If you want to get started on pre-exposure prophylaxis, or PrEP, to reduce your chance of contracting HIV, you first must see a doctor or another health care professional who can prescribe medications — Truvada, the only drug approved in the U.S. for PrEP, is available by prescription only.
But there can be problems in broaching the subject with health care providers. “You don’t have to talk to an HIV specialist to get PrEP. You can talk to any general health provider who is qualified to write a prescription, including doctors, nurse practitioners, physician assistants,” notes PrEPFacts, a website sponsored by the San Francisco AIDS Foundation. Be do know “a lot of general practitioners and even some HIV specialists still don’t know about PrEP” and unfortunately some health professionals may harbor prejudices about using Truvada as an HIV prevention pill.
Here are some tips on having the PrEP discussion, whether you're seeing a new doctor or don't know how to broach the subject with your own doctor.
If your doctor doesn’t know about PrEP, you may have to educate him or her. Start by educating yourself. In The Advocate’s PrEP series this month, we’re offering a wealth of information about this strategy for HIV prevention and our sibling publication HIV Plus also reports on PrEP regularly, in print and online. PrEPFacts is another helpful source on all things PrEP. Further information, some of it for consumers, some especially aimed at health care professionals, is available from the Centers for Disease Control and Prevention, which has recommended PrEP as a prevention option for people at risk of contracting HIV. (The World Health Organization has recommended it as well.) Also check out studies of PrEP’s effectiveness and safety, such as iPrEx, an international study of PrEP use by gay and bisexual men. You can refer your doctor to all these resources, if he or she isn't familiar with the treatment. The CDC offers prescribing guidelines, and the Clinician Consultation Center, based at the University of California, San Francisco, has just opened a “PrEPline” where medical professionals can obtain information and advice on prescribing PrEP to their patients.
If your doctor doesn’t feel competent enough to prescribe PrEP or is generally opposed its use, seek out another health care provider. Some physicians may feel genuinely at sea when it comes to PrEP, while ohers may think it enables people to take more risks in their sex lives — something not borne out by reputable studies — or become “promiscuous.” This is unprofessional behavior from a physician —imposing their beliefs about the morality of sexual activity on their patients — LGBT people know it happens all to often. Bottom line: Dump any doctor who shames you.
If your doctor won’t prescribe PrEP, ask for a referral to a physician who has a greater level of knowledge and/or comfort. Don't worry if he or she can’t or won’t make such a referral, there are other ways to find physicians who’ll meet your needs. Most major cities have an LGBT-focused health clinic where you can find appropriate, nonjudgmental care, or at least an LGBT community center that will offer you a referral. If you’re in a smaller community, you might want to contact the nearest medical center affiliated with a university. The Gay and Lesbian Medical Association can also help you find a physician.
But first, make sure listen closely and speak clearly. Your doctor might not be a slut shaming homophobe; he or she might not opposed to PrEP on principle but merely thinks it’s not right for you. It’s not for everyone. Things you need to discuss with your doctor to see if it’s appropriate for you include the consistency of your condom use, frequency and number of sexual partners, whether you’re in a relationship with someone who’s HIV-positive, if you’re in an open or an exclusive relationship, and have both tested negative recently. Some very experienced HIV doctors will talk with you about drug use (since it dovetails with HIV transmission often) and whether you're meeting men via an app like Scruff or Grndr. They will explain what it takes to be on the drug: the frequency of your return visits, what tests you need before and after you're on the drug, whether they'll do an anal pap exam before they prescribe the medication, and any vaccines the may need you give you ahead of time (hepatitis vaccines are mandatory per the CDC, but many doctors will also give you an HVC vaccine as well). Make sure you understand what your doctor is saying, and if something isn’t clear, ask for further explanation. The doctor has expertise, but he or she is at your service, so be assertive about what you want and need, and make sure you are getting the information you require. (After all, you wouldn't leave McDonalds with the wrong order for fear of speaking up, would you?)
And if you still can’t have this conversation comfortably with your doctor… Find another doctor!
Make sure you’re prepared to do your part. If you go on PrEP, it means taking a pill every day without fail. In the iPrEx study, Truvada as PrEP reduced the risk of HIV transmission among men who have sex with men by 99 percent, whether or not condoms were used, if it was taken daily. You also need to commit to seeing your physician and being tested for HIV every three months. Many doctors will not refill your prescription if you do not adhere to this, because it could affect your health greatly: if you’re HIV-positive and don’t know it, taking Truvada for what you think is PrEP can cause you to develop a resistance to the drug, which can cut down your options for HIV treatment. Your doctor will also test your kidney function (and possibly liver function), STDs, and hepatitis serologie at these intervals. Even though you are taking it every day, Truvada is not effective immediately, and the drug can take a week to reach effective levels in rectal tissue. Your physician should explain potential side effects and make sure you’re prepared to deal with them. Most are minimal, but there can be serious ones in rare cases.
Check out your insurance options. Most insurers are covering PrEP, but the co-pay varies. If you don’t have private insurance, look into the patient assistance program offered by Gilead, the maker of Truvada, or whether Medicaid will cover the drug, something that varies state by state. A website called My PrEP Experience offers extensive information on insurance and Medicaid coverage. Show your physician you’ve done your homework and that you’re willing to do whatever else is necessary.
Take a deep breath and relax. If you’re nervous about approaching your health care provider regarding PrEP, you might want to rehearse the conversation with a friend. But remember, the doctor is working for you. A good doctor wants to give patients the best care possible, and your attitude should be that you deserve no less. If you aren’t satisfied, seek out a different doctor.