PrEP stands for “pre-exposure prophylaxis.” It’s a medical approach used to prevent HIV infection. The Department of Health and Human Services says:

PrEP can help prevent HIV infection in people who don’t have HIV but who are at high risk of becoming infected with HIV… If a person is exposed to HIV, having the PrEP medicine in the bloodstream can stop HIV from taking hold and spreading throughout the body.

So is PrEP a medicine? A pill? An injection?
The term “PrEP” can be used in a few contexts. It can refer to the strategy of HIV-negative individuals using anti-HIV medications before coming into contact with HIV to reduce their risk of becoming infected. The medications work to prevent HIV from establishing infection inside the body. That strategy, method, or approach of taking anti-HIV medications before coming into contact with HIV to reduce their risk of becoming infected can be called PrEP. But PrEP is also the colloquial way people refer to the medications themselves.

OK, and what are the medicines?
According to The Department of Health and Human Services, “PrEP involves taking an HIV medicine called Truvada every day. Truvada contains two HIV medicines (tenofovir disoproxil fumarate and emtricitabine) combined in one pill.” Truvada is taken once a day.

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When do people take it? Just when they might come into contact with HIV?
Truvada is taken once a day, whether or not you’re planning on being sexually active or injecting drugs. Truvada’s website makes sure to point out that it is “not something you take only when you plan to have sex. And it’s not a ‘morning-after pill.'” Missing a pill or failing to take it consistently can increase chances of infection.

Do people who use PrEP stop using condoms?
The Truvada website strongly urges against that, as PrEP/Truvada alone won’t necessarily prevent HIV infections.

And PrEP is a preventative measure, right? It’s not to be taken if you think you’ve been exposed to HIV?
Correct. There’s also PEP, which stands for “post-exposure prophylaxis.” The Department of Health and Human Services says:

PEP involves taking HIV medicines within 72 hours after a possible exposure to HIV to prevent becoming infected with HIV. PEP should be used only in emergency situations. It is not meant for regular use by people who may be exposed to HIV frequently. PEP is not intended to replace regular use of other HIV prevention methods, such as consistent use of condoms during sex or pre-exposure prophylaxis (PrEP)…

…PEP might be prescribed for you if you are HIV negative or don’t know your HIV status, and in the last 72 hours you:

  • Think you may have been exposed to HIV during sex
  • Shared needles or drug preparation equipment (“works”)
  • Were sexually assaulted

In addition, PEP may be prescribed for a health care worker following a possible exposure to HIV at work, for example, from a needlestick injury.

Got it. And neither of these are long-term treatments for people who have HIV, right?
Absolutely correct. PrEP and PEP are treatments to prevent the infection of HIV. They are not treatments for people who already have HIV.

And is it effective?
According to a March 2019 Washington Post story, Truvada is “more than 90 percent effective at preventing HIV infection via sex and more than 70 percent effective in blocking it in drug injections.”

In April 2019, Poz Magazine reported that researchers at the Robert Koch Institute in Berlin studied how many people got PrEP online, from friends or through other channels outside the medical system, and what risk factors came with these practices. Researchers cautioned:

Nonprescription PrEP users were less likely to use PrEP according to current guidelines… This could increase the risk for undetected HIV and STI infections in this group. Our findings highlight the need for patients to access PrEP through health care systems in order to allow safe use.

So does this mean doctors recommend PrEP?
Yes. Or, rather, a noticeable contingent of doctors recommend PrEP. In that same Washington Post story, Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, said “theoretically, you could end the epidemic tomorrow” if people already infected with HIV got access to antiretroviral therapy and people at risk got PrEP.

So what’s stopping that from happening?
The Post story explained that part of the reason that the drug wasn’t as widely used was because only some doctors knew about it:

The Food and Drug Administration approved Truvada in 2012, but a 2015 survey of primary-care doctors showed that a third of them had not heard of it, according to the CDC. The health agency estimates that 1.1 million people should be on PrEP but that only 90,000 were taking it in 2016.

Use of the drug is climbing nationally, but the South still lags far behind. When researchers at Emory University’s Rollins School of Public Health calculated a ratio of PrEP use to need for the drug in 2017, they found it was more than three times higher in the northeastern United States than in the South.

Another reason mentioned in the article was the high price tag:

Truvada sells for more than $1,600 a month. Until recently, it was not covered by all insurance companies and sometimes carried large co-payments. That changed in November, when the U.S. Preventive Services Task Force recommended that all people at high risk of contracting HIV take the medication. When the recommendation becomes final, insurance companies will have to cover the drug without co-payments.

But otherwise, people at risk of HIV would want to use PrEP?
Kathryn Macapagal, a research assistant professor at the Institute for Sexual and Gender Minority Health and Wellbeing at Northwestern University, wrote an article for STAT in 2018 about why more people don’t use PrEP. Just as the Post article said many doctors don’t know about PrEP, Macapagal said that many people who could use it don’t know about it, either. Another factor, Macapagal said, was the “unfounded perception that PrEP users are promiscuous.” Macapagal was not alone in that sentiment: A study published in 2015 stated that “it is essential for science to trump stereotypes and sex-negative messaging in guiding decision-making affecting PrEP access and uptake.”

Macapagal suggested it was imperative to get PrEP on the radar of at-risk teens and their parents:

Although there are no widespread campaigns to promote PrEP for at-risk adolescents right now, getting parents on board by focusing on its long-term benefits rather than its short-term risks for gay and bisexual teen boys can prevent PrEP from encountering a fate similar to the HPV vaccine.

We talk about one day achieving an HIV-free generation. It is the responsibility of parents, health care providers, and public health professionals to equip teens with information about PrEP as part of routine sex education, and advocate for them to get PrEP if it’s right for them. Until then, one of the most potent tools in the fight against HIV in one of our most vulnerable populations will remain tragically underused.

The Sydney Morning Herald reported in March 2019 that an Australian man tested positive for HIV after using PrEP occasionally but not daily. The Sydney Morning Herald quoted Andrew Grulich, an HIV professor at The Kirby Institute, who said “PrEP only works if it is taken correctly, so non-adherence is certainly a factor in some cases.” The patient himself said, “What happened to me doesn’t change the fact that PrEP is still the most powerful HIV preventative we have ever had.”

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