In July 2012, the Food and Drug Administration (FDA) approved the use of the HIV drug Truvada as a pre-exposure prophylaxis (PrEP). This was the same time period that the FDA approved over-the-counter sale of rapid HIV tests. Both of these have provided new tools to help prevent the spread of HIV; both have also been received with varied responses.
Self-testing has been largely given the cold shoulder by HIV/AIDS organizations. To date, few testing organizations inform people of this option, missing opportunities to engage new allies—such as the counseling profession—in HIV testing. I have written about this in the past.
More recently, PrEP has become a source of controversy in the HIV/AIDS activist community. As is so often the case, public discourse does little more than create divides and oversimplify issues, rather than provide space for informative conversations (see a synopsis of the debate here). For the counseling profession, however, it is important that we wade through the debate and get some important questions about PrEP answered.
Among them are:
- Does PrEP prevent the spread of HIV? Not in all cases. It does reduce the risk of contracting HIV. Studies showed that Truvada reduced transmissions by 45% among men who have sex with men (MSM) and 75% in heterosexual couples.
- Why is PrEP being so highly touted by some, given that risk still exists? No prevention method is foolproof. Condoms are not 100% effective. Rapid testing as prevention misses those who are newly infected and is not 100% accurate. But when PrEP is used in conjunction with testing and other prevention methods, it can move closer to eliminating the spread of HIV.
- What about PrEP in serodiscordant couples (where one partner is HIV-positive, the other negative)? If the HIV-positive partner is on treatment and has an undetectable viral load, and the negative partner is regularly taking PrEP, the risk of transmission of HIV while having unprotected sex is also greatly reduced. This is not the same as having no risk, no having a false sense of security is a concern, but informed risk is far better than carelessness. From a public health standpoint, this is celebrated. For the rare individual who may get HIV under these circumstances, it can still create a crisis.
Other things to consider:
- For people taking PrEP who have multiple partners—especially of unknown HIV status, it is important to recognize the increased risks even while taking PrEP.
- PrEP does not prevent other sexually transmitted infections (STIs) that are on the rise.
- Taking PrEP may lead to further stigmatization of HIV, in that people will talk about it even less than they do now. The assumption can be that everyone is taking pills, and therefore we no longer need to talk about HIV. Silence about HIV has always been a problem, so we have to be diligent to not move in the wrong direction.
For counselors working with clients who are sexually active, returning to the dating scene, or working with people who are in relationships with HIV-positive individuals, knowing about PrEP and being comfortable talking about help our clients greatly in navigating this tricky world of HIV. People may think the pill is the answer; it is up to us to support them in seeing the rest of the picture in a supportive and safe environment.
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