It has been 10 years since the Food and Drug Administration (FDA) approved pre-exposure prophylaxis (PrEP) as a biomedical intervention to prevent HIV infection. And while it is now considered a standard part of HIV prevention strategies, misunderstandings about the proper use of PrEP abound. When used as prescribed, PrEP protects HIV-negative individuals from contracting HIV, even if they have had unprotected sex.
Despite numerous conversations about the effectiveness of PrEP and other safer sex options, an acquaintance within my friend group recently confided in me that he had tested positive for HIV, even though he had a month's supply of PrEP. While discussing his testing and prevention strategies, this acquaintance revealed that he rarely used his own supply of PrEP because many of his sexual partners claimed to already be using it.
Whenever he thought he might have been exposed to HIV "because something didn't feel right," he would take his PrEP pills afterward "for a day or two," just like he would PEP.
PEP (post-exposure prophylaxis) is an antiretroviral drug regimen that can prevent seroconversion when taken as prescribed within 72 hours of HIV exposure, dosed daily for 28 days. PEP is not intended for regular use or as a substitute for other HIV prevention methods.
Although both PrEP and PEP are used to prevent HIV infection, they are different medications with unique functions that are not necessarily interchangeable. My acquaintance's misunderstanding about PrEP and PEP is far from unique. I've also spoken with many people who incorrectly believed that the two medications can protect them from other sexually transmitted infections (STIs), such as chlamydia or gonorrhea. To be clear, PrEP and PEP only work against HIV infection.
Misconceptions among patients are common
Michael Chancley, MSW, says he's not surprised to hear such misunderstandings. Chancley is a social worker, educator, and HIV advocate who serves as communications manager for PrEP4All, an organization fighting to make PrEP accessible to everyone in the United States, as well as administrator of PrEP Facts: Rethinking HIV Prevention and Sex, a Facebook group that educates more than 20,000 people about HIV prevention.
Reflecting on his observations as a sexual health educator and PrEP navigator, Chancley says many non-medical professionals struggle with PrEP messaging and medical jargon because information is often delivered without assessing how it has been received. He says that “many times, people just nod when they don’t necessarily understand,” and that some people are afraid to ask for clarification.
To overcome that communication gap, Chancley says that when she talks to clients or colleagues about how PrEP works and how STIs are transmitted, she uses a call-and-response technique in which she asks directly, "Did you understand what I was saying? Do you have any questions? Does this make sense?"
As an added touch, Chancley asks clients and colleagues to explain in their own words what she has told them. This is a similar technique to the one David Malebranche, MD, MPH, an internal medicine, sexual health, and HIV physician, uses to empower his patients and ensure they feel comfortable with what he has told them.
“That’s how you get a sense of whether a person is getting the message or just hearing words,” Chancley says. If something is misunderstood, “it gives me a chance to explain further or give them the opportunity to ask questions for clarity.” She finds that some clients worry about being “misinformed.”
These moments serve as a reminder that patient care requires a two-way dialogue rather than a lecture. Chancley says this may require spending more time with a client to give them ample time to digest the information, which she welcomes because it means those individuals will leave with a firm grasp of PrEP's effectiveness and how to protect their sexual health.
Check for understanding and allow time for questions.
For Chancley, educating clients about PrEP is more than just telling them to take a pill. That's why she follows a simple checklist when conveying information about sexual health:
- Establishing a level of comfort with clients. For Chancley, this includes informing clients that he doesn't have a scientific background. Rather, he's a social scientist and can answer any questions they may have about PrEP.
- He explains how HIV is transmitted and how PrEP works. Chancley uses very simple language to explain that HIV is a blood-borne infection that affects a person's white blood cells and weakens their immune system. He explains that PrEP protects these white blood cells and prevents HIV infection.
- Have the customer explain what they just heard in their own words. Chancley continues his explanation by asking the customers to use their own words to repeat what he just told them.
- Ask and answer follow-up questions. Chancley says she will ask clarifying questions if she discovers there has been any misunderstanding, and will encourage a patient to ask any questions they may have until they feel comfortable and confident with their knowledge about PrEP.
Sometimes, this conversation will expand to address prevention for people who have been exposed to HIV without PrEP or before it has had time to become effective in the body. This means explaining how PrEP works. For Chancley, these conversations typically occur with clients who have discontinued their PrEP use because they no longer need it, have stopped having sex, or have changed their sexual behavior to reduce potential exposure.
PrEP on demand
For cisgender men who have stopped using daily PrEP and have sexual plans that could potentially involve HIV exposure, one option is on-demand PrEP (also called 2-1-1 PrEP) . According to the Centers for Disease Control and Prevention (CDC), seven days of daily use of a single-tablet PrEP is needed for cisgender men and transgender women to achieve maximum protection against HIV during receptive anal sex. On-demand PrEP allows cisgender men to avoid acquiring HIV by taking a double dose of PrEP two to 24 hours before planned sex, followed by a single dose 24 and 48 hours after the initial two pills.
Although the CDC does not recommend on-demand PrEP and the approach is not FDA-approved, clinical studies have shown effective protection for men who have sex with men using this method , and the CDC's updated PrEP guidelines provide information on how to properly use the 2-1-1 schedule.
When discussing on-demand PrEP with clients, Chancley explains that “if there is a possibility of HIV exposure, the regimen of taking two pills before and two after, according to the spaced schedule,” will offer them the same protection as daily PrEP use. He cautions that this has only been proven effective for cisgender men who have sex with men and with emtricitabine/tenofovir disoproxil fumarate (Truvada). Currently, there is insufficient evidence to determine whether it works with emtricitabine/tenofovir alafenamide (Descovy).
Chancley points out that discussions about PrEP and on-demand PrEP as HIV prevention methods remain stigmatized among medical professionals and researchers who don't have sex, despite their proven effectiveness. Instead of leaving people in the dark, she says it's important to equip people with the information they need to protect themselves. That includes acknowledging that health guidelines are slow to be updated, but that clients should feel comfortable expanding their sexual health prevention methods when provided with scientific evidence.
Therefore, while people who do not use PrEP should use PrEP if they feel they have been exposed to HIV, cisgender men can use on-demand PrEP to prevent HIV acquisition instead of daily PrEP if that method works better for their sexual schedule.
When discussing on-demand PrEP, Chancley urges medical professionals to ensure the individual understands how it works, just as they would with daily PrEP. This includes asking them to explain the regimen in their own words. For some medical professionals, this may mean setting aside personal moral beliefs about what a person should or shouldn't do and instead focusing on which HIV prevention method is right for their lifestyle. Ultimately, anything that protects people from HIV infection is the right choice.
From: https://www.thebodypro.com/article/prep-vs-pep-clearing-misconceptions-empowering-patients-knowledge