This is an excerpt from an article by Howard Grossman, M.D. that first appeared in TheBody.com here.
Those of you who have read my blog know that I am on pre-exposure prophylaxis (PrEP) to reduce my risk for HIV infection. And more and more of my patients are also beginning to take Truvada (a pill combining the antiretroviral drugs tenofovir and emtricitabine) as PrEP to prevent HIV infection. And all of my patients are asking me what my recommendations are for condom use in light of the data on PrEP.
If you ask most clinicians, researchers and public health officials, the usual answer is: "Well, you should continue to use condoms because, of course, Truvada does not protect against STIs (sexually transmitted infections)."
The problem is THAT IS NOT THE QUESTION PATIENTS ARE ASKING!
Let's face the fact that everyone hates condoms! We hear a lot about gay men not using condoms these days, but how many heterosexual men are using them if their female partners are on birth control? Are doctors counseling that all of their straight patients need to use a condom every time in every situation, now and forever? You know they're not. But that's the only message we've had for gay men for a long time. It's a message that was vital in the days when we had no other tools, had unreliable testing and did not understand transmission well. It's a message that saved countless lives. But now it's a message that pathologizes gay sex and fails to recognize that people are making reasonable and rational choices about risk. Now we have PrEP and treatment as prevention (TasP).
People want to know if using PrEP could actually allow them to go without condoms. They are looking to their doctors for guidance. If we sidestep the question by talking about STIs, then we leave people fumbling around to find their own way. PrEP opens the door to talking about situations where the risk of HIV infection will be so low that perhaps going without condoms is a reasonable choice. I will share with you the guidance I give my patients.
Seat Belts Plus Airbags
If some people want to take PrEP and still use condoms, I salute their choice. They will be the safest among us. Some have likened this to using a belt and suspenders to hold up one's pants. I don't like this image because it implies that those who choose it are a bunch of nerds (see Urkel). I prefer the analogy of the use of seat belts and airbags in cars. Both are there to protect us, but they work in different ways to do so -- and outcomes are best when we use both modalities.
At this point, I think most people would agree that those in a long-term, stable monogamous relationship where both partners are the same serostatus do not need to use condoms.
Let's Look at the Numbers
If we look at several different scenarios for sexual encounters outside of a long-term, stable monogamous relationship with partners of like serostatus, we can see some areas where PrEP and TasP can reduce risk so much that choosing not to use condoms can be a rational choice.
The U.S. Centers for Disease Control and Prevention (CDC) has calculated the risk of HIV transmission for multiple sexual and other exposures. The risk for receptive anal intercourse (bottoming) is 134 for 10,000 exposures. Just to be clear, from a public health standpoint, this is a high risk.
If one partner is HIV positive and is undetectable on medication (viral load <40 copies/mL on some tests and <20 copies/mL on others), then the chance of passing HIV is reduced by 97% or so (conservatively).
This is according to a number of studies -- including the PARTNER study, which showed no transmission among over 700 serodiscordant couples who were not using condoms and where the HIV-positive partner was on suppressive antiretroviral therapy and the negative partner was not on PrEP. If the negative partner is on PrEP, and taking the medications reliably, then that person's risk of acquiring HIV is reduced by, let's say, 92% to 100% according to various studies. With these reductions in risk (97% and then 95%), the risk becomes something like 1 out of 50,000 encounters. If we use a 99% figure for PrEP, we're looking at 1 per 250,000 episodes. I think we can reasonably ask: What more HIV risk reduction we can get from using condoms in this situation?
To read the rest of the article go here.
About the author: Howard Grossman, M.D., is the director of AlphaBetterCare, an LGBT-friendly primary care provider serving New York City and New Jersey. An HIV physician and researcher for more than 20 years, Grossman is also a senior attending physician at Mount Sinai Roosevelt Hospital.