Assuming you do not currently have a viral load of HIV, you go to your provider, indicate that you are high risk, and request a prescription for PrEP [1] (Planned Parenthood can assist with sourcing if you don't have a PCP or other stable medical providers). Longer term, it is likely there will be a shift to a twice yearly injectable (Gilead’s Lenacapavir) [2]. State of the art is an undetectable viral load due to antiviral treatment means you cannot transmit to others [3] [4] [5].

Not medical advice, educational purposes only. Seek a medical professional's guidance for your personal circumstances.

[1] https://www.hiv.gov/hiv-basics/hiv-prevention/using-hiv-medi...

[2] https://news.ycombinator.com/item?id=40742163

[3] https://www.hiv.gov/hiv-basics/staying-in-hiv-care/hiv-treat...

[4] https://www.niaid.nih.gov/diseases-conditions/treatment-prev...

[5] https://www.hiv.gov/blog/science-validates-undetectable-untr...

From [5] https://www.hiv.gov/blog/science-validates-undetectable-untr...:

> Even when viral load is undetectable, ... may have detectable HIV genetic material in ... semen, but there is no scientific evidence that such material is associated with HIV transmission.

What? Isn't that the primary transmission vector?

Transmission has never been found when the number of copies of the HIV RNA are below 200 copies/mL--the quantity of virus matters.

For context, the typical ejaculation from someone untreated contains between 10,000 and 1,000,000 copies/mL. With treatment, the average is 1-10 copies/mL.

Besides HPTN 052, there have been three other studies--PARTNER, PARTNER 2, and DISCOVER, of real-world (condomless) usage in mixed serotype couples

https://www.idsociety.org/science-speaks-blog/2021/u--u-the-...

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8942556/

From that same link you cite:

> Findings from the breakthrough NIH-funded HPTN 052 clinical trial, a decade-long study involving more than 1,600 heterosexual couples, offered clear-cut evidence that ART that consistently suppresses HIV also prevents sexual transmission of the virus. In 2011, the HPTN 052 investigators reported that starting ART when the immune system is relatively healthy, as opposed to delaying therapy until the immune system has been weakened by the virus, dramatically reduces the risk of sexually transmitting HIV. The protective effect of starting ART early was sustained over four additional years of follow-up. Importantly, when viral loads were measured, no HIV transmissions were observed when ART consistently, durably suppressed the virus in the partner living with HIV.

Wild speculation is that the genetic material you mention is inactivated and therefore unable to transmit the virus, but is still detectable. I am just an internet rando surfing the knowledge graph, but the science appears sound.

https://www.nih.gov/news-events/news-releases/hiv-control-th...

https://web.archive.org/web/20150106032855/http://www.niaid....

https://www.clinicaltrials.gov/study/NCT00074581

>1,600 heterosexual couples

Is there a similar study of gay men who are not in a monogamous relationship?

Studying the group with the lowest transmission rate who could still transmit seems kind of dishonest.

It's not 'dishonest'. It's important data for parts of the world where heterosexual transmission of the virus is common.

And yes, there is a similar study: https://www.thelancet.com/journals/lancet/article/PIIS0140-6...

I don't buy U=U, I've not seen a proper impossibility proof re. provirus mutation. There's probably infections drowned out against the background rate.

This has been extensively studied and you are wrong.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6...

I don't think I am, in the provirus state you can think of it as essentially a DNA virus in an inert state, and if the DNA fragments the right way it would turn into something similar to a bare DNA vaccine. That design of vaccine essentially does not work, but they have an effect that is not literally zero. I think there's enough holes in the layers of "Swiss cheese" that normally prevent this chain of events that U does not literally equal U.

Edit: right, I'm also assuming the possibility of provirus mutation before this chain of events, and I don't think anyone can deny at least the mutation of HIV before it becomes a provirus.

Are you a virologist, epidemiologist or other specialist with peer-reviewed research pointing in the direction opposite to the conclusions in the paper above? If so, you should publish your findings because that would be a huge refutation of current knowledge and would possibly help the epidemiology of transmission in the greater public.

