Dr Fiona Bisshop

There has been another story reported of an Australian man who has contracted HIV whilst on PrEP.  Many of you are taking PrEP to protect yourselves against HIV, or are relying on your sexual partners being on PrEP to protect them, and it’s quite reasonable that stories like this might give you the jitters.

I think it’s important to put this into perspective, and look at the bigger picture of what we know about PrEP and how well it works.  This story is one of only 7 known cases of HIV transmission among the hundreds of thousands of PrEP users around the world (not counting those cases where the PrEP user was not taking their pills as directed).  The only reason this story even makes the news is because it is so rare.  PrEP is still statistically incredibly effective at preventing HIV infection.  These numbers speak for themselves.  Countries where PrEP has been implemented on a large scale have seen a tremendous drop in new cases of HIV.

There is no doubt that PrEP is more effective than condoms, and short of complete celibacy (or monogamy) it is the best HIV prevention strategy that exists.  There’s also no argument that the advent of PrEP has relieved many people of a heavy mantle of fear when it comes to sex and intimacy, and we shouldn’t lose confidence in the ability of PrEP to protect.  At the same time, PrEP has given HIV positive people relief from their own fear and guilt, and I believe that one day HIV stigma will be dismantled thanks to a combination of PrEP and highly effective HIV treatments.

I would also like to thank Steve, the Sydney guy who came forward with this story.  It took a lot of guts, and kudos to him for seeing the greater good he is doing by sharing his story.  He was using PrEP “on-demand”, meaning he didn’t take it every day, but only when he needed it.  There are very clear instructions for how to use PrEP in this manner before and after a sexual encounter, and we know from large studies that it is just as effective as daily PrEP when used this way.

We don’t know why Steve became infected while using PrEP, but the fact that he was having regular checkups meant that it was diagnosed very early, and he transitioned immediately onto treatment, and remains undetectable and healthy.  To me this is one of the greatest and most welcome changes in how HIV is diagnosed.  Instead of people being diagnosed late when their immune system may already have been damaged, their infection is picked up early and they are able to start treatment straight away to avoid any health impact.  Being diagnosed so quickly also means there’s far less chance that they may have passed the virus on before they were aware. And once a person is undetectable, they cannot transmit the virus, thanks to the evidence of U=U, and this is the other big game-changer.

Perhaps “PrEP failure” is not the best term to use, because PrEP protected Steve for years, and continues to protect the vast majority of people who use it. 

There will likely continue to be new stories of HIV infection in PrEP users in the future, we know that.  But the numbers will be very very small when compared to the total number of people using PrEP, and we should not let these cases detract from the wonderful liberation that PrEP has brought to people who want to live their lives free from stigma and fear.

I have always been a huge advocate for PrEP, and will continue to recommend it as the best way to protect yourself from HIV infection.