[Question #9482] Do I need to be concerned about contracting HIV while on PrEP?

32 months ago

Hello Doctors,

I did not think I would be back here again, but here I am. Basically, I've been on PrEP (Truvada), for about 5 months now. Take it same time everyday, think I may have missed one dose in total. During this time I have had a number of sexual encounters with men (crossdressers). I was planning to wear protection in the beginning, but I noticed I have difficulty maintaining an erection sometimes in general, and condoms do not help. Have been prescribed Viagra 100 mg. So some of these encounters, have been unprotected. I am a top, so insertive anal sex only. I make sure to ask the person beforehand like always their status, but how can one really know for sure? Maybe they are not truthful, or just do not know. After the fact, this has brought about concern and worry similar to the past. My counselor said to trust the medication and I don't have much to worry about, but I don't know, I'm having a difficult time accepting. I have read online a handful of cases where PrEP has failed. Is this true? And if so, do you know how many of these cases were among tops like myself? Should I be as concerned and worried as I am? Went for my checkup in early November and everything looked good. This is on my mind constantly and it's effecting my life in a negative way. I would not reach out to you again if it was not.

Thanks very much,

H. Hunter Handsfield, MD

32 months ago

Welcome back, but I have mixed feelings about it. Seeking professional advice when in doubt is of course a good thing. However, as previously discussed, you have an inflated perspective on HIV risks and prevention. (See my closing comment in your most recent thread 4 months ago.)

Of course condoms are recommended for insertive anal sex in addition to PrEP. However, they add little if anything to the protection from PrEP. Condoms remain a very good idea to prevent other STDs, but PrEP alone is virtually 100% effective against HIV. In other words, your counselor is right: trust the medication! Most apparent failures probably involved improper use or timing of PrEP, whether admitted (or remembered) or not. Sorry, but I do not know what sexual practices were involved in such cases.

You're also doing the right thing by discussing HIV status with your partners. Of course there is no guarantee for their replies, but the consistent opinion of experts is that most people are truthful when asked directly about their HIV status.

I don't mean to imply it is OK to dispense with condoms for anal sex, either receptive or insertive. You are taking serious risk in regard to other STDs: keep up this approach, and you're pretty well guaranteed to someday have to deal with gonorrhea, chlamydia, herpes, HPV and -- most important by far -- syphilis. The risk of truly serious outcomes (e.g. blindness, stroke) is a lot higher than the chance you'll ever get HIV.

As for skipping condoms on account of erectile dysfunction, it seems this is something to discuss with your counselor. Of course there is no physiologic rationale for such an effect; it's obvious a psychological issues. It seems to me this adds to the overwhelming evidence -- on display in all your threads on this forum --of some sort of underlying psychological issues, perhaps that you are seriously conflicted about your sexuality. Keep working with that counselor! (In the meantime, maybe it would be wise to forego insertive anal sex until the condom/erection issues are resolved.

I hope these comments are helpful. Best wishes and stay as safe as you can -- I hope safer than implied by condomless anal sex!

HHH, MD

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32 months ago

Thanks for answering Dr. Handsfield. What about my perspective is inflated? In addition to PrEP, condoms provide little if any protection against HIV really? Do you know if other forms of PrEP, pills or injectables that are more effective than Truvada? I try to take my PrEP at the same time everyday, I may be 30 minutes or so late some days, would this have any effect on the effectiveness? I just don’t trust anyone, especially hookups, that is a major reason I got on PrEP, to protect myself first, not rely on their word. If I were to contract another STD, for example gonorrhea, would I be more at risk to contract HIV while on PrEP? I would hate to contract any STD to be honest, I have no symptoms currently. I believe you’re onto something. I’m very discreet about my encounters, and I think deep down I feel shame and the need to be punished for my behavior. Maybe it doesn’t happen all the time, I may have overstated. One night I didn’t have much trouble while protected. I think the person was more my type, nice and thin body type, very feminine appearing, and the oral sex was quite good. So it depends, a number of factors have to come together. I know I’ve said it before but I think I will highly consider adhering to condom use from now on unless I really know someone. I think it’s just the right thing to do, and I really don’t want those other STDs you mentioned.

H. Hunter Handsfield, MD

32 months ago

You misinterpret my comment. What I said is that PrEP is so effective that condoms add nothing to the protection from PrEP. (You can't get much better than 99-100% protection.) Stated another way, when people are on PrEP, adding condoms does not increase their protection against HIV.

"deep down I feel shame and the need to be punished for my behavior." This exactly duplicates my judgment that you present "overwhelming evidence...of some sort of underlying psychological issues, perhaps that you are seriously conflicted about your sexuality." This is very sad, and I am extremely sorry you feel that way. Of course it is common in men who love other men. Presumably you are in discussions with your counselor about these feelings. Good luck.

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32 months ago

Thanks for your help and support Dr. Have a Merry Christmas.

H. Hunter Handsfield, MD

32 months ago

Thanks for the thanks; I'm glad to have helped. Merry Christmas to you as well.---