Until then, I'll take the word of public health practitioners who've been steeped in the field for their entire careers. Their work has been significant enough to be published in Lancet which is a pretty good signal to this layman (though with a bachelor's of science in an unrelated scientific field, so no stranger to reading primary literature).

I probably could write something, but HIV is an epidemiologist's game at this point, and I honestly think the epidemiologists want to say HIV can't transmit in ways that the Hepatitis B virus, a DNA virus, has clearly been demonstrated to transmit. If you press a virologist in private I'm not sure they'll stick to "can't", especially after the COVID-19 virus mutation rate fiasco, and, though not a virus, the prion situation.

I think "can't" deserves at least something physically (as in physics) unlikely, not something that's been demonstrated in a DNA virus previously (and like I said, HIV in provirus form is not unlike a DNA virus).

>Their work has been significant enough to be published in Lancet which is a pretty good signal to this layman (though with a bachelor's of science in an unrelated scientific field, so no stranger to reading primary literature).

i've no opinion on the topic at hand, but I would urge you to find a plethora of signals to form your opinions.

The Lancet has been responsible for quite a few negative 'public health' trends.

The Lancet is responsible, at least partially, for the whole 'vaccines == autism' thing of Andrew Wakefield's; and even ignoring that they have a history of poor review and retraction of work that ends up either being entirely wrong, or guilty of experimental misconduct.

In 1992 they published stuff that suggested a causal link between HIV infection and the oral polio vaccines.

In 1998 they published a (big tobacco funded) peper indicating that second hand smoke doesn't have as much risk as earlier thought.

In 2000 they published a study that claimed that St Johns Wort was as effective an anti-depressant as conventional SSRIs and TCAs.

Just because something has become 'prestigious' doesn't mean it should be trusted wholeheartedly.

This isn't about the Lancet specifically. It's about someone on the internet challenging the overwhelming medical consensus without providing a shred of evidence to support their claims. I can assure you that 'people saying things on the internet' have a far worse record on medical matters than the Lancet, or the medical consensus more generally.

You could try asking a virologist if they think it's possible for the HIV-1 provirus to ever be in a state where it could theoretically be infectious given the right DNA fragmentation.

Why don't you ask one and post what they say here? Or better still, post a reference to some published work that makes your point.

From what I’ve read you need an absolute minimum of 10 virons for infection to happen.

I find "absolute minimum" an unfortunate choice of phrasing when the process necessarily has large elements of randomness and could in principle well proceed from a single cell getting successfully infected.

But it's interesting to note that the way HIV generates its infamous genetic variability can result in a remarkably large fraction of the virions being mutated beyond viability.

https://journals.plos.org/plosbiology/article?id=10.1371/jou...

The infection risk would have to involve a factor of virions getting to a susceptible cell without getting destroyed anyway of course, but given that many of the contenders might not be capable of infecting even if they get there it seems even more understandable if one would usually end up with 10 as the number needed to satisfy some chosen level of statistical significance.

> Longer term, it is likely there will be a shift to a twice yearly injectable (Gilead’s Lenacapavir)

That's debatable. Injectable PrEP has been around for years already (Lencapavir is not the first, just the most recent). Lencapavir has also not yet been tested on all at-risk groups, so unlike other forms of PrEP, it's not a universal solution because it cannot be prescribed to all candidates.

Given the price, which is quite high even with the programs Gilead has said that it will issue to reduce the cost, it remains to be seen how widely-used Lencapavir becomes outside of specific markets.

The problem I think really comes down to there being a generic Truvada.

Insurance for a bit seemed fine with covering Descovy but it seems that is less of a case now since it’s so much more. I would expect the same with a shot like this.

However I would hope that the added benefit of not needing to worry about adhering to taking it every day could outweigh that financial cost for insurance.

I recently switched insurance companies and my new one covers Truvada completely, not even a copay. It’s honestly kinda wild I pay more for my Adderall than I do prep. Obviously I don’t know for sure but I have wondered if it is related to it being preventative and the potential alternative cost makes it smarter to remove any barriers.

