Should I start PrEP?

Dear Reader,

It’s great that you’re thinking about ways to be sexually active with your partner while also minimizing your risk of contracting human immunodeficiency virus (HIV). HIV spreads through the exchange of bodily fluids including blood, semen, vaginal and rectal fluids, and breast milk from a person who lives with HIV. Since you and your husband are in what is referred to as a HIV-discordant or serodiscordant relationship (where one of the two of you, not both, are living with HIV), understanding the various medications and methods that may help reduce the risk of HIV transmission can go a long way in fostering a healthy, safer, and fulfilling sex life. 

The array of medications and other HIV-related acronyms may seem confusing at first. Post-exposure prophylaxis (PEP) refers to the drugs taken immediately after someone who doesn't live with HIV is exposed to HIV. It can help to prevent infection, and it’s a single-use medication that is only effective when taken within 72 hours of exposure. Though it isn’t recommended for serodiscordant couples such as yourself, exceptions are made in emergency cases such as after a broken condom or sexual assault. Because your husband is already living with HIV, he wouldn't be eligible to take PEP. He would, however, be a prime candidate for antiretroviral therapy (ART) — a popular treatment that prevents virus replication. Good compliance with daily ART has been shown to decrease the viral load of those living with HIV to levels that are often undetectable. This is good news for you because those with undetectable viral loads are less likely to transmit HIV to their partners as well. While ART can’t cure HIV, the low viral load will help your husband’s body to produce immune cells that will help strengthen his immune system to fight off further infection, allowing him to live a long and healthy life.

The next medication acronym to address is PrEP or pre-exposure prophylaxis. As you’ve noted, PrEP is available to people like you who aren't living with HIV but are considered at risk for getting HIV due to possible exposure. In pregnant people, PrEP might also be a good way to reduce the risk of HIV transmission to the fetus. PrEP combines two drugs, tenofovir disoproxil fumarate (TDF) and emtricitabine, into one pill taken once a day. For people who take the drug every day and engage in other HIV prevention activities (e.g., consistent condom use, HIV couples counseling, etc.), research has found that (depending on the population) PrEP is between 62 to 92 percent effective at preventing HIV transmission. PrEP is commonly found as an oral pill but is in development as vaginal or rectal microbicides, long-acting vaginal rings and intramuscular injectables. No matter the medication method you choose, these therapies must be prescribed by a medical professional who’ll likely provide additional testing and consultations going forward to ensure your and your husband’s health and safety.

While there is no 100 percent effective way of preventing HIV transmission while having sex, serodiscordant couples have options to help maintain a healthy and satisfying sex life. In addition to the medications discussed, some other safe sex practices to consider that prevent the spread of HIV include:

• Couples counseling: Open communication may help to increase your partners’ and your comfort regarding an uncomfortable topic. Additionally, counseling has been clinically proven to help prevent HIV spread between serodiscordant couples by increasing education and compliance with medications.
• Regular testing for sexually transmitted infections (STI): STIs are common among people with HIV and may amplify transmission. For this reason, you may consider regularly testing for STIs in addition to regularly testing for HIV.
• Condom use: The Centers for Disease Control and Prevention (CDC) recommends using a condom that fits properly with water- or silicone-based lubricant to prevent the slipping and breaking of condoms to further prevent STI transmission.
• Consider other forms of sexual intimacy: While anal and vaginal sex are considered high-risk activities for HIV transmission, oral sex and other sexual activities that don’t involve exchange of bodily fluids have low to no transmission rates.
• Circumcision: For people with penises who are at risk of contracting HIV, circumcision is considered as an effective method to preventing transmission.  
• Restrict needle sharing: Don’t share needles, syringes, or other drug equipment with your partner as HIV spreads through non-sexual bodily fluids such as blood.

Regardless of the approach you choose, it may be beneficial to speak with both a medical and mental health professional to help you and your husband embark upon your sexual journey while doing your best to reduce the risk of transmission!