What is the recommendation for pre-exposure prophylaxis in a bisexual male?

Hi,

Welcome to icliniq.com.

I thoroughly read your query and understand your concern.

It is good that you are trying to behave responsibly in terms of sexual exposure at most times, but by not using barrier contraception and pre-exposure prophylaxis, you are increasing the chances of acquiring HIV (human immunodeficiency virus) infection in both you and your partners. As you have rightly mentioned, pre-exposure chemoprophylaxis is only effective against HIV and does not provide protection against any other sexually transmitted infection (STI). However, amongst all STIs, including hepatitis or blood-borne infections such as syphilis, chlamydiae, gonorrhea, and herpes infections, HIV is the most fatal illness and can never be cured but prevented and controlled. It is here that the pre-exposure prophylaxis (PrEP) comes in handy. Before starting pre-exposure prophylaxis for HIV, please ensure that you have tested negative for HIV infection and then start PreP therapy under close monitoring and advice by HIV physicians and consultants. The critical feature of the PrEP regimen is that adherence to medication must be total. If you regularly miss doses of PreP medication, you will be at a high risk of acquiring HIV.

1. Based on guidelines issued by the Centers for Disease Control and Prevention (CDC), a fixed-dose combination of Tenofovir 300 mg and Emtricitabine 200 mg taken once daily is effective and safe in decreasing the risk of HIV infection in adults. The drug combination was approved by the FDA in July 2012 for PrEP against sexual HIV acquisition by men who have sex with men (MSM), as well as for heterosexually active serodiscordant women and men. Other generic brands are also available worldwide. There are several adverse effects possible due to this medicine, especially over long-term usage. In the short term, headache, nausea, vomiting, rash, and loss of appetite are common. In some people, Tenofovir can increase creatinine and transaminases. These are enzymes related to the kidneys and liver. In long-term usage, this medication can cause damage to the liver and increase liver enzymes (which should be monitored regularly, at least every month). It may damage the kidney, and monitoring of blood values of kidney parameters such as creatinine may be required. Tenofovir can reduce bone mineral density, especially in individuals with existing osteoporosis or bone rarefaction. Calcium or vitamin D supplements may be helpful.in preventing osteoporosis. Levels of lactic acid in the blood increase in some people taking Tenofovir and Emtricitabine. Rarely, people taking Emtricitabine had some temporary changes in skin color.

2. Another fixed-dose combination of Emtricitabine and Tenofovir alafenamide 200 mg and 25 mg is also approved for at-risk adults and adolescents for HIV-1 pre-exposure prophylaxis (PrEP) to reduce the risk of HIV-1 infection from sex, excluding those who have receptive vaginal sex. Other generic brands are also available around the world. This will also have similar adverse effects as Truvada, but it has fewer liver and kidney-related adverse effects; hence it is preferred globally.

3. An extended-release IM (intramuscular) injection, Cabotegravir was approved by the FDA for PReP for adults and adolescents in December 2021), administered as a gluteal intramuscular injection every two months. It was shown that Cabotegravir IM was superior to daily oral TDF-FTC in preventing HIV infection. However, Cabotegravir also causes similar adverse effects, such as headache, nausea, vomiting, abdominal pain, liver toxicity, etc, over the short and long term.

4. There are other risks associated with the usage of PreP: An increased high-risk sexual activity behavior and lack of inhibition could happen. Hence, see that you continue safe sex, including condom usage, illicit sexual activities, avoiding any harmful injectable drugs of abuse, and avoiding regular usage of alcohol (which you mentioned that you are an occasional user). This is good. Preferably, abstain while on PreP. If you evaluate the risk-benefit profile, it is beneficial to undertake PreP under medical supervision, regular monitoring, and continued safe sex practice; the HIV transmission risk is minimized.

In addition to the above, you must get tested for sexually transmitted infections (STIs) other than HIV before starting PreP. If found positive for other STIs, please get advice from a neighboring infectious disease physician for evaluation and treatment for the particular STI that would have been detected. In such a case, advice must be taken for the need for PreP or post-exposure prophylaxis (PEP).

I suggest you undergo the following investigations:

1. HIV test- P24, antibody.

2. STI panel tests.

Follow up with reports of laboratory results.

Kind regards.

Hello,

Welcome back to icliniq.com.

I understand your query and concern.

It is heartening to know that you are negative for all STIs, considering your bisexual inclination. I would suggest you get tested for STIs every year, at least. Having one partner protects you, provided he is single-partnered, as well. You have no control over his PreP medication-related compliance, as well. Thus, despite your discipline, your risk of getting HIV is not minimal. I would still suggest at least Cabotegravir once in two months injection in case TAF (Tenofovir alafenamide) and Emtricitabine are of concern to you. However, the latter at a much reduced Tenofovir dosage is much safer, as well. Adverse events (AEs) happen with all drugs regardless of the medicinal system, and the rates mentioned are indicative of occurrence during either controlled settings (clinical trials) or may have been collected in a structured manner (non-interventional studies). Spontaneous AEs are a third source, usually from hospital settings, rarely by the patients. Hence, those situations may not completely apply to you.

However, it is your decision. In case you decide not to take PreP, it is suggested you rigorously use barrier method contraception such as condoms in every sexual exposure. In case you decide to undertake a PreP regimen, it should happen after doing the following:

1. Blood tests - HIV, STI tests (do not repeat if done recently last three to four weeks).

2. Blood tests - Liver function tests, renal function tests, hematology tests like CBC (complete blood count), ESR (erythrocyte sedimentation rate), and CRP (C-reactive protein).

3. X-ray chest PA (posteroanterior) view.

4. Urine examination - Routine and culture sensitivity.

Monitoring of liver functions and renal functions should be done every three months or as per local HIV physician policies and treatment guidelines.

I hope this helps.

Revert in case of queries.

Regards.