Almost all health insurance companies in the USA are required to fully cover PrEP, including Descovy. This doesn't stop health insurance companies from trying to deny you, of course. You would have to appeal the denial all the way up to your state's department for health insurance, but you would definitely win.

EDIT: I was mistaken, this only applies in California.

That… is good to know. I knew they were required but figured generic Truvada was the requirement.

Well kinda irrelevant. My previous insurance loved to deny things, it’s why my company changed.

I worked with my doctor, tried multiple times to get them to cover Descovy (I struggled with the larger pills, I finally just forced myself to get used to it) and was never successful. Just gave up.

See my sibling comment. GP is half-correct. They are not required to cover Descovy specifically. Covering Truvada is sufficient to comply with the law (assuming they are also covering all associated labwork and outpatient visits, and not requiring you to pay anything out-of-pocket for any of those).

> Almost all health insurance companies in the USA are required to fully cover PrEP, including Descovy. They aren't even allowed to require that you try (generic) Truvada first before trying Descovy.

They are required to cover PrEP, but that doesn't mean that they are required to cover Descovy specifically. If they cover Truvada and all associated labwork or outpatient visits without any out-of-pocket costs for you, that's sufficient to comply with the law.

> This doesn't stop health insurance companies from trying to deny you, of course. You have to appeal the denial all the way up to your state's department for health insurance, which you will definitely win.

Having helped many people who've been in this exact situation, it's unfortunately not a given that you will win (you have to play your cards exactly right), and most people who need it can't afford to pay over $2000/month for the several months it takes for this to happen[0].

The most likely scenario is that the insurance company wins, because you give up.

[0] The insurance company has something like 30 days to respond for the first appeal, then an additional 45 for the second and third rounds, and that's assuming everything happens on schedule and you respond to everything immediately.

You are right, my comment is only valid in California.

There is also an emerging market for companies that will help you fight health insurers, and I'd have to imagine that they have some playbooks or can develop them for common situations.

And if not, maybe there should be. I saw some ugly shit in my days working for a company that wrote software for some of the bigger insurers.

Hmm.

> The problem I think really comes down to there being a generic Truvada.

Truvada has been generic for about six years now.

> I recently switched insurance companies and my new one covers Truvada completely, not even a copay. It’s honestly kinda wild I pay more for my Adderall than I do prep.

That's because under the ACA, insurance companies are legally required to cover PrEP at no out-of-pocket cost, without any cost-sharing, copays, or deductibles applied. This also applies to associated labwork and outpatient office visits.

Unfortunately, many insurance companies ignore this requirement, and it's very difficult as an individual to get them to comply.

I’m confused. The parent comment said “longer term,” and you went on to discuss how it is not going to be used in the short term, due to the need for more testing and cost.

Cost comes down over time, and more testing occurs over time, somewhat by definition.

So… what specifically is debatable about the longer term?

> Cost comes down over time, and more testing occurs over time, somewhat by definition.

Truvada has been around for over twenty years, and generic for 4-5 years. It still costs $2000/month list price.

More testing doesn't just magically happen either. Gilead has chosen for years not to pursue testing, let alone approval, for Descovy in various groups excluded from the original clinical trials. They've decided it's not profitable enough for them. The same could very easily happen with lencapavir, and in fact there's good reason to suspect it will.

Why is it so expensive? And is it covered by insurance? If so, then I'm not sure the list price matters all that much from a 'to most people' perspective, even if there is a moral argument to be had here (in which we'd probably agree).

I'm not entirely sure what the argument is, though - is it just the cynical argument of "well, these companies don't care about solving problems, just profit, so they're never going to do anything with it"? If so, then at least I understand your argument, even if I don't necessarily agree.

But I tend to be an optimist.

What I have noticed is that in most situations saying "PrEP" is enough. For my doctor that meant discussing Truvada, Descovy, and what is just kinda dubbed "Injectable Prep". This aligns with most apps also just saying "on prep" with no distinguishing between what prep.

