Time To Put Some PrEP In Our Step

Time To Put Some PrEP In Our Step

Back in the day, there was an old saying, ‘It’s a Black thing; you wouldn’t understand.’ Black people used it to convey to their White friends the idea that learning the slang and ‘hanging out with the bruthas’ can only take you so far. And no matter how sincere and well-meaning the effort, on some level the only way to truly understand and appreciate the ‘Black experience’ is to be Black. The saying highlights the difference between sympathy and empathy. Sure, you could sway to the rhythms and sample the flavors, but to understand Black, you ultimately had to ‘be Black’

Not quite as far back in the day, I saw a patient that was living with HIV disease. He was a young gay Black man who was otherwise in good health. After we concluded the medically-related portion of his clinic visit, we talked casually about his social life. He had a new job and had started dating a new man. ‘New Boo’, as he called him, was HIV negative, and they were reaching the point in their relationship where they wanted to ‘take it to the next level’ (i.e. physical intimacy). The patient wanted to get my thoughts on Pre-Exposure Prophylaxis (PrEP) as a means of protecting his partner from getting HIV.

Of course, I reminded him that condoms are not optional, and he should continue to use them during sexual relations. I also informed him that the fact that his HIV viral load was undetectable was an added protection to reduce transmission risk. But, that’s not what he was asking, and I knew it. He wanted to know about the use of the medication, Truvada, taken by the HIV negative person to prevent transmission of HIV.

I acknowledged that several studies had demonstrated the effectiveness of this medication to reduce HIV transmission. However, I then found myself emphasizing that while short term safety looked good, a new and improved version of Truvada, would be out soon and might be better for the long term. I mentioned kidney and bone health as well as the periodic monitoring requirements. I mentioned the adherence requirements and the potential for resistance if transmission occurred. All of these are important considerations when discussing PrEP.

However, I then went a step further; I rhetorically asked why someone would want to take a pill every day to prevent HIV when condoms are very effective when used religiously and properly and when undetectable adds another buffer against risk? It just seemed to me that daily pill-taking and accepting the risk associated with ingesting a chemical was a hassle that went over and beyond. To me, it was like wearing a helmet while driving a car; sure, the helmet may add some protection, but who does that?

And then something clicked! I remembered another HIV positive young Black gay patient I had several years before. That patient had called me out for assuming he would prefer a once daily treatment over another one because it twice daily. While it stills seems a little odd to me, the patient preferred the twice daily regimen. He went on to educate me on all sorts of things over the next several years as I took care of him in clinic. And one thing he told me that rang true and undeniable was that I didn’t know everything. And no matter how hard I tried and no matter how sincere and well-meaning I was, when it comes to some things he said, ‘It’s a positive thing; you wouldn’t understand’.

Fast forward to my patient with the PrEP question, and I started to realize that perhaps unintentionally I had formed a bias against the use of medication to prevent HIV transmission. Yes, this is the same HIV that I had dedicated a great portion of my professional career to fight. Who was I to suggest that daily pill-taking and ingesting a chemical to prevent HIV was too big a hassle or risk? Perhaps I couldn’t be empathetic; but I should at least be sympathetic. If a patient wants to do everything possible to protect his partner, I need to leave my bias out of it.

The data clearly tilts toward reduced transmission and minimal side effects. And I’m sure that some will try to substitute Truvada for condoms no matter how much I plead with them not to as this negates the added protection condoms provide against other sexually transmitted diseases. Truvada without condoms has not been formally studied; so we don’t know if the protection from transmission demonstrated in conjunction with condom use would be the same if Truvada was used without condoms.

So fast forward again to today. Here we are still struggling after 30+ years to stop the spread of HIV. We find ourselves armed with this information and empowered with this tool, and I must ask myself how is it that we haven’t embraced it more readily? Is it some bias? Is it some failure to sympathize? Is it somehow a ‘positive thing’, and we negatives just don’t understand?

Regardless of the reason for delay, I get it now; we must move forward. When the consequence of inaction is more infections and potentially more deaths at the hands of this disease, then we must employ the ‘all of the above’ approach and deploy all available weapons. We must empty the clip on HIV. And yes, that includes the appropriate use of Truvada as PrEP for at-risk individuals. Understanding is optional, but acting in the best interest of the public health is not. Beyond all the things we may or may not understand, it’s time to put some PrEP in our step and stamp out the spread of HIV.

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Dr. Lewis is an Internal Medicine physician with more than 20 years of clinical and research expertise treating patients diagnosed with Hepatitis C, HIV, high blood pressure, diabetes, obesity, gout, fatigue, depression, headaches, hypothyroidism, osteoporosis, sleep apnea, chronic obstructive pulmonary disease, antibiotic resistance, end of life issues, women’s health, etc. Dr. Lewis believes in taking care of the whole patient. Dr. Lewis is a nationally recognized researcher and HIV specialist by the American Academy of HIV Medicine. Dr. Lewis’ motto is “I am here to care for the patient.”