medication as prevention
PrEP – THE BEFORE PILLS
Previous preventative measures – such as condom use during sex – have not been sufficient to stop the spread of HIV and AIDS en Colombia. Here 5.500 persons are getting infected with HIV every year, most of them men who have sex with men.
PrEP, a new medical option for HIV/AIDS prevention in the form of a pill, will hopefully be available for everyone here sometime soon.
People at a greater risk of HIV infection now have additional options for effectively protecting themselves. This flyer aims to help you decide whether PrEP is the right choice for you and how to get it.
It’s been specifically written for men who have sex with men (including inter, trans*, bi, cis, pan, gay, hetero, queer or other) and for all who are interested in the topic. It’s been written with the belief that everyone – who needs or wants PrEP – must have access to it in Colombia as quickly as possible.
WHAT IS PrEP?
PrEP is the use of anti-viral agents to prevent an HIV infection (only the HIV-1 subtype, which is by and large the only kind that occurs in The Americas). PrEP stands for:
- PRE before
- EXPOSURE to the HIV virus
- PROPHYLAXIS prevention of infection
When using PrEP, substances are taken regularly or on a case-by-case basis before any potential sexual contact. This is a combination of the same substances that are taken during treatment for people with HIV.
Currently a number of different medications are available worldwide as PrEP. They combine two agents in one caplet and rarely cause relevant side effects.
PrEP is not a morning after pill, a vaccination against HIV or a cure. It should not be confused with post-exposure prophylaxis (PEP), which is taken after a situation in which unprotected contact occurs in order to attempt to prevent an infection.
In the US, health agencies and some insurance companies have considered PrEP to be effective since 2012 and have advertised for it as such and covered its costs. In Colombia as well, a small and growing group of people have started using PrEP. At the same time, general knowledge of it is not widespread. PrEP will most certainly be used more intensely – with or without covered costs – by individuals to protect themselves from HIV infection and both with or without condoms.
PrEP can be taken regularly (daily) or for just a few days. Studies have shown that both methods are effective. You are best protected if you take PrEP every 24 hours. A planned, short-term use before potentially risky situations, like special weekends, can also be a practical and affordable form of protection.
For both kinds of PrEP, it’s important to remember that for every dose you forget, the protection is reduced!
HOW EXACTLY DOES PrEP WORK?
For the HI virus to reproduce in the body,
it must constantly replicate its genetic material (RNA) in the genetic material of human cells (DNA). The virus must first rewrite its genetic information in human form to do that. That’s done with a tool that HIV brings with it: the reverse transcriptase enzyme. The active agents in PrEP block this process by integrating false components into the DNA. This prevents the virus from reproducing.
Because the active agents remain in the blood and anal mucosa along with other places for longer periods of time, the virus is no longer able to integrate its genetic information into human cells and disappears from the body, unsuccessful in its attempt to convert its genetic information into human DNA.
WHICH PrEP MEDS ARE AVAILABLE?
Tablets are currently available for PrEP, which combine the active ingredients emtricitabine FTC and tenofovir TDF, in short: FTC/TDF.
These are Truvada® (Gilead is the manufacturer) and its generics (medication with the same active ingredients). Worldwide generics like Tenof EM®, Ricovir-EM® and others are available. It’s legal to get these products with a prescription in Colombia (see chapter below).
Whether the Truvada® successor Descovy® is more suitable for PrEP than the FTC/TDF combination is currently being researched.
HOW SAFE IS PrEP?
Long-term – meaning daily – and consistent use of PrEP has been proven in studies to be as least as effective as correct condom use or ‘treatment as prevention‘ (non-infectivity through effective HIV treatment = being “undetectable”).
Different use regimens of short-term PrEP – with increments – can also offer a high level of protection.
As a rule of thumb for short-term PrEP: the more days you regularly take medication for short-term PrEP before having sex, the better the protection will be. Beginning four days ahead of time can be calculated to have the same level of protection as a long-term PrEP regimen.