I would imagine that if/when this comes to market it would likely similarly fall under "Prep" for the general community and then you discuss the specifics with your doctor.

Edit: There is also Doxypep (I just say Doxy), which while related to STD's is not related to HIV.

There are people announcing their PrEP status on dating apps so they can raw dog with strangers? Have people forgotten that there are plenty of STD besides HIV? I think this is highly problematic and lifestyle PrEP seems to be counterproductive as a public health measure.

But I am open to arguments that I’m wrong. It’s possible that I am biased as a monogamous heterosexual who has grown up in a culture where sex without condom, especially outside committed relationships, is generally frowned upon and 1980-1990s HIV scares are still in the consciousness of people.

Nobody’s giving or getting head with a condom. People who stay on top of preventative measures tend to not bother with condoms since PrEP became prevalent, because the rest of them you can get with or without a condom due to oral.

Preventative:

1. Gardasil 9 (vaccine against 9 strains of HPV, prevents genital warts and cancers caused by HPV)

2. Monkeypox vaccine

3. Meningitis ACYW vax

4. Meningitis B vax (35% effective against gonorrhea)

5. doxyPEP (two pills of doxycycline taken after sex, 90% effective against syphilis, 80% chlamydia, 50% gonorrhea)

6. PrEP (prevents HIV infections)

7. and the usual suite of vaccines against the rest like hepatitis A/B, mumps etc

Treatment of the bacterial ones (which transmit through oral too):

1. syphilis - butt shot of penicillin

2. chlamydia - 1/2 pills of an antibiotic

3. gonorrhea - a week of doxycycline pills or one butt shot of ceftriaxone

Remaining: HSV. Half of the population has it. Condoms dont prevent it either.

Hepatitis requires blood contact and as such is not necessarily considered an STI, but hepatitis c is curable these days thanks to DAAs taken over the course of 8-12 weeks. a/b variants have vaccines.

Thank you for adding this here, I was working on compiling something similar for another comment on the thread. This is pretty much the gold standard and yeah those that keep up on preventatives and testing are usually the least likely to pass anything along. More information is better, not less! These puritanical views on human sexuality, like the comment above yours to which you're responding and others, only cause more hurt and don't really have any sort of deterrent effect. Peeps be fuckin', nothing you can do to stop it besides get the best info and treatments out there.

Hi, I wanted to clarify here that I don’t have „puritanical views“ on human sexuality, but I am aware of my bias and wanted people to give me further information. I could already „smell“ that I was wrong with my perception, hence the comment. I didn’t want to cause any hurt with my questions, please assume naïveté and not malice.

Great list. Although suddenly sex when single seems like even more of a bother than before.

HSV is inevitable if you hookup, but its also not that bad.

They know other STDs exist but thanks for the insinuation that all homosexuals - sorry - "people" are stupid

> lifestyle PrEP seems to be counterproductive as a public health measure

No. Preventing HIV is not "counterproductive" because maybe some people got chlamydia when they shouldn't have.

First off, PrEP is more effective at preventing HIV than condoms. Doing away with PrEP to "improve public health" WILL give more people HIV.

Second off, people don't always use condoms. We can sit here all day and argue about what people should do or morality or discipline or whatever. None of that matters. What matters is what people ACTUALLY do. We have not yet unlocked mind control so we have to work within the constraints of humanity.

Third, people who do use condoms don't actually use them right, generally. Syphilis, chlamydia, and gonorrhea are all transmitted through oral sex. Nobody, even heterosexuals, uses a condom for oral sex.

Lastly, other STIs are actually very treatable. While they sound big bad and scary, they're nothing like HIV. 5 days of antibiotics and a runny nose is not equivalent to a lifetime of being HIV positive. People treat other STIs as less serious because they are, especially if you get tested regularly. Gay men and especially gay men on PrEP get tested very, very regularly. The odds of long-term syphilis side effects or whatnot is basically 0.

