PrEP is Not for Everyone: Understanding Who Should Consider It

In recent years, a groundbreaking treatment has emerged in the fight against HIV: Pre-Exposure Prophylaxis, commonly known as PrEP. This medical intervention has been hailed as a game-changer, offering a new layer of protection against HIV infection. But here’s the thing: while PrEP is undeniably effective, it’s not a one-size-fits-all solution. Just as you wouldn’t wear sunscreen at night or take malaria pills for a trip to Canada, PrEP isn’t necessary or suitable for everyone. So, who should consider it? Let’s dive in and find out.

What’s the Deal with PrEP?

So first things first: what is PrEP? A daily pill taken as directed will help prevent HIV infection in people who do not have the virus. Consider it birth control, but instead of preventing pregnancy, it prevents HIV. The most common medication for PrEP is a combination of two medicines to treat HIV: tenofovir and emtricitabine. It is commercially available and sold under the brand names Truvada and Descovy.

Here’s how it works: If you are exposed to HIV through sex or injecting drugs, these medicines can stop the virus from establishing a permanent home inside your body. According to the Centers for Disease Control and Prevention (CDC), PrEP dramatically lowers the risk of getting HIV from sex—by about 99% when taken daily. In a person who injects drugs, at least 74% of the risk is reduced.

But — and this is important — PrEP only prevents HIV. It doesn’t protect you from any other STI, such as gonorrhea, chlamydia, or syphilis. It also doesn’t prevent pregnancy. So, while PrEP is an essential new tool in the toolbox for preventing HIV, it’s not a replacement for condoms or other prevention methods.

Who’s at High Risk for HIV?

Now that we understand PrEP, let’s discuss who needs it most. The CDC recommends PrEP for HIV prevention for high-risk people. But what does “high risk” mean? It’s not just about who you are; it’s also about what you do.

Men Who Have Sex with Men (MSM)

Gay, bisexual, and other men who have sex with men are the group most affected by HIV in the United States. In 2019, they accounted for 69% of new HIV diagnoses. Why? Several factors contribute:

Biology: The lining of the rectum is thin and can easily tear during anal sex, creating entry points for HIV.
Higher prevalence: There’s a higher percentage of people with HIV in this community, increasing the likelihood of exposure.
Stigma and discrimination: These can lead to risky behaviors, substance abuse, and avoidance of healthcare.

If you’re a man who has sex with men and you’ve had anal sex without a condom in the past 6 months, have been diagnosed with an STI in the past 6 months, or are in an ongoing relationship with an HIV-positive partner, you should seriously consider PrEP.

Injection Drug Users

People who inject drugs are another high-risk group. In 2019, they accounted for about 7% of new HIV diagnoses. The risk here is straightforward: if you share needles, syringes, or other drug injection equipment with someone who has HIV, their blood can enter your bloodstream, transmitting the virus.

But it’s not just about needles. Many people who inject drugs also engage in high-risk sexual behaviors. They might trade sex for drugs or money, have multiple partners, or not use condoms consistently. All these factors amplify their risk.

If you’re injecting drugs and sharing equipment, or if you’re trading sex for drugs or money, PrEP could be a lifesaver. It provides a layer of protection even in situations where you might not be able to control all the risks.

Partners of HIV-Positive Individuals

Are you HIV-negative but in a relationship with someone who is HIV-positive? You’re in what’s called a serodiscordant or mixed-status couple. Thanks to effective HIV treatment, many people with HIV have what’s called an “undetectable viral load.” This means the amount of virus in their blood is so low that they can’t transmit HIV through sex. It’s often described as “Undetectable = Untransmittable” or “U=U.”

But what if your partner’s viral load isn’t consistently undetectable? Or what if you have other sexual partners whose status you’re unsure about? In these cases, PrEP provides an extra layer of protection. It allows you to stay safe while maintaining intimacy in your relationship.

The CDC recommends PrEP if you’re in an ongoing sexual relationship with an HIV-positive partner. This is true even if your partner is taking HIV medicine and has an undetectable viral load. Why? Because life happens. Your partner might miss doses, or their viral load might fluctuate. PrEP gives you control over your protection.

Situational Factors That Increase Risk

HIV risk isn’t just about who you are; it’s also about specific situations you might find yourself in. Here are some scenarios where your risk might spike:

Multiple Partners: More partners mean more potential exposure to HIV, especially if you’re not sure of everyone’s status.
Anonymous Partners: Meeting partners online or at bars can make it harder to have honest conversations about HIV status.
Substance Use: Alcohol and drugs can impair judgment, making you less likely to use condoms or more likely to engage in risky behaviors.
While Traveling: Being in a new place can lead to more adventurous behavior, and healthcare might be harder to access.
During Life Changes: Stress from events like divorce, job loss, or a move can lead to risky sexual encounters.

