Adjusted PrEP plan

[Riobard]

My pharmacist gave me some new instructions for on-demand tenofovir/emtricitabine for upcoming trips south. Perhaps I had been previously unaware of the options.

I had been taking one tab for 7 consecutive days prior to potential activity. It is apparently adequate to consume 2 tabs within 2-24 hours prior to activity initiation, followed by one tab per day every 24 hrs subsequent to the initial double dose, including 48 hours following last activity (for good measure I will do 72 hours, that is, 3 follow-up doses post-coital) to adjust for where in the 24-hour block final activity occurs). My big head gets muddled cuz my little head is not amenable to pill alert apps.

As far as on-demand interruption, say for example a break of 2 weeks in activity, this suggests that one can be off the meds for about 11-12 days duration. However, some consumers may wish to maintain the antiviral protection and continue taking it as opposed to starting fresh prior to the next schedule of activity. It is a matter of preference and practicality as well as renal burden because, as most of you know, drug resistance is not a problem. If a known HIV exposure occurs, it remains recommended to seek post-exposure PEP measures because the extra medicinal component is more effective.

I like this new system because I may delay activity following sex-candy shop arrival, but can predict if sex will occur a few hours later from any given point in time, unless accidentally unintentionally prison-raped Adibisi-style (without the peaches can concussion) on any social anthropological Santo Domingo jail tour. 

In fact, I have previously taken up to 2-3 weeks unnecessarily due to activity postponement, but in 'just in case' mode. In sum, several weeks technically unnecessary consumption over 18 months. Luckily my social universal health care covers the majority of the cost. And I think greater uptake perhaps assisted me to eventually tolerate better the initial side effects. 

kkkkkkk ... a pop-up response alert just occurred as I was writing this, related to a different thread. Quelle surprise. Alack, alas, time's up and moving on. I hope it wasn't apologist [insert JustJack and Karen(exWalker) raucous laughter]. 

 

 

Edited February 22, 2019 by Riobard

[TotallyOz]

Perhaps I am ignorant and I apologize. But, I never knew PreP could be used this way. I assumed once started, you took it daily without interruptions.

[Kevie770]

@TotallyOz That’s what my doctor told me! It’s nice to hear something different! 

 

Edited February 22, 2019 by Kevie770

[TotallyOz]

@Kevie770 Mine told me the same thing. You start and you always take.

[Riobard]

Yes, there is "continuous" pre-exposure prophylaxis for preventing transmission for those who are regularly sexually active, that is, at risk due to intimacy encounters any number of times on a weekly basis, OR "on demand" as needed among those whose sexual activity occurs in cycles.

I only engage in (protected) intercourse a few months of the year. The "as needed" on-demand became an option a few years back when research found that stop-start-stop-start Truvada was not associated with drug resistance, that is, the body's incapacity to utilize a medication due to the antivirus mutating to win out over the drug when the drug is not continually in one's system. 

This more recent option is win-win for pharma, and for sexual 'playas' interested in taking only as necessary and sparing renal (kidney) burden, $ costs, the problems of remembering each day, etc. I have taken maybe 120 daily doses, 1-3 weeks at a time overall over 18 months. 

Unfortunately, I tend to get travellers diarrhea and it is unclear whether this is now due to side effects versus pathogens where I travel. 

Post-exposure prophylaxis is a 30-day block with a different medication. Nobody should dick around and take Truvada exclusively if there is the possibility of an exposure, eg, no condom, breakage, etc. This is also why regular testing is critical for either PrEP method. My pharmacy is within the PrEP clinic itself and is Draconian about dispensing repeats without evidence of non-reactive lab results. 

In short, you are apparently being appropriately transparent with your physician about being a serious serial full-time slut, whereas I am but a merely mortal dabbler.

 

Edited February 23, 2019 by Riobard

[HotBottom4U]

I'm with Totally OZ - my doctor said  it should be taken every day - not as an "after morning pill".  Also, your pharmacist should NOT be prescribing you medication or instructing you how to take it - that should strictly come from your doctor.

[TotallyOz]

Never heard of On Demand.

"Participants can choose whether to follow the on-demand dosing schedule (sometimes referred to as ‘event-driven’ or ‘event-based’ dosing) that was validated in the IPERGAY study, or to use daily dosing, which is more commonly used in other parts of the world. On-demand dosing involves taking a double dose of PrEP (two pills) from 2-24 hours before anticipated sex, and then, if sex happens, additional pills 24 hours and 48 hours after the double dose. In the event of sex on several days in a row, one pill should be taken each day until 48 hours after the last sexual intercourse.

At enrolment, on-demand dosing was chosen by 54.6% and daily by 45.4%. The number choosing on-demand is much higher than in the Belgian and Dutch studies, reported below."

http://www.aidsmap.com/On-demand-dosing-as-effective-as-daily-dosing-in-first-year-of-French-PrEP-study/page/3312313/

And, another useful link:

https://www.iwantprepnow.co.uk/how-to-take-prep/

[Riobard]

I agree that one should ensure one's physician and pharmacist are on side. Pharmacists cannot prescribe medication. In my case, the clinic is a specialty HIV program with a research component, where physicians and Allied Health colleagues work as an integrated team, with pharmacy down the hall. I get 20 minutes with the nurse (questionnaire, venipuncture, etc), however long I need with the pharmacist, and 1-2 minutes with the doctor who looks at a screen and asks if I need a script. He had agreed to be my GP, as he completed FamMed, but I have to remind him sometime when I require generic attention and he is (I hope) less frazzled. 