When taking the medication only before a risky situation, this may not be the case, but still considerably reduces the transmission of HIV.
But you may not feel that that’s enough protection. If you don’t use condoms (all the time), it’s still a better option than no protection against HIV at all. In addition, infections with HIV are possible if the virus is resistant to substances in PrEP, but extremely unlikely. There are only four documented cases of infection worldwide (until April 2018), only two of which are attributed to resistance. And no safer sex method, including condom use can guarantee complete protection from HIV.
What’s important for PrEP is to know that every forgotten dose reduces the amount of it in your system and lowers its protection.
HOW IS PrEP TAKEN?
The manufacturer of Truvada® recommends the following for long-term use as PrEP (applies to the generics, too). Take one pill at the same time daily:
For short-term PrEP, participants in the French IPERGAY study were supposed to take the following dosage: two pills between 2-24 hours before potentially being exposed to HIV, and then one pill every 24 hours for up to two days after.This scheme is widely promoted by health professionals in France.
Dosage recommendation for Truvada®, short-term, IPERGAY study
(applies for anal and not for vaginal mucosal membranes.)
The ‘quick-start‘ from IPERGAY is controversial. Whether taking two tablets directly before sex is sufficient or not is yet to be proven. But what’s certain is that the earlier you begin to take PrEP before having sex, the better the protective effect will be. Ideally, you should start taking PrEP a few days in the row beforehand, every 24 hours.
Before starting PrEP, you must be sure that you’re not already infected with HIV. You must also be checked for Hepatitis B infection to avoid any possible complications. It is also a good idea to have your blood levels checked beforehand and then again every three months after starting treatment. The creatinine levels in your blood are the most important to pay attention to because they indicate how well your kidneys are functioning (see Side Effects below).
You should have yourself tested for other sexually transmitted infections (STIs) at the same time. If you take FTC/TDF during meals, you can increase the intake of contained tenofovir in your body by about a third.
Once again: Taking the medication regularly is the decisive factor in its effectiveness! Taking it daily will likely be the most practical and effective form of PrEP. Only you will be able to find the right variation that works best for you.
SIDE EFFECTS, INTERACTIONS
When FTC/TDF is taken for PrEP, it may cause nausea, fatigue and headache. When its use is discontinued, any side effects experienced will completely disappear over time.
In rare cases, FTC/TDF can reduce bone density or cause kidney damage. You should never take it without consulting a doctor, especially if you have a history of kidney problems.
Additionally, the lactose contained in the medication may also cause a problem for those with lactose intolerance. You can learn about interactions with other medications by consulting a doctor, or from the package lea et. FTC/TDF cannot be taken in combination with adefovir dipivoxil (Hepsera®).
Alcohol and other drugs do not limit the effectiveness of PrEP. However, consuming them simultaneously can put further strain on your metabolism, liver and kidneys.
There are claims that HIV can be more easily transmitted when another STI is already present. PrEP also effectively inhibits the transmission of HIV in this case.
PrEP‘S STATUS IN COLOMBIA
PrEP medications are not covered by colombian health insurances (“sistema de salud”) right now. With a private prescription everyone can buy it in pharmacies. The doctor has to prescribe it on his own responsibility (“off label”) because companies never officially applied for the preventional use of this medication, only for treatment of HIV.
At the moment you are on your own, if you wanna start with PrEP here in Colombia. You have to pay it (and not everyone can afford it). At least for accompanying measures however, a method of covering the costs can often be found. Ask your doctor or your local community health center especially for free testing.
You may receive information about PrEP from some doctors or health professionals which is sometimes half true or moralistic, some may have never heard of it. But there are a lot of experts who are convinced that PrEP is essential for effective prevention! HIV/STD treatment centres are your best guess to find the right doctor.
Currently it is important to spread reliable information, help each other and stand together as a community for the right for PrEP. This is just the beginning!
