PrEP: what it is and how it protects against AIDS

This article is published in issue 49 of Vanity Fair on newsstands until 6 December 2022

“A few years ago, I didn’t know PrEP existed. I had unprotected sex with a guy I just met. The next day he confessed to me that he was HIV positive. I thought I was dying», says Marco, 33, a building contractor from the province of Varese. «He tried to reassure me by explaining to me that he was being treated, that he had a zero viral load, that he was therefore not contagious. He said I had to stay calm. But how could I? I was desperate. And angry that he didn’t tell me right away. He replied that he didn’t have to tell me precisely because he was sure he wasn’t a danger. I retorted that it was still my right to know, it was my right to choose. I didn’t sleep for nights until the blood test results put my worries to rest. That anguish, however, I have never forgotten. So, when some of my friends started talking to me about PrEP, the miracle pill that protects against AIDS, I didn’t think twice about getting a prescription for it».

English acronym for Pre Exposure Prophylaxis, PrEP is a preventive treatment to avoid contracting the HIV virus. If done well, thus respecting dosages and methods of intake, it is 99 percent safe. You can take it continuously, one tablet a day, or in the «on demand», i.e. only in the period in which you plan to have unprotected sex. Monthly cost: 60 euros, the price of sex without anguish. The tax to be paid in order not to swell the ranks of the 130,000 HIV-positive people present in Italy (of which 25,000 in Lombardy alone).

Of course, if caught in time, HIV-positive people are treated today, their viral load drops until it becomes undetectable, therefore non-transmissible: they will therefore be able to have unprotected intercourse and even children without fear of infecting partner and fetus. But they will never heal. All their lives they will have to take pills, with no possibility of going overboard; even just an hourly variation in taking medicines can jeopardize the outcome of the treatment and allow the virus to replicate again. «Not only», adds Andrea Gori, director of the Infectious Diseases Unit of the Sacco Hospital in Milan and President of Anlaids Lombardia, «from the moment they publicly declare that they have HIV, in the eyes of most they will cease to be people and will become “the infected”. The AIDS stigma in Italy it is still very strong».

And also fear, especially in the Lgbtqi+ community: “The fear of contracting this disease binds the whole life of us homosexuals,” says Vincenzo, 41, a Milanese doctor who takes PrEP. «Most gays experience their sexuality first with a sense of guilt, then with the fear of becoming infected. Since taking PrEP, however, I’ve been much less anxious. I have rediscovered the pleasure of oral sex and, sometimes, I even allow myself the luxury of complete intercourse without a condom, if I know that the other person is also in therapy”. To find out, some limit themselves to asking their partner from time to time; others trust what is stated on Grindr, the dating app for homosexuals where you can specify if you are taking prophylaxis; still others ask trick questions, like Matteo, 43, a web specialist from Milan: «When I travel to New York or London for work, I realize that everyone there takes PrEP. In fact, you’re considered out of your mind if you don’t. In Italy, however, we are behind. Many look at it with suspicion: they immediately associate the drug with libertinism. Many others claim to take it only to avoid the use of condoms. But I don’t fall for it. When I meet a new guy who proclaims himself “on PrEP,” I ask which doctor he is being treated by and at which hospital. In Milan we know very well doctors and structures that deal with this issue: if one hesitates, the condom stays. I’m paranoid: I only take it off in the longest relationships where I’m sure my partner also takes PrEP.”

Taking PrEP means, in fact, being definitely negative for HIV (you are tested before prescribing it) and under control with regard to other sexually transmitted diseases (blood tests are mandatory every three months). “However, under control does not mean safe,” underlines Professor Gori. “From chlamydia, syphilis and gonorrhea, which are growing exponentially today, hepatitis C and papilloma virus protect themselves only with the use of a condom”. Which, incidentally, remains the main shield against AIDS as well.

