While you're deciding, consider how much sex you anticipate having in future and how planned that sex will be. And don't rely on how much you have been having since you said you've put off sex while waiting for PrEP to be available in France. That may help guide your decision.

One last thought: About Truvada being a "heavy drug." It's not. The reason it was chosen to test for use as PrEP in the first place is because it is so well tolerated by those taking it. Very few people have any side effects and of those, most are mild and go away in the first few days or weeks. (Yes, a very few people have bad reactions and can't tolerate it but they are a tiny percentage (<1%).

You are HIV negative and want to stay negative. I applaud your decision to protect yourself.

[paris_student]

Thank you for your kind words I wish there more young people like me who'd take HIV seriously...

 

I guess you're right. And I don't think Truvada is a heavy drug, it was presented to me as a "heavy drug" by the medical staff.In fact back in the day I remember going on PEP (post-exposure prophylaxis) and not feeling any side-effects whatsoever.

 

Another thing is that here in France we don't have to worry that much about affordability and costs, since it's taken care of by our Social Security system which gives us the pills for free. The only thing I need to pay for is the HIV test & bloodwork (~€30) and the appointment (€23). So in the end the total cost would be €53 every three months, which is more than acceptable.

[backpackguy]

tallbtm is correct. There have been numerous studies on Truvada as a PrEP in the U.S. by major American universities, such as UC Berkeley and UC San Francisco. All support it's use on a daily basis. If it is taken on less than a daily basis, as your docs suggest, it's ability to block HIV replication drops off considerably. It also has been selected for use as a PrEP because it's side effects are relatively minimal in comparison to other drugs. That is not to say that some people do not suffer from side effects. In my case, I have been on PrEP for 2 years (next month) w/almost no issues (prescribed by the Infectious Disease (HIV Specialist) at Stanford University Medical Center). 

 

BLUF (Bottom-line Up Front): Get on PrEP (Truvada) and take it daily. Read the PrEP protocals and studies posted on the CDC (U.S. Center for Disease Control) website.

[kikou]

 I wanted to ask you all is whether you think that not using PrEP daily would have the same levels of protection as daily use.

We have evidence from the only randomised controlled trial of intermittent PrEP so far conducted, Ipergay, that this way of taking PrEP can be highly effective. In Ipergay, a two-pills-before-sex-plus-two-pills-after regimen of intermittent PrEP http://www.aidsmap.com/Intermittent-PrEP-may-be-a-robust-strategy-for-anal-sex-vaginal-much-less-certain/page/2986809/

Edited March 24, 2016 by kikou

[backpackguy]

Thanks kikou for the info on the latest European studies on PrEP usage and protection. I like to keep up to date on this subject. I recall that when I met with the Infectious Disease (HIV Specialist) at Stanford University Medical Center a couple of years back while going through the process of getting on Truvada, the two main lines of discussion were my involvement in "risky" behavior (raw fucking w/numerous partners) and the need to "religiously" take it on a daily basis for maximum protection. Since I already take Protonix daily for Esophigal Reflux, I just take my PrEP along with it. (I've only forgotten to take it 3 times in the past 2 years.) The doc was pleased with my response and stressed that it was most effective when taken daily. Dudes got "knocked up" when they took it intermittantly. 

[paris_student]

Wow, kikou... ! Thank you for your VERY detailed response, it's a very refreshing read, with lots of things I personally did not know. It's a gold mine in terms of useful info for anyone who's interested in PrEP, thanks again.

 

Nevertheless I still quite frankly find it strange that the doc offered me to take PrEP with an "on-demand" protocol, considering that:

 

- IPERGAY isn't finished yet, which means that it is an ongoing trial which needs to be continued, with the results not being definitive (yet). So what it entails is that doctors must trust the WHO and thus stick to, as you say, "recommend[ing] daily PrEP as the best option."

 

- I personally find that daily pills are way easier to take (think about women) than "on-demand" doses, especially because sex is a very spontaneous act that doesn't always go along with the "2 pills two hours before sex + 1 pill the day after + another pill another day after that" type of policy.

 

- the best predictor of future behavior is not (always) past behavior (cf. the questionnaire they ask you to fill out before your appointment that enquires about your sexual behavior in the past 3 months --> what kind of rubbish is that ??), since men are extremely inconsistent beings in general...

 

Sorry for the long posts and my bitching, but I just want to determine what's best for me and for my health. Thank you in advance for your answer(s). 

Edited March 24, 2016 by paris_student