PrEp: What is it & what about the side effects?

What is PrEp?

Pre-exposure prophylaxis, or PrEP, is a way for people who do not have HIV but who are at substantial risk of getting it to prevent HIV infection by taking a pill every day. The pill (brand name Truvada) contains two medicines (tenofovir and emtricitabine) that are used in combination with other medicines to treat HIV. When someone is exposed to HIV through sex or injection drug use, these medicines can work to keep the virus from establishing a permanent infection.

When taken consistently, PrEP has been shown to reduce the risk of HIV infection in people who are at high risk by up to 92%. PrEP is much less effective if it is not taken consistently.

PrEP is a powerful HIV prevention tool and can be combined with condoms and other prevention methods to provide even greater protection than when used alone. But people who use PrEP must commit to taking the drug every day and seeing their health care provider for follow-up every 3 months.

Side Effects Abstract Study:

Prescribing tenofovir/emtricitabine (TDF/FTC) as PrEP raises questions about side effect risks in HIVnegative people.

Side effects that arise in the first weeks of PrEP — nausea, abdominal cramping, vomiting, dizziness, headache, and fatigue — usually resolve without withdrawing TDF/FTC. But providers should alert PrEP candidates to these possible problems so they do not stop PrEP unnecessarily if side effects occur. Cohort studies that enroll HIV-positive people and similar HIV-negative people at risk of HIV infection offer unique insights into risks of two well-known TDF side effects, impaired kidney function and declining bone mineral density (BMD). This research indicates that many HIV-negative PrEP candidates have risk factors for kidney and bone complications, but these people do not appear to have higher than normal rates of kidney and bone problems in published studies. Through 1 to 2 years of follow-up, placebo-controlled PrEP trials found higher rates of declining kidney function and BMD in HIVnegative people randomized to TDF/FTC. But these problems affected only small proportions of people assigned to TDF/FTC during these trials. In HIV-positive people, some research indicates that TDF-linked kidney toxicity improves when TDF stops, but a 10,000-person Veterans Affairs study found that it may not. Another prospective study of HIV-positive veterans figured that every year of TDF use boosts the risk of osteoporotic fracture 12%, while other cohort studies and trials confirmed dwindling BMD with TDF therapy but found no greater fracture risk. TDF/FTC PrEP should not be prescribed for people with creatinine clearance below 60 mL/min, and pre-PrEP DEXA scans of BMD may be prudent for people with a past fracture or other bone risk factors.

Damon L. Jacobs ( Gay and over 40) checks in with his own PrEP Experience after 855 doses of Truvada as PrEP (more than 2 years.)

Beginning the use of Truvada as PrEP on July 19, 2011 was not without some reservation.

Sure, I knew it could offer me an opportunity to feel more in control of my body and my health. Sure, I knew it could enable me to experience sexual intimacy without fear of HIV for the first time in my life. And sure, I knew it could enhance my ability to educate about safer sex practices as a therapist and an activist.

But what about the side effects?

The prospect of having damaged kidneys did not thrill me in the least. Plus bone density reduction? I didn’t even know what that was! Nausea, diarrhea, abdominal cramping? Those were not the kind of adventures I welcomed. What about all the unintended side effects that nobody could predict? How was I going to deal with all that?

I was relieved to find during my first few weeks of taking Truvada that I experienced no physical side effects whatsoever. But what about the problems I wouldn’t be able to detect? What about the harm to my vital organs that I may not be able to sense? Was protection from HIV worth the risk?

For this reason, my doctor began the pattern of seeing me regularly, and drawing blood consistently. During the first year of using PrEP he saw me every three months. Beginning the second year he expanded it to every four months. By doing this he’s been able to monitor all my liver enzymes, kidney levels, and a bunch of other stuff that I don’t fully understand.

On November 20, 2013, I met with my doctor for my routine checkup. I had my blood drawn a few weeks earlier. As usual, this process was done with some trepidation on my part. Have I been damaging myself by using this medication? Am I willingly depositing toxic chemicals in my system? Am I sabotaging my organs for sexual pleasure?

After two years and four months (or 855 doses), my kidneys are fine. My organs are great. As a matter of fact, at age 42, I’m in the best shape of my life. How is that even possible?

As it turns out, taking PrEP has not only been a regular commitment to my physical health, but it has also prompted me to take active self-care measures in other areas.

Feeling protected from HIV helps me to feel more affirmative sexually. Feeling affirmative sexually gives me more confidence and energy. More confidence and energy leads me to exercise consistently and eat healthier. Exercising more and eating healthier gives me more strength and confidence. Having strength and confidence promotes improved mood, happier relationships, and more satisfaction in my professional life, which all positively impacts my physical health.

So have there been unintended side effects of taking Truvada the last two years and four months?

You bet!

It unintentionally has had an affirmative and healthy impact in every other area of my life. It unexpectedly has given me a sense of efficacy, empowerment, and freedom that has benefited my physical, emotional, and sexual well being.

If those are the side effects, I’ll be looking forward to a whole lot more!

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Damon L. Jacobs is a Licensed Marriage Family Therapist in New York City, who specializes working with individuals and couples in the GLBT community. He has spent 17 years treating issues related to HIV/AIDS, stress management, bullying trauma, grief/loss, social alienation, suicide management, care-taking fatigue, substance abuse, domestic violence, and anxiety disorders. He created and monitors the “PrEP Facts: Rethinking HIV and Sex” page on Facebook. He is also the author of the new book “Rational Relating: The Smart Way To Stay Sane In The Crazy World Of Love.” Please contact at Damon@DamonLJacobs.com.

More Resources:

Clinical Practice Guidelines

• Preexposure Prophylaxis for the Prevention of HIV in the United States: A Clinical Practice Guideline  (May 2014)
• Preexposure Prophylaxis for the Prevention of HIV in the United States: Clinical Providers’ Supplement  (May 2014)

Web Resources

• Basic PrEP Q&As
• Fact Sheet: Pre-Exposure Prophylaxis for HIV Prevention 
• Feature: PrEP for HIV Prevention
• Basic Prevention Q&As
• PrEP Guidelines Provider and Patient Information Sheets
• Press Release: New guidelines recommend daily HIV prevention pill for those at substantial risk
• Informational Videos:
  • CDC HIV PrEP Guidelines: Why is PrEP Important
  • CDC HIV PrEP Guidelines: What are the Key Points?
• PrEP Infographic
• Talk to Your Doctor About PrEP: English  and Spanish 

Clinical Trials

• iPrEX: Grant RM, Lama JR, Anderson PL, et al; iPrEx Study Team. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med 2010;363(27):2587-99.
• TDF2: Thigpen MC, Kebaabetswe PM, Paxton LA, et al; TDF2 Study Group. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. N Engl J Med 2012;367(5):423-34.
• Partners PrEP: Baeten JM, Donnell D, Ndase P, et al; Partners PrEP Study Team. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med 2012;367(5):399-410.
• Bangkok Tenofovir Study: Choopanya K, Martin M, Suntharasamai P, et al; Bangkok Tenofovir Study Group. Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet 2013;381(9883):2083-90.

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