Does PrEP work if condoms are not used?

Dear Bob,
I am a heterosexual male and I recently began taking PrEP.  Are there any research studies that will be able to assess if Truvada is effective for people who don’t use condoms? I use condoms but there are times when they break or slip off without a person’s knowledge until later. Currently all the studies are used in combination with condom use and it makes me wonder if in reality, much of the benefit comes from having patients who are more attuned to using condoms once they are enrolled in a study, etc.
Slipping on Condoms,
Dear Slipping,
First, congratulations on finding and starting PrEP and raising this important question about condom use and PrEP.
Only 1 in 6 gay men use condoms consistently, and condom use among heterosexuals may be even less.  Condoms may slip, they may break, or they may be forgotten entirely in the heat of the moment.  Couples in long term relationships tend to use condoms the least.  I know people who desire a long term relationship so they may feel safe enough to enjoy the intimacy that comes with familiarity and sharing fluids.
Yet, condoms are our friends, although not perfect friends.  Condoms protect against HIV, many forms of syphilis, gonorrhea, and chlamydia.  Condoms can prevent pregnancy.  PrEP only protects against HIV, and possibly provides some protection against herpes infections in heterosexuals.
Truvada (which is the tradename for emtricitabine and tenofovir combined into a single tablet) for PrEP prevents HIV infection when used.  You are right that all the studies of PrEP offered and recommended condoms as well.
Not everyone took our advice about condoms.   We found that PrEP provided the greatest benefit for HIV prevention to people who were using condoms the least.  We saw this in the iPrEx clinical trial.  In the subsequent iPrEx OLE project, we found that people who were not consistently using condoms (compared with consistent condom users) were more likely to start PrEP, more likely to adhere to PrEP, and more likely to stay in PrEP services.  People used PrEP when it was needed the most.  This reflects agency, or ability to act one ones own behalf.  Agency is a key to staying well.  This applies to HIV prevention, and all other aspects of wellness.
So the benefits of PrEP for HIV prevention do not require the use of condoms.  Still, condoms have many benefits and a key role to play in many people’s plans for overall sexual health.  Condoms are our friends.

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Posted on

April 15, 2015

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