PrEP or Pre-exposure prophylaxis

refers to the preventive use of a medicine against a disease before one consciously enters a situation in which one can get that very disease. For an epidemiologist in a malaria area, this is an ingenious solution.

This preventive measure also makes limited sense in HIV prevention. However, preventive therapy is currently no safer than consistent adherence to the safer sex rules^[1]. Therefore, PrEP does not represent a fundamental improvement in HIV prophylaxis, but merely another pillar in prevention.

The idea of HIV PrEP is not to make barebacking acceptable. However, it is a way for sexually active persons to protect themselves in the best possible and self-determined way against an HIV infection. It cannot and should not do more. It does not replace personal confrontation with the problem. It should also only be carried out under medical supervision and in combination with regular medical checks for side effects of the medication and possible infections with other sexually transmitted germs. It is also long-term, i.e. the tablets have to be taken regularly over a longer period of time to be effective, and they cost money.

Dealing with this issue can be tricky. If a platform here (perhaps due to a lack of staff) only distributes information as widely as possible via the internet, it may suggest to the recipients of the information a security that does not and cannot exist. One has to talk intensively with each person concerned and make the consequences of their actions clear to them. Anyone who takes this information unreflectively and interprets it as a carte blanche (à la “PrEP is like a headache tablet that you take once to fuck and everything is fine”) is endangering himself and others!

My concern is that insufficient education of the affected group of people about the possibilities and limits of PrEP does not solve the basic problem of sexually transmitted diseases, but makes it worse. There are enough of these diseases against which one cannot protect oneself with PrEP and which, in the wake of PrEP, have meanwhile spread strongly again in the scene.^[5] Not to mention the physical side effects of the active substances used and the spread of Truvada-resistant HIV strains (yes, they exist!) provoked by a widespread use of PrEP.^{[2, 4]}.

Antibiotics were once an effective weapon against infectious diseases. Until people started feeding them to their animals on a regulary base. HIV prophylaxis could easily take a similar course if people continue to use retroviral drugs across the board and without precise control. There are now resistant strains to all current HIV drugs. As a consequence, a similar situation could arise in HIV therapy as is already a sad reality in the fight against conventional infectious diseases with antibiotics. There are only a limited number of drug classes (no new antibiotics have been discovered for decades) and the emergence of multi-resistant pathogens is a central problem in therapy today.^[3]

The available drug classes in HIV therapy (at least as a combination preparation) still work reliably (as long as they are tolerated). However, PrEP blunts the central weapons in HIV therapy, namely retroviral drugs! We can only hope that the consequences remain manageable.

Personally, I think PrEP does not replace safe sex. It only complements it. And I think that as long as we don’t tell each individual in a personal conversation what they are getting into with a preventive therapy (see above), we are sending them into a grey area in which they have to be careful as hell not to make themselves liable to prosecution.^[2]

Even though a lot has happened in the last few years in terms of medication, this does not change the relevance of this article.

Sources (german):
1) Wikipedia – https://de.wikipedia.org/wiki/Präexpositionsprophylaxe
2) IwwIt.de – http://www.iwwit.de/blog/2016/03/hiv-trotz-prep-interview/
3) Wikipedia – https://de.wikipedia.org/wiki/Antibiotikum
4) Out.com – https://www.out.com/news-opinion/2018/10/09/sixth-case-man-contracting-hiv-while-adhering-prep-confirmed
5) Deutschlandfunk Kultur: https://www.deutschlandfunkkultur.de/geschlechtskrankheiten-die-rueckkehr-von-syphilis-und.976.de.html?dram:article_id=418123