#hiv prep

Truvada (Tenofovir Disoproxil Fumarate/Emtricitabine [TDF-FTC]) - well tolerated; most studied regimen; can be used in all populations; can be administered as event-driven therapy for men who have sex with men and other persons who engage only in anal sex. However, event-driven dosing should be avoided in those with chronic HBV infection. Adverse effects: reduced kidney function, can result in bone loss; for patients with chronic HBV, they are at risk for flare of their liver disease if therapy is discontinued. TDF should not be used in persons with an eGFR <60. Patients require monitoring of creatinine on therapy.

Descovy (tenofovir alafenamide fumarate/Emtricitabine [TAF-FTC]) - Well tolerated; less bone and renal toxicity compared with TDF; Should only be administered as daily therapy. Higher rates of mild triglyceride elevations and weight gain compared with TDF-FTC; considered an alternative agent for those whose main risk for HIV is vaginal (frontal) sex or who inject drugs since there is less data compared with TDF-FTC. There is also limited data in adolescents. For patients with chronic HBV, they are at risk for flare of their liver disease if therapy is discontinued.

Apretude (Cabotegravir LA) - well tolerated; every other month dosing via clinic-administered IM injection. Clinical trials suggest greater efficacy compared with TDF-FTC (possibly related to improved adherence). May be used for patients with conditions that are associated with an increased risk of adverse events with TDF-FTC or TAF-FTC (eg, those with reduced kidney function, bone disease). Cabotegravir LA levels may be detectable for up to 6 months. Because these levels are not protective, an oral agent (TDF-FTC or TAF-FTC) or consistent condom use is needed for a period of time in those who discontinue injectable therapy but continue to engage in behaviors that put them at increased risk for HIV. Oral therapy is also needed if the patient needs to miss a dose of cabotegravir. Patients may be at risk of developing an integrase inhibitor-resistant strain of HIV if infection is acquired when cabotegravir levels are suboptimal (e.g., missed dose or discontinuation). If this occurs, future HIV treatment options may be limited. Required proximity to a center that administers cabotegravir LA. Injection site reactions (generally mild). For those who are concerned about side effects of cabotegravir, oral cabotegravir (30 mg once daily) can be administered for a 4-week lead-in period prior to initiating injections.

I know a person who is not a sex worker but, instead, a very successful self-employed person in the tech field, with the sort of wit I can only dream of. He has more male sex partners than he can actually count, mostly because, given his taste for chemsex parties, he can’t always be sure how many partners he’s had - or whether or not they were protected.

This is a lifestyle choice made by a highly intelligent and successful person, his chosen way to have fun, and he’s free to choose to enjoy life that way.

The welfare state of the country I live in pays for his PrEP. So I, and every other tax payer in this country pay for it.

About a year ago, next to me in a public hospital’s A&E in the country’s capital city, there was an elderly lady with oesophageal cancer who required an urinary catheterisation. It is a painful procedure normally done with lidocaine gel which both lubricates and helps numbing some of the pain. There was no such gel in that A&E. According to the staff, the department had run out of it months before, and there was no budget to buy more. Yet, budget hasn’t run out for my wealthy (and healthy) acquaintance’s PrEP.

Yes, I have read the studies and understood the numbers in the PrEP’s “profitability” projections. There will be (according to the experts) savings in the long run. That is, if we include HIV prevention vs the costs of treating HIV in the equation, and basically nothing else.

That equation, however, seems to forget “human factors”, which we know can be instrumental in producing both miracles and disasters.

Generations have grown up dreading HIV-AIDS. Other STIs are treatable, but not this one. HIV is *THE* STI. To protect ourselves from it, we use condoms, and we don’t stop to think about how many other STIs they help protecting us from. No one truly fears those other STIs - nowhere near as much as we fear HIV, at least.

Here comes the miracle of the PrEP. We are safe from HIV - and HIV is, again, *THE* STI. Remove HIV from our list of worries and sexual freedom increases exponentially. Other STIs are easily treatable - what is a meagre course of antibiotics, after all?

