PrEP and drug resistant HIV?

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Written by Dr.Deyn Natthakhet Yaemim, 24 March 2018

Medically Reviewed and updated by Dr.Deyn Natthakhet Yaemim, 9 March 2021

Q: What is PrEP?

A: PrEP means Pre-Exposure Prophylaxis, and it's the use of anti-HIV medication that keeps HIV negative people from becoming infected.

Q: What is Wild-type HIV?

A: Is the HIV in its most natural state, non-mutated strain of a virus.

Q: What is drug resistant HIV?

A: This means the ability of HIV to mutate and multiply/reproduce itself in the presence of antiretroviral drugs that usually kill them (HIV treatment and PrEP).

Q: How does drug resistant HIV happen?

A: Here's how

Transmission of drug-resistant HIV. Most HIV positive people are infected with wild-type HIV but around 10% are infected with drug-resistant HIV.
Many HIV-positive people now take HIV drugs for treatment. If someone's HIV has developed resistance to one or more of these HIV drugs and has unprotected sex or shares needles with other who is not infected, it is possible that they can infect their partner with a drug-resistant HIV.
Before HIV treatment. Even if someone is infected with wild-type HIV, genetic changes still happen, even before treatment is started. This ends up creating a large mixture of virus in the body. Some of these variants contain the necessary mutations that can partially, or fully, resist an antiretroviral drug.
During treatment. After combination HIV drug treatment is started, the amount of wild-type virus is dramatically reduced to undetectable level. If we keep the HIV suppressed, the mutation to drug-resistance won't happen. However, if the amount of virus isn’t pushed down and kept at very low levels, HIV variants can continue replicating, acquiring additional mutations. And once the virus has accumulated enough mutations, a high level of resistance to the drugs being used can occur, causing viral load to increase and CD4 cells to drop.
HIV treatment halted and poor treatment adherence. HIV treatment only work perfectly when taken exactly as prescribed. Abrupt discontinuation of treatment (such as skipping doses, not taking medication correctly, not getting refilled because of COVID-19 or because of chemsex or because simply forgot the appointment or stuck in country where HIV meds are not available) can cause the amount of an HIV drug to decrease in the bloodstream. If the drug level becomes too low, HIV can reproduce more freely and accumulate additional mutations. There are a number of reasons why someone might struggle with treatment adherence, including side effects, chemsex, COVID-19, a hectic schedule, forgetfulness, poor schedule management. If you’ve been having difficulty adhering to your drug regimen, it’s nothing to be embarrassed about—be sure to tell our doctor so that we can up with solutions.
While taking PrEP. In the US, Truvada was approved by US Food and Drug Administration (FDA) in July 2012 to prevent people from HIV. But there is the possibility that PrEP could be started in people who are newly infected with HIV, but HIV tests that we use nowaday can not detect their infection.

Q: Why Is PrEP and Drug Resistance a Concern?

A: We know that PrEP works very well to prevent HIV infection when taken correctly and consistently, we prove that PrEP works well by checking your HIV status through testing. However, there are a lot of people who don't want to get tested and start PrEP. Those who don't get tested doesn't mean they don't have HIV. Maybe they just DON'T KNOW they have it.
They may start PrEP before they know they are infected, or they can become infected with HIV while using PrEP. If this happens, the virus in their body could change, or mutate, and become resistant to these ARV drugs. People who have HIV typically need to take 3 ARV drugs to stop the virus from making copies of itself (also called replicating). When drug resistance occurs, some ARVs are no longer able to stop HIV from multiplying and the person would need to start taking a different combination of ARV drugs and 10 times more expensive. Ultimately, this means that the PrEP user may have fewer choices of the ARV drugs that they can use for treatment when they become infected with drug resistant HIV.

Q: Why do some people not get tested before taking PrEP?

A: There can be many reasons, according to my 6 years experiences they;

are stigmatized and have fear to get tested.
are worried doctors in their city will not be nice to them.
are worried that their doctors will report it to the government.
are afraid of positive HIV result because they know they have been having risks or high risk lifestyle.
are ignorant people which cover simply don't know or simply stupid.
think they're fine, they think they don't have HIV. So no need for a test.
don't want to pay for a test or doctor fee.
are lazy, they don't want to wait at clinic or hospital to get tested and PrEP.
are concerned about their privacy. They want to be discreet. Going to healthcare providers in many cities can be a nightmare.
- so they buy PrEP from online pharmacy or from street pharmacy because it's easier, faster, and they can save some money. They are putting themselves and everyone at risks.

Q: I don't want frequent doctor visit can I buy PrEP from pharmacy without getting test?

A: If you don't get tested and proceed with PrEP, later on when you find out you are HIV positive with drug resistant HIV, you'll not be able to avoid frequent doctor visit as a HIV positive person. And you will have to do that for the rest of your life if you don't want your HIV infection to develop to AIDS. If that happens, don't say I never warn you. We allow people to refill PrEP by buying online from our pharmacy only if they have prescription from their doctor beforehand.

Q: Will drug resistance become a bigger problem when PrEP is rolled out at larger scale?

A: Maybe, possibly. We do know that the risk of drug resistance was low in completed clinical trials where study participants were assigned to take a daily PrEP. But the risk of drug resistance in the “real world” may differ because:
- In clinical trials, study participants received free HIV testing ONCE A MONTH which allowed research clinicians to immediately stop PrEP use once infection was identified; in the real world, HIV testing may be done every three months, or different intervals, or NOT DONE AT ALL !!!
- We do not know how well each PrEP users take their PrEP; when PrEP is not taken consistently, risk of HIV infection is greater and more chance for drug resistant to develop.
- There is the possibility that PrEP could be started in people who are newly infected with HIV, but HIV tests that we use nowaday can not detect their infection, you can miss the diagnosis even in tight control setting as in research.

Q: What can I do?

A: If you're on PrEP, don't put yourself at this risk. Don't fuck with any people who's taking PrEP without getting tested. If they tell you they're on PrEP, ask them when was the last time they get tested. They should have blood test results on their email address or a photo of their last test results. There are people who even fake their blood test results just to fuck bareback with you guys. And trust me, short course of heavenly fun is not worth the risk to fuck with the wrong guy.

- Take PrEP as prescribed.
- Don't create your own way of taking PrEP.
- Don't share your PrEP to anyone else who's not tested.
- If you want to take PrEP, you get tested before!
- If you're taking PrEP, get tested as suggested!
- Tell your friends and who you fuck with to do it right.
- Don't fuck with those who don't do it right. We have been doing a lot of hard work together in order to keep you safe.

DON'T FUCK IT UP OURSELVES AND DON'T LET SOMEONE ELSE FUCK IT UP! --- Dr.Deyn