BTW, a friend is a PhD pharmacist, not a physician. He is the go-to even for top-tier Infectious Diseases physicians specializing in HIV care. Complex regimens involving drug interactions are carved out by this Pharmacy dude. This is also the case in many programs where the pharmacist is not a PharmD. You know, most physicans do NOT have the attitude: 'me physician, you lesser life form'.

Further, how many doctors have the time in their 12-minute patient care blocks to sit patiently going over instructions for consumers that may need a lot of medication support and guidance? 

Pharmacists do not need a dressing down. The real problems relate to laypersons giving their family, friends, associates, etc, misinformation that is swallowed hook line and sinker. 

This thread is not about who is correct ... there is no opinion called for because by now it should be clear that nobody here has presented debatable info about PrEP models. 

Edited February 23, 2019 by Riobard

[TotallyOz]

I didn't see anyone trying to debate you or say your opinion was incorrect. I had never heard of this as an option and asked for clarification.  I am checking on this with my doctor but as you say, it may not be very known to him.

[AdamSmith]

This side effect seems to have been documented two years ago as insignificant vs. its benefits.

Truvada as PrEP Against HIV Leads to Modest Decline in Kidney Functioning 

https://www.poz.com/article/truvada-prep-hiv-leads-modest-decline-kidney-function

[BenjaminNicholas]

Bottom line, a pharmD is not a prescribing PhD and isn't in the same category as an infectious disease MD/specialist.  

https://www.onlineschoolscenter.com/difference-pharmd-phd-online-degrees/

PrEP is to be taken every day for it to be as effective as designed.

https://www.hiv.va.gov/patient/faqs/PrEP-not-everyday.asp

 

This thread is about misinformation and the spread of it.  PrEP is to be taken EVERY SINGLE DAY

 

Edited February 24, 2019 by BenjaminNicholas

[AdamSmith]

56 minutes ago, BenjaminNicholas said:

Bottom line, a pharmD is not a prescribing PhD and isn't in the same category as an infectious disease MD/specialist.  

https://www.onlineschoolscenter.com/difference-pharmd-phd-online-degrees/

PrEP is to be taken every day for it to be as effective as designed.

https://www.hiv.va.gov/patient/faqs/PrEP-not-everyday.asp

 

This thread is about misinformation and the spread of it.  PrEP is to be taken EVERY SINGLE DAY

 

Agree with your central point.

But disagree with the radiant points. My pharmacists, and my 90 yo mother’s, have again and again given very useful refinements to her and my PCP’s directions.

The docs always agreed, when checked with.

[Riobard]

3 hours ago, TotallyOz said:

I didn't see anyone trying to debate you or say your opinion was incorrect. I had never heard of this as an option and asked for clarification.  I am checking on this with my doctor but as you say, it may not be very known to him.

I was not at all putting forth an opinion (or even dreamt my prescribed treatment protocol would be challenged), other than describing how on-demand fits my needs better. But I am picking up challenges to this method and that there were members here implicitly aligned with you, TotesAwesome, when in fact you just posed a lack of updated info, as you correctly state. In contrast to you, one member is eschewing appreciative inquiry in favour of rabid fundamentalism. Sheesh! Reminds me of the female-condom activist years ago at conferences, screaming disruptively that the medical system was remiss in not promoting an anal condom version for MSM. 

WTF, our respective physicians are not going to go all pistols at dawn. He said, she said, I said, you said, you didn't say, etc etc etc was certainly not where I anticipated this would go. But then, again, how dumb am I to not have forecasted heated controversy?

This is now to some degree getting to the crazy-town level of vaccine denialism, expressed by a subsection of the membership, with the difference that the denialism is in the direction of prophylaxis scheduling overkill for patients who are intermittently sexual. 

I think I will favour the rigourous research findings over misguided cherry-picking of drug package insert phrasing. 

 

Edited February 24, 2019 by Riobard

[BenjaminNicholas]

3 hours ago, Riobard said:

I think I will favour the rigourous research findings over misguided cherry-picking of drug package insert phrasing. 

 

Can you please provide a link to research that supports your 'on-demand' taking of PrEP provides the same level of protection as daily use?

[AdamSmith]

5 hours ago, BenjaminNicholas said:

Can you please provide a link to research that supports your 'on-demand' taking of PrEP provides the same level of protection as daily use?

I looked, and find nothing in the literature.

So I too am curious.

