Pre-Exposure Prophylaxis for HIV: What Therapists Need to Know

Two Male Friends Walking Outdoors In Autumn Park TogetherIn 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.

© Copyright 2014 GoodTherapy.org. All rights reserved. Permission to publish granted by Bradley D. Ogilvie, MS, LPC, LMFT, therapist in Washington, District of Columbia

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

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  • Talisa

    Talisa

    May 13th, 2014 at 10:20 AM

    I wish that you could explain what PrEP actually is? I guess I am sort of confused because I didn’t see a real good explanation for what it actually is.

  • Amy Armstrong

    Amy Armstrong

    May 13th, 2014 at 12:53 PM

    Public health issues seem to be the universal way to get people stirred up. I know people who work on vaccinations and they encounter a lot of similar issues—especially when the vaccination is against something sexually transmitted. In the United States, we seem to get so hung up on controlling who can and can’t have sex that it often seems like restrictions on a lot of these medications are designed to “punish the fornicators.” I guess that one thing I would be nervous about in discussing PrEP use with a client is that having a partner who is HIV+ or multiple partners with—who knows—is always going to be risky. However, for clients who engage in risky sexual behavior, this seems like good information to share with them. aids.gov/hiv-aids-basics/prevention/reduce-your-risk/pre-exposure-prophylaxis/

  • Damon L. Jacobs

    Damon L. Jacobs

    May 13th, 2014 at 9:15 PM

    @Talisa – “PrEP”stand for “Pre-Exposure Prophylaxis.” It is taken by an HIV negative person who chooses to use a medication regimen to significantly reduce possibility of HIV infection if exposed.

    This is a very constructive article, which unfortunately lists some incorrect data. PrEP has been demonstrated to be 99% effective in preventing new infections amongst people who use it consistently. There has not been a single person, in any research study, or real world setting, who has become HIV positive while using PrEP seven days a week. It is because of this exceptionally high efficacy that the FDA quickly approved PrEP in 2012. [natap.org/2012/CROI/croi_10.htm]

    There has been no study that has yielded a “45%” efficacy as the author states in this piece. The original study the author refers to was called the “iPrex” study – which took place between 2007-2009. There were 2499 male participants in six different countries (including the U.S.) who participated.

    In iPrex, half the participants were given Truvada (PrEP) and the other half were given placebo (sugar pill). Amongst the 1251 participants that were given Truvada – some people took it 7 days a week as instructed, and some took it 0 days a week. When the researchers averaged the rate of infections amongst those who didn’t take the drug, with those who did, they measured a 44% reduction rate in HIV, compared to the group that was given the sugar pill.

    However, amongst those who took Truvada four or more days a week, there was a 96% reduction in new infections. And amongst those who took it seven days a week, there was 99% reduction. That is a VERY level of protection from just “44%”.

    To learn more about PrEP, please check out whatisprep.org. Or, come visit my FB group at facebook.com/groups/PrEPFacts .

    I agree with the author that no method of prevention is foolproof. But keep in mind we take risks every single day that we get out of bed. 23 people died in 2013 in the U.S. after getting struck by lightening. ZERO people in the U.S. became infected with HIV while using PrEP.

  • Brad Ogilvie

    Brad Ogilvie

    May 14th, 2014 at 5:33 AM

    Amy – You touched on what I think is the most important role we counselors can play in this: working with clients to recognize that minimizing risk still comes with risk, and with that comes responsibility to handle the consequences. Talisa – apologies for the oversight, but the link Amy posted above is a good resource.

  • Randi

    Randi

    May 14th, 2014 at 7:45 AM

    Has anyone even consulted the HIV positive community to determine what they think are the best ways to educate the public about the spread of the disease and at the same time come up with ideas that they think would be the ebst way to reach out to those who are the most at risk? We have to engage everyone here, from those who have already been exposed to the disease down to those who have had only one monogamous partner and have never used IV drugs. This has to be something that we are all willing to talk about and to discuss without letting tempers and personal beliefs get the best of us. Even though we don’t talk about it enough this is still a serious problem world wide and to stop the spread of the disease something has to be done to continue to spread the word about the danger that this disease poses.

  • Brad Ogilvie

    Brad Ogilvie

    May 14th, 2014 at 8:52 AM

    Randi – I have had HIV for 28 years, and my partner for 15 years. I am also actively involved in a few HIV-prevention committees. So in answer to your question, yes, there has been much consultation with people with HIV. The fact is that there are many voices so it’s hard to talk about the HIV+ “community” as a monolithic voice. Even PrEP is a very contentious issue among people with HIV, advocates and activists. That’s why I think counselors can play a calming role but also well-armed with the facts.