That assumes that everyone you are engaging with knows their status.

If someone knows they are HIV+ and are undetectable than you are more informed about the risk than you are in many other situations.

Also, if your partner is positive are you really not going to want to be with someone just for that reason?

Really need to get past the stigma around this and focus on education instead.

Edit: You changed your comment to no longer mention just not engaging with people who are HIV+...

Yeah, or just not "engage" with anyone. Manage risk, assume unknown or not completely trustworthy = positive.

One doesn’t always know. And besides, if in modern times the risk is essentially zero, then it’s worth considering.

PrEP - An HIV negative person taking Truvada or Descovy once a day to prevent HIV infection.

PEP - An HIV negative person taking a course of antiretrovirals within 72 hours after exposure to HIV to prevent HIV infection.

This article is referring to injectable PrEP. This is already available via an injection every two months and is typically used in populations that can't be expected to take a pill every day (drug addicts, etc.). The article is referring to a new form of injectable PrEP that extends this to once every six months.

> This is already available via an injection every two months and is typically used in populations that can't be expected to take a pill every day (drug addicts, etc.).

That is a pretty bold parenthetical statement. Not only is it not true that "drug addicts" can't be expected to take a pill every day, but neither cabotegravir nor lenacapavir are tested or approved for HIV acquired through non-sexual means, which makes them a poor choice for PrEP for "drug addicts" compared to oral forms, which are effective against all forms of HIV transmission.

Source: former counselor and educator for HIV and substance use

> Not only is it not true that "drug addicts" can't be expected to take a pill every day,

The general population can't be expected to take a pill every day, what would make anyone believe people with SUD are able to?

Source: person who's expected to take a pill every day, and knows other people who are supposed to taste a pill every day.

> The general population can't be expected to take a pill every day, what would make anyone believe people with SUD are able to?

The general population does take PrEP regularly enough to be protected. You seem think that people with substance use disorders are excluded from that, and that belief is grounded in stereotype and bias, not science.

Source: clinical data and professional experience

Adherence to a single tablet regimen is significantly higher than a multi tablet regimen. Bringing some actual data into this, adherence to either in a broad population is not 100%: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5253105/#:~:tex....

People with substance abuse disorders are not binarily excluded or included from adherence to taking a daily regimen. However, it is not an unreasonable expectation that someone shooting heroin every week in a flop house is less likely to take a daily medicine than the average population.

The belief that drug addicts can't be expected to take a daily pill is not grounded in stereotype and bias, it's a realistic and down to earth perspective that for some of them, their addiction is crippling their ability to function.

This kind of unrealistic thinking from up on a high horse is exactly what I'd expect from a former HIV counselor/educator, hence our historic inability to get this virus under control.

PEP means "post-exposure prophylaxis"; PrEP means "pre-exposure prophylaxis". You take PrEP regularly (if you know you're at risk due to sexual habits etc whatever), but only take PEP in response to a specific possible-exposure event (and not already on PrEP). You want pre-exposure instead of post-exposure because post-exposure is very hard on your body and makes you feel sick.

Why is post exposure so hard on the body. Isn’t it still just a 2 drug cocktail (truvada+another one)?

Don't have sex with strangers you don't trust.

Clinics are pretty good. But in general, if you’re a woman in a first world nation your odds of getting it are really low, unless you do significant amounts of anal sex with bisexual men or inject drugs.

Same thing with men. Straight men aren’t at much risk. Bi and gay men are at high risk.

If you have a hiv+ partner, prep is good enough to keep you safe. Just take it always as prescribed.

Pep in for when you may have been exposed, and you need to get it as soon as possible. It’s like a morning after pill. Within 72 hours of exposure but sooner is better.

Then for anyone who does unprotected casual sex, there’s doxypep which reduces likelihood of bacterial stds by a lot, so gonorrhea, chlamydia, and syphilis.

If you want a person to explain this to you in real life, there’s different clinics in every American city that would love to take the time to teach you about all of this. Part of their funding is to educate