[Thomas_88]

http://www.aidsmap.com/Pre-exposure-prophylaxis-also-stops-86-of-HIV-infections-in-Ipergay-study/page/2947854/

[AdamSmith]

39 minutes ago, Thomas_88 said:

http://www.aidsmap.com/Pre-exposure-prophylaxis-also-stops-86-of-HIV-infections-in-Ipergay-study/page/2947854/

Thank you. From the cited article:

"In Ipergay, gay men and other men and transgender women who have sex with men, and were at high risk of HIV infection, were asked to take two Truvada pills (or a placebo) from one day to two hours before they anticipated having sex. If they actually did have sex, then they were to take another pill 24 hours after having sex and a fourth pill 48 hours after it. The period of taking PrEP would thus cover two to three days. If they continued having sex, they were told to continue taking PrEP until 48 hours after their last experience.

My problem is I very rarely "anticipate" having sex. It just happens in the moment.

[BenjaminNicholas]

43 minutes ago, Thomas_88 said:

http://www.aidsmap.com/Pre-exposure-prophylaxis-also-stops-86-of-HIV-infections-in-Ipergay-study/page/2947854/

Interesting, but with a much less effective rate.  86% leaves a lot more wiggle room than the 92-99% effectiveness of daily regime PrEP.

Bottom line (for me), until the manufacturer and leading ID doctors say it's as effective, I would never do intermittent cycles.  Daily use results in maximum protection.  Protection is the very reason why we take the drug.  Why would I want to cripple the effects?

 

Edited February 24, 2019 by BenjaminNicholas

[Thomas_88]

BenjaminNicholas, agreed.

[AdamSmith]

9 hours ago, BenjaminNicholas said:

Interesting, but with a much less effective rate.  86% leaves a lot more wiggle room than the 92-99% effectiveness of daily regime PrEP.

Bottom line (for me), until the manufacturer and leading ID doctors say it's as effective, I would never do intermittent cycles.  Daily use results in maximum protection.  Protection is the very reason why we take the drug.  Why would I want to cripple the effects?

 

Agree too. A 14% failure rate is ridiculous.

[tassojunior]

Kaiser gave me a prescription for Prep but it was $1000. Has anyone tried the Indian mail-order stuff? Hopefully Kaiser would still monitor me .

[caeron]

 

I think it far more likely that the difference in numbers isn't because of the effectiveness of this particular protocol, it's that people don't actually follow it. 

[Riobard]

The Prevenir study ... my clinic where I receive consultation is one of the cohort sites. i believe another study was truncated because the evidence of efficacy was incontrovertible in the early stages and there is only so much funding, and clinicians may be satisfied that replicated findings are less important than one solid longitudinal temporally prospective cohort design. Again, the two options depend on sex patterns and preference. There should be a journal-level report eventually. I am on holiday and do not wish to spend hours using my faculty library privileges for a thorough online search and report. 

Also consider that many populations do not prophylax due to lack of access to costly meds. On demand may help mitigate infection among these, though sadly not solve the larger socioecon factors. 

Look, I am reasonably qualified to interpret the findings and make an informed choice. I am a retired clinician/researcher/educator with 12 years of uni ed. This is not the place to more specifically self-identify, but if admin here wants the option to corroborate that my capacity to weigh in ranks highly, I am willing to share with admin my credentials and live with how admin rates me out of 10 viz expertise on this subject. Brooklyn 99 ... not a doctor. That said, I AM NOT GIVING CLINICAL ADVICE. And I don't want the volleying back and forth here to be farthically thilly. 

A 10% difference is the usual standard for the threshold of clinical significance. I do not have the time or interest to drill down further. I take my health very very very very seriously but I have former trustworthy associates who have world-class status in Infectious Diseases / Genitourinary Medicine. I am not a contrarian on the current subject. I do other pro bono work and folks here can and will put on their bigboy investigation pants. Not my wage grade to be convincing here. 

I have rather sloppily added some screenshots. 

And now, breakfast and on to today's collision course of dick, cum and last night's true-vada blue pill swallow.

Edited February 26, 2019 by Riobard

[Riobard]

PS: the Ipergay study is the same lead researcher Molina and compares on-demand to placebo (placebo is no drug; subjects double-blind except side effects may be a giveaway), predates Prevenir research project by a few years, and does not compare on-demand to permanent daily uptake. Very different research approach. In Prevenir, obviously both treatment arms open label unblinded. 

The team is not self-contradictory. But read, interpret, and behave at will and according to resources and prefernce. 

[Riobard]

On 2/24/2019 at 9:39 PM, AdamSmith said:

Agree too. A 14% failure rate is ridiculous.

It would be, but you have grossly misinterpreted Ipergay. You need to read beyond the brief summary abstract.

On demand Truvada 1% infection annually; 99% effective, not 86% effective. Placebo, no drug, 7% annual infection. All considered, fucking without any Truvada, 93% safe. Remember, HIV is a wimpy retrovirus until you get one particle germinating in your bloodstream.

A 14% failure rate might occur in a study arm of full--time darkroom ass-in-sling non-HAART-consuming bttms. For low infection rates, 86% more effective is impressive. Do not get caught up in the complex stats math ... things like rigourous confidence intervals override simple arithmetic and are extreme in taking our wellbeing seriously. 

Edited February 26, 2019 by Riobard