  • Brad Ogilvie

    Brad Ogilvie

    May 14th, 2014 at 12:04 PM

    Thank you, Damon, for clarifications. I’ve seen lots of numbers, and your sentiment that just living has risk is something I often remind people as I work with groups of youth and the parents want guarantees nothing will happen. As I put it, if you really want guarantees nothing bad will happen, stay in bed and hope the roof doesn’t collapse.

  • Brad Ogilvie

    Brad Ogilvie

    May 14th, 2014 at 2:19 PM

    I just received the new CDC guidelines for PrEP:
    “The guidelines say PrEP should be considered for HIV-uninfected patients with any of the following indications:
    · Anyone who is in an ongoing sexual relationship with an HIV-infected partner.
    · A gay or bisexual man who has had sex without a condom or has been diagnosed with a sexually transmitted infection within the past six months, and is not in a mutually monogamous relationship with a partner who recently tested HIV-negative.
    · A heterosexual man or woman who does not always use condoms when having sex with partners known to be at risk for HIV (for example, injecting drug users or bisexual male partners of unknown HIV status), and is not in a mutually-monogamous relationship with a partner who recently tested HIV-negative.
    · Anyone who has, within the past six months, injected illicit drugs and shared equipment or been in a treatment program for injection drug use.”

    Again, for our purposes, the question is when/where is it useful working with clients, especially those for whom we are a primary support/confidence.

  • Carly

    Carly

    May 15th, 2014 at 3:45 AM

    What is the general consensus on self testing for HIV?
    I have never really thought that this was such a great idea, I hate the thought of someone being all alone when they are testing and receiving information that they may not be ready to handle on their own. I think that it seems like a much better idea to be somewhere with a doctor and a counselor who can walk you through all of this and to help you process the news that you receive.
    Whenever you are doing something this big with potentially so much capability of changing your life drastically then I don’t think that this is something that you need to do alone. You need to have some supportive and educated people with you so that you have someone to lean on if the news isn’t quite what you hoped that it would be.

  • Brad Ogilvie

    Brad Ogilvie

    May 15th, 2014 at 10:22 AM

    Carly – a few thoughts on that:
    1. In some cases this is not dissimilar than home-pregnancy tests. It’s life-changing, especially if the person doesn’t want to be pregnant, and yet we manage it often well.
    2. The research has shown that people can do it well.
    3. It’s not for everyone, but it may certainly be for the informed tester who doesn’t want to always have to go to a clinic. It’s also good for people in sero-discordant relationships.
    4. Most important for therapists of all stripes, it allows the client to choose the trusted person he/she wants to test with, rather than go to a clinic that may impose intrusive questions.

    All to say, it is a resource that can be of use in a lot of arenas. My efforts in this in this network are to make sure that counselors and therapists of all kinds are educated about self-testing and, now, PrEP.

  • Cole

    Cole

    May 17th, 2014 at 6:00 AM

    I am not saying this in a judgemental way but do you think that a pill like this would actually be a step backwards when it comes to taking safety and precaution seriously with regards to having unprotected sex? I think that a lot of people would see this as a get out of jail free card when it comes to using protection and it is not like that at all. You still have to be safe and use some common sense, or otherwise the numbers of new cases of HIV infection are only going to continue to rise. I really thought that this was a disease that we had under control until I have been looking over this and other information and see that this is still on the rise among certain demographics. As much as we know and have learned over the past three decades I find that to be unacceptable.

  • Brad

    Brad

    May 17th, 2014 at 10:30 AM

    Cole – You point out some very important concerns. Initially, PrEP was thought to be a good option for those who were not utilizing current options and where HIV is on the rise. It’s another vital tool to stop the spread, but it’s not a magic bullet. It’s a great risk-reduction which, in conjunction with other tools (such as HIV+ people having undetectable viral loads), but has its limitations (such as needing to be consistently on PrEP – not just when engaging in sex).

    One thing I find is a step back is the move towards having to identify “High-risk” as the person to go on PrEP. The process of identifying high-risk can be stigma-producing and push those at highest risk away from this option. I am also concerned that the celebratory nature of these new guidelines might further marginalize HIV to greatest impact where people lack access to medication – the message being that those lives don’t count.

    Still, it’s a valuable tool but we need to be responsible in how we communicate about it and try to recognize the social messages and consequences.

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