Does PREP really prevent HIV / AIDS

World AIDS Day : Can These Pills Eradicate HIV?

Every day Sebastian Meier (name changed) takes one of the blue oval tablets against HIV. Prophylactic. "I am HIV-negative and I want to stay that way," says the 34-year-old. He lives in a stable partnership, "but neither of us believe in monogamy".

For Meier, every adventure with another man has been overshadowed by the fear that the condom could tear and the dangerous virus attack his immune cells. For the first time, with the pills, he was “no longer afraid that something might happen,” says the Berliner. "I perceive this as a liberation and definitely more pleasurable sexuality."

How does the pill work?

Prophylaxis against HIV has been in place since 2016. It is the same active ingredients that prevent the outbreak of the immune deficiency disease in HIV-positive people. Only the pills are sold for prevention. “Pre-exposure prophylaxis” is what doctors call it, “prep” in the community. Whoever takes them is a "prepper". Until recently, the medicine cost 820 euros per month, but since October 2017 it has been available for 51 euros. That sparked a boom.

HIV protection pills are a big issue among homosexuals and some straight people. Sex without the risk of AIDS in the neck is a sexual revolution for them. But the prep also heats the minds of those who do not take it at all. Proponents believe the tablets could eradicate HIV entirely. The opponents fear that as a result condoms will be used less often and that other sexually transmitted diseases could be transmitted more frequently. What does the second sexual revolution really mean?

The tablets for carefree sex are based on the two active ingredients emtricitabine and tenofovir. These are substances that prevent the HI virus from multiplying. Several studies have shown that they can protect against HIV infection. The two most important of these surveys from Europe are the Ipergay and Proud studies, the results of which the researchers published in 2015.

Several hundred homosexual men and transsexuals took part in both. Regardless of the study, they did not always protect themselves with condoms during anal sex. On average, they had eight different partners in two months. In both studies, roughly half were given a placebo. After just a few months, the preventive pills began to have an effect: the preppers were significantly less likely to be infected with the HI virus. In both surveys, protection was 86 percent. “If you look closely at the data, you can see that the few men who became infected did not take the tablets as prescribed. The actual protection should therefore be even higher, ”says Heiko Jessen from the largest HIV practice in Germany. Experts give the protection when taken properly at 99 percent. The pill against HIV offers a very high, but not absolute, security.

How is the current situation?

The Prep has been approved for daily use in Germany since October 2016. Swallowing the pills only when needed, such as before a sex party, has not been adequately researched. The US Centers for Disease Control and Prevention (CDC) recommends that men start taking the pills five days before risky sex, and women seven days beforehand. “I keep hearing that disco visitors in Berlin get the pill from their partner and say that it would work in 15 minutes. That's nonsense, ”warns Jessen.

The health insurance companies do not pay the cost of the prep pill. The result: In the scene, people who repeatedly have sex with changing partners stocked up on the Internet, mostly via dubious channels from Thailand, India or Swaziland. It was uncertain whether the pills actually contained the active ingredients against HIV. "If the tablets are exchanged in this way without medical care, it is extremely problematic in terms of health policy," says sociologist Phil Langer from the International Psychoanalytical University in Berlin, who has conducted intensive research into the prevention of HIV.

In July 2017, however, the patent protection of the manufacturer Gilead for one of the active ingredients of the Prep expired. In October a pharmacist from Cologne put the monthly pack into circulation for 51 euros. “Since then, demand has skyrocketed. We didn't expect that, ”says Jessen. On December 1st, Ratiopharm is now also lowering the price to 69.90 euros for the monthly pack.

Can the pill eradicate AIDS?

With the cheap prep, a second sexual revolution is imminent in Europe, believes Jessen. A development that he sees as entirely positive. “For the first time, healthy people can really protect themselves against HIV in a self-determined way. You are no longer just dependent on your partner using a condom. "

In the US, more than 80,000 people are already “on prep,” as it is called. The US health authority CDC has high hopes for this. The Prep could reduce the number of new HIV infections by 70 percent and thus prevent 185,000 new cases by 2020. Just as the vaccination banned polio from almost all industrialized countries, the pills against HIV could massively contain the epidemic of the sexually transmitted disease.

The vision of an HIV-free world is fueled by developments in various major US cities. In New York and Los Angeles, the number of new infections has fallen by up to 40 percent - also thanks to Prep, judges Jessen. The “Getting to Zero” campaign by the city of Los Angeles is particularly considered a success. Posters in subways and buses advertise condoms plus prophylaxis. The number of new infections in the metropolis fell below the 2000 mark for the first time in 2013. According to preliminary data, it collapsed significantly in 2015 and 2016 in particular. Seen in this way, prophylaxis can protect the health of the population selectively. This is why the statutory health insurance companies in France, Belgium and Sweden pay for the tablets.

"Despite prep, a nationwide decline in new infections has not yet occurred in the USA," warns Swiss infection researcher Pietro Vernazza from the St. Gallen Cantonal Hospital. He considers the hope for a world without HIV to be exaggerated. Medicines will not stop them, if only because the tablets are too expensive and unavailable for many people in poorer countries. You have to make ends meet on a dollar a day.

How is the situation in Germany?

In Germany, it is difficult to conduct an offensive prep campaign based on the model of large US cities. Change is slow to set in: Years ago even the experts from the German Aids Aid were outraged about the prep. Only safer sex seemed morally acceptable. Today the organization is campaigning for the expansion of the prep and for the insurance companies to assume the costs. “The assessment has completely changed,” says Langer. But not so in the authorities.

The Federal Center for Health Education is silent on its websites and in its brochures about the prep and is sticking to its well-known and proven "do it yourself" message. "Sexual health is backward in Germany," criticized Jessen. In any case, little is happening at the moment. The number of new HIV infections remained at 3,100 in 2016. Basically, the insurance companies in this country pay vaccinations, but not lifestyle prophylaxis with drugs - be it the birth control pill or the prep. At the Robert Koch Institute, experts have calculated that around ten percent of homosexual men in this country could have a need for the prep. That would be 80,000 people.

Does the pill work for women too?

The experts didn't even count the women. In the USA, it was primarily women who initially protected themselves from the virus with tablets. In the meantime, their share there is still 40 percent. The World Health Organization concludes that prophylaxis is just as effective in women as it is in men. In the few studies on prep in heterosexual couples, the results were not as convincing for other reasons: The participants did not take the tablets consistently.

Behind the notorious exclusion of women is the most archaic gender discrimination: “A man who has a lot of sex is a hero. A woman who has a lot of sex is a slut, ”regrets Jessen. The tablet could very well protect sex workers against HIV, for example.

What do critics say about prep?

Prep doesn't just elicit cheers. The infection researcher Vernazza expects that more people will forego the condom - precisely because one or the other feels safe enough with the pill in their blood.

Just as the birth control pill has changed sexual behavior since grandmother's time, so will the prep, but in a much more subtle way than some critics suggest. “Less the sexual behavior, but the prevention behavior will change. Other sexually transmitted diseases such as syphilis and chlamydia will spread more rapidly. These are a cause of infertility in both men and women, ”explains Vernazza. The studies already indicated that the venereal diseases could spread as a result of the prep. The rate among preppers rose slightly.

That is why prophylaxis is tied to an examination: every three months, users must be examined for sexually transmitted diseases. The package insert also states that the drug only protects against sexually transmitted diseases with the condom. A visit to the doctor is also mandatory because the tablets can also have side effects. Tenofovir damages the kidneys of some users. In these cases, the drug must be discontinued. Some preppers also vomit or often have headaches in the early stages.

“I was lucky and didn't even notice the tablet,” says Sebastian Meier. He has not caught any other sexually transmitted diseases either. “But I also rarely have sex outside of the relationship. And for me the prep is no reason to go without the condom. "

A look back at history: Over the years shortly after the outbreak of AIDS and the awareness campaign of the group "Act Up!" The award-winning film "120 BPM" is currently showing in cinemas. Our critic finds it a masterpiece - read her review here.

You can find more LGBTI topics on theQueerspiegel, the queer blog of the Tagesspiegel.

To home page