Well, in the great scheme of things, it is a lot, and increasingly so. Everyone has heard terms and expressions like “antimicrobial resistance” or “antibiotic stewardship” but, thankfully (lucky them), not many have come face to face with those terms’ reason for being.

We have used and, sadly, abused antibiotics for decades (we’ve been literally feeding what we once called “magic bullets” to the pigs, for goodness sake!) and, whilst the bugs have been getting used to and, therefore, immune to our “magic bullets”, no new classes thereof have been introduced into the healthcare context recently.

What we see now, are pathogens that once responded well to certain antimicrobial agents no longer doing so - some of them being those behind STIs. Superbugs like MRSA, which were once limited to healthcare facilities, are now popping out of apparently nowhere in the midst of the community. And that’s just one such superbug, many others are out there - and new ones keep showing up - they adapt according to what’s thrown at them, and what we throw at them are antimicrobial agents, such as antibiotics.

Back to the PrEP - the moment we are protected from HIV and start feeling that barrier protections are more “nice to have’s” than anything else, what happens in terms of the myriad of other STIs, some of which many of us have never even hear of? They are overwhelmingly treatable, so that’s precisely what we’ll do: treat them - with antimicrobials - thus exacerbating the major global problem of antimicrobial resistance.

We may say that a few courses of doxycycline is cheaper than a lifetime of integrase, protease, etc inhibitors, and that’s quite true. But once that doxycycline no longer works and we start going for the “heavy machinery” to handle “trivial bugs turned monsters”, can we really say how much that will cost?

And when exposing all sort of pathogens (not only STI-related ones, but everything out there) to that “heavy machinery” starts turning some amongst that virtual infinity of “benign” bugs into superbugs, how much will that cost, both in terms of the financial burden to our NHS’s and in terms of lives?

Everything is connected but, from everything I’ve read over the last year or so, not enough connections seem to have been explored as to allow us to say with any degree of certainly that “the PrEP is cost-effective in the long run”.

Add to that everything that is lacking in our healthcare systems, which our governments, whichever they are, can’t squeeze out of the tax payer to pay for and, from proton beam therapy to the widespread use of viral vectors in cancer immunotherapy (mentioning oncology alone, and there’s a lot beyond it), given that my acquaintance has chosen his lifestyle, but my A&E “neighbour” didn’t choose her cancer, can we really say that the PrEP should be our budget priority?

I’ll just say one thing. “Don’t ever get rid of that crop top” I actually SCREAMED at this point. It was so unexpected!

It was a beautifull chapter Roc. It did not disappoint me at all (I’m the James lover anon), i loved the way you conveyed james paranoia and what he thinks when he loses some control over himself in a way. I also loved the way you described everything unspoken, THE FINAL TENSION I felt it all!

Plus: I like the way you “advertise” safe sex

Hi James lover anon 💕

Thank you so much, I’m glad you enjoyed it! This and ch13 (the one with James’ memories) were the hardest two to write. Focusing on James’ internal turmoil whilst including his feelings about Regulus and also the progress he’s making is very hard on me. It’s draining mentally and emotionally and it never feels quite good enough. So makes me super happy when it gets appreciated, thank you so much dear 😊

And yes, safe sex! Although Regulus does not need to take the PrEP, I don’t think many people have heard about it and I wanted to include it in the story. It would be more relevant for the Marauders, their risk as injecting drug users is much higher than Regulus’, but I wanted to show it from the sexual point of view.

I posted the chapter extremely sleep deprived so my end notes explanation was a bit poor. I updated it now, but here it is too, for people who may be interested:

To learn more about HIV PrEP and how it can protect you from HIV, contact our medical team at CM Mediclinic. https://www.cmmediclinic.com/hiv-prep-chiangmai.html #hivprotection #hivprep #hiv #prep #hivmedication #hivprepchiangmai #hivprepthailand #cmmediclinic #chiangmai #prepclinic #hivclinic