If you find yourself in these situations, especially if they’re combined with being in a high-risk group, PrEP could provide crucial protection. It’s not about judgment; it’s about recognizing that life is complex and protecting yourself accordingly.

Okay, we’ve covered who should consider PrEP, but let’s flip the script.

Who doesn’t need it?

The short answer: people at low risk for HIV. But what does “low risk” look like?

Monogamous Relationships

Are you in a committed, monogamous relationship where both you and your partner have tested negative for HIV? Monogamous—not “monogamish” or “mostly monogamous.” If you’re truly exclusive and you’ve both been tested, your HIV risk is very low. PrEP probably isn’t necessary.

But let’s be real: monogamy requires trust and open communication. If there’s any doubt, or if either of you has other partners, it’s worth reconsidering. No judgment here—relationships are complicated. The goal is to match your prevention method to your actual situation, not your ideal one.

Always Using Condoms… Always

Consistent, correct condom use is highly effective at preventing HIV. I’m talking about using a condom every single time you have sex, from start to finish. No “just for a minute” without it. No taking it off halfway through. Every. Single. Time.

If this describes you, whether with one partner or many, you’re already practicing excellent HIV prevention. PrEP would be an extra layer of protection, but it might not be essential. That said, if using condoms consistently is a struggle (hey, we’re all human), or if you’re in a high-risk group, adding PrEP could give you peace of mind.

Low-Risk Sexual Activities

Not all sexual activities carry the same HIV risk. Some have virtually no risk at all. These include:

– Kissing

– Touching

– Mutual masturbation

– Oral sex (extremely low risk)

If these are your primary sexual activities, and you don’t engage in higher-risk behaviors like anal or vaginal sex without condoms, your HIV risk is very low. PrEP probably isn’t needed.

No Recent High-Risk Exposures

Maybe you had a phase of higher-risk behavior, but that’s solidly in the past. You’ve been tested, you’re HIV-negative, and your lifestyle has changed. If you haven’t had any high-risk exposures in the last six months and don’t anticipate any in the future, you might not need PrEP right now.

Remember, though, life is unpredictable. If your situation changes—a new relationship, a wild vacation, whatever—it’s okay to reconsider. You’re not locked into one decision forever.

Alternative HIV Prevention Methods

PrEP is a fantastic tool, but it’s not the only one in the toolbox. Here are other effective ways to prevent HIV:

1. Condoms: Old school but still golden. When used correctly, they’re highly effective against HIV and many other STIs.

2. Abstinence: No sex means no sexually transmitted HIV. Simple, but not always easy.

3. HIV Treatment as Prevention: If your partner has HIV and maintains an undetectable viral load, they can’t transmit the virus (U=U).

4. Regular Testing: It doesn’t prevent HIV directly, but it ensures early detection, which improves health outcomes and prevents further spread.

5. Post-Exposure Prophylaxis (PEP): If you’ve had a high-risk exposure in the last 72 hours, PEP can stop HIV in its tracks. It’s emergency medicine, not for regular use.

Also, don’t forget about combination methods. Using condoms plus having an undetectable partner, or using condoms plus getting tested regularly—these combos provide robust protection without PrEP.

Wrapping It Up: PrEP Is Powerful, But Personal

So, there you have it: PrEP is a remarkable step forward in the prevention of HIV. It puts people in control of their sexual health in ways that have never before been imagined. For those at high risk—men who have sex with men, injection drug users, and partners of HIV-positive individuals—it can be a game changer. The same goes for anyone whose life circumstances put them in unacceptably high-risk situations.

But PrEP is not for everyone. You might not need it if you’re in a monogamous relationship in which your partner is HIV-negative if you always use condoms, and if you stick to low-risk activities or haven’t had high-risk exposures lately. Other protection you have available: condoms, treatment for HIV as prevention, and regular testing.

The key is personalization. Prevention of HIV isn’t one-size-fits-all; it’s about finding what’s suitable for your life, relationships, and behaviors. So maybe that means PrEP. Perhaps it means condoms. Perhaps it means a combination. The right choice is the one that keeps you healthy and aligns with how you live, not how you think you should live.

Remember, there’s no shame in considering PrEP. It doesn’t mean you’re promiscuous or reckless: it means you’re taking control of your health. In a world where millions are still affected by HIV, it will be considered worth being proactive about.

So, take a moment to think it over—a risk assessment for yourself. Talk with a healthcare provider. And whatever you decide about PrEP, do keep putting your sexual health first. Get tested regularly. Communicate openly with partners. Stay informed about prevention options.

Because here’s the truth: when it comes to fighting HIV, information is power. The more you know about PrEP and other risk factors, plus all of your options for preventing it, the more you can make informed decisions that are right for your health; and in the end, this is what all this is about—empowering you to live the best, healthiest life you can.