So why prescribe drugs to healthy individuals who might otherwise protect themselves? “Because since AIDS hardly ever dies, above all the new generationsunaware of the massacre of the 80s, tend to underestimate the danger, and to refuse the use of condoms. It is true that, in a sense, PrEP endorses promiscuity, but at the same time it safeguards those who practice it. It is a harm reduction policy similar to that of providing clean syringes to heroin addicts: obviously it would be desirable to discourage addiction tout court, but among repeat offenders it is still better to avoid sharing needles. That said, we don’t recommend PrEP for everyone, only those with high-risk behaviors for infection. For now, this prophylaxis is widespread above all within the Lgbtqi+ community of large cities, Milan as the leader with about 2,000 individuals under treatment, but I would also like to extend it to heterosexuals who have promiscuous sexual relations with strangers, primarily sex workers. In particular, women, who are anatomically more receptive than men to sexually transmitted diseases, should protect themselves”.

Could the cost of 60 euros per month be a deterrent to the diffusion? “I don’t think so,” replies the professor. “Suffice it to say that 8 percent of members of the LGBTQI+ community engage in activities such as chemsex (literally, chemical sex): weekends based on orgies and drug cocktails that cost much more than 60 euros». “The real deterrent is the difficulty of accessing PrEP in too many Italian cities,” adds Giuseppe, 51, showroom manager and organizer of gay evenings in Milan. «I have friends in Naples, Matera, Bari, Catania who encounter enormous difficulties in obtaining a prescription: in many hospitals there really is no unit specifically dedicated to sexually transmitted diseases, the doctors are not prepared and are often the first to look askance who makes this kind of request. The underlying thought: You want PrEP, so you’re a debauchee. I don’t care about prejudices: I’m the first to admit that I frequent certain clubs and practice group sex, but I do it by protecting myself. For me, PrEP is a godsend. But those of a different character may be held back by the unpreparedness or hostile attitude of the medical staff. Moral: there are those who give up and those who buy pills on the Internet, take them without being followed, with all the harmful repercussions that follow».

The greatest danger, Professor Gori? «Mixing PrEP with incompatible drugs, but above all taking it if you are unknowingly HIV positive: PrEP is made, in different dosages, of the same active ingredients that reset the HIV viral load which, however, if taken incorrectly, can make the virus resistant to the drug. With disastrous results for the patient who worsens their health conditions and for potential partners, all at very high risk of contagion. For this reason, taking PrEP does not mean just ingesting one tablet a day. It means entering a program that includes an initial interview, HIV testing, psychological support, if desired, and quarterly blood tests in specialized centers”.

“I am very happy to be part of this program also because it normalizes a situation otherwise faced with ill-concealed distrust and blame”, says Marco, the entrepreneur from Varesotto. «Years ago, when I went to have blood tests of my own free will at any sampling point, I always witnessed this scene: the gentleman before me asks to measure his cholesterol, the secretary replies calmly, indicating the price of the ticket and the waiting room in which to stop. My turn comes, I list the venereal disease exams I want to undergo. The secretary moves back with her chair as if to distance herself from the infector. She begins to whisper in a pitying tone as if we are talking about something unseemly. He treats me as a sick person, and as a sinner, even before taking the sample».

• On December 1st It’s World AIDS Day.
• About three thousand are the new cases of AIDS in Italy every year.
• 88.1 percent of new diagnoses of HIV infection can be traced back to infections that occurred during unprotected sexual intercourse. The Aids Operations Center of the Istituto Superiore di Sanità says so. Of these, 42.4 percent concern heterosexuals and 45.7 men who have homosexual relationships.
• The side effects treatments for AIDS can be particularly heavy. Among others, gastrointestinal intolerances, nightmares and metabolic alterations resulting in weight gain. Even PrEP, in the first few days of taking it, can present similar side effects, but of lesser importance.
• Truvada is the name of the original drug that PrEP is made of. Manufactured by Gilead, it is a single tablet containing tenofovir DF and emtricitabine.
• In Italy, PrEP it did not go through the National Health Service. But, as the President of Anlaids Lombardia Andrea Gori explains, «we are working to make it free. We are trying to convince the Italian Medicines Agency that it is more convenient from an economic point of view to put all those who have a promiscuous sex life in preventive care, rather than supplying medicines to those who then contract the virus”.
• Who is not on PrEP and realizes that he has exposed himself to the risk of contagion, he can resort to PEP, a post-exposure prophylaxis that reduces the probability of contracting the virus. It is a sort of “morning after pill” against AIDS.

Youth and sexuality: only 8% have a dialogue on the subject with their parents

World AIDS Day: more than 300,000 children infected in 2020

AIDS, Giusi: “I’m HIV positive, stop judging us”

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