An ongoing dialogue on HIV/AIDS, infectious diseases,
March 28th, 2015
Quick Question: Should HIV-Negative People in Serodiscordant Relationships All Get PrEP?
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.”
- 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.
- Reassure him that the discussion is 100% confidential.
- 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.
- 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.
- 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?