With less wonky capitalization, PrEP may be something you do before anal sex or date night, but it's also the name of a medication HIV-negative people might take in order to reduce the risk of contracting HIV during sex. That's right, there's a medication out there — known as pre-exposure prophylaxis, or PrEP — that greatly reduces the risk of HIV, the most deadly sexually transmitted infection. (Related: What's the Difference Between an STD and STI?)
Unfortunately, due to cultural misconceptions around who's at risk for HIV, most people don't realize people all across the gender and sexuality spectrum are at risk of transmission and eligible for PrEP, and that it's not just for gay men.
Here's everything you need to know about HIV and PrEP. Read on to learn what HIV is, how it is transmitted, and how and for whom PrEP can offer protection.
First, a Refresher On HIV and AIDS
To really understand why someone might want a medication that can help reduce the risk of HIV transmission (PrEP), you need to understand a bit more about HIV and AIDS.
First things first: The two are not synonymous. Human immunodeficiency virus (HIV) is a virus that attacks the white blood cells in your body that are designed to help your body fight off infection (known as the CD4 cells or T-cells), explains Jennifer Pena, M.D., chief medical officer for queer-inclusive sexual health start-up Nurx. This attack on your white blood cells ultimately makes the body more susceptible to other infections and disease.
HIV is transmitted via bodily fluids (including semen, vaginal and anal secretions, breast milk) primarily through sex and intravenous drug use. (Note: If you're struggling with drug use or abuse, visit the Substance Abuse and Mental Health Services Administration for resources or to call their national helpline, which can refer you to local treatment facilities, support groups, and community-based organizations.) When left untreated, it can develop into acquired immune deficiency syndrome, or AIDS. "AIDS is the stage of HIV infection when the immune system cells that fight infection have been so badly damaged that the person is so immunodeficient that they cannot fight off infections," she explains. For frame of reference: People with a healthy immune system (for example, most HIV-negative people) have T-cell count between 500 and 1,600, while people with AIDS have less than 200. How long it takes for untreated HIV to become AIDS varies from person-to-person, but on average it takes 5 to 10 years, she says.
Currently, there is no cure for HIV — but there is treatment. Known as antiretroviral therapy (ART), HIV treatment involves taking a series of medications that work as a team to manage the virus by preventing it from replicating in the body, making the viral load very low. This gives the HIV-positive person's CD4 cells an opportunity to repopulate, which allows the immune system to re-strengthen.
Of course, to be prescribed HIV treatment you need to be HIV positive — and know that you are HIV positive. "Unfortunately, HIV doesn't present with symptoms that are any different from any other viral infection," says Dr. Pena. "In early stages it actually presents quite similarly to the flu with swollen lymph nodes, slight fever, night sweats, and chills," she says.
Because of that, most doctors will rule out other viral infections prior to testing someone for HIV — unless a person asks for HIV testing, or the doctor knows they are in an at-risk population. "These days we screen someone to see if they have HIV by checking for antibodies in their blood," says Dr. Pena. Antibodies are what the body makes in response to infection, so when antibodies are present, someone is HIV-positive; when they are not present, they are HIV-negative. (Related: What to Know About COVID Antibody Tests)
How to Reduce Risk of HIV Transmission
HIV is no longer the death sentence it was prior to the early 1990s when ART was not yet FDA-approved. In fact, current treatment plans can make the viral load undetectable, meaning someone who's HIV positive but undergoing treatment can pose effectively no risk of transmitting HIV to their HIV-negative partners through sex, according to the Centers for Disease Control and Prevention. However, as with any infection, prevention is truly the best medicine. So, how do you prevent HIV transmission?
The best thing people can do to reduce the risk of HIV transmission is first to understand what HIV is and how it spreads (check ✅). Second, is to "talk to any potential partner about their STI status," says Dr. Pena, as well as know and disclose your own STI status. Next, is to use that STI status information to make informed decisions about what safer sex barriers to use, and how to protect against infection. For example, during vaginal or anal intercourse, you might use an external or internal condom. (Related: How to Have the Safest Sex Possible Every Time You Get Busy)
Another Option: PrEP — Here's What PrEP Is
STI testing, barriers, and fresh needles (if you're an intravenous drug user) aren't the only way to reduce the risk of STI transmission. In fact, according to Dr. Pena, the latest and most effective way to reduce the risk of HIV transmission (besides abstinence!) is with PrEP.
