People who are not having sex while social distancing or sheltering in place due to COVID-19 do not need to keep taking pre-exposure prophylaxis (PrEP). But for those who wish to continue, the Centers for Disease Control and Prevention (CDC) has provided new guidance on HIV and sexually transmitted infection (STI) monitoring and prescribing practices.

“One of the great things about PrEP is that it can be adapted to whatever is going on in people’s lives,” Julia Marcus, PhD, MPH, of Harvard Medical School and the Fenway Institute in Boston, told POZ. “It’s perfectly fine to take a break from PrEP while not having sex.”

“If someone anticipates physical distancing for long periods of time, they can certainly discontinue PrEP. The challenge is being able to anticipate risk,” Kenneth Mayer, MD, codirector of the Fenway Institute, concurs.

For those who want to stop taking PrEP, some health officials advise taking the daily prevention pill for 28 days after the last sexual exposure. However, World Health Organization (WHO) guidelines note that most programs for gay and bisexual men advise that PrEP can be stopped after two daily doses following the last exposure.

When it’s time to restart, the CDC’s PrEP guidelines state that it takes about seven days to achieve full protection for exposure through receptive anal sex, but it may take up to 21 days to achieve protection for receptive vaginal or frontal sex. WHO notes that pharmacological studies suggest full protection may require just four doses of PrEP for anal sex and seven doses for vaginal sex.

“The CDC suggests that optimal protective concentrations of tenofovir-based PrEP for people exposed to HIV anally are achieved after a week of daily dosing,” Mayer told POZ. “The data are more limited, and there is more controversy about the time for protection for cisgender women and transgender men who may be exposed to HIV through frontal sex, with the CDC suggesting that it may take three weeks to achieve adequate protection and the WHO suggesting that one week is sufficient.”

Another option for men who have sex with men is taking Truvada (tenofovir disoproxil fumarate/emtricitabine) according to an on-demand, or 2-1-1, schedule. This involves taking two doses between two and 24 hours before anticipated sex, one dose 24 hours after the initial double dose and a final dose 24 hours after that. Although this regimen is not yet approved by the Food and Drug Administration, it was found to be highly effective for gay and bi men in clinical trials, and some PrEP clinics in the United States now offer it. The 2-1-1 regimen has not been adequately studied in cisgender women or trans men, nor should it be used with Descovy (tenofovir alafenamide/emtricitabine).

In addition, Marcus advises, “Before having sex again, I’d suggest that people check in with their health care providers about testing for HIV and other STIs that may have stuck around during quarantine.”

Despite rumors, there is currently no evidence that antiretrovirals used for PrEP or HIV treatment can prevent acquiring the new coronavirus or reduce the risk of developing severe illness. However, several studies are underway, including a Spanish study evaluating whether Truvada might help prevent infection or lessen disease severity in health care workers. In the meantime, experts agree that there is no reason to start or stay on PrEP solely in an effort to prevent COVID-19, and people taking these medications should observe all coronavirus prevention precautions recommended for the public at large.


CDC Guidance 

To protect patients or clients from exposure to the new coronavirus and to reduce the demand on the health care system, experts initially urged people to minimize in-person medical visits—for example, by utilizing telemedicine or delaying monitoring tests—but this is not a viable long-term strategy. HIV and STI tests are recommended qaurterly for people on PrEP, but shelter-in-place restrictions and reduced services are now in their third month in some areas.

Eugene McCray, MD, and Jonathan Mermin, MD, MPH, of the CDC issued a “Dear Colleague” letter on May 15 offering guidance for providing PrEP when facility-based services and in-person medical visits are limited.

“Reducing the number of new HIV infections remains a public health priority, and providing PrEP care is an essential health service,” they wrote. “Clinicians should continue to ensure the availability of PrEP for patients newly initiating PrEP and patients continuing PrEP use.”

Quarterly HIV testing should be continued for patient safety, they state, and lab visits for HIV testing and other monitoring are preferred.

If these are not available or feasible, the first option is to use home specimen collection kits, which are covered by most insurance plans. These kits contain supplies to collect a blood sample from a fingerstick for HIV testing or genital/anal swabs or urine samples for STI testing. These tests kits are mailed to a lab and results are returned to an individual or their physician. “This laboratory-conducted test is sensitive enough to detect recent HIV infection,” according to McCray and Mermin.

A second option is an oral swab self-test for HIV. Although this type of test is usually not recommended for people seeking or using PrEP due to its lower sensitivity for detecting recent HIV infection, it is a potential option if others are unavailable.

McCray and Mermin do not mention kidney function monitoring, which the CDC recommends every six months because tenofovir can cause kidney impairment in susceptible individuals; this is especially true of the older formulation in Truvada. However, new kidney problems are rarely seen in people taking PrEP, and when they do occur, they usually develop slowly.

Once HIV-negative status is confirmed, doctors can prescribe PrEP for 90 days, rather than the usual 30 days with two refills, to minimize trips to the pharmacy and to facilitate adherence, McCray and Mermin recommended. Several programs are available to help provide affordable PrEP, including the nationwide “Ready, Set, PrEP program, Gilead Science’s Medication Assistance Program, and various state programs.

Finally, they noted, if a PrEP clinic is considering closing or suspending services temporarily, providers should refer people to other clinics, telemedicine services or pharmacies—some of which do home delivery—so clients may remain engaged in PrEP care.


Sex in a Pandemic 

Studies to date suggest that the new coronavirus (officially known as SARS-CoV-2) is probably not transmitted in semen. The virus has been detected in feces, suggesting that transmission may be possible through activities such as rimming. Studies so far have not found the virus in vaginal fluid.

But even if the new virus can’t be transmitted directly through sexual activity, it can still be spread through the air and potentially via contact with surfaces and objects when people have sex. The virus is present in saliva, and experts think kissing is probably an easy transmission route.

The New York City Department of Health and Mental Hygiene has issued pointers on navigating sex during the pandemic. These include avoiding sex with people outside your household. If you do have sex with others, limit the number of partners—a small circle of people lessens the risk of exposure—and avoid group sex. Similarly, the Netherlands recently recommended that single people choose a “sex buddy” and reach an agreement about their mutual level of risk.

Alternatives to in-person sex include masturbation, video dates, sexting and chat rooms.

Public health experts and advocates learned lessons from the AIDS pandemic about the futility of a “just say no” approach when it comes to reducing sex-related risk.

“Given that abstinence-only recommendations are likely to promote shame and unlikely to achieve intended behavioral outcomes, sex-positive recommendations regarding remote sexual activity are optimal during the pandemic, balancing human needs for intimacy with personal safety and pandemic control,” Mayer and colleagues recently wrote in the Annals of Internal Medicine. “For some patients, complete abstinence from in-person sexual activity is not an achievable goal. In these situations, having sex with persons with whom they are self-quarantining is the safest approach. Those unable to take this approach may benefit from risk reduction counseling, which has proven effective in other realms of sexual health.”

Looking to the future, Mayer and colleagues suggested, “As was seen during the HIV epidemic, antibody tests may play a key role in how we evaluate sexual risk…. This may allow for the serosorting of individuals for sexual activity, with those testing positive for anti-SARS-CoV-2 antibodies presumed safe to engage in sex together with regard to SARS-CoV-2 transmission, if not for HIV or other sexually transmitted infections.”

However, they stress that it is not yet known whether people who test positive for coronavirus antibodies are in fact protected from future infection and, if so, how long this immunity might last.

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