So a few updates on my quest to try out PrEP…

First, PrEP is going to be a bit expensive. The insurance company is a bit weird. They won’t say how much the drug is going to cost until AFTER it ships, but based on their cost estimator it looks like it’s going to cost me about $225 per month – and that’s with them covering 81% of the cost.

The costs in the graphic above are for a 3 month supply. If I were poz Gilead, the maker of Truvada, would cover my out-of-pocket cost of Atripla. But since they’ve got the only approved drug for PrEP they’re not quite so generous for neg guys – according to their website they’ll only cover the cost for guys who are completely uninsured. Personally I think they need to address the issue of cost issue if they want PrEP to really catch on. I can probably afford the cost, but my boyfriend is already complaining about it. So we’ll see if I continue after 3 months…

Second, PrEP really does have to be taken daily. My initial reading of the data I saw was that there was decent protection when taken every other day (or 4x/week), but my understanding of things was incomplete. The Maverick Men guys referred me to someone in Boston who’s been working in HIV research for 10 years now and currently involved in a study on PrEP. I’m just going to quote his response since he says things more simply and eloquently than I can…

You’re spot on in terms of 42% being the total protection which included people not taking their drugs.  The difficulty with the >90% protection is that those numbers come from post hoc (after the fact) analysis.  To achieve those numbers in the real world, we would have to enroll people, watch them take the medication every day, and see what the results are, which is clearly not possible.

As it stands now PrEP is only authorized for daily use. In the future that may change, and it is possible that you would receive some benefit from dosing every other day, but to achieve maximum efficacy it would make sense to take the medication daily.  Additionally, infrequent dosing could potentially lead to lingering GI side effects such as nausea or changes in bowel habits.  From a side effect standpoint, Truvada was chosen for PrEP because it does have such a great safety profile; less than 5% of people on Truvada experience any side effects, and for most of those people they resolve within a matter of weeks.  The two more concerning side effects – changes in kidney function and changes in bone density, would be monitored for by your doctor, and if they occur are reversible by simply stopping the medication.  More importantly, it is generally easier to incorporate a daily medication into your routine than an every other day.

In terms of going on and off PrEP, Truvada has a long half life so missing a dose here and there will not leave you completely unprotected.  However, if you choose to start and stop taking the medication, it is possible that you could experience ongoing startup GI side effects.  To avoid these, it is advised to take the medication daily.

That’s a pretty good explanation of why daily PrEP is the way to go. I’m not 100% happy about that – I’d prefer a more casual / less intensive relationship with the PrEP meds, but it sounds like that may be problematic. I mean I don’t feel like I have to have “maximum efficacy” – I’m OK with “pretty good efficacy” – but the thing is that the study that implies decent efficacy when taken 4x/week isn’t based on direct data. Hell, the efficacy of daily PrEP is based on the same study and may not be nearly as good as people think – there’s a long way between 42% and >90% and it is just a regression model. It’s probably right, but there’s no guarantee.

So daily PrEP it is.

[BTW, the guy in Boston recommended two more documents for people interested in knowing more about PrEP. This one is a little dense because it’s aimed at medical providers, but you may find it an interesting read if you like details. Meanwhile this one is more of a simplified version for patients.]

My pills should arrive end of the week or beginning of next week. So I’ll be starting soon…