HOW DO I GET PrEP?
In Colombia the cheapest product we could find is ‘Emtricitabine 200MG+Tenofovir 300MG’ from Aurobindo Pharma® for 142.000 COP at the Liga contra el Cáncer medication sales office (this is almost the price at the black market of about 120.000 COP). Another generic of Seven Pharma® costs about 180.000 COP at pharmacies. A better known product may be Emtrivir Teva® for about 240.000 COP. All these prices may drop down soon. If you wanna buy PrEP medication at a pharmacy ask for the cheapest generic of combined Emtricitabine 200 MG and Tenofovir 300 MG.
However, another way to get PrEP products to Colombia is to bring it with you from abroad. You (or someone else) can bring PrEP generics from your travels (pills for up to 6 months are permitted for personal requirements). INVIMA (the Colombian food and drug administration) informed us that it is perfectly legal if you carry a prescription copy in your luggage.
Also, it is possible to order generics from certain international online pharmacies. Regulations for online ordering do not seem to exist. At the same time private imports are practiced widely and without problems. Imports are not forbidden and can be notably cheaper in total than PrEP from local pharmacies. You get a monthly package incl. shipping normally for 150.000 COP (55 US$) and a six-months package for 550.000 COP (198 US$), e.g. RICOVIR EM®, TENVIR EM®. The cheapest offer we’ve googled was: 6 packages of Tenof EM® at Greencross pharmacy for 250.000 COP (91 US$) incl. shipping! You’ll find a list of providers here (we are not advertising any of this): www.iwantprepnow.co.uk/buy-prep-now
Shipments will possibly be checked by customs. Orders at online pharmacies must be accompanied with a prescription from a doctor. The prescription must show the doctor’s registration number, address, telephone number as well as the doctor’s signature on the prescription. For customs clearance some online pharmacies also require a copy of your passport.
In addition, generics for others are brought cheaply from abroad, prescribed PEP is taken as PrEP or pills are purchased from acquaintances. This creative procurement is an expression of the fact that PrEP simply is not affordable for everyone.
Organising PrEP on your own could means medical supervision and regular testing. However, we consider this to be essential when taking PrEP.
WHAT ARE THE PROS + CONS OF PrEP?
If you’re thinking about starting PrEP, then you are making a decision for yourself. PrEP only works correctly if you take it regularly. Condoms also only work if you choose to use them. What’s certain is that condoms don’t work at all if you forget to use them. If you forget to take your PrEP for a day, the protection is not completely gone, although it is reduced.
Condom use may be neglected while under the influence of alcohol, other drugs or if you’re just lost in a moment of love, but the PrEP that was taken when you were sober still works!
Unlike condoms, PrEP offers no protection against other STIs. However, condoms (during oral intercourse or other contact with bodily fluids) don’t offer complete protection against STIs either. PrEP is also a good method for people who don’t use condoms or who use them irregularly or incorrectly, and therefore may not be protected from other STIs anyway. An important advantage of a regular PrEP treatment is that during the necessary regular lab test (every three months) you can also be tested for any other STIs (which doesn’t always happen automatically). That way they can be detected and treated early.
The same applies to Hepatitis C. Based on our current knowledge, this virus is generally passed on through more extreme sexual practices (for instance, if there’s blood). Anyone who wants to be safer about this needs special safer sex rules – PrEP or condom use are not sufficient.
PrEP gives you the control over your protection against HIV because you are the one who must use the pills correctly. Talking about safer sex is still very important. You may have had a hard time addressing the topic of safe sex in the past and ended up taking risks without proper protection. Trying PrEP may allow you to have more enjoyable sex without feelings of fear and guilt afterwards. This kind of psychological relief may allow you to speak more openly about protection from HIV and other STIs. It may even make certain situations with condoms less stressful!
The different options for safe sex shouldn’t be in competition with one another. They can be combined and in many situations, just one method is enough.
