March 28th, 2015

Quick Question: Should HIV-Negative People in Serodiscordant Relationships All Get PrEP?

18480762_blogFrom a very thoughtful and experienced primary care provider came this query:

Hey Paul, quick question —
One of my patients, an HIV-negative gay man, is in a long-term relationship with one of your HIV-positive patients — my patient says his partner has been on successful HIV treatment for years. Obviously I can’t check his partner’s record to confirm this, but my patient is quite reliable and why should he be lying about this? He says they always use condoms.
He asked me today if he should go on PrEP — should he? He seems awfully low risk, denies other sexual exposures, etc.
Feel free to suggest that I send him to see you for a formal consult.

Unless you’ve been hiding under a rock (cold and damp down there, isn’t it?), you know by now that pre-exposure prophylaxis (PrEP) works incredibly well to prevent HIV in high risk, seronegative men who have sex with men (MSM) — even better than we thought, according to the recent PROUD and IPERGAY studies presented at CROI.

Related to my colleague’s query, note that the USA guidelines clearly state the following is an indication for PrEP in MSM:

Is in an ongoing sexual relationship with an HIV-positive male partner 

So end of story — PrEP should be started, right?

But there are several reasons why it’s not quite so obvious what to do in this exact situation — which is actually quite common:

  • Treatment of HIV is all but 100% effective in preventing transmission of the virus. Remember the “Swiss Statement” that condoms weren’t even required if the positive member of serodiscordant couple was virologically suppressed? The results of HPTN 052 and observational studies (most recently this one) support this prescient claim.
  • Eligible participants in the MSM PrEP studies were at “high risk” for getting HIV. In IPERGAY, for example, to be eligible a person needed to report “condomless anal sex with > 2 partners within the past 6 months.” A man in a monogamous relationship with an HIV positive partner on suppressive therapy — who also uses condoms — would never have been enrolled.
  • The incremental risk reduction — if any — of a man taking PrEP whose sole partner is already on suppressive ART could never be justified on a “number needed to treat” or cost-effectiveness basis. This is pretty obvious, but is worth explicitly stating, if only so that when such treatment is prescribed, we all acknowledge that it’s done for other reasons.

So what might those reasons be? First, as my friend and colleague Raphy Landovitz puts it, “people aren’t completely honest with their providers about the who’s and whats of their sexual relationships – including as it relates to condom use.” Remember HPTN 052, and those “unlinked” HIV transmissions from outside the couple? That alone should give us pause.

Second, some patients I’ve seen understandably remain very nervous about catching HIV from their partners, even if on suppressive treatment — PrEP provides them an additional layer of security. The TDF/FTC is acting here more as a benzodiazepine than an antiviral. Again, per Raphy: “It restores peace-of-mind to something that the HIV/AIDS epidemic has stolen from gay men.”

From a practical standpoint, here’s what I have done:
  1. See him (the HIV negative guy) alone. Or if he’s uncomfortable seeing his partner’s doctor, offer to have him see one of my colleagues.
  2. Reassure him that the discussion is 100% confidential.
  3. Tell him the pros and cons of PrEP. Efficacy, safety, and cost, of course, but also the characteristics of the patients in the studies — that they were high-risk HIV negative gay men.
  4. Inform him that PrEP has never been explicitly tested in the HIV negative partners of people on suppressive ART in a monogamous relationship — and likely never will be since the risk of transmission is already so low.
  5. Let him decide.

In my anecdotal experience thus far, some have chosen to go on PrEP, and some haven’t.

And whether those who opted in did so because they’re actually at higher risk than they’re disclosing, or for peace of mind, or some combination — does it really matter?

2 Responses to “Quick Question: Should HIV-Negative People in Serodiscordant Relationships All Get PrEP?”

  1. Martin says:

    Dear Paul,

    I think your recommended approach is very reasonable.
    I think the simplistic recommendation from the guideline stating that any male who “is in an ongoing sexual relationship with an HIV-positive male partner” is a “RECOMMENDED INDICATION(S) FOR PREP” is both not supported by the evidence, as you say, and not reasonable.
    From a pubic health perspective, I do believe that people should have access to necessary medical / preventive care regardless of their ability to pay, but this is clearly not part of that. So should the patient, understanding the information you discussed, want to go on PrEP, I could understand it. But I don’t think it would be reasonable to expect insurers, or state insurance plans, to pay for it.

    On the one hand, as you state, patients can be less than forthcoming about the actual risk they are taking. On the other hand, as well proven in PrEP studies, they can have less than perfect adherence with medications which clearly affects the efficacy of PrEP, as you know.

    With this I am not trying to say that it should not be offered, especially with all the info that you’re discussing, but I do disagree with a blank statement that every MSM in a relationship with an HIV-infected individual should be on PrEP.

    I think that is also what you’re stating but different than what a quick review of the guidelines might suggest.



  2. Dhananjay Patil says:

    Hi ,
    Well i will just like to point the danger of quoting figure of ” 100% ” in Swiss statement .

    ” Subsequent clarification has established the Swiss did not actually mean to state there is zero risk under these circumstances, but that the risk of HIV transmission is within the normal bounds of everyday risks which they estimated to be in the region of 1 in 100,000 ”

    So we know that the risk is practically low …but not 100% .

    Viral suppression in plasma compartment need not correspond to viral suppression in CNS compartment of seminal compartment . Given the maturation cycle of spermatozoa and dynamics of HIV transmission via infected sperm ….the possibility of HIV transmission from virally suppressed partner is a possibility ( although a distant one )
    when it comes to prevention of HIV infection as you pointed out additional layer of security is always welcome .

    This should off course be an informed decision by the client .

    I was just afraid that statements such as ” 100 % efficacy” and ” no need of using condoms” quoting Swiss statement could be totally misleading .

    Would you mind adding disclaimer / clarification ?


HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

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Infectious Diseases

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