PrEP is a a daily oral medication that, when taken correctly, is 99 percent effective at protecting an HIV-negative person from becoming HIV-positive if they come into contact with the virus through sex, explains Emily Rymland, D.N.P, FNP-C and AAHIVS-certified HIV specialist and director of clinical operations at Nurx. It's also 70 percent effective at protecting an HIV-negative person from becoming HIV positive, if they come into contact with the virus from intravenous drug use, according to the CDC.
PrEP is a single pill containing two medications often used to treat HIV (tenofovir and emtricitabine); after one to three weeks of consistent daily use, if someone comes into contact with the virus, PrEP blocks the virus from infecting your body. Basically, it creates a protective "wall" around the T-cells, keeping the virus from entering the cells and reproducing. "You can sort of think of it like birth control for HIV protection," says Rymland. After all, both protect against an unwanted risk of certain sex acts when it's taken every day at the same time, she says.
It's worth noting that PrEP has few side effects including fatigue, stomach pain, and diarrhea, but they rarely occur, says Dr. Pena. Even so, fear of side effects is what usually keeps eligible individuals from moving forward with a prescription. When symptoms do occur, they're usually mild.
Who's a Good Candidate for PrEP?
Currently, the majority of people on PrEP are gay men, specifically white gay men, according to Harvard Medical School. But (white) gay men are not the only people who are at risk for HIV. Someone's actions — not their sexual orientation or gender or race — are what determine their risk of HIV and AIDs, says Rymland.
"There a huge misconception that HIV is only a disease that afflicts gay men," says Dr. Pena. This misconception is connected to the fact that when HIV first started afflicting people, it primarily impacted gay men, she explains. In fact, between 1981 and 1982, before AIDs was known by that name, it was called GRID, which stands for Gay-Related Immune Deficiency.
"This pervasive cultural misconception has been a huge disservice to straight men, women, and non-binary people," says Dr. Pena. And not just that — it's scientifically and statistically inaccurate. Today, in the United States, of the more than 1.1 million people living with HIV, 23 percent are women, according to the CDC. And worldwide, of the 17.8 million people living with HIV, 52 percent are women, according to UN Women. (There is currently no information about how many non-binary individuals are HIV positive.)
Okay, so who is at risk for HIV? "Anyone who has multiple partners, a partner(s) who is HIV positive, is having sex with someone who has ever have sex with somebody whose HIV status you're not sure of, if you have one partner but aren't sure of that person's status or think they may not be monogamous, or if you inject drugs or have a partner who injects drugs you might be a good candidate for PrEP," according to Rymland. "Any HIV-negative person who is at risk (or thinks they may be at risk) for contracting HIV could be a good candidate for PrEP," she says.
Does that mean anyone not in a monogamous relationship should be taking PrEP? It's impossible to make broad-sweeping statements here. Because ultimately, it depends on your current STI status, what level of risk you're comfortable assuming, and what (if any) STI conversations you feel comfortable having. When in doubt, talking to your doctor is always a good idea. (Related: How to Deal with a Positive STI Diagnosis)
How to Talk to Your Provider About PrEP
Any health care provider who can write prescriptions can write a prescription for PrEP. So if you feel comfortable talking to your current doctor, or any provider at your local urgent care, or Planned Parenthood, you might say:
"I'd love you to tell me more about PrEP. I think I might be a good candidate for it."
"I recently got out of a relationship and want to protect myself against HIV. Can you tell me more about PrEP."
"My partner and I recently opened up our relationship, and I want to protect myself from HIV as I begin sleeping with new people."
How much PrEP costs will depend on your insurance. Most private health insurance companies, Medicaire, and Medicaid will cover the costs, according to Planned Parenthood. "But even for those who don't have insurance, PrEP is incredibly affordable," says Pena. There are also a number of PrEP medication assistance programs available for people who are uninsured or under-insured that can help you get the drug for free. Meaning, don't let the cost keep you from talking to your provider about whether or not you're a good candidate for it.