There’s no reason, whether political, financial, or otherwise, to prevent people from deciding to use PrEP and taking control of their health and well-being. For that reason, many institutions have recommended introducing PrEP to the EU, such as the WHO World Health Organization.
WHAT HAPPENS IF I UNKNOWINGLY HAVE HIV AND TAKE PrEP?
If you’re HIV positive and take PrEP, you’re not getting all you need to successfully treat HIV, as the virus may not be kept at undetectable levels (currently the measurement for a successful HIV treatment). Taking FTC/TDF, which combines two active agents, is sufficient for an effective PrEP, but an HIV treatment requires additional medication.
That’s why having an HIV test is absolutely necessary before starting PrEP! That means a dependable (and anonymous) test at a healthcare institute or a community testing station. A rapid test is not sufficient.
It’s also possible that resistance to medicine used for PrEP may form, though this has not been frequently observed in studies.
FTC/TDF is not associated with this sort of resistance.
However, this is not relevant for people who are HIV negative because no virus is present that could form a resistance.
WHO NEEDS PrEP?
PrEP is recommended for people who are at a high risk for HIV infection.
Only you can answer the question of whether or not you belong to this group. If you can’t or don’t want to use condoms, if you’ve had an STI in the last year or an anal STI, if you find the topic of safe sex scary or hard to talk about, or if you’ve found yourself doing things during sex under the influence of drugs that you wouldn’t otherwise do,
then PrEP is a good option for you to consider. In the end, that question is personal and can only be answered by you: Simply wanting to have more fun and enjoyment during sex – without a condom – is a legitimate enough reason to decide to start taking PrEP. All people should have the right to expand their possibilities for their personal freedom.
Because PrEP is important for truly ending the HIV crisis, we’re demanding that costs are covered immediately by the health system! PrEP has to become a part of an integral response for prevention of HIV in Colombia. Authorities are called to integrate PrEP into the mandatory health plan (Plan Obligatorio de Salud, POS).
HIV and Aids are a reality for LGBTI people and vulnerable communities like sex workers, drug users or homeless people: They all require special information, suitable access and – in addition to other prevention tools – PrEP. Everyone who needs it should have free access!
Without any moral concerns of others: For enjoying a free and informed sexuality in the future, we have to take the next step: PrEP NOW!
WHERE DOES THIS INFORMATION COME FROM?
The two large studies, the PROUD study based in England and the IPERGAY study based in France, provided us with the first important findings. You can read more about that in our link list. We have also collected info about PrEP from the Internet and events. We’ve had intense discussions about what this new information means for our lives and future. We believe that it’s so important that we have made it available for anyone – in particular those who are at a high risk of HIV infection.
WHERE CAN I FIND MORE INFORMATION?
If you wanna talk with someone about PrEP we recommend:
- Red Somos Bogotá
(1) 6 31 61 54
Diagonal 30 #14-49, Bogotá
You may remain anonymous here.
WE ARE LOVELAZERS!
Lovelazers is an open activists group of friends worldwide. We are focusing our efforts on new forms of safer sex and cyber- and nightlife. Some of us are in gay, discordant relationships (HIV+ and -) and have been educated in the fields of sociology, medicine, art and law. We’re independent of any specific institutions (especially of pharma companies). We are active in Bogotá, Berlín and Zúrich. You can join us: firstname.lastname@example.org
© Lovelazers, 2018. We do not assume any liability for accuracy or completeness.
Foto: “Tupamaraz On The Streets” by Raul Vidales, Bogotá 2018.
Thanks for comments, help and impulses: Iván, Angel, Nicolas, Diego Hannibal, La Vergony, Alejo, Daniel, Jona, Andrés, Laika, William, Cami, Red Somos, Marcy + Jonathan.
Friends and co-publishers: KUIR Festival Bogota, El Parche Artist Residency, House of Tupamaraz
ACT UP! PrEP NOW!
There is a non country specific brochure in english, too: