Ask the Doc: Bareback Sex, PrEP & A Casualty of the Party

In this installment of Ask the Doc, Dr. Howard Scheiner looks at the real risks of PrEP with Truvada, including the risk that it won't work, and you'll become HIV-positive.

A nonchalant attitude can be put to the test if what you think of as an iron-clad guarantee against HIV lets you down. As the doc notes, it's not a money-back guarantee, it's just another tool in the fight.

Dr. Scheiner also looks at the risks that Truvada might give its users the feeling of invincibility, and play a role in sexual addiction.

PrEP with Truvada is a wonderful new tool in the arsenal against HIV infection, but Ask the Doc shows you both the pros and cons surrounding its use.

The Real Risks of Truvada

Q: Dear Doc, Are you seeing any patients in your practice converting to positive while on Truvada?

A: It was only a matter of time. I have indeed just seen my first patient who failed on PrEP. And, I have no doubt there will be others.

This particular patient told me, "I don't remember what a condom looks like. Is it square?" He was all about the intimacy that he felt without a latex barrier. And while I tell patients that Truvada was approved to be used along with condoms and risk reduction, for many it is seen as a "free pass" to party and play. Many, also, are cavalier about converting, this patient included. For all his bravado, this patient's brief moment of tears were not the tears of joy. For it is never a joyful moment. It is still an illness to live with -- treatable of course -- but still an illness. And with possibly 50-60 years of life ahead of him, it remains a challenging and still uncharted road to travel over that many years.

So, what it the real risk of party and play with Truvada on board? As I've said before there are too many variables and confounding variables to give an across the board answer to a provocative question. Studies to date do not give a clear answer. Lightning has been known to strike on a clear day and on a dark night.

PrEP as a prevention modality has become part of a national prevention strategy for decreasing the pool of HIV transmissibility. But Truvada doesn't come with a money-back guarantee and PrEP is clearly not an ironclad prevention for a given individual. PrEP is a tool. And with a tool, it's probably a good idea to have a toolbox, with some other tools as well, to maximize risk reduction, if that is the goal. The best answer to the question of "real risk" with Truvada as PrEP and bareback sex remains "it depends."

But, as I've written before, it you play sexual roulette, the risk goes up as the number of high risk plays you make.

As with all things, it is a matter of choice. There is no prudish judgment here, just a wider lens to view the "game" of life. Life is about choice. It's your life to lead as you choose. If on balance, the thrill of "roulette" or the feeling of "intimacy" tips the balance from "safety" first, then you roll with it. Choosing wisely is not always apparent, as the consequences of choice cannot be appreciated in anticipation. Intuition is often best seen in hindsight.

As I have written before, "Population studies, mathematical models, and cohort analysis do not answer the question of whether to take PrEP or not for the individual patient." And to take it as the only prevention strategy for bareback sex, comes with risk. As time goes by, studies will probably give better insight and more information on PrEP failures in the real world.

The benefits and risks for you and your health should be assessed in the patient-doctor setting with personalized advice from your physician to make the best choice(s) going forward.

PrEP and Sexual Addiction

Q: Is PrEP playing a role in sexual addiction?

A: I am certain it is playing a role. Without delving into the many reasons people may be hypersexual, or even whether to consider it a definable illness, PrEP can play a valuable role in decreasing the risk of HIV transmission from 44-75 percent based on various studies. It can certainly lessen the attendant anxiety about getting HIV.

Whether it leads to an increase in risky behavior has not yet been clearly answered by current studies. From a purely anecdotal and personal medical perspective, for some it does and for others it doesn't.

Winnie McCroy is the Women on the EDGE Editor, HIV/Health Editor, and Assistant Entertainment Editor for EDGE Media Network, handling all women's news, HIV health stories and theater reviews throughout the U.S. She has contributed to other publications, including The Village Voice, Gay City News, Chelsea Now and The Advocate, and lives in Brooklyn, New York.

This story is part of our special report: "Ask the Doc". Want to read